2008-07-28
Introduction
Abdominal pain is regarded as pain in the area from just below the xiphoid (lower part of the sternum or “breastbone”) down to the pubis (front of the pelvis)—referred to by many as the “stomach” or “belly.” Chronic abdominal pain is one of the most common symptoms for which patients seek care. It is termed chronic when the pain occurs for a few months; that length of time distinguishes it from acute pain that is usually limited to a few days to weeks (see Acute Stomach Pain). There is no absolute symptom duration that separates acute and chronic; in fact, pain lasting several weeks is sometimes termed subacute.
When disease affects the gastrointestinal system, pain often results, and there are only a few other symptoms that can signal a problem: usually vomiting, diarrhea, and/or constipation. Depending on the disorder, the pain and associated symptoms can range from an easily ignored inconvenience to a disabling illness. The severity of symptoms also varies greatly among patients with the same disorder. Practitioners are aided by the specific features of the pain and other symptoms in individual patients (e.g., its location in the abdomen, frequency, duration, what makes it worse and what improves it), so sometimes the diagnosis is depends on how the patient reports these details. The absence of certain other symptoms also can be important clues to the problem. In many patients, however, a physical examination does not yield the diagnosis, so some testing is usually performed.
Organic Versus Functional Illness
Disorders that cause chronic abdominal pain are conventionally classified as either organic or functional. Organic disease is defined by a structural (e.g., detected by the naked eye, x-ray tests, or microscopic examination of tissue), infectious (e.g., bacterial or viral), or metabolic (e.g., elevated blood sugar level) abnormality detected by diagnostic tests. In contrast, functional disorders lack such features but may stem from underlying disturbances that cannot be identified with a microscope or other ordinary laboratory tests; sometimes this can be an intestine that is unusually sensitive or contracts too forcefully, other times it can be discomfort associated with anxiety. However, strict adherents to this classification system tend to assign organic disease to the body and functional illness to the mind. Consequently, there are those who might ascribe less legitimacy to pain from functional disorders and limit the treatment options.
This simplified, deficient view fails to recognize that psychological, social, and cultural factors affect illness and a person’s reaction to it. A more comprehensive concept of illness acknowledges that many factors (e.g., genetics, organ sensitivity, early life experiences, and current circumstances of living) interact to influence how an illness manifested by abdominal pain affects a person. This “biopsychosocial” model of illness suggests wider treatment choices, selected according to an individual’s need. This model has received most attention with regard to functional abdominal pain, but it is just as applicable to organic disease. For example, we all realize that emotional stress increases the impact of any illness.
Another
difficulty with the dualistic organic-functional view is that modern
research technology is uncovering “organic” disturbances in patients
with heretofore “functional” disorders that were not evident with older,
more limited research tools. Thus, the border between traditional organic and functional disorders is becoming blurred. A
notable distinction is that organic diseases range from minor
inconveniences to fatal disorders, but functional disorders are not
life-threatening. Nevertheless, the functional disorders
that cause abdominal pain reduce some sufferers’ quality of life as much
or more than do some organic diseases. Moreover, people with chronic abdominal pain due to functional disorders far outnumber those with underlying organic disease.
Despite these legitimate questions about the organic-functional paradigm, it is still used in diagnosis because the subtle laboratory abnormalities that research tests can show in patients with functional disorders are hidden to the everyday diagnostic tests available in clinical practice. Therefore, functional disorders must be defined by the symptoms that the patient reports to the doctor instead of an abnormal test result. Practitioners carefully consider which tests are needed for a patient to confidently diagnose the disorder underlying the pain. The needed tests vary depending on many factors but, when certain chronic symptoms are present and symptoms suggestive of organic disease are absent, the testing can often be limited to routine laboratory, x-ray and/or endoscopic procedures.
Traditionally,
organic causes of chronic abdominal pain are treated primarily with
medical or surgical therapy directed at the underlying disorder found by
testing (e.g., eradication of bacterial infection), and symptom
treatment (e.g., a pain-killing drug) is prescribed as needed. Therapy
of chronic functional pain varies from pain reduction treatment alone
and therapy for the presumed functional disturbance to such things as
treatment to affect how the brain modulates pain, such as with
psychotherapy or medications that have been conventionally used to treat
depression. Despite these legitimate questions about the organic-functional paradigm, it is still used in diagnosis because the subtle laboratory abnormalities that research tests can show in patients with functional disorders are hidden to the everyday diagnostic tests available in clinical practice. Therefore, functional disorders must be defined by the symptoms that the patient reports to the doctor instead of an abnormal test result. Practitioners carefully consider which tests are needed for a patient to confidently diagnose the disorder underlying the pain. The needed tests vary depending on many factors but, when certain chronic symptoms are present and symptoms suggestive of organic disease are absent, the testing can often be limited to routine laboratory, x-ray and/or endoscopic procedures.
When to Seek Medical Care
A person with chronic abdominal pain should consider how the pain and any associated symptoms affect his or her life. This summary cannot be a guide for every situation and includes only the most common reasons to call for medical evaluation. Emergency care is usually not needed, but it is usually prudent to seek care for chronic pain with the following features:
- Abdominal pain that interferes with activities of living, including work, recreation, and eating
- Abdominal pain that awakens the individual from sleep
- Abdominal pain that spreads to the back
- Abdominal pain that is associated with a change in bowel habit (e.g., diarrhea or constipation)
- Abdominal pain with anorexia, dysphagia (difficulty swallowing food), nausea, vomiting, abdominal distension, fever, bloody urine or stool, dark urine or yellow skin and eyes, or unintended weight loss
- Abdominal pain with abnormal menstrual bleeding or other gynecological symptoms
Gynecologists may term pain in the low abdomen “chronic
pelvic pain,” which can have various causes (e.g., endometriosis,
tumors, or a functional cause). The reader should consult gynecology sections for information on chronic pain from the female genital system. Brief summaries of some important non-gynecological organic and functional causes of chronic abdominal pain follow.
Common Causes of Chronic Abdominal Pain: Signs, Symptoms, Diagnosis, and Treatment
Peptic Ulcer Disease—The normal stomach constantly produces hydrochloric acid and the digestive enzyme pepsin – and increases secretion after meals. Normally, the stomach’s mucosal epithelium (surface layer) resists “peptic” damage. When the mucosal resistance is impaired, however, ulcers (sores extending through the mucosa) occur, most often in the stomach (gastric ulcer) or duodenum (duodenal ulcer), the first part of the small intestine. A few million people in the United States have this disease, and the percentage of the population increases with age. The main causes are infection of the mucosa with the bacteria, Helicobacter pylori (abbreviated H. pylori) and use of non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, which reduce mucosal resistance. However, most people infected with H. pylori do not have peptic ulcer disease. Cigarette smoking can slow ulcer healing. Psychological stress is a controversial factor, but despite long-held beliefs there is little evidence that dietary factors are important. Rarely, the cause is excessive stimulation of the stomach by excessive production of the hormone gastrin by the pancreas.
Dyspepsia is the term for a variety of unpleasant sensations in upper abdomen. This is the most common symptom of a peptic ulcer, and it sometimes occurs after eating or awakens the patient at night. Ulcer dyspepsia tends to occur for a few days to weeks with symptom-free intervening periods. It is usually distinguishable from gastroesophageal reflux disease (irritation of the esophagus from refluxed acid), typically indicated by an ascending discomfort beneath the “breastbone”, especially with laying down.
If the ulcer erodes into a blood vessel, sudden bleeding causes the sufferer to vomit blood or pass black stool and, perhaps feel dizzy or pass out. The other complications are perforation of an ulcer completely through the stomach or duodenum with leakage of gas and bacteria into the abdomen, obstruction of the stomach or duodenum by swelling that blocks stomach emptying, and penetration of the ulcer into an adjacent organ (e.g., pancreas). Importantly, some patients feel well—little or no dyspepsia occurs—until they have one of these serious events.
Functional Dyspepsia—When dyspepsia occurs without an organic cause, it is called functional or non-ulcer dyspepsia, and this disorder is more common than peptic ulcer disease, affecting 20% to 30% of people in many countries each year. There is so much overlapping of symptoms between these disorders that physicians generally cannot separate them without diagnostic testing. Individuals can have various symptoms in the upper abdomen that comprise the term dyspepsia: pain, burning, fullness after meals, feeling full after eating only a little food, and bloating in the upper abdomen. Many patients report increased symptoms after eating. Nausea, vomiting, and belching may also occur.
Functional dyspepsia tends to come and go over time; sometimes it can follow an episode of acute gastroenteritis (see Acute Stomach Pain). Some people with functional dyspepsia also have irritable bowel syndrome (discussed later) at the same time or while their dyspepsia is inactive. Anxiety is a common link between these disorders, but is not the sole cause of either.
Specialized tests, some only done in medical referral centers, can show changes in acid secretion, stomach motility (emptying and relaxation), sensitivity of the stomach or duodenum to stimulation, and activity of the nerves and hormones that regulate the stomach.
Diagnosis—Functional dyspepsia is diagnosed after organic disease, especially peptic ulcer, has been excluded by testing. Endoscopy is more accurate than barium x-ray examination and allows biopsies to be taken.Treatment—It is usually not known exactly which functional abnormalities cause dyspepsia in a particular patient, and there is no single therapy that is reliable in all patients. Even when patients have subtle abnormalities detected by specialized tests, medications that could diminish them, such as those that affect motility, do not predictably alleviate dyspepsia. Testing for H. pylori is widely practiced in the primary care of patients less than about 50 years of age who have not had endoscopy, followed by eradication therapy if they are positive. However, most patients with a positive result do not improve with such therapy, and if they improve, they could have had an unproven peptic ulcer. Proton pump inhibitors, the most potent drugs that reduce stomach acid production, have helped a minority patients in research studies, but some of these patients might have had undiagnosed gastroesophageal reflux disease, which is well known to respond to these drugs.
Further research is being done on therapies for which there is preliminary evidence of benefit, including antidepressants, herbal preparations, psychotherapy, hypnosis, and some experimental drugs. Since many patients must cope with this disorder for a long time, announcements of any treatment that helps research volunteers for a few weeks should be viewed with some skepticism regarding its long-term benefit. Since medication therapy is less than optimal, professional explanation and reassurance along with such common-sense measures as a healthy diet, exercise and balanced life are the mainstays for patients to cope with the disorder.
Irritable Bowel Syndrome—This syndrome includes a group of symptoms that can occur when certain aspects of finely-tuned gastrointestinal function go awry without an organic cause. About 10% to 20% of people throughout the world have this problem, which is characterized by chronic abdominal pain and diarrhea, constipation, or both and, often, bloating as well as other symptoms. Both the frequency and severity of symptoms vary from constituting a mere nuisance to a disabling disorder. Patients with severe irritable bowel syndrome may miss time from work and have difficulty performing other usual activities of living. Some patients have functional dyspepsia as well, and this disorder can also follow acute gastroenteritis (see Acute Stomach Pain).
The abnormal, underlying gastrointestinal function can have various components, including abnormal motility, increased intestinal sensitivity, subtle inflammation, nervous system and hormonal effects, genetic influences, past and current life stress, and other psychological factors. These factors vary greatly among patients.
Diagnosis—As with functional dyspepsia, there are no organic abnormalities detected by laboratory, endoscopic, or x-ray testing. The diagnosis is based on the typical symptoms and the absence of organic disease that explains them. There is no universal agreement on absolute symptoms and their duration and frequency, but every few years a group of international experts revises the diagnostic symptom criteria used by many researchers and practitioners (the Rome criteria). Recurrent abdominal pain or discomfort that improves with defecation and occurs with a change in the frequency or appearance of stool comprise the heart of the criteria.
These symptom criteria are so reliable that if there are no worrisome signs, such as unintentional weight loss or rectal bleeding, there may be no need for diagnostic testing, particularly for patients who are young and at no increased risk for cancer or other organic diseases. Basic blood and stool tests and sometimes endoscopy of the large intestine are commonly performed.
Anxiety and/or depression are common co-morbidities (simultaneous illnesses) in addition to functional dyspepsia, which can affect the impact of irritable bowel syndrome. These patients are also predisposed to other functional disorders (e.g., fibromyalgia).
Websites
American College of Surgeons, http://www.facs.org. Patient education, including illustrated descriptions of common operations.
American Gastroenterological Association,http://www.gastro.org. The AGA Patient Center with information on gastrointestinal disorders.
International Foundation for Functional Gastrointestinal Disorders, www.iffgd.org. Information on functional bowel disorders, including irritable bowel syndrome. Quarterly member publication and reprinted articles on many topics available.
National Institute of Diabetes and Digestive and Kidney Diseases, www.niddk.nih.gov/, NIH site with patient education, including Spanish language material, and link to practice guidelines.
National Library of Medicine, www.nlm.nih.gov/medlineplus/healthtopics.html. Comprehensive source of medical information.
UpToDate, http://patients.uptodate.com. Comprehensive information on numerous medical disorders written for the lay public by physician experts.
References
-Costanza CD, Longstreth GF, Liu AL. Chronic abdominal wall pain: clinical features, health care costs, and long-term outcome. Clinical Gastroenterology and Hepatology 2004;2:395-399.
-Drossman DA, Corazziari E, Delvaux M, Spiller RC, Talley NJ, Thompson WG, Whitehead WE (eds). Rome III. The Functional Gastrointestinal Disorders, 3rd edition, Degnon Associates, Inc., McLean, Virginia, 2006.
-Huang JQ, Sridhar S, Hunt RH. Role of Helicobacter pylori infection and non-steroidal anti-inflammatory drugs in peptic-ulcer disease: A meta-analysis. Lancet 2002; 359:14-22.
-Longstreth GF, Heaton KW. Understanding Your Bowels, Dorchester Publishing, New York, 2006.
-Malfertheiner P, Megraud F, O'Morain C, Bazzoli F, El-Omar E, Graham D, Hunt R, Rokkas T, Vakil N, Kuipers EJ, The European Helicobacter Study Group. Current concepts in the management of Helicobacter pylori infection: the Maastricht III Consensus Report. Gut 2007; 56:772-781.
-Moayyedi P, Deeks J, Talley NJ, Delaney B, Forman D. An update of the Cochrane systematic review of Helicobacter pylori eradication therapy in nonulcer dyspepsia: resolving the discrepancy between systematic reviews. American Journal of Gastroenterology 2003; 98:2621-2626.
-Wang, WH, Huang, JQ, Zheng, GF, et al. Effects of Proton-Pump Inhibitors on functional dyspepsia: a meta-analysis of randomized placebo-controlled trials. Clinical Gastroenterology and Hepatology 2007; 5:178-185.
Common Causes of Chronic Abdominal Pain: Signs, Symptoms, Diagnosis, and Treatment
Peptic Ulcer Disease—The normal stomach constantly produces hydrochloric acid and the digestive enzyme pepsin – and increases secretion after meals. Normally, the stomach’s mucosal epithelium (surface layer) resists “peptic” damage. When the mucosal resistance is impaired, however, ulcers (sores extending through the mucosa) occur, most often in the stomach (gastric ulcer) or duodenum (duodenal ulcer), the first part of the small intestine. A few million people in the United States have this disease, and the percentage of the population increases with age. The main causes are infection of the mucosa with the bacteria, Helicobacter pylori (abbreviated H. pylori) and use of non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, which reduce mucosal resistance. However, most people infected with H. pylori do not have peptic ulcer disease. Cigarette smoking can slow ulcer healing. Psychological stress is a controversial factor, but despite long-held beliefs there is little evidence that dietary factors are important. Rarely, the cause is excessive stimulation of the stomach by excessive production of the hormone gastrin by the pancreas.
Dyspepsia is the term for a variety of unpleasant sensations in upper abdomen. This is the most common symptom of a peptic ulcer, and it sometimes occurs after eating or awakens the patient at night. Ulcer dyspepsia tends to occur for a few days to weeks with symptom-free intervening periods. It is usually distinguishable from gastroesophageal reflux disease (irritation of the esophagus from refluxed acid), typically indicated by an ascending discomfort beneath the “breastbone”, especially with laying down.
If the ulcer erodes into a blood vessel, sudden bleeding causes the sufferer to vomit blood or pass black stool and, perhaps feel dizzy or pass out. The other complications are perforation of an ulcer completely through the stomach or duodenum with leakage of gas and bacteria into the abdomen, obstruction of the stomach or duodenum by swelling that blocks stomach emptying, and penetration of the ulcer into an adjacent organ (e.g., pancreas). Importantly, some patients feel well—little or no dyspepsia occurs—until they have one of these serious events.
Diagnosis—Gastrointestinal
x-rays obtained after drinking a barium-containing liquid reveals
ulcers, but upper gastrointestinal endoscopy (examination with an
illuminated, flexible tube passed through the mouth) is more accurate
and allows biopsies, which can exclude malignancy (cancer) and detect
the bacteria H. pylori. Breath and stool tests also detect current H. pylori infection; a blood test detects current or past infection.
Treatment—Acid-inhibitor drugs (histamine 2-blockers or proton pump inhibitors) heal most ulcers. H. pylori eradication
with an acid-inhibitor drug and antibiotics is important because
elimination of the infection usually prevents recurrence. Patients should not take NSAIDs during treatment and minimize their use later, and some specialists advise stopping alcohol. Due
to the effectiveness of these medical interventions, surgery for peptic
ulcers is declining, except for emergencies. Surgery is now typically
reserved for ulcers that are resistant to medical treatment or produce
complications, or for those times when physicians suspect there is a
malignancy. Functional Dyspepsia—When dyspepsia occurs without an organic cause, it is called functional or non-ulcer dyspepsia, and this disorder is more common than peptic ulcer disease, affecting 20% to 30% of people in many countries each year. There is so much overlapping of symptoms between these disorders that physicians generally cannot separate them without diagnostic testing. Individuals can have various symptoms in the upper abdomen that comprise the term dyspepsia: pain, burning, fullness after meals, feeling full after eating only a little food, and bloating in the upper abdomen. Many patients report increased symptoms after eating. Nausea, vomiting, and belching may also occur.
Functional dyspepsia tends to come and go over time; sometimes it can follow an episode of acute gastroenteritis (see Acute Stomach Pain). Some people with functional dyspepsia also have irritable bowel syndrome (discussed later) at the same time or while their dyspepsia is inactive. Anxiety is a common link between these disorders, but is not the sole cause of either.
Specialized tests, some only done in medical referral centers, can show changes in acid secretion, stomach motility (emptying and relaxation), sensitivity of the stomach or duodenum to stimulation, and activity of the nerves and hormones that regulate the stomach.
Diagnosis—Functional dyspepsia is diagnosed after organic disease, especially peptic ulcer, has been excluded by testing. Endoscopy is more accurate than barium x-ray examination and allows biopsies to be taken.Treatment—It is usually not known exactly which functional abnormalities cause dyspepsia in a particular patient, and there is no single therapy that is reliable in all patients. Even when patients have subtle abnormalities detected by specialized tests, medications that could diminish them, such as those that affect motility, do not predictably alleviate dyspepsia. Testing for H. pylori is widely practiced in the primary care of patients less than about 50 years of age who have not had endoscopy, followed by eradication therapy if they are positive. However, most patients with a positive result do not improve with such therapy, and if they improve, they could have had an unproven peptic ulcer. Proton pump inhibitors, the most potent drugs that reduce stomach acid production, have helped a minority patients in research studies, but some of these patients might have had undiagnosed gastroesophageal reflux disease, which is well known to respond to these drugs.
Further research is being done on therapies for which there is preliminary evidence of benefit, including antidepressants, herbal preparations, psychotherapy, hypnosis, and some experimental drugs. Since many patients must cope with this disorder for a long time, announcements of any treatment that helps research volunteers for a few weeks should be viewed with some skepticism regarding its long-term benefit. Since medication therapy is less than optimal, professional explanation and reassurance along with such common-sense measures as a healthy diet, exercise and balanced life are the mainstays for patients to cope with the disorder.
Irritable Bowel Syndrome—This syndrome includes a group of symptoms that can occur when certain aspects of finely-tuned gastrointestinal function go awry without an organic cause. About 10% to 20% of people throughout the world have this problem, which is characterized by chronic abdominal pain and diarrhea, constipation, or both and, often, bloating as well as other symptoms. Both the frequency and severity of symptoms vary from constituting a mere nuisance to a disabling disorder. Patients with severe irritable bowel syndrome may miss time from work and have difficulty performing other usual activities of living. Some patients have functional dyspepsia as well, and this disorder can also follow acute gastroenteritis (see Acute Stomach Pain).
The abnormal, underlying gastrointestinal function can have various components, including abnormal motility, increased intestinal sensitivity, subtle inflammation, nervous system and hormonal effects, genetic influences, past and current life stress, and other psychological factors. These factors vary greatly among patients.
Diagnosis—As with functional dyspepsia, there are no organic abnormalities detected by laboratory, endoscopic, or x-ray testing. The diagnosis is based on the typical symptoms and the absence of organic disease that explains them. There is no universal agreement on absolute symptoms and their duration and frequency, but every few years a group of international experts revises the diagnostic symptom criteria used by many researchers and practitioners (the Rome criteria). Recurrent abdominal pain or discomfort that improves with defecation and occurs with a change in the frequency or appearance of stool comprise the heart of the criteria.
These symptom criteria are so reliable that if there are no worrisome signs, such as unintentional weight loss or rectal bleeding, there may be no need for diagnostic testing, particularly for patients who are young and at no increased risk for cancer or other organic diseases. Basic blood and stool tests and sometimes endoscopy of the large intestine are commonly performed.
Anxiety and/or depression are common co-morbidities (simultaneous illnesses) in addition to functional dyspepsia, which can affect the impact of irritable bowel syndrome. These patients are also predisposed to other functional disorders (e.g., fibromyalgia).
Treatment—All
patients should have a therapeutic relationship with a physician and
try to conduct a generally healthy life that includes a balanced diet,
exercise, and management of emotional stress. Beyond these basic measures, additional treatment depends on the dominant symptoms and their severity. Patients
are sometimes disappointed with available drug therapy for this
long-term disorder, but the pain may respond to medications that relax
the intestine. Antidepressants are increasingly tried, and they may have the additional benefit of alleviating insomnia. Constipation
is best initially treated with dietary fiber (e.g., whole grain instead
of white bread) or fiber supplements (e.g., psyllium, methylcellulose,
or calcium polycarbophil), but both approaches can increase bloating and
flatulence. Over-the-counter polyethylene glycol and other laxatives may be effective. For
diarrhea, non-prescription loperamide can be helpful, especially if
taken before meals or at other times when diarrhea tends to occur. Bloating
may be diminished in some patients by reducing intake of certain foods,
such as fresh fruits or juices, beans, and wheat products. However, patients should avoid highly restrictive diets. Effective
treatment of depressed or anxious patients can help irritable bowel
symptoms, and others have also been helped by various psychological
approaches (e.g., psychotherapy, cognitive-behavioral or biofeedback
therapy, and hypnosis).
Preliminary research indicates that certain probiotics (beneficial bacteria) can help some symptoms, especially bloating. Research has shown some herbal preparations to help, but no recommendations can be made yet about specific preparations. Antibiotics have helped some patients in research, but concern about side effects, especially with long-term use, calls for caution. Research on drugs that could help the multiple symptoms continues.
Chronic Abdominal Wall Pain—Most patients and many physicians think first of a problem inside the abdomen to explain abdominal pain. However, chronic pain in the wall of the abdomen—composed mainly of muscle, fat and skin—is much more common than generally recognized. In one gastroenterology practice, one of every six patients referred for symptoms had this type of pain. Women predominated over men in a ratio of four to one.
The pain can occur in various parts of the abdomen, but is most common in the upper abdomen. It can be constant or intermittent and feel like a burning, sharp, aching, pressure, or dull discomfort. Doctors often suspect peptic ulcer disease, but treatment for that disorder does not relieve the pain. The exact cause of the pain is unknown, but some physicians think pressure on a nerve in the abdominal wall is sometimes the cause.
Diagnosis--This is one of the few causes of chronic abdominal pain that can be confidently diagnosed by physical examination. When the patient is lying on his or her back and the painful area is pressed with the examiner’s fingers, there is tenderness, which increases when the patient raises the head or the legs while they are straight, thus tensing the abdominal muscles. In contrast, if the cause of the pain is intra-abdominal, tenderness from finger pressure is usually reduced during abdominal muscle contraction. Laboratory and radiology tests reveal no abnormality that explains the pain, and many patients have undergone extensive negative testing before the diagnosis is made.
Treatment—The primary goal is to make the pain more tolerable, not cure it. Many patients become less distressed merely from knowing what is wrong. Simple measures such as applying heat to the painful area and taking acetaminophen two or three times a day for a few days to weeks usually helps If this approach is inadequate, a low dose of an antidepressant medication taken at bedtime can help, just as it can benefit other kinds of chronic pain. For the most bothered patients, injection of a local anesthetic directly into the painful area – sometimes with a corticosteroid medication – can help, but the relief may not last long. Fortunately, the pain usually diminishes or disappears over time.
Preliminary research indicates that certain probiotics (beneficial bacteria) can help some symptoms, especially bloating. Research has shown some herbal preparations to help, but no recommendations can be made yet about specific preparations. Antibiotics have helped some patients in research, but concern about side effects, especially with long-term use, calls for caution. Research on drugs that could help the multiple symptoms continues.
Chronic Abdominal Wall Pain—Most patients and many physicians think first of a problem inside the abdomen to explain abdominal pain. However, chronic pain in the wall of the abdomen—composed mainly of muscle, fat and skin—is much more common than generally recognized. In one gastroenterology practice, one of every six patients referred for symptoms had this type of pain. Women predominated over men in a ratio of four to one.
The pain can occur in various parts of the abdomen, but is most common in the upper abdomen. It can be constant or intermittent and feel like a burning, sharp, aching, pressure, or dull discomfort. Doctors often suspect peptic ulcer disease, but treatment for that disorder does not relieve the pain. The exact cause of the pain is unknown, but some physicians think pressure on a nerve in the abdominal wall is sometimes the cause.
Diagnosis--This is one of the few causes of chronic abdominal pain that can be confidently diagnosed by physical examination. When the patient is lying on his or her back and the painful area is pressed with the examiner’s fingers, there is tenderness, which increases when the patient raises the head or the legs while they are straight, thus tensing the abdominal muscles. In contrast, if the cause of the pain is intra-abdominal, tenderness from finger pressure is usually reduced during abdominal muscle contraction. Laboratory and radiology tests reveal no abnormality that explains the pain, and many patients have undergone extensive negative testing before the diagnosis is made.
Treatment—The primary goal is to make the pain more tolerable, not cure it. Many patients become less distressed merely from knowing what is wrong. Simple measures such as applying heat to the painful area and taking acetaminophen two or three times a day for a few days to weeks usually helps If this approach is inadequate, a low dose of an antidepressant medication taken at bedtime can help, just as it can benefit other kinds of chronic pain. For the most bothered patients, injection of a local anesthetic directly into the painful area – sometimes with a corticosteroid medication – can help, but the relief may not last long. Fortunately, the pain usually diminishes or disappears over time.
Websites
American College of Surgeons, http://www.facs.org. Patient education, including illustrated descriptions of common operations.
American Gastroenterological Association,http://www.gastro.org. The AGA Patient Center with information on gastrointestinal disorders.
International Foundation for Functional Gastrointestinal Disorders, www.iffgd.org. Information on functional bowel disorders, including irritable bowel syndrome. Quarterly member publication and reprinted articles on many topics available.
National Institute of Diabetes and Digestive and Kidney Diseases, www.niddk.nih.gov/, NIH site with patient education, including Spanish language material, and link to practice guidelines.
National Library of Medicine, www.nlm.nih.gov/medlineplus/healthtopics.html. Comprehensive source of medical information.
UpToDate, http://patients.uptodate.com. Comprehensive information on numerous medical disorders written for the lay public by physician experts.
References
-Costanza CD, Longstreth GF, Liu AL. Chronic abdominal wall pain: clinical features, health care costs, and long-term outcome. Clinical Gastroenterology and Hepatology 2004;2:395-399.
-Drossman DA, Corazziari E, Delvaux M, Spiller RC, Talley NJ, Thompson WG, Whitehead WE (eds). Rome III. The Functional Gastrointestinal Disorders, 3rd edition, Degnon Associates, Inc., McLean, Virginia, 2006.
-Huang JQ, Sridhar S, Hunt RH. Role of Helicobacter pylori infection and non-steroidal anti-inflammatory drugs in peptic-ulcer disease: A meta-analysis. Lancet 2002; 359:14-22.
-Longstreth GF, Heaton KW. Understanding Your Bowels, Dorchester Publishing, New York, 2006.
-Malfertheiner P, Megraud F, O'Morain C, Bazzoli F, El-Omar E, Graham D, Hunt R, Rokkas T, Vakil N, Kuipers EJ, The European Helicobacter Study Group. Current concepts in the management of Helicobacter pylori infection: the Maastricht III Consensus Report. Gut 2007; 56:772-781.
-Moayyedi P, Deeks J, Talley NJ, Delaney B, Forman D. An update of the Cochrane systematic review of Helicobacter pylori eradication therapy in nonulcer dyspepsia: resolving the discrepancy between systematic reviews. American Journal of Gastroenterology 2003; 98:2621-2626.
-Wang, WH, Huang, JQ, Zheng, GF, et al. Effects of Proton-Pump Inhibitors on functional dyspepsia: a meta-analysis of randomized placebo-controlled trials. Clinical Gastroenterology and Hepatology 2007; 5:178-185.