When back pain is a sign of serious illness

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Sometimes organs send pain signals to other body parts - notably the back
For instance, kidney and bladder problems are easily mistaken as back pain
GPs can't fully explain why this happens, though they have some theories
Here, we examine some of the other causes of back pain

By Louise Atkinson

Published: 17:11 EST, 11 November 2013 | Updated: 17:17 EST, 11 November 2013

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Frighteningly common: Back pain often masks the symptoms of other potentially serious health conditions

Michelle Law's childhood was blighted by back pain. Her mother took her to the GP many times, only to be told that the constant gnawing ache in Michelle's back was growing pains or a pulled muscle.

She'd be sent home with painkillers or muscle relaxants - none of which helped.

The pain between her lowest rib and pelvic bone on the right-hand side of her back dogged Michelle into adulthood.

When she was 35, a new GP referred her for investigations on her kidneys because of the site of the pain.

'I had dozens of scans and tests over four years, but they couldn't find anything wrong,' says Michelle, who lives in Hastings, East Sussex, with her four children and is studying to be a veterinary nurse. 'By that time I was relying on morphine for pain relief and had become house-bound.'

Apart from the pain, she had no other obvious symptoms, but for a couple of years she had developed cystitis-like symptoms - an increased need to urinate and occasional blood in her urine - but with no sign of infection.

The breakthrough came 18 months ago when Michelle was referred to a specialist in female urology at Eastbourne Hospital, who ordered tests on her bladder.

She was given a cystoscopy (where a tiny camera is inserted into the bladder) and biopsies under a general anaesthetic.

These revealed that Michelle had been suffering from interstitial cystitis, which attacks the lining of the bladder. When she came around from the anaesthetic, Michelle was told there was nothing the specialists could do to save it.

Her bladder was so badly scarred that it could not stretch or shrink as it should. Even a tiny amount of liquid - 20ml, or less than 4tsp - would cause it to empty (a healthy bladder should hold 700ml to 1,000ml).

'I was told the tissue was so damaged it fell apart in the surgeon's hands,' she says.

Michelle's only option was to have a new bladder surgically formed out of her bowel tissue. Today, she suffers from frequent infections (the bowel tissue produces mucus that attracts bacteria) and, because the new bladder has no muscle control, Michelle has to empty it using a catheter, further raising the risk of infection. In the future she may need to have a permanent catheter, as well as a urostomy (an external bag).

Though Michelle's case is extreme, it is frighteningly common for back pain to mask the symptoms of other potentially serious health conditions.

Deceptive: Kidney, bladder and gallbladder problems can easily be mistaken as back pain. So can pancreatic problems and even some cancers

Kidney, bladder and gallbladder problems can easily be mistaken as back pain, particularly in women, says Dr Zaki Almallah, consultant urologist at the Birmingham Bladder Clinic and the Queen Elizabeth Hospital in Birmingham. 'I've seen patients complaining about their bed or talking about a fall and generally trying to find reasons to justify their back pain,' he says.

'Quite often patients will have gone back and forth, sometimes for months, with different diagnoses and treatments before they come to me.'

Sometimes the organs can send pain signals to other parts of the body - notably the back - by a process called 'referred pain'.

Doctors cannot fully explain what happens, but believe strong pain messages running along nerves 'leap' or 'overwhelm' adjacent nerves, causing pain to be felt where that series of nerves originates.

Certainly, Michelle's specialist believes her persistent back pain could have been caused by the diseased bladder sending pain signals to her right kidney or by pain triggered by urine being occasionally flushed up to the kidney by her shrinking bladder.

Back pain is a common symptom of pancreatic problems - pancreatitis (inflammation of the pancreas) and pancreatic cancer.

Dr Steve Pereira, a consultant gastroenterologist at the Royal Free Hospital, London, estimates 20 to 30 per cent of pancreatitis sufferers see their GP about back pain before they are properly diagnosed.

This condition, which causes inflammation of the pancreas, is believed to be triggered when a problem develops with some of the enzymes in the pancreas, which causes them to digest the organ.

Pancreatitis is often linked to gallstones (in women) and sometimes to excessive alcohol consumption (usually in men) and typically affects middle-aged and elderly people.

In fact, Dr Pereira is using the back pain trigger in a new screening programme to try to improve the early diagnosis of pancreatic cancer, a condition that is notoriously tough to treat, as it is usually spotted late.

'Sometimes the organs can send pain signals to other parts of the body - notably the back - by a process called "referred pain".'

'In recent studies of 3,000 patients with pancreatic cancer, 17 per cent reported back pain as a prominent symptom,' he says.

Dr Pereira is hoping back pain will be flagged up by GPs in conjunction with other possible symptoms of pancreatic cancer (such as weight loss, jaundice and sometimes abdominal pain or indigestion) to improve the speed of diagnosis.

More rarely, back pain is associated with other cancers such as lung, colon and very occasionally ovarian cancer if tumours grow large enough to press on nearby nerves or organs.

Andy Whitfield, who starred in the TV series Spartacus: Blood And Sand, saw no reason to worry about the back pain he noticed when he began training for the series.

The physical workload to build an authentic Spartan physique was intense and a certain amount of pain was to be expected.

But when filming finished and the back pain became more severe and constant, he went to see his doctor.

A scan revealed a large tumour pressing against his spine. He was diagnosed with non-Hodgkin's lymphoma (which starts in the lymph nodes). He died 18 months later at the age of 39. Martin Ledwick, Cancer Research UK's head information nurse, says: 'For a small number of people, a dull ache in their back can be a symptom of some types of cancer, but it will usually be caused by something else.

'If you notice any changes that are out of the ordinary, visit your doctor to rule it out. Cancers that are found early are the most easily treated.'

Fatal mistake: Andy Whitfield, who starred in the TV series Spartacus: Blood And Sand (right), attributed his back pain to the grueling training he did for the series

If you have back pain that does not have an obvious cause, a good GP will usually conduct other tests (such as a urine test) to screen for all possible causes, either direct pain or referred, says Dr Pereira.

But Dr Almallah stresses the importance of effective communication.

'If you know you have done nothing to hurt your back, if your range of movement is unimpaired and yet painkillers are not helping, then it is important that you tell your GP about your concerns,' he says.

Michelle Law wholeheartedly also urges those suffering from back pain to be persistent with their doctor.

'If I had been properly diagnosed sooner, things wouldn't have got this bad,' she says.

'I'm so angry with the doctors who failed me and devastated that I've missed out on years with any quality of life because of this misdiagnosis.'

Here, we examine some of the other causes of back pain.

PAIN ON ONE SIDE OF LOWER BACK

OTHER SYMPTOMS: Fever (feeling shivery and sick), a GP's dipstick may reveal blood in the urine.

POSSIBLE CAUSE: Kidney infections - these are six times more common in women than men.

Bacteria (usually E.coli) travel up from the bladder into one or both kidneys, often as a complication of an untreated bladder infection.

The more your back pain is localised to one side, the more likely it is to be kidney pain. If it is closer to the spine and becomes worse with movement, it is more likely to be musculoskeletal.

In a kidney infection, the pain is just above the pelvic 'saddle' and can radiate to the hip and groin.

TREATMENT: Antibiotics and painkillers usually work within two weeks. If left untreated, the condition can cause permanent kidney damage.

PAIN IN MIDDLE OF BACK ON ONE SIDE

OTHER SYMPTOMS: Severe pain in the abdomen or groin, pain urinating, blood in the urine.

POSSIBLE CAUSE: Kidney stones - when waste products in the urine (such as calcium, oxalate and phosphorus) build up, they form crystals that collect inside the kidneys as hard, stone-like lumps.

There can be a genetic link making some people more susceptible to stones. Not drinking enough water (which means urine is more concentrated) increases your risk.

Three in 20 men and one in 20 women will suffer kidney stones. They are more likely if you are overweight and between the ages of 20 and 40.

'It is common for someone with kidney stones to go to their GP with back pain first,' says Dr Almallah. 'However, the GP will generally pick up that the pain is on one side only, may suspect kidney problems and ask for a urine sample - a kidney stone will often cause blood in a urine sample.'

The back pain may be consistent or intermittent.

TREATMENT: Some stones can be passed in the urine without the need for treatment (albeit with pain relief and extra fluids to help move the stone along). Larger stones can be crushed using shock waves or broken up with a laser.

ABDOMINAL PAIN RADIATES TO BACK

OTHER SYMPTOMS: Pain in the abdomen (just below the ribs), feeling sick, vomiting. The pain, which is often described as a 'boring' sensation, may be made worse by eating.

POSSIBLE CAUSE: Pancreatitis - also known as inflammation of the pancreas. This can be acute (lasting a week, causing no serious problems) or chronic (persisting, sometimes for years).

It's characterised by pain just below the ribs that spreads to the back, which may be sudden and intense, or mild.

Pancreatitis is caused by enzymes in the pancreas starting to digest the organ; 90 per cent of cases are linked to gallstones (if a stone gets stuck at the point where the bile duct and pancreatic duct meet) or excessive alcohol consumption.

It usually strikes middle-aged and elderly people, and affects around 20,000 people a year.

Dr Emmanuel warns that binge-drinking can make you vulnerable.

'If you drink steadily, the liver is able to generate metabolites and antioxidants to deal with the alcohol, but binge-drinking can overwhelm this mechanism.'

TREATMENT: The acute version is treated in hospital with intravenous fluids, pain relief and oxygen. Drinking alcohol should be avoided.

PAIN IN RIGHT RIBS AND SHOULDER

OTHER SYMPTOMS: Abdominal pain (under the rib on the right side), nausea, wind, pain when inhaling deeply, arm pain.

POSSIBLE CAUSE: Infected or inflamed gallbladder or gallstones - the gallbladder is a small bag under the liver that stores bile, which is emptied into the stomach when we eat, but it can become infected, inflamed or blocked by tiny stones (made from cholesterol, bile salts and calcium).

The gallbladder area will be tender to the touch, but sometimes pain radiates through to the shoulder blade.

'It can be intermittent or constant, sharp or dull, but tends to occur in the evening (particularly after a meal).

'The nerve supply to the gall-bladder travels through the abdominal nerves or up the spinal cord,' says Dr Anton Emmanuel, gastroenterologist at University College London.

'The most stereotypical gall-bladder pain is under the right rib and the tip of the right shoulder.'

Gallstones are common, particularly in women who have had children and are overweight.

'The old saying that gallstones strike people who are fair, fat, female, fertile and 40 is largely true,' says Dr Emmanuel.

'But family history is recognised as an important risk factor.'

TREATMENT: An ultrasound scan will identify gallstones that may need to be surgically removed via keyhole surgery or endoscope.

DULL PAIN IN THE PELVIS AND BACK

OTHER SYMPTOMS: Urgent need to urinate often, pain or stinging on urination, pain in lower belly.

POSSIBLE CAUSE: Cystitis - this is an inflammation of the bladder and is usually caused by an infection (when bacteria gets in the bladder) or irritation (from a tampon, diaphragm, tight clothing or chemical irritants).

It is common, particularly in women, affecting 15 per cent each year. If no cause can be found and it doesn't respond to antibiotic treatment, interstitial cystitis may be diagnosed. This affects 500,000 women each year, though doctors are still baffled as to its cause.

It's thought it could be some sort of immunological reaction, causing inflammation.

TREATMENT: Bacterial cystitis clears up with antibiotics. Untreated cases can lead to kidney infections. Interstitial cystitis is complex and may require painkillers, antidepressants or surgery.

For more information, visit the Cystitis and Overactive Bladder Foundation at cobfoundation.org and CORE Charity at www.corecharity.org.uk