Management of patients with chronic abdominal pain in clinical practice

Laparoscopy as a Diagnostic and Therapeutic Modality for Chronic Abdominal Pain of Unknown Etiology: A Literature Review

BACKGROUND

Investigate the diagnostic and therapeutic utility of laparoscopy in the management of patients with chronic abdominal pain of unknown origin.

METHODS

Ovid MEDLINE, PubMed, and SCOPUS databases were queried to identify relevant published studies. Data on the diagnostic and therapeutic utility of laparoscopy were abstracted and summarized.

RESULTS

Laparoscopy achieved a diagnosis in 65% to 94% of patients with chronic abdominal pain of unknown origin. Common intraoperative findings included adhesions, chronic appendicitis, hernias, and enlarged mesenteric lymph nodes. These findings corresponded with the therapeutic procedures that were performed, including laparoscopic adhesiolysis, appendectomy, and hernia repair. Therapeutic utility of laparoscopy based on pain relief, patient satisfaction, and quality of life ranged from 63% to 94%.

CONCLUSIONS

Based on current available evidence, diagnostic laparoscopy (DL) is a safe and effective method for identifying organic causes of chronic abdominal pain. Laparoscopic treatment also resulted in substantial pain relief for a majority of patients. However, the efficacy of laparoscopic adhesiolysis remains controversial. We would recommend the use of DL as an early diagnostic tool, but more robust studies are needed to establish the breadth of its therapeutic utility in clinical practice.

The small bowel diseases detected by capsule endoscopy in patients with chronic abdominal pain: A retrospective study

Chronic abdominal pain (CAP) remains a particular challenge because of its complicated causes, especially when the disorders involve the small bowel, where it is quite difficult to intubate the flexible endoscopes. This study was to investigate the small bowel diseases detected by capsule endoscopy (CE) in CAP patients to evaluate the role of CE on CAP, and analyzed the relationship among the clinical characteristics of CAP patients and the positive rates of CE findings to search for the indications of CE for CAP patients.This retrospective study included 341 patients with CAP defined as recurrent abdominal pain for no <3 months. Each patient underwent CE after a negative diagnostic work-up. All CE images were reviewed by 3 gastroenterologists independently. The positive findings were defined as abnormal findings in the small bowel that might have been the causes of CAP. The final diagnosis was confirmed by CE findings, clinical features, histopathology, and a response to the treatment during the follow-up for at least 3 months after CE.The overall positive rate of CE findings was 28.15% (96/341). The positive rate in CAP-A (CAP with associated symptoms) group was significantly higher than that in CAP-O (CAP only) group (33.16% vs 21.38%, P = .017). Multivariate logistic regression analysis revealed that weight loss (odds ratio [OR] = 2.827, 95% confidence interval (CI) = 1.938-4.926), hypoalbuminemia (OR = 6.142, 95%IC = 4.129-8.274), elevated erythrocyte sedimentation rate (ESR) (OR = 4.025, 95%IC = 3.178-6.892), or increased C-reactive protein (CRP) (OR = 7.539, 95%CI = 5.365-11.723) were significantly associated with high positive rates. On follow-up, final diagnosis was confirmed in 56 of 69 (81.16%) patients with positive CE findings. About half of these patients (46.38%, 32/69) were diagnosed as inflammatory diseases, including Crohn disease (12), tuberculosis (5), NSAID enteropathy (4), etc. Tumors were proved in 21.74% (15/69) patients, including malignant in 7 cases and benign in 8 cases. Parasitosis was found in 9 (13.04%) patients.This study suggests that CE may be helpful for CAP patients to detect the small bowel diseases, half of which were comprised of inflammatory diseases. Besides, weight loss, hypoalbuminemia, elevated ESR, or increased CRP may be regarded as the indications of CE for CAP patients.

Construction and validation of a questionnaire distinguishing a chronic abdominal wall pain syndrome from irritable bowel syndrome

OBJECTIVE

The irritable bowel syndrome (IBS) population is heterogeneous, harbouring a variety of abdominal symptoms. Therefore, IBS is often termed a 'diagnosis of exclusion'. Chronic abdominal wall pain (CAWP) is a poorly recognized entity, frequently caused by the anterior cutaneous nerve entrapment syndrome (ACNES). Some patients may be misdiagnosed because IBS and CAWP share symptoms. Aim of this study was to construct and validate a questionnaire to distinguish patients with CAWP (including ACNES) patients with IBS.

DESIGN

A questionnaire was designed of 17 ACNES characteristic items obtained from ACNES patients (n=33) and expert opinion of two specialized surgeons. Eleven IBS-related items ('Rome III' criteria) were added leading to a questionnaire containing 28 items. This was validated in a 'gold standard' ACNES group (successfully operated ACNES patients, n=68) and a 'prospective' IBS group (n=64) as well as in a 'prospective' ACNES group (n=47). Distinctive power of individual items was analyzed by χ². Reliability was tested with Crohnbach's α. ROC curve was used to determine cut-off values.

RESULTS

Eighteen of 28 items were significantly distinctive (p<0.01) between ACNES and IBS patients leading to an 18-point ACNES score with good internal consistency (α=0.85). Cut-off value of 10 points resulted in 94% sensitivity, 92% specificity and areas under the curve (AUC) of 0.98. Evaluation of the prospective ACNES group led to 85% sensitivity, 92% specificity and AUC 0.95 indicating high discriminative properties of the questionnaire.

CONCLUSIONS

This novel questionnaire may be useful and valid as a simple tool distinguishing patients harbouring a CAWP syndrome from those having IBS.

The efficacy of laparoscopy in the diagnosis and management of chronic abdominal pain

BACKGROUND

Chronic abdominal pain is a difficult complaint. It leads to evident suffering and disability, both physically and psychologically. Many diagnostic and therapeutic procedures have been described in literature, but with little proof or evidence of success. Laparoscopy is one of the modalities that could be of benefit in such cases. We aim to evaluate the diagnostic and therapeutic value of laparoscopy in cases with chronic abdominal pain.

MATERIALS AND METHODS

Thirty patients with chronic abdominal pain were included in this prospective descriptive cross-sectional study. The pain in all patients was of unclear etiology despite all the investigative procedures. All patients were subjected to laparoscopic evaluation for their conditions. The findings and outcomes of the laparoscopy were recorded and analyzed.

RESULTS

The most common site of pain was the periumbilical region (30%). A definitive diagnosis was made in 25 patients (83.3%), while five patients (16.7%) had no obvious pathology. Adhesions were the most common laparoscopic findings (63.3%) followed by appendiceal pathology (10%), hernia (3.3%), gall bladder pathology (3.3%), and mesenteric lymphadenopathy (3.3%). Postoperatively, pain relief was achieved in 24 patients (80%) after two months.

CONCLUSION

Laparoscopy is an effective diagnostic and therapeutic modality in the management of patients with chronic abdominal pain.

Chronic abdominal wall pain--a diagnostic challenge for the surgeon

BACKGROUND

Chronic abdominal wall pain (CAWP) occurs in about 30% of all patients presenting with chronic abdominal pain.

METHODS

The authors review the literature identified in a PubMed search regarding the abdominal wall as the origin of chronic abdominal pain.

RESULTS

CAWP is frequently misinterpreted as visceral or functional abdominal pain. Misdiagnosis often leads to a variety of investigational procedures and even abdominal operations with negative results. With a simple clinical test (Carnett's test), >90% of patients with CAWP can be recognized, without risk for missing intra-abdominal pathology.

CONCLUSION

The condition can be confirmed when the injection of local anesthetics in the trigger point(s) relieves the pain. A fasciotomy in the anterior abdominal rectus muscle sheath through the nerve foramina of the affected branch of one of the anterior intercostal nerves heals the pain.

A novel herbal preparation desensitizes mesenteric afferents to bradykinin in the rat small intestine

Herbal preparations are evolving as promising agents for the treatment of functional gastrointestinal disorders which are considered to be secondary to visceral hypersensitivity. We aimed to determine whether a new combination of six herbal extracts reduces the sensitivity of intestinal afferents in rat. Male Wistar rats (250-350 g, n = 6 per group) were gavaged with either vehicle or 2.5, 5 or 10 mL kg(-1) of STW 5-II, a herbal preparation which contains six extracts. Two hours later, animals were anaesthetized and extracellular multi-unit mesenteric afferent nerve recordings were obtained in the proximal jejunum in vivo. Afferent discharge to 5-hydroxy-tryptamine (5-HT) (5, 10, 20 and 40 microg kg(-1), i.v.), luminal distension (0-60 mmHg) and bradykinin (BK) (15, 30 and 60 microg kg(-1), i.v.) was recorded. At baseline, spontaneous afferent discharge was not different following pretreatment with the various doses of STW 5-II compared with vehicle. The pressure-dependent increase in afferent discharge to intraluminal ramp distension and the dose-dependent increase in afferent firing following 5-HT were also uninfluenced by STW 5-II pretreatment. In contrast, the afferent nerve responses to 15, 30 and 60 microg kg(-1) of BK were reduced following 10 mL kg(-1) STW 5-II with peaks at 106 +/- 19, 153 +/- 22 and 156 +/- 25 imp s(-1) compared with 160 +/- 15, 228 +/- 14 and 220 +/- 16 imp s(-1) following vehicle pretreatment (mean +/- SEM, P < 0.05). Intestinal afferent sensitivity to BK which plays a prime role in nociception was reduced following STW 5-II. Thus, STW 5-II may be of therapeutic use for conditions that involve neuronal hypersensitivity and the release of BK in the intestine.

Sensory transmission in the gastrointestinal tract

The gastrointestinal (GI) tract must balance ostensibly opposite functions. On the one hand, it must undertake the process of digestion and absorption of nutrients. At the same time, the GI tract must protect itself from potential harmful antigenic and pathogenic material. Central to these processes is the ability to 'sense' the mechanical and chemical environment in the gut wall and lumen in order to orchestrate the appropriate response that facilitates nutrient assimilation or the rapid expulsion through diarrhoea and/or vomiting. In this respect, the GI tract is richly endowed with sensory elements that monitor the gut environment. Enteric neurones provide one source of such sensory innervation and are responsible for the ability of the decentralized gut to perform complex reflex functions. Extrinsic afferents not only contribute to this reflex control, but also contribute to homeostatic mechanisms and can give rise to sensations, under certain circumstances. The enteric and extrinsic sensory mechanisms share a number of common features but also some remarkably different properties. The purpose of this review is to summarize current views on sensory processing within both the enteric and extrinsic innervation and to specifically address the pharmacology of nociceptive extrinsic sensory pathways.