What causes upper abdominal pressure under right rib area?

Question

Hi doctor,

I am a 52-year-old male, and I am health-conscious. I rarely drink on holidays and eat pretty healthy and clean. My current issue is a weight loss of ten pounds from last year. It is hard to keep weight on, and I have major debilitating fatigue. I have been burping a lot, and I feel a fullness under my right rib cage when I breathe in.

Rib cage muscles feel sore and tight under the right pectoral muscle. When I breathe in, it feels full, and the ribs ache sometimes. I also notice a lot of sticky sputum when I exhale, which is stuck in my neck (no cough or fever). The doctor did a full blood panel, including testing for multiple myeloma, and everything was normal, and there was no thyroid or diabetes.

I went to two GI doctors for weight loss and oily bowel movements, and they did work and showed fat in the stool. The retest had no fat in the stool. Then, I was tested for pancreatic insufficiency was 288, then slightly insufficient at 178. Putting me on Creon made me ill.

Then they ordered an EUS of my pancreas, and everything looked normal. I still feel fatigued. Some days, I feel a little better. Sometimes, I feel like I need to go to the hospital.

So, went back to PCP 30 days ago because I had a fullness feeling in my chest, and breathing felt funny and warm in the chest (no pain). For as long as I can remember, I have had clubbed fingers. But last year, the nail beds got more swollen and red.

So, to be safe, PCP did an X-ray of the fingers, and an X-ray and CT scan of the chest were normal. The cardiologist did a stress test, and the echo was normal. So, my PCP is sending me to a pulmonologist and rheumatologist because my fingers are also feeling very numb and cold at times.

The challenge is because of COVID-19, everything is shut down, and because I do not feel well, I do not know what is going on, diagnosis-wise.

Do you think that a normal CT scan of the lungs rules out lung cancer? Online, it says clubbing is 90 % of the time due to lung cancer or pleural effusion. With all the gastro issues, fats in stool, and clubbed fingers, I should pursue a sweat test for cystic fibrosis. I am trying to figure it out before it is too late to treat.

Please suggest.

Please guide.

Answer 1

Hello,

Welcome to icliniq.com.

After going through your description, I learned that you are an otherwise healthy lifestyle man with good nutrition, and no significant addictions. The investigations and tests done so far regarding the lung and abdominal complaints are normal, and there is no need to worry significantly about them.

So, I will not go into the details as everything appears normal. Now, coming to your concern regarding feelings of malaise, fatigue, and a slight cough, it appears to be functional rather than due to any organic cause.

Such complaints are due to many factors, like faulty posture, faulty food, irregular food habits, and lack of exercise. So, after having all the reports normal, it is very difficult to pinpoint any chest or abdominal disease. So, there is nothing to worry about any grave diagnosis in the absence of typical symptoms.

As you said, you have long-standing clubbed fingers, and in most cases, it is asymptomatic clubbing without any underlying disease. All the differentials you mentioned are chronic conditions with symptoms for at least more than a year, and in your case, it is very unlikely.

Most of the time, it is physiological clubbing, and there is nothing to worry about (with normal computed tomography - CT scans and the absence of chronic symptoms).

Cystic fibrosis is more common in the pediatric group of patients, and it is diagnosed very obvious on chest X-ray. As your X-ray and CT scans are normal, there is no need to perform a sweat test. Also, there is no pleural effusion. So, most probably, you are suffering from dyspeptic symptoms due to indigestion.

So, I suggest:

Continue GERD (gastroesophageal reflux disease) treatment for a month and take OTC (over-the-counter) muscle relaxant tablets for pain relief.
Similarly, give attention to the body posture and type of food taken, and maintain regular meal times.
Include more green leafy vegetables, salad, and fruits in your diet, and avoid fast food.

I hope this helps.

Thank you.

Answer 2

Hello,

Welcome back to icliniq.com.

I can understand your anxiety regarding clubbing, but most of the time, it is physiological and nothing to worry about if major investigations like a chest X-ray and CT scans are normal.

As I answered previously, clubbing of fingers is a common finding in general practice, and in the majority of cases, there is no cause found even after detailed investigations. Also, clubbing is seen in lung cancer and chronic lung disease, but it can be due to other cardiovascular, GIT (gastrointestinal tract), and liver diseases.

Assuming normal lung tests, respiratory causes are ruled out, and we should focus on other possible etiologies to find the probable cause. There is no harm in doing the sputum cytology, but none of the symptoms or imaging tests point to lung malignancy.

If you are in doubt, you can proceed with the cytology test. More information can be given upon actual physical examination. So it is advisable to consult a specialist to get a detailed history and thorough physical examination once the lockdown is over. Until then, you can continue the same medicines.

I hope this helps.

Thank you.