Chronic Abdominal Pain: Seeking Answers for Persistent Right Upper Discomfort

Q: Chronic Abdominal Pain: Seeking Answers for Persistent Right Upper Discomfort

Hello： 1. <br>For asymptomatic pancreatic pseudocysts, it is recommended to have regular follow-ups to observe if they will resolve on their own. <br>2. <br>Regarding the right upper quadrant pain, with only elevated ACP and VGT, and multiple tests yielding no definitive results,

Please, doctor, help me with my long-standing abdominal pain?

Symptoms: I feel a dull pain in the upper right abdomen all day, whether sitting or standing, as if there is a heavy object pressing down.
I can't tolerate it after sitting or standing for too long, and it doesn't relate to eating.
Lying down is more comfortable.
Painkillers don't help.
Duration: This has been ongoing for the past three years.
Medical history: I have undergone abdominal ultrasound, CT, MRI, MRCP, gastroscopy, colonoscopy, small bowel endoscopy, capsule endoscopy, and endoscopic ultrasound, all of which showed no issues.
Unfortunately, after a small bowel endoscopy last August, I developed acute pancreatitis.
Now, a recent CT scan shows a pseudocyst in the tail of the pancreas, which the doctor said is a complication from the previous acute pancreatitis.
Chest X-ray and chest CT were normal.
Blood tests for GOT, GPT, bilirubin, cholesterol, HDL, amylase, lipase, as well as CEA, CA15-3, and CA19-9 were all normal, but ALK-P was 412 and TG was 375, which are elevated.
Additionally, I have hypertension, approximately 140/100, and fatty liver.
I have been taking many medications without effect...
Many doctors have been unable to find the cause over the years...
Furthermore, regarding the pseudocyst that developed after the acute pancreatitis last August, I only feel pain in the upper right abdomen; the left upper abdomen and left side do not hurt.
Some doctors suggest performing external drainage to drain the pseudocyst, while others say to wait for it to resolve naturally since there are no symptoms.
My pseudocyst is about 6 cm and was a complication from the acute pancreatitis last August...
Should I undergo external drainage? A physician from China Medical University suggested I do ERCP to investigate the cause of my upper right abdominal pain.
Is laparoscopic examination possible? Are there significant risks associated with these procedures?

peter, 30~39 year old female. Ask Date: 2012/04/27

Dr. Chen Qifeng reply Gastroenterology and Hepatology

Hello: 1.
For asymptomatic pancreatic pseudocysts, it is recommended to have regular follow-ups to observe if they will resolve on their own.
2.
Regarding the right upper quadrant pain, with only elevated ACP and VGT, and multiple tests yielding no definitive results, ERCP could be considered; however, due to the presence of a pseudocyst in the tail of the pancreas, performing it at this time poses risks.
It is advisable to wait until the pseudocyst resolves before considering laparoscopic intervention.
Additionally, if previous MRIs did not specifically emphasize the examination of the biliary and pancreatic ducts, an MRCP could be considered.
Wishing you good health, Dr.
Chi-Feng Chen, Taoyuan Hospital, Department of Health.

Reply Date: 2012/04/27

More Info

Chronic abdominal pain, especially when localized to the right upper quadrant, can be a complex issue that requires thorough investigation and careful consideration of various potential causes. Given your extensive medical history and the numerous tests you've undergone, it’s clear that you are dealing with a challenging situation.
The symptoms you describe—persistent discomfort in the right upper abdomen that feels like pressure or heaviness—can be associated with several conditions. Since you have a history of acute pancreatitis and now have a pseudocyst in the tail of the pancreas, it is essential to consider the implications of this condition. Pseudocysts can sometimes cause discomfort or pain, especially if they are large or if they exert pressure on surrounding structures. The fact that your pain is not related to eating and is alleviated by lying down suggests that it may not be directly related to gastrointestinal motility or food intake, which is often the case with conditions like gastritis or peptic ulcers.

In terms of the management of your pseudocyst, the decision to perform external drainage or to allow it to resolve spontaneously depends on several factors, including the size of the cyst, the presence of symptoms, and any potential complications. A pseudocyst that is around 6 cm in size may warrant consideration for intervention, especially if it is causing significant discomfort or if there are concerns about infection or rupture. However, if the cyst is stable and not causing acute symptoms, some physicians may recommend a conservative approach, monitoring it over time.

Regarding the suggestion of performing an Endoscopic Retrograde Cholangiopancreatography (ERCP), this procedure is typically used to diagnose and treat conditions related to the bile ducts and pancreatic duct. If there is suspicion of a blockage or other issues in these ducts that could be contributing to your pain, ERCP may be a valuable diagnostic tool. However, it is essential to discuss the risks and benefits of this procedure with your healthcare provider, especially considering your history of pancreatitis.

As for laparoscopic examination, this minimally invasive procedure can be useful for diagnosing and treating various abdominal conditions. However, it is crucial to evaluate the risks involved, particularly in the context of your previous pancreatitis and current pseudocyst. The risks of surgery must be weighed against the potential benefits, and this decision should be made collaboratively with a surgeon who is experienced in managing pancreatic conditions.

Given your ongoing symptoms and the complexity of your case, it may be beneficial to seek a second opinion from a specialist in gastroenterology or a pancreatic specialist. They can provide a fresh perspective on your situation and may suggest additional diagnostic tests or treatment options that have not yet been considered.

In summary, your chronic right upper abdominal pain could be related to your history of acute pancreatitis and the presence of a pseudocyst. The decision to drain the pseudocyst or pursue further diagnostic testing like ERCP should be made based on a careful assessment of your symptoms and the potential risks involved. It is crucial to work closely with your healthcare team to explore all possible avenues for diagnosis and treatment, ensuring that you receive the most appropriate care for your condition.

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