Teenage son’s unknown abdominal pain in lower left region

There is a condition called FAPS - functional abdominal pain syndrome.  This is different from IBS which causes bowel habit change.  Maybe ask your Gastro doctor about that.  You could ask doctor for an antispasmodic to manage the pain in the meantime. This may help combined with Tramadol.

The primary symptom of FAPS is abdominal pain. The pain can often be very severe and impact the quality of life of patients significantly. This can even disrupt their normal daily routine due to inability to take part in certain activities. It can also have a financial impact on their wellbeing and may increase levels of stress.

The condition is not usually associated with gastrointestinal symptoms such as diarrhea or constipation, and the findings from imaging and laboratory tests are often unable to explain the cause of the pain.

The pain is actually associated with changes in the sensitivity to nerve impulses between the gut and the brain. It is, therefore, a functional problem and not associated with abnormal intestinal motility.

It is important to note that the symptoms of FAPS often appear or worsen after certain events, such as an infection, traumatic life events, or significant stress

For people with FAPS, there is an alteration in the brain-gut axis and ability of the nervous system to regulate the pain signals for the gastrointestinal tract. As a result, even small stimuli that disturb the intestines can become amplified and lead to severe pain, known as central hypersensitivity.

In some cases, repeated injury to the abdomen may be associated with causing FAPS, due to over-sensitization of the nerve receptors in the area. For example, people who have had multiple abdominal surgeries, recurrent infections or a history of physical or sexual abuse are more likely to be affected by the condition.

The diagnosis of FAPS typically involves a series of diagnostic tests to identify the cause of the pain. This may include X-rays, ultrasound imaging, computed tomography (CT) scans, endoscopy, and blood tests. For patients with FAPS, these tests are not able to reveal a specific cause of the pain.

It can be helpful to keep a pain diary to record symptoms and possible triggers that may have caused a flare-up of symptoms. Over time, this information can help to identify problematic time and causes of worsened symptoms, which can be helpful when developing management strategies.

The role of the brain in the experience of pain is an important factor in the treatment of FAPS. Certain factors, such as anxiety, depression, focusing on the pain can lead to increased severity of the pain. In contrast, relaxation and diversion techniques can help reduce the severity.

Non-pharmacological management techniques for FAPS include:

Meditation or other relaxation techniques to manage stress

Hypnosis or diversion therapy to refocus attention away from the pain

Cognitive behavioral therapy (CBT) to change thoughts, perceptions, and behaviors related to symptoms of pain.

Constipation? IBS? My son suffer from constipation when he was 14 he did not went to the bathroom for weeks and he never told until was too late 

Just 3 rare ideas if checked:

A) Abdominal HAE (heriditary angoedema) - easy to test with serum C1 esterase inhibitor, which is NOT included in basic usual ER bloods!

B) ask specifically for nutcracker syndrome of the left renal vein. Blood is dammed , collaterals form, but often insufficient, dammed blood can cause pelvic congestion in girls and boys. It s not included in a normal abdominal ultrasound.

C) very far fetched and in case fever involved: FMF (familiar Mediterranean Fever), always has abdominal pain.

D) porphyria with only abdominal symptom (not the skin blister one)

We had a long run and all imaging overlooked my girl's problem until I saw it in an MRE and found the right doc to check do vascular compressions like nutcracker.

Hence my list of rarer diagnosis before being put into the IBS draw.

Best of luck!

Google Anterior Cutaneous Nerve entrapment Syndrome.

Learn how to do the Carnett's test - you can do it yourself.

Lie your son down. Find the pain spot. Put your finger tip on the spot and press in.

Does it hurt. How much?

Release pressure off finger but keep it on same spot.

Get your son to raise his head, thus tensing his abdominal muscles.

Press in again. Does it hurt. How much?

If the pain is very localised and it hurts more when you press against tensed abdominal muscles suspect ACNES, or possibly a hernia, though they should have spotted that by now.

The difficult thing will be finding a doctor to treat it, but it is a lot easier the closer you are to adult - i.e. over 15

Hi Audrey.

If Lidocaine reduced the pain for 12 hours that is generally a sign of ACNES. It can be treated with a neurectomy. They usually give 3 steroid/lidocaine injectionss before trying neurectomy though, and . But by the sound of it your daughter may have other problems. The compression you described sounds like MALS/Nutcracker etc. Vomiting? Also not typically an abdominal wall problem.

However you seem to be being treated by experts in these conditions - just never forget that you can have both syndromes - it is not impossible even though both are rare.

On the other hand you say that your daughter's pain occurred because her hips grew. Could be correct. Consider another possibility or factor. At certain ages of development adolescents and girls especially are susceptible to something called central sensitisation. This is a fairly new but pretty solid science (experiments on mice, human volunteers, clinical experience) but seems to be only really understood by anaesthetists/pain doctors.

Central Sensitisation ramps up the 'volume' control in the spinal cord, amplifying what used to be minor pains, or minor conditions that happened before or during this period of development. This means that if your daughter was susceptible to anything hurting then the pains could have appeared from multiple conditions all at the same time. CS can also be triggered by even short bursts of stress, and probably other stuff that we don't know about yet.

You seem to be in good hands if you know about compression syndromes and abdominal wall pain.

Good luck with your search and remember that science is advancing all the time, even if knowledge takes time to spread.

Oops - I seem to have replied to two people's posts at once.

Thank you adrian!

The problem is, 

that this 

'central sensitisation' 

word is used to accuse anything and explain everything very quickly, prematurely.

This, what you mentioned in your post about central sensitisation, went through my heart like a knife:

"sensitisation disorder' was the FIRST LINE diagnosis by paediatrician and pain specialist prior any ANY imaging for my hugely suffering teenaged child,

and we had to go to ......

psychologists, 

try antidepressants and physio. 

Try neuropathic pain meds to no end (Lyrica, Neurontin, Amitryptilin, Sandomigrain,...you name it)

All to no help (other than unburden our budget from immense amount of dollars!).

We also did try acupuncture and naturopathic GP, who get's you do 1000s USD of tests and supplements. It helped nothing. plain and simple, because it is not a nerve amplification or general heavy metal intoxication.

You might understand from this, my personal experience years ago and still hanging in there, 

that I got 

my personal 'sensitisation' 

to this blanket term 

of anything, that can't be explained with basic tests 

to be called 'central sensitisation', 'pain disorder' too easily.

It is often not the case at all. 

It is just 'not found yet' or 'rare' or 'too small and overlooked'.

(often IBS is too)

I had to discover the vascular issues in old MRE, no radiologist did (it was not the indication I have to admit, to look for nutcracker or pelvic congestion or coeliac artery - for coeliac artery we would need a special exhaling protocol, otherwise images will almost always come back 'normal'. The problem is not only the knowledge of referrer - who needs to name the issue to look for- but also radiologists and technicians involved. A 'normal' result is by no means a 'nothing up' result.

 

We never ever had any vascular MRIs or CTs still as docs are in denial and easy brush offs or ignorance even if obvious to the blind in MRE or ultrasound. 

Tricky conditions are not as easy as an ovary or liver or tumor diameter measurement.

That's how good the hands are we are in. Unfortunately.

A physical issue is quickly denied, far too quickly,

because as a teenager 

everything must be just hormones, growth spurt or a difficult stressful time.

.....

I had to ask for Carnett's sign re-test and trial of Lidocaine. 

No hands, no docs would have just come up by themselves for it! 

Yet shoulders are shrugged what to do now, as Lidocaine helped (steroid did not), but not completely. 

It might well be, that culprit to be lower down inside than that superficial rectus abdo muscle nerve.

Ureters can cramp for example. Do docs know about it? Do they know a loin pain haematuria syndrome does not always have to have blood in urine, even if 80% have, it means, 20% don't!?

We are stranded. 

Also vomiting and nausea is a big issue for us, 

both triggered for the worse when lying down or after drink/food. 

Hence very physical! This is not sensitisation.

It has nothing to do with a weekday, Sunday or holiday, sleep in (which is impossible due to pain and vomiting) days or not, test days or not. So it is not psychological, stress.

It does get better a bit with more weight and that alone says much.

We try weight gain to gain more fat pad around the aorta to get the AA/SMA angle wider and relieve more of duodenum and LRV. 

It is not always successful but sure worth a conservative trial. Yet my girl has to go overweight as she has those physical signs being normal weight (not underweight at all).

The pain came on together with vomiting and nausea, headache is very frequent too,

after walking home from bus station, feeling odd and eating something. There was no gastroinfection, no diarrhoea, always a GI standstill and by now proven slow gastric emptying and slow colonic transit.

But this GI slowness is like measuring fever.  

We know GI is slow, but not as to why.

There was no insult that could simply 'continue'.

I have asked about AAG (autoimmune autonomic gaglionopathy), but even the test for ganglionic AChR antibody doesn't exist in the continent I live in! That's how good  the hands are. 

Our pain started in the most active year, with a lot of intraabdominal pressure paired with weak connective tissue (call it HSD or hEDS).

Yet we are accused that the abdominal one spot, lidocaine partially responding spot was due to 'poor posture' and a RESULT of years of becoming weak. ......???

Docs totally ignoring, that the abdominal pain was the same from the very start, when she was active and fit, when she was already Carnett's sign positive and hence gyn said to see pain specialist, who did not want to inject anything as it was as so often considered 'too invasive'.

Docs often twist the time line of events around so that it makes sense to them.

There are also things like "obturator hernias" in YOUNG people (study of a 12 year old is available online) WITHOUT gut involvement. 

6mm small so that imaging misses it, especially if no gut is pushed through pelvic floor which anyone can diagnose, any blind one can.

This 12 year olds obturator hernia was seen in laparoscopy due to luckily the ovary being stuck there and ..... NOT closed, because again arrogance of surgeons assuming, this tiny thing couldn't cause pain. 

BUT IT WAS. 

Only months later, in a second, totally avoidable surgery, it was closed with two stitches and the pain: gone.

So for example this possibility of obturator hernia get's dismissed instantly as 'old women disease' and 'can't be' and 'MRE didn't show' and it does exist and is invisible to any imaging if so small and no gut pushing through pelvic floor. It is rare, but no one should just dismiss it as a possibility.

It could only be seen in laparoscopy AND if surgeon was looking for it. 

Also in laparoscopy it is often enough coincidental, if one and the same reason for pain was found or not, if it was small enough to be overlooked, but big enough to cause an issue (see subtle endometriosis, frequently overlooked).

Such patients then get into the sensitisation draw and actually have a physical, but tiny, rare ailment.

It is not sensitisation then, it is normal reaction of the nerve rightfully sending 'pain'.

I have to fight windmills! 

We are not in good hands unfortunately! 

But I will keep on fighting, that's for sure! ;-)