Question: I am a 50-year-old man, who has been experiencing daily abdominal pain (at the bottom of the right rib) for five months along with unexplained weight loss (25 to 30 lbs). I was hospitalized and I had extensive gastrointestinal testing which included: ultrasound, CT scans, MRI, endoscopy, capsule endoscopy, colonoscopy, barium fluoroscope for the small intestines, and lab work. Other than a borderline enlarged liver, all tests were normal. My weight has stabilized, however I'm unable to gain weight no matter what I eat. My doctors have diagnosed a possible muscular-skeletal strain in which my gastrointestinal doctor prescribed Flexeril and my primary care physician prescribed ibuprofen. I don't agree. What should I do next?

Dr. Hibberd's Answer:

You are absolutely correct. Right-sided abdominal pain such as you describe MUST be further investigated. I am impressed by your weight loss and agree with you that musculoskeletal pain is unlikely in the context of abdominal pain with associated weight loss. I recommend you seek a re-investigation and perhaps even consider a malabsorption workup as well as further imaging. Be sure to include the chest and vascular system, since symptoms of problems may include upper abdominal pain. Note that pancreatic pathology can be very subtle and may be missed by conventional imaging.

At this point, the slate needs to be systematically re-assembled starting with a complete history and physical by a physician well-experienced in sleuthing difficult cases. Select a physician who is willing to examine every detail of your health for further clues. Appropriate imaging and support studies need to be repeated, and perhaps even a whole body PET scan may be necessary. You also need to have a suitable reason for why your liver is enlarged.

Cases such as yours that are investigated that end with no apparent good working diagnosis are well suited for review by tertiary referral centers such as the Mayo Clinic. Let me know your results.