Chronic Abdominal Discomfort: Insights from CT Scan and Diagnosis

Chronic abdominal discomfort and abdominal CT diagnosis?

Dear Dr.
Chen,
I have been experiencing persistent abdominal discomfort for about 8 months, including symptoms of indigestion, bloating, and loose stools.
The bloating sensation can last all day, and the discomfort is located above the navel and on the left side.
I have undergone two upper endoscopies, one colonoscopy, and an abdominal CT scan.
The upper endoscopy six months ago revealed a small (1-2 mm) fundic gland polyp, for which the doctor prescribed medication for indigestion and gastric/duodenal ulcers, but there was no significant improvement.

The second upper endoscopy, performed a month ago, showed mild gastroesophageal reflux disease (GERD), and I was prescribed a dissolvable medication, but again, there was no noticeable effect.
Both endoscopies only reached the pylorus.
A week ago, I had a colonoscopy, which identified a tubular adenoma polyp approximately 1 cm in size in the right ascending colon, but this location is unrelated to my discomfort, and this small polyp should not cause significant symptoms.
The doctor diagnosed me with functional dyspepsia and myofascial pain syndrome (as I have a hard and tense area above and to the left of my navel, where I can feel a movable lump).
However, the doctor believes that the lump I feel is just a muscle bundle, as it is only palpable in that specific area, which is the only region that feels hard and tense, causing dull pain upon pressure.
However, the deep pain does not feel like muscle soreness.
I have taken muscle relaxants and used patches, but there has been no effect.
The dull pain feels like pressure on an organ, but the doctor mentioned that the abdominal CT did not show any significant masses, insisting it is a muscular issue.

I have not engaged in any strenuous activity, and I am currently at home waiting to enlist, which is quite relaxing.
I have attached some abdominal CT images here: https://drive.google.com/drive/folders/0BwKmzeu3uxdpbXVvY0FyN3JMWlE.
I hope Dr.
Chen can take a look to see if everything appears normal.
The area indicated by the arrow is my upper pain point, which corresponds to the jejunum of the small intestine.
I feel that the small intestine appears somewhat enlarged, but the doctor explained that it is due to the intestines being convoluted, which can happen after a CT scan.
However, whether viewed in cross-section or longitudinally, it measures close to 4 cm, and it does not show clear segmentation like other parts of the small intestine.
Could you please advise if the area of the small intestine indicated in the images is indeed enlarged due to being folded together, or could it be due to a tumor or other reasons? Additionally, my left rib cage is noticeably more prominent than my right rib cage.
Due to the long-term discomfort and the lack of improvement from the prescribed medications, I am concerned about the possibility of a small intestine tumor, even though the likelihood of such tumors is relatively lower compared to those in the stomach and colon.

I would greatly appreciate your professional guidance on this matter.
Thank you, and I wish you peace and joy.

A-Lin, 20~29 year old female. Ask Date: 2016/10/08

Dr. Chen Jiaming reply Surgery

After several days of contemplation and discussion with colleagues regarding the information and imaging you provided, there are no significant abnormalities observed in the gastrointestinal tract on the imaging.
Indeed, the left thoracic cavity appears more prominent, which may explain why the left rectus abdominis muscle is wider than the right.
Small intestine tumors are rare, and symptoms rarely present as localized abdominal pain, as most of the small intestine is mobile; instead, manifestations such as bleeding and obstruction are more common.
In fact, the likelihood of functional gastrointestinal issues remains the highest, but these are also the most challenging to resolve.
If you are genuinely concerned about the possibility of hidden tumors or cancer, you might consider opting for a positron emission tomography (PET) scan at your own expense.
I hope this information is helpful to you.

Reply Date: 2016/10/08

More Info

Chronic abdominal discomfort can be a challenging issue to diagnose, especially when multiple imaging studies and endoscopic evaluations have been performed without yielding clear answers. In your case, the symptoms of dyspepsia, bloating, and soft stools, along with the findings from previous endoscopies and CT scans, suggest a complex interplay of functional gastrointestinal disorders rather than a straightforward structural problem.

Firstly, it is important to understand the role of imaging studies like CT scans in the evaluation of abdominal pain. A CT scan is a powerful tool that provides detailed cross-sectional images of the abdomen, allowing for the assessment of various organs, including the intestines, liver, pancreas, and kidneys. In your case, the CT scan did not reveal any significant masses or abnormalities, which is reassuring. However, it is crucial to note that while CT scans can identify structural issues, they may not always detect functional disorders, which can be the underlying cause of chronic abdominal discomfort.

The findings from your endoscopies, including the small gastric polyp and mild gastroesophageal reflux disease (GERD), may not fully explain your symptoms. Functional dyspepsia is a common diagnosis in patients with similar complaints, characterized by symptoms of discomfort or pain in the upper abdomen without any identifiable organic cause. This condition can be exacerbated by stress, dietary factors, and other lifestyle influences.

The presence of a palpable hard area in your abdomen, as described, raises the question of whether this is related to muscular tension or a deeper visceral issue. Your physician's assessment that this could be muscular in nature is plausible, especially if there is no evidence of a mass on imaging studies. Muscle tension can lead to referred pain and discomfort in the abdominal region, mimicking gastrointestinal issues.

Regarding your concerns about the appearance of the small intestine on the CT scan, it is not uncommon for loops of bowel to appear larger or more prominent due to their positioning or the presence of gas. The intestines can sometimes overlap or coil, creating the illusion of increased size. However, if there are no signs of obstruction, significant wall thickening, or other concerning features, it is likely that the appearance is benign.

Given your ongoing symptoms and the lack of improvement with medication, it may be beneficial to explore additional avenues for diagnosis and treatment. Here are some recommendations:
1. Consult a Gastroenterologist: If you haven't already, consider seeking a second opinion from a gastroenterologist who specializes in functional gastrointestinal disorders. They may suggest further testing, such as motility studies or breath tests for conditions like small intestinal bacterial overgrowth (SIBO).

2. Dietary Modifications: Keeping a food diary to track your symptoms in relation to your diet may help identify potential triggers. A trial of dietary changes, such as a low FODMAP diet, could be beneficial for managing symptoms of functional dyspepsia or irritable bowel syndrome (IBS).

3. Stress Management: Since stress can exacerbate gastrointestinal symptoms, incorporating stress-reducing techniques such as mindfulness, yoga, or cognitive behavioral therapy may provide relief.

4. Physical Therapy: If muscle tension is suspected, working with a physical therapist who specializes in abdominal or pelvic floor therapy may help alleviate discomfort.

5. Follow-Up Imaging: If your symptoms persist or worsen, further imaging studies, such as an MRI or ultrasound, may be warranted to rule out any overlooked issues.

In conclusion, while CT scans and endoscopies are valuable diagnostic tools, they may not always provide definitive answers for chronic abdominal discomfort. A multidisciplinary approach that includes dietary management, stress reduction, and possibly physical therapy may be necessary to address your symptoms effectively. Always communicate openly with your healthcare providers about your concerns and the impact of your symptoms on your quality of life.

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