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Which Specialist to see?
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My mother who is in her mid 60s constantly having problem with her digestive system. She often complain of having very sharp stomachache and have fainted more than 10 times in the past 6 months. She is quite careful with the food that she ears, but not sure what exactly caused that problem.

I like to know if anyone had similar problem? Who is the best doctor to treat such symptom? She went to Timberland and they have performed scope on her from the throat and from the bottom, they can't see any problem except a small gall bladder stone which they didn't think it was the cause of it. I prefer to have a second opinion and would appreciate anyone who can suggest me a name of the doctor and which specialist centre is he based and any phone contact number.0

Posted on: 2009/11/16 17:54
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Re: Which Specialist to see?
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The abdominal pain may be related to fainting or maybe not or is it too painful until fainted?

A lot of details need to be taken as acute abdomen is a magic box & anything can happen.

History taking is vital:

C/O: 60s F with abdominal pain of 6/12 duration asso. with faintings

Describe the pain:
Site
Onset
Character
Radiation
Associated symptom
Time (duration) - pain for 6 months or recently? or fainting since 6 months ago and recently abd pain?
Exacerbating factors and relieving factors
Severity (pain score 0-10 etc.)

Describe the faint:

Systemic review: 60+ yrs old F (old)
General: fever, loss of appetite, loss of weight?
cardiovasular:
respiratory:
git
neuro
genitourinary
musculoskeletal
endocrine
others

gyne hx
obstetric hx
past medical hx dm, hpt, malignancy

Is she diabetic (DM)? too much sugar or too low can cause fainting. diabetes can cause ischemia (low blood supply) to intestinal blood vessels too (like heart attack & stroke) causing abdominal pain.

past surgical history: surgery done before? can lead to adhesion colic

drug hx anti hypertensive (overdosage?)
family hx dm, hpt, malignancy
personal hx
social hx


Acute abdomen (abdominal pain) but 6 months is kinda long and not acute
Anyways,
Its causes can be divided into:

1. Surgical
i. Inflammation eg ac. pancreatitis, cholecystitis(gallstone), cholangitis,
ii. Obstruction eg intestinal obs., biliary, ureteric colic
iii. Ischemia eg mesenteric ischemia, torsion of viscus (organs)
iv. Perforation eg peptic ulcer, diverticular etc

2. Medical
i. Cardiovascular eg MI (heart attack can present as ac. abdomen)
ii. Gastrointestinal eg gastritis, hepatitis
iii. Abdominal wall
iv. Genitourinary eg Urinary tract infection
v. Neurological
vi. Hematological
vii. Endocrine eg diabetes
viii. Metabolic
ix. Infective

3. Gynecological
i. Ovarian
ii. etc

1stly think of common things.

sharp pain (somatic pain), localised to an area? parietal peritonitis, even appendicitis can cause it. where is the pain? right lower abdomen?

Chronic pain is due to more serious illnesses like cancer spread etc.


You can try bringing her to see a physician. A physician majors in medical illnesses not surgical but he or she will have wide differential diagnoses. however, even a good general practitioner can diagnose. a specialist will have narrowed differential diagnoses. surgeon will straight away put a scope into the gastrointestinal tract to view (and to earn money). usually they don't think of medical causes anymore.





Posted on: 2009/11/16 19:11
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Re: Which Specialist to see?
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I would say she is quite healthy in every aspect. She has to take medication for her diabetes. And even so, her blood sugar is very well controlled (Normally below 6.0).

The problem is, she very frequently has this very acute, very sharp adominal pain. When she had this pain, she would rush for the toilet and she would faint easily because she can't bear with the pain. She had this pain for a few years now. But in the recent 6 months, the frequency of her having such sharp pain has increased. Like I said, she fainted because of the pain more then 10 times in half a year. Previously, she had sharp pain now and then, but not as often as I can remember in this recent 6 months. She can't pin point to a specific food that she ate which caused the problem. Sometimes she had been eating at home all week and she just collapsed due to her pain. Sometimes she ate out all week and never had any problem. I am not sure if it was the food that she ate or what actually causes it.

She have not got high blood pressure when she tested herself at home. But the doctor in the GH often said she has got high blood pressure and they presribed her the medicine for high blood pressure. She also consulted Dr. Patrick Lau in Timberland. Dr. Lau said she hasn't got high blood pressure either but would still recommend her to take anyway. I am not sure if there is indeed such a thing call White Uniform Syndrome. Doctor attributed the cause of her high blood pressure to her seeing nurses and doctors wearing white uniform and because she feel tense, her blood pressure goes up when she is in GH. But Dr. Lau still suggested her to take the high blood pressure medicine nevertheless. I am beginning to suspect could it be the high blood pressure medicine.

Posted on: 2009/11/16 19:55
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Re: Which Specialist to see?
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Anti hypertensives rarely cause abdominal pain.
white coat hypertension is quite common indeed.
is the abdominal pain generalized or localised? can she point using finger or whole palm to her abdomen?
associated with nausea and vomiting?
constipation or diarrhea?
stool color?

Abdominal migraine (usually in children but can occur in adult too) can be one too and usually no cause can be found. Pain relief by strong analgesic is the only treatment. The best thing to do is to consult a physician and stay on with him or her so that he/she will know the history, your mum's character etc. sometimes psychological problems can cause abd. pain (real or fake-to get attention) too. it is not advisable to be a doc hopper.



Posted on: 2009/11/16 20:22
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Re: Which Specialist to see?
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As far as I know, her abdominal pain is everywhere, there is no single area where she feel extremely painful. Her pain is normally very sharp for 10-15 minutes. And she would have diarrhea if she had that pain. Stool is dark brown / black colour. No nausea or vomitting, just sharp abdominal pain and diarrhea. A few times, she fainted in the bathroom, had bump her head on the bathroom sink. She fainted at the car porch, while rushing to the toilet. Fainted on the doorway into the house. I don't think she faked her pain. My dad found her fainted with stain on her pants.

I really don't think it is the food, because my dad always eat the same food as she does. My dad is as healthy as usual, never had problem with the food.

I tried to wiki on the ischemic condition. I realised that the sympton matches very closely to what she had. Maybe that might be a good starting point.

My mum was a nurse many years ago, working for Normah then Timberland last time. She is very loyal to Timberland. But I am getting disappointed with Timberland because I don't think they have been able to diagnose her properly. We spent quite a bit of money trying to find out what causes it. And so far, they said they don't know what causes it.

I want to bring her to Normah or Kuching Specialist Centre to have a second opinion.

Posted on: 2009/11/16 22:30
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Re: Which Specialist to see?
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perhaps jingpeng can meet up with storm. i can tell jingpeng has some knowledges on this particular. This will be easier for both of you.

Posted on: 2009/11/17 10:30
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Re: Which Specialist to see?
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Umm you should ask her to see a gastroenterologist at one of the specialist centres. Seeing a gynaecologist and a renal physician will be good as well.

A pain that comes on with intervals points to a 'colicky pain'. May be due to bile stone, a stone in the kidneys/ureter
It may be a cyst in the ovaries that hurts when there is bleeding or expansion of the cyst

Pain that has been going on for a while and is severe may indicate cancer but not common-unless its involving the pancreas or there is severe blockage of the colon.

Make sure you take note of whether she develops fever, stays very still with the pain, vomits, and change in skin colour-yellow, pale so that when a specialist asks, you can provide more details into your mother's condition.

I reccomend that you take her to see a GI or Gynae specialist as soon as possible rather than waiting for what people in this forum may offer you in terms of medical advice.

Posted on: 2009/11/17 15:33
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Re: Which Specialist to see?
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And another thing-its highly unlikely to be MI(heart attack)-your mother would not be alive with that many attacks

Posted on: 2009/11/17 15:38
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Re: Which Specialist to see?
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I actually came to the forum to ask which doctor to see. At the moment, I am clueless as which doctor to see. I don't know any gastroenterologist in Kuching. If only I could have a name, at least I could start arrange an appointment. I would also have to arrange a flight ticket back to Kuching. So, it is not quite an easy task as in just to walk into the clinic.

I was hoping someone could suggest a name, like ... Dr. Chua (an example), he is based in whatever, Jalan Ang Cheng Ho. At least, it is a starting point for me to start arranging an appointment.


Posted on: 2009/11/17 20:49
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Re: Which Specialist to see?
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If the stool is dark, it can be due to blood due to bleeding somewhere in the GI tract. But 'dark' is very subjective and one has to see the stool. black tarry stool with offensive smell is another.

If so, it might be lower GI bleed (ileum to anus).

If there is vomiting of blood, then probably upper GI (mouth to duodenum) bleed. Laboratory test like Full blood count might show anemia.

But I believe that Timberland doctors are capable of diagnosing the disease. since relevant investigations had been done (colonoscopy and endoscopy are the mainstay investigative tools) and no cause has been found, it could be irritable bowel syndrome (IBS). Still abdominal migraine can be one. But these 2 diseases are diagnoses of exclusion. The investigations done by them were mainly to diagnose, to take biopsy and also TO EXCLUDE other diseases common in the elderly:
1. cancers: stomach, small bowel, large bowel,
2. colonic disease: eg perforation due to diverticula, diverticulitis
3. others like intussussception

Going to Normah might just be the same.

IBS is common in middle age but still, it can occur in the 60s and usually females are more prone to it.

However, mesenteric ischemia can be one as diabetes mellitus can cause it. Her cholesterol profile is important too.

Well, I think a proper history taking is still vital.
questions whether she is having low grade fever and night sweats, loss of appetite/weight, all these can point to ileo-caecal tuberculosis or other tbs infection of the GI tract (extra-pulmonary TB) as she worked as a nurse before and I am sure had been exposed to TB patients before and as she gets older, the immune system will reduce thus flaring up of TB. FYI, TB vaccination does not provide much immunity to TB. it can prevent you from getting the worst type of TB (miliary) but not other milder ones.

Timberland, normah and sgh all have gastroenterologists. again, unlike a physician, they might not think of complications of diabetes mellitus and just result to mouth and anus and to put a scope immediately to peek from both sides.










Posted on: 2009/11/17 21:40
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