metricas
covid
Buscar en
Gastroenterología y Hepatología (English Edition)
Toda la web
Inicio Gastroenterología y Hepatología (English Edition) Chronic abdominal pain originating in the abdominal wall
Información de la revista
Vol. 41. Núm. 2.
Páginas 114-115 (febrero 2018)
Vol. 41. Núm. 2.
Páginas 114-115 (febrero 2018)
Scientific letter
Acceso a texto completo
Chronic abdominal pain originating in the abdominal wall
Dolor abdominal crónico originado en la pared abdominal
Visitas
1876
Noelia Alcaidea,
Autor para correspondencia
noelialcaide@hotmail.com

Corresponding author.
, Sara Lorenzo Pelayoa, Enrique Ortega Ladrón de Cegamab
a Servicio de Aparato Digestivo, Hospital Clínico Universitario, Valladolid, Spain
b Servicio de Anestesiología, Hospital Universitario Río Hortega, Valladolid, Spain
Este artículo ha recibido
Información del artículo
Texto completo
Bibliografía
Descargar PDF
Estadísticas
Texto completo

Abdominal wall pain is an under-diagnosed cause of chronic abdominal pain. Since abdominal wall pain is not usually suspected as the origin of chronic abdominal pain by doctors, patients usually undergo extensive diagnostic testing and different treatments, and are often classified as having a functional or non-specific pain syndrome before the right diagnosis is finally reached, sometimes years after the onset of symptoms.1

A 34-year-old male patient was referred to the digestive health clinic after suffering from fluctuating, but daily, abdominal pain in his left side for 3 months. This pain was interfering with his usual activities, improved when lying down and got worse with hyperextension and flexion of the trunk. He complained of suffering from dyspepsia with slow digestion and reflux symptoms for several years that had not got any worse recently. He had not experienced any changes in bowel habits or weight loss. Upon physical examination, the patient complained of pain and tenderness on his left side, with a trigger point that reproduced pain and was accompanied by vagal reactions that worsened with extension of the abdominal musculature; no masses could be felt. The patient was assessed regularly over 4 months at the clinic with objective evidence of pain, resulting in the following tests being ordered: full blood count, faecal calprotectin, abdominal ultrasound, abdominal CT scan, endoscopy with rapid urease test and duodenal biopsies, ileocolonoscopy, MR enterography and soft tissue ultrasound. All results were normal, or showed insignificant alterations, that did not explain the patient's symptoms. The patient experienced no improvement after being treated with common analgesics, anti-inflammatory drugs, antispasmodic drugs or low-dose antidepressants. The patient was also assessed by general surgery which proposed performing an exploratory laparoscopy, although this offered little chance of finding a cause, and was assessed by the pain management unit, which initially ruled out any treatable disease. Given that the symptoms continued and that the doctors suspected abdominal wall pain, the patient was referred again to the pain management unit. The unit performed an initial infiltration of topical anaesthetic, which failed, followed by a second infiltration between the two abdominal obliques with complete remission of all symptoms. After being on this treatment for 6 months, the patient is still asymptomatic.

Abdominal pain is a common disorder, seen by both primary care and specialist doctors. It is estimated that 10 to 30% of patients with chronic abdominal pain of unknown cause actually have abdominal wall pain, although it is still currently an under-diagnosed disorder due to low clinical suspicion.2 Before diagnosis, patients have usually already undergone numerous diagnostic examinations and failed treatment attempts, and have been classified as having a functional or non-specific pain syndrome.1

Abdominal wall pain is pain originating in the anatomical structures of the abdominal wall (skin, subcutaneous tissue, peritoneum, muscles, nerve endings) and is more common in women aged 30–50 years. The most common cause is abdominal wall hernias, while other causes include cutaneous nerve entrapment, surgical scarring, haematomas, endometriosis, Herpes zoster, abdominal pain referred from thoracic nerve endings or obesity due to an increase in intra-abdominal pressure.3

Diagnosis is based on the patient's medical history and abdominal examination.4 Pain is chronic and suffered every day; it is usually localised to a single point and is not associated with other accompanying digestive symptoms. Carnett's sign can be used to diagnose this entity.5 It is performed with the patient lying face up; the doctor presses on the tender point while the patient lifts his/her head and trunk to contract the abdominal muscles. If the pain increases or remains unchanged (positive Carnett's sign), it is considered to originate from the abdominal wall. However, if it decreases (negative Carnett's sign), the cause is visceral since the tensed muscles protect the viscera.6

When the pain is tolerable and the patient's quality of life does not deteriorate, the use of local measures and postural education may be sufficient. The effectiveness of analgesics and antidepressants is limited. When the pain is more severe, local injection of topical anaesthetics into the tender area is effective, and also helps confirm the diagnosis.7 Corticosteroids may be used concomitantly to prolong the effect and several sessions are sometimes required because recurrence of symptoms is common. In exceptional cases, surgery may be required to release trapped nerves or remove wall lesions.8

References
[1]
M. Rivero Fernández, V. Moreira Vicente, J.M. Riesco López, M.A. Rodríguez Gandía, E. Garrido Gómez, J.M. Milicua Salamero.
Dolor originado en la pared abdominal: una alternativa diagnóstica olvidada.
Gastroenterol Hepatol, 30 (2007), pp. 244-250
[2]
R. Srinivasan, D.S. Greenbaum.
Chronic abdominal wall pain: a frequently overlooked problem. Practical approach to diagnosis and management.
Am J Gastroenterol, 97 (2002), pp. 824-830
[3]
R.O. Lindsetmo, J. Stulberg.
Chronic abdominal wall pain, a diagnostic challenge for the surgeon.
Am J Surg, 198 (2009), pp. 129-134
[4]
D.S. Greenbaum, R.B. Greenbaum, J.G. Joseph, J.E. Natale.
Chronic abdominal wall pain. Diagnostic validity and costs.
Dig Dis Sci, 39 (1994), pp. 1935-1941
[5]
J.B. Carnett.
Intercostal neuralgia as a cause of abdominal pain and tenderness.
Surg Gynecol Obstet, 42 (1926), pp. 625-632
[6]
H. Koop, S. Koprdova, C. Schürmann.
Chronic abdominal wall pain.
Dtsch Arztebl Int, 113 (2016), pp. 51-57
[7]
J.R. Glissen Brown, G.R. Bernstein, F.K. Friedenberg, A.C. Ehrlich.
Chronic abdominal wall pain: an under recognized diagnosis leading to unnecessary testing.
J Clin Gastroenterol, 50 (2016), pp. 828-835
[8]
S. Weum, L. de Weerd.
Perforator-guided drug injection in the treatment of abdominal wall pain.
Pain Med, 17 (2016), pp. 1229-1232

Please cite this article as: Alcaide N, Lorenzo Pelayo S, Ortega Ladrón de Cegama E. Dolor abdominal crónico originado en la pared abdominal. Gastroenterol Hepatol. 2018;41:114–115.

Copyright © 2017. Elsevier España, S.L.U.. All rights reserved
Descargar PDF
Opciones de artículo
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos