A member presented a medical case:
18 yo competitive tennis male; 1 year of stomach pain near navel, plus three random cases of vomiting. Occasional constipation; also low back pain. Evaluation w/o clear diagnosis. Next steps.....?
18 yo competitive tennis male, with 1 year of stomach pain near navel, plus three random cases of vomiting. Occasional constipation; also low back pain. Evaluation w/o clear diagnosis. Next steps.....?
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Patient demographics
Gender
male
Age
18
Ethnicity
Occupation
Chief complaint or problem to solve
18 yo competitive tennis male, with 1 year of stomach pain near navel, plus three random cases of vomiting. Occasional constipation; also low back pain. Evaluation w/o clear diagnosis. Next steps.....?
Case history
Patient is a competitive tennis player who began this case issue with unknown nausea and stomach pain last year. Full panel blood work and x-ray of abdominal last year showed nothing abnormal just constipation cured by Miralax. Stomach pain had a few instances of vomiting that was unexplained- stomach pain instantly gone after his vomiting episode in these 3 Instances of vomiting over the past year. Pain is only in belly button area and rectal exam showed nothing as well. GI diagnosed IBS but another GI was suspect of eosinophiliac esophagitis. A few months after stomach pain surfaced patient experienced low back pain that was originally thought to be a muscle strain. Rest did not help over the past three months and this back pain is on his lower right side close in proximity to his L5, deep "annoying" pain that has recently been shooting down to his ankle- pain comes and goes in the low back and Ct scan and Mri showed nothing. Most recently patient had three instances of nausea and very severe reflux that surfaced after eating and then playing tennis. His GI pain came and went in a matter of hours and prohibited him from finishing his tennis competition. Endoscopy and blood work showed negative for pancreatitis and EOE. The endoscopy showed nothing as well. Possibly sliding hiatal hernia? Is the back pain related to stomach pain? No answers from three separate GIs and sports medicine specialists. As of now, his fine point back pain was also given a medial branch block at
L5 S1 which was positive and radiofrequency ablation was recommend to relieve pain in low back. What is the cause of the stomach or low back pain? Any correlation?
Purpose of case discussion
Diagnostic dilemma: "What are the next steps for evaluation?"
Supplemental Materials

Dr. Katharine Cox
Pediatrics - Emergency Medicine
10 doctors agree

In brief: Abd. Pain etc

Your combination of symptoms requires an exam by your physician.
Generally peri umbilical pain by itself is benign. All the best.

In brief: Abd. Pain etc

Your combination of symptoms requires an exam by your physician.
Generally peri umbilical pain by itself is benign. All the best.
Dr. Katharine Cox
Dr. Katharine Cox
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1 comment
Dr. Dheeraj Nagpal
Abdominal CT recommended
Dr. Laura Anissian
Internal Medicine
9 doctors agree

In brief: Stomach issues

I am sorry to hear that you have had problems for a year- and hard when competing in sports.
Firstly, these symptoms may or may not be related to ea other. You could have irritable bowel syndrome, have had intermittent vomiting due to virus or reflux, or other. If you have had fever, weight loss or blood in stool, you should get worked up. Back pain muscular? Start w exam by PCP!

In brief: Stomach issues

I am sorry to hear that you have had problems for a year- and hard when competing in sports.
Firstly, these symptoms may or may not be related to ea other. You could have irritable bowel syndrome, have had intermittent vomiting due to virus or reflux, or other. If you have had fever, weight loss or blood in stool, you should get worked up. Back pain muscular? Start w exam by PCP!
Dr. Laura Anissian
Dr. Laura Anissian
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Dr. Edward Hellman
Orthopedic Surgery
9 doctors agree

In brief: Further workup

Further workup including probably a ct scan abdomen and pelvis for starters, this would also allow for a good look at your lumbar spine through Sagittal reconstructions of the scan.

In brief: Further workup

Further workup including probably a ct scan abdomen and pelvis for starters, this would also allow for a good look at your lumbar spine through Sagittal reconstructions of the scan.
Dr. Edward Hellman
Dr. Edward Hellman
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3 comments
Dr. Herman Hammerstead
MRI better modality for this diagnosis
Dr. Louis Delcampo
I'm not sure what this statement means? "As of now, his fine point back pain was also given a medial branch block at L5 S1 which was positive" ? Was the median branch block successful at relieving the pain you described? if Yes, how long did the block last? Also with negative results on ALL diagnostic modalities why? or What was the reasoning for doing a median branch block?
Dr. Laurentiu Boeru
Anesthesiology
8 doctors agree

In brief: Further studies

A gstrografin study in Trendelenburg will show the sliding hiatal hernia, or any defect into the diaphragm that could be hidden.
Also some small fissure into the lower esophageal linning. I would also suggest a pipida scan...just in case

In brief: Further studies

A gstrografin study in Trendelenburg will show the sliding hiatal hernia, or any defect into the diaphragm that could be hidden.
Also some small fissure into the lower esophageal linning. I would also suggest a pipida scan...just in case
Dr. Laurentiu Boeru
Dr. Laurentiu Boeru
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Dr. Lucas Bryant
Facial Plastic Surgery
6 doctors agree

In brief: Primary doc

This could be a variety of things including gas pain.
Was vomiting associated with the pain or separate event? Seeing a primary care physician. Would be a great first step.

In brief: Primary doc

This could be a variety of things including gas pain.
Was vomiting associated with the pain or separate event? Seeing a primary care physician. Would be a great first step.
Dr. Lucas Bryant
Dr. Lucas Bryant
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Dr. Jon Ahrendsen
Family Medicine
3 doctors agree

In brief: Consider a visit with a psychologist to help cover all bases.

On first glance when reading about an 18 year old competitive tennis player who has abdominal pain and vomiting I would consider this to be stress induced or "nerves".
Parent and child might be offended by the suggestion, but common things occur commonly and rare things (eosinophilic esophagitis) rarely. Constipation could come from dehydration from excessive exercising, also the back pain. At any rate, even if this is not stress or 'nerves' the fact that these symptoms are distressing to him, warrant a counseling type session to help him cope or deal with it. Again the parents and child may reject the notion that he take a break from competitive tennis , but this is also worth considering. Since all these other medical tests (scopes, MRI, CT) have been viewed as 'normal', it is time to consider other differential factors.

In brief: Consider a visit with a psychologist to help cover all bases.

On first glance when reading about an 18 year old competitive tennis player who has abdominal pain and vomiting I would consider this to be stress induced or "nerves".
Parent and child might be offended by the suggestion, but common things occur commonly and rare things (eosinophilic esophagitis) rarely. Constipation could come from dehydration from excessive exercising, also the back pain. At any rate, even if this is not stress or 'nerves' the fact that these symptoms are distressing to him, warrant a counseling type session to help him cope or deal with it. Again the parents and child may reject the notion that he take a break from competitive tennis , but this is also worth considering. Since all these other medical tests (scopes, MRI, CT) have been viewed as 'normal', it is time to consider other differential factors.
Dr. Jon Ahrendsen
Dr. Jon Ahrendsen
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Dr. Edward Workman
Pain Management
3 doctors agree

In brief: Likely 2 separate problems, GI and Low Back

GI issue; given the negative findings so far but continuation of GI symptoms, I would recommend a Barium Swallow to monitor flow of partial obstruction vs reflux.
Low back Pain: The symptoms suggest a problem at the L5/s1 level on the right. The positive medial branch block implicates the facet joint complex at L5/s1. A medial ablation would stop some of the pain at that level for possibly many months (50%+ of the nerves return). But if pt is having pain down to the ankle that suggests some degree of impingement on the L5/s1 nerve by a hypertrophied facet. MRI is insensitive to facet pathology; CT with and without contrast is more sensitive and Ultrasound is even more sensitive in trained hands. Suggest the ablation and targeting the L5/s1 facet inflammation with steroid injections if ultrasound confirms pathology at that site.

In brief: Likely 2 separate problems, GI and Low Back

GI issue; given the negative findings so far but continuation of GI symptoms, I would recommend a Barium Swallow to monitor flow of partial obstruction vs reflux.
Low back Pain: The symptoms suggest a problem at the L5/s1 level on the right. The positive medial branch block implicates the facet joint complex at L5/s1. A medial ablation would stop some of the pain at that level for possibly many months (50%+ of the nerves return). But if pt is having pain down to the ankle that suggests some degree of impingement on the L5/s1 nerve by a hypertrophied facet. MRI is insensitive to facet pathology; CT with and without contrast is more sensitive and Ultrasound is even more sensitive in trained hands. Suggest the ablation and targeting the L5/s1 facet inflammation with steroid injections if ultrasound confirms pathology at that site.
Dr. Edward Workman
Dr. Edward Workman
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Dr. Derrick Lonsdale
Preventive Medicine
2 doctors agree

In brief: You have beriberi

Beriberi is due to thiamin deficiency and is easily caused by taking sugar in the diet.
If you look up the symptoms of beriberi, you will find that there are many, none of which are diagnostic by themselves. Unfortunately, it is almost always diagnosed as psychosomatic because physicians don't believe that this disease occurs in America

In brief: You have beriberi

Beriberi is due to thiamin deficiency and is easily caused by taking sugar in the diet.
If you look up the symptoms of beriberi, you will find that there are many, none of which are diagnostic by themselves. Unfortunately, it is almost always diagnosed as psychosomatic because physicians don't believe that this disease occurs in America
Dr. Derrick Lonsdale
Dr. Derrick Lonsdale
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Dr. Joseph Marra
Radiology
2 doctors agree

In brief: Suggest CT scan

I do agree with comments regarding the possibility of symptoms being related to anxiety and nervousness, however, I do feel a workup for a physical cause is in order. If endoscopy did not show any significant findings, I do think imaging with CT scan of Abdomen and pelvis might be helpful.
It is possible symptoms could be related to partial obstruction. This could be related to such things as small bowel adhesion from prior surgery (if applicable), or possibly a herniation of bowel causing partial obstruction. Also an Upper GI series with small bowel follow through might help in the evaluation.

In brief: Suggest CT scan

I do agree with comments regarding the possibility of symptoms being related to anxiety and nervousness, however, I do feel a workup for a physical cause is in order. If endoscopy did not show any significant findings, I do think imaging with CT scan of Abdomen and pelvis might be helpful.
It is possible symptoms could be related to partial obstruction. This could be related to such things as small bowel adhesion from prior surgery (if applicable), or possibly a herniation of bowel causing partial obstruction. Also an Upper GI series with small bowel follow through might help in the evaluation.
Dr. Joseph Marra
Dr. Joseph Marra
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Dr. Richard Zimon
Internal Medicine
2 doctors agree

In brief: Inflammatory

bowel disease ..
.ruled out?? Syndromes with spondylitis and inflammatory bowel disease... Just a thought! Z

In brief: Inflammatory

bowel disease ..
.ruled out?? Syndromes with spondylitis and inflammatory bowel disease... Just a thought! Z
Dr. Richard Zimon
Dr. Richard Zimon
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