Persistent Upper Right Abdominal Discomfort: Possible Causes

The body has been experiencing issues for a long time?

For the past two to three months, I have been experiencing a sensation of heat and swelling in the upper right abdomen, near the lower edge of the ribs (specifically in the area just above the navel and slightly below the right rib cage).
I have previously undergone chest X-rays in the pulmonology department, which showed no abnormalities (are the X-rays taken in pulmonology the same as those taken in orthopedics?).
I have also had an upper endoscopy, colonoscopy, ultrasound, upper abdominal CT, and upper abdominal MRI; aside from mild gastritis, no other conditions were found, but the symptoms persist daily.
They are becoming increasingly severe and lasting longer, sometimes continuing for most of the day, and have been ongoing for over four months.
What could be the possible causes?
Additionally, during a health check-up last month, it was found that my total protein (TP) and globulin (Glo) levels were elevated, while other routine blood test values were normal.
Urine and kidney function tests were also normal, with serum total protein (TP) at 8.7 g/dL, albumin (Alb) at 4.8 g/dL, and globulin (Glo) at 3.9 g/dL (is this significantly high?).
Following recommendations, I visited a rheumatology and immunology specialist for further blood tests, which revealed an abnormal eosinophil count of 6.5% and slightly elevated immunoglobulin G (IgG) at 1506 mg/dL (with an upper limit of 1560 mg/dL), immunoglobulin A (IgA) at 277 mg/dL, and immunoglobulin M (IgM) at 95 mg/dL.
Recently, I have also experienced tenderness at the lower ribs in certain positions.
Could this indicate multiple myeloma?

Huang, 30~39 year old female. Ask Date: 2022/03/09

Dr. Gao Jiankai reply Internal Medicine

Hello, thank you for your inquiry.
The likelihood of multiple myeloma is low, as the levels of immunoglobulins (such as IgG, IgA, and IgM) are within normal ranges, and the albumin/globulin ratio is also normal, so there is no need to worry about myeloma.
As for the pain below the rib cage, it could be due to localized tendonitis or nerve compression symptoms.
I suggest discussing with your primary physician the possibility of a local corticosteroid injection, which can sometimes alleviate localized rib pain.
The Allergy, Immunology, and Rheumatology Department at Changhua Hospital cares about your well-being.

Reply Date: 2022/03/09

More Info

Understanding persistent upper right abdominal discomfort can be quite complex, especially when multiple diagnostic tests have been performed without definitive findings. Based on your description, it seems you have undergone a comprehensive evaluation, including X-rays, endoscopies, ultrasounds, CT scans, and MRIs, which have largely ruled out significant structural abnormalities. However, the persistent nature of your symptoms and the recent laboratory findings warrant further discussion.

Possible Causes of Persistent Upper Right Abdominal Discomfort
1. Functional Gastrointestinal Disorders: Conditions such as Functional Dyspepsia or Irritable Bowel Syndrome (IBS) can lead to chronic abdominal discomfort without any identifiable structural abnormalities. These disorders are often exacerbated by stress, dietary factors, and other lifestyle choices.

2. Gastritis or Peptic Ulcer Disease: You mentioned having mild gastritis. This condition can cause discomfort in the upper abdomen, particularly after eating. If the gastritis is chronic, it may lead to persistent symptoms. Peptic ulcers can also cause similar discomfort, especially if they are located in the duodenum or stomach.

3. Biliary Issues: Although your imaging studies did not reveal gallstones, conditions such as biliary dyskinesia or sphincter of Oddi dysfunction can cause biliary colic-like symptoms, which may present as discomfort in the upper right quadrant.

4. Musculoskeletal Pain: Given the location of your discomfort near the lower ribs, it is possible that musculoskeletal issues are contributing to your symptoms. Costochondritis or muscle strain in the intercostal muscles can cause localized pain that may be mistaken for abdominal discomfort.

5. Visceral Pain: Sometimes, pain from internal organs can be perceived in areas that are not directly related to the organ itself. For example, liver or gallbladder issues can sometimes manifest as pain in the upper right abdomen, even if imaging shows no significant pathology.

6. Autoimmune or Inflammatory Conditions: Your lab results indicating elevated eosinophils and immunoglobulins could suggest an underlying inflammatory or autoimmune process. Conditions such as Eosinophilic Gastroenteritis or other systemic conditions may need to be considered, especially if you have other symptoms.

7. Psychosomatic Factors: Anxiety and stress can exacerbate physical symptoms, leading to a cycle of discomfort that may not have a clear medical explanation. Given your history of anxiety, it may be beneficial to explore this aspect further with a mental health professional.

Laboratory Findings and Concerns
Your lab results show elevated total protein and globulin levels, which can indicate various conditions, including chronic inflammation or immune responses. The slight elevation in IgG and eosinophils may warrant further investigation, particularly if you have symptoms suggestive of an allergic or autoimmune condition. However, these findings alone do not indicate multiple myeloma, especially in the absence of other concerning symptoms such as bone pain, anemia, or renal dysfunction.

Recommendations
1. Follow-Up with Specialists: Given the complexity of your symptoms and lab findings, it may be beneficial to continue working with a gastroenterologist or a rheumatologist to explore potential autoimmune or inflammatory conditions further.

2. Consider a Multidisciplinary Approach: Engaging with a pain management specialist or a psychologist may help address the psychosomatic aspects of your discomfort.

3. Lifestyle Modifications: Keeping a symptom diary, noting any dietary triggers, stress levels, and physical activity may help identify patterns that could be contributing to your discomfort.

4. Further Testing: If symptoms persist, further testing such as a repeat ultrasound or specific autoimmune panels may be warranted.

In conclusion, while your extensive testing has ruled out many serious conditions, the persistence of your symptoms suggests a multifactorial issue that may require a comprehensive and multidisciplinary approach to management.

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