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PROBLEM: Chronic abdominal pain, nausea, vomiting, abnormal liver function tests.

HISTORY: The patient is a 23-year-old female referred for evaluation due to a chronic history of abdominal pain and extensive work-up for abnormal liver function tests and this chronic nausea and vomiting referred here for further evaluation due to the patient's recent move from Eugene to Portland. The patient is not a great historian. Most of the history is obtained through the old history and chart that the patient has with her. According to what we can make out, she began experiencing nausea, vomiting, recurrent epigastric and right upper quadrant pain in 2001. She was initially seen by Dr. A back in September 2001 for abdominal pain, nausea and vomiting. During those times, it was suspected that part of her symptoms may be secondary to biliary disease and underwent a cholecystectomy performed in Oregon by Dr. A in August 2001. It was assumed that this was caused by biliary dyskinesia. Previous to that, an upper endoscopy was performed by Dr. B in July 2001 that showed to be mild gastritis secondary to anti-inflammatory use. Postoperatively she continued to have nausea and vomiting, right upper quadrant abdominal pain and epigastric pain similar to her gallbladder pain in the past. In addition, she had significant abnormal liver function tests with ALT in the 600's, AST 300's with a bilirubin 2.5 and alkaline phosphatase in the 200's. Ultrasound shows common bile duct of 6 mm post cholecystectomy. The patient was then eventually referred to Dr. W in Oregon. Given the abnormal liver function tests and abnormal ultrasound, Dr. W performed an ERCP with sphincterotomy in September 20, 2001. Because of the symptoms and the suspicions of Sphincter of Oddi dysfunction, a sphincterotomy was performed during the ERCP. Procedure was uneventful. The patient did well for a few months, but unfortunately got hospitalized again in May 2002 for recurrence of the abdominal pain and markedly elevated liver function tests with ALT in the 600 to 900 range, again with nausea and vomiting. After transient elevation, her liver function tests would normalize.

During her hospitalization, extensive work-up including CT scan, 24 hour urine collection for porphyrins, a percutaneous liver biopsy, and Hepatitis panel, all of which were normal. A repeat ERCP with placement of endobiliary stent was uneventful and did not show evidence of PBC or PSC. After placement of the biliary stent, according to Dr. W's note, it apparently helped the patient with her symptoms with decreased frequency of nausea, vomiting, and pain. MRI of the abdomen was also performed in May 2002 showing a horseshoe kidney, which was previously known on old CT scans. While the biliary stent was in place, the patient did have recurrent bouts of nausea and vomiting and pain rated 7 out of 10 in intensity. Finally in August 2002, the endobiliary stent was removed and there were no signs of obstruction. Thereafter, the patient actually did fairly well for about a year, but because of a recurrence of her symptoms, Dr. W actually sent the patient up to OHSU for evaluation of this continued fairly mysterious abdominal pain. The patient states that she saw Dr. A who recommended some laboratory tests and a repeat ERCP for further evaluation, but the patient did not want to go up to OHSU as she was somewhat unhappy with initial care.

Then, over the course of the next several month, at the beginning of 2004, the patient's symptoms of nausea, vomiting, and recurrence abdominal pain returned. In fact, recently as the last documentation in May and June, the patient visited Emergency Room several times due to her symptoms. Lab tests show normal CBC with no signs of elevated white count. AST and ALT were normal. Alkaline phosphatase was in the low 200's with minimally elevated lipase of 78. Bilirubin was completely normal. The patient was given some Zofran and that seemed to control her symptoms and then she was discharged and now referred to us for further evaluation. At the present time, the patient is not having any abdominal pain. She states she threw up three times in the morning and is feeling well at this point. Her abdominal pain, nausea and vomiting symptoms are random. It does not associate with food. It is not pre or post meal and occasionally will wake her up in the middle of the night. She has not lost any weight despite this chronic nausea and vomiting and abdominal pain. Her bowel habits have been fairly normal. No hematemesis or melena. No rashes, joint pain, or other symptoms have been noted.

ALLERGIES: The patient has allergies to Sulfa and Codeine.

OPERATIONS: Laparoscopic cholecystectomy, two ERCP's including stent placement and sphincterotomy.

ILLNESSES: Juvenile rheumatoid arthritis for which Dr. B is following.

MEDICATIONS: The patient is on some type of anti-inflammatory, for which the name is unknown to her. She is also taking some Zofran.

HABITS: She does not drink or smoke.

SOCIAL HISTORY: The patent moved up from Eugene. She currently lives up here and works in Portland.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: The patient has seen primarily Dr. B, her rheumatologist, as primary care.

DATA: The patient's extensive chart was reviewed. It took over 45 minutes to sort through the chart and the labs.

PHYSICAL EXAMINATION: The patient is a 23-year old female who appears well developed with no acute signs of distress. HENT: Normocephalic, atraumatic, PERRLA, EOMI, sclerae are anicteric. Nares are patent and symmetrical. The oropharynx is clear with moist mucus membranes and no obvious mucosal lesions. The tongue is midline. NECK: Supple without adenopathy, JVD, or thyromegaly. There's no supraclavicular adenopathy. LUNGS: Clear bilaterally with normal respiratory effort. BACK: Nontender to palpation and there's no CVA tenderness or obvious spinal deformity. CARDIAC: Regular rate and rhythm. No murmur. ABDOMEN: Soft, nondistended and nontender to palpation throughout with no appreciable hepatosplenomegaly, masses, fullness or ascites. Bowel sounds were present and did appear normal. RECTAL: Deferred. EXTREMITIES: Without edema, calf tenderness or joint swelling. NEUROLOGIC: Shows the patient to be alert and oriented x's 3 with normal gait. SKIN: Warm and dry with normal color and no rashes.

IMPRESSION: A 23-year-old female with fairly mysterious symptoms of nausea, vomiting, and abdominal pain status post cholecystectomy and ERCP with sphincterotomy. She continues to have very intermittent elevated liver function tests and symptoms of nausea, vomiting, and abdominal pain. There was some discussion with Dr. W in the past regarding extending the sphincterotomy to ensure that a complete sphincterotomy was performed if the patient should have sphincter of Oddi dysfunction, however, at this time I am reluctant to do so without further reviewing the patient's chart and investigating other avenues. I think we will check another repeat liver function test and I think it may be helpful to repeat a liver biopsy to ensure we are not missing other primary liver diseases before concentrating purely on the biliary tree itself. In addition, AMA will be obtained along with a liver function test. I would also like to obtain some discharge summaries from Dr. W's office to further clarify what has transpired over the past three years.

PLAN:
1. Obtain discharge summaries from Dr. W's office.
2. Send the patient for a complete metabolic panel, AMA.
3. Send the patient for ultrasound and possible ultrasound guided liver biopsy.
4. The patient will return to see me in three weeks. We will consider further options pending on these results of the test and review of the patient's discharge summaries from Dr. W's office. If the patient should show symptoms of pain and elevated liver function tests to be consistent with Sphincter of Oddi dysfunction, we may repeat the ERCP and extend the sphincterotomy. The entire case was discussed with the patient. The patient is agreeable to the current plan. Thank you for this consultation.

FOLLOWUP: In two to three weeks.

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