Chronic Abdominal Wall Pain Research Articles

A Remarkable Pitfall in Inguinal Open Mesh Herniorrhaphy

A patient was referred to SolviMáx, our 'centre of excellence for chronic abdominal wall and groin pain' because of persistent inguinodynia after a Lichtenstein repair. A surgical exploration revealed a spermatic cord that was divided by the mesh, supposedly during the primary repair. As a consequence, the patient had developed severe neuropathic pain originating from a damaged genitofemoral nerve. Following a tailored neurectomy, he became pain free.

Long-term success rates after an anterior neurectomy in patients with an abdominal cutaneous nerve entrapment syndrome

Surgery occasionally is proposed in patients with chronic abdominal wall pain caused by an anterior cutaneous nerve entrapment syndrome (ACNES) who are refractory to injection therapy. An anterior neurectomy may seem successful, but follow-up is usually short and populations are small. The primary aim of this study was to determine the long-term success rate of surgery in a large ACNES population. In this retrospective observational study, patients with ACNES ≥18 years who underwent a primary anterior neurectomy between January 2004 and February 2012 in one single center were studied. Pain scores were obtained before surgery, after surgery, and at the moment of questioning using a pain intensity numeric rating scale (PI-NRS 0-10) and a 6-point verbal category rating scale. Success was defined as a ≥50% PI-NRS reduction or ≥2 point verbal rating scale reduction. Data of 181 neurectomies in 154 individuals were available for analysis (female, n = 127, 82.5%; age 47 ± 17 years, range, 20-83). Pain before operation was severe (mean PI-NRS 8.08, SD 1.43). Short-term (1-3 months postoperative) success was 70% (127/181 procedures). Three subjects showed spontaneous remission of complaints after ≥3 months. After a mean 32 months (range, 3-93) follow-up, a success rate of 61% (109/180) on the long-term was found. A 70% short-term success rate and a 61% long-term success rate after a primary anterior neurectomy in patients with chronic abdominal pain due to ACNES were attained. Surgery is the method of choice in ACNES patients who are refractory to a conservative regimen.

Efficacy of Subcutaneous Hydrocortisone Injection in Patients Diagnosed With Chronic Abdominal Wall Pain

Introduction: Chronic abdominal wall pain (CAWP) occurs in up to 10% of patients referred to gastroenterology clinics for abdominal pain. It represents a focal pain thought related to peripheral nerve entrapment. We describe the single-center experience for management of chronic abdominal wall pain using injection of hydrocortisone with local anesthetic. Methods: A total of 22 patients with diagnosis of chronic abdominal wall pain by physical examination were treated with a subcutaneous injection of hydrocortisone 100 mg/mL (3-5 mL) with a local anesthetic (Sensorcaine or Marcaine) at the point of maximal pain. We described treatment response as no need for subsequent intervention including recurrent clinic visit for pain, imaging for pain, narcotic use, repeat injections, or additional referrals needed for abdominal pain. Response was measured over yearly time points. We assessed post-treatment outcomes including response rate at 1 year and 3 years, number of return visits for abdominal pain, narcotic use, imaging studies, and physical therapy referral. Results: Between 1995 and 2013, 22 patients with chronic abdominal wall pain received subcutaneous injection of hydrocortisone. Eighty-one percent were female. Eighty-one percent were white. Median age was 56.5 years (range 17-79 years). A number of patients were on proton pump inhibitor (50%) or treatment for irritable bowel syndrome (50%) at the time of injection. The overall response rate after subcutaneous injection at 1 year and at 3 years was 55% for both. Only 6 patients (27%) required repeat injection. The average period of time before repeat injection was 4 months. Twenty-seven percent of patients required imaging for abdominal pain within 3 years. Only 4% required addition of narcotics for abdominal pain at any time. Thirteen percent of patients required referral to physical therapy. Conclusion: In our single center evaluation of patients with a clinical diagnosis of chronic abdominal wall pain treated with hydrocortisone injection, 55% experienced ongoing treatment response up to 3 years after therapy. Further randomized, placebo-controlled evaluations would be valuable to determine the true efficacy of this intervention.

Use of Targeted Transversus Abdominus Plane Blocks in Pediatric Patients with Anterior Cutaneous Nerve Entrapment Syndrome

Anterior cutaneous nerve entrapment syndrome (ACNES) is a commonly overlooked source of chronic abdominal wall pain. A diagnosis of ACNES should be considered in cases of severe, localized abdominal pain that is accentuated by physical activity. Providers should consider diagnosing ACNES once a patient has both a positive result from a Carnett’s test and precise localization of pain. We describe the use of transversus abdominus plane (TAP) blocks to treat ACNES in the pediatric patient population. TAP blocks are a treatment modality which have been described less frequently in the management of this syndrome, with rectus sheath blocks being used more commonly. TAP blocks can be used effectively for ACNES by targeting the site of maximal tenderness, which was identified using ultrasound guidance. Moreover, TAP blocks are an attractive procedure option for ACNES as they are less invasive than other commonly used techniques. We present 3 case series reports of pediatric patients evaluated at our institution for severe abdominal pain to describe the clinical manifestations, sequelae, and outcome of ACNES. Though the exact incidence of ACNES in the pediatric population is unknown, this condition has significant implications from chronic pain. Chronic pain can lead to significant emotional and social impacts on these pediatric patients, as well as their on their families. Further, the extensive utilization of health care resources is impacted when children with undiagnosed ACNES undergo invasive treatments when ACNES is not in the early differential. The purpose of this case series report is to prompt better recognition of the condition ACNES, and to highlight the efficacy of TAP blocks as a management strategy. Key words: TAP block, pediatric patients, abdominal pain, ACNES

Chronic Abdominal Wall Pain Misdiagnosed as Functional Abdominal Pain

The abdominal wall is often neglected as a cause of chronic abdominal pain. The aim of this study was to identify chronic abdominal wall pain syndromes, such as anterior cutaneous nerve entrapment syndrome (ACNES), in a patient population diagnosed with functional abdominal pain, including irritable bowel syndrome, using a validated 18-item questionnaire as an identification tool. In this cross-sectional analysis, 4 Dutch primary care practices employing physicians who were unaware of the existence of ACNES were selected. A total of 535 patients ≥18 years old who were registered with a functional abdominal pain diagnosis were approached when they were symptomatic to complete the questionnaire (maximum 18 points). Responders who scored at least the 10-point cutoff value (sensitivity, 0.94; specificity, 0.92) underwent a diagnostic evaluation to establish their final diagnosis. The main outcome was the presence and prevalence of ACNES in a group of symptomatic patients diagnosed with functional abdominal pain. Of 535 patients, 304 (57%) responded; 167 subjects (31%) recently reporting symptoms completed the questionnaire. Of 23 patients who scored above the 10-point cutoff value, 18 were available for a diagnostic evaluation. In half of these subjects (n = 9) functional abdominal pain (including IBS) was confirmed. However, the other 9 patients were suffering from abdominal wall pain syndrome, 6 of whom were diagnosed with ACNES (3.6% prevalence rate of symptomatic subjects; 95% confidence interval, 1.7-7.6), whereas the remaining 3 harbored a painful lipoma, an abdominal herniation, and a painful scar. A clinically relevant portion of patients previously diagnosed with functional abdominal pain syndrome in a primary care environment suffers from an abdominal wall pain syndrome such as ACNES.

When it is not a Spigelian Hernia: Abdominal Cutaneous Nerve Entrapment Syndrome

Abdominal wall pain at the linea semilunaris is classically the result of a Spigelian hernia. If no hernia is detected, these patients may be left with chronic pain without a diagnosis or treatment. A retrospective review was performed of patients presenting with abdominal wall pain at the linea semilunaris between 2009 and 2012. Of the 14 patients, three (21%) were diagnosed with a Spigelian hernia confirmed by imaging. The remaining patients were eventually diagnosed with abdominal cutaneous nerve entrapment syndrome (ACNES). The average delay in diagnosis was 4 years with patients with ACNES suffering twice as long with chronic pain. Patients with a Spigelian hernia and ACNES had different demographics and presenting complaints. Physical examination findings were nondiagnostic. Of the patients with ACNES, five (50%) had resolution of pain with serial nerve blocks alone; another five proceeded to surgical neurectomy with resolution of their pain. Thus, to prevent delay in diagnosis and treatment, patients with chronic abdominal wall pain at the linea semilunaris should first be ruled out for Spigelian hernia. Then, they should be evaluated and treated for ACNES.

Chronic Abdominal Wall Pain in Children may be Improved By Physiotherapy

Functional abdominal pain is common in children and a proportion of these children suffer from chronic abdominal wall pain (CAWP). CAWP is suggested when a positive Carnett's sign is elicited in a child where the pain gets worsened by movement. Analgesics are generally not helpful in children with CAWP. We describe a novel approach with physiotherapy (by core stability programme) for managing children with this condition. The therapy was delivered by a paediatric therapist after other organic causes of abdominal pain were ruled out. Forty two out of 49 children (85%) showed improvement with this therapy. As the improvement was noticed during the therapy and sustained thereafter we suggest that this therapy is helpful in children in CAWP.

Outcomes and Predictors of Ultrasound Guided Trigger Point Injections for Chronic Abdominal Wall Pain

Purpose: Chronic abdominal wall pain (CAWP) is reported to account for up to 30% of cases of chronic abdominal pain. Diagnosis relies upon history and identifying a focal area of tenderness with a positive Carnett's test (CAWP increases with tensing rectus abdominis). Ultrasound guided trigger point injection (TPI) with local anesthetic is used as a treatment of CAWP, however, little is known about outcomes of this treatment. The aim of this study was to determine the effectiveness of ultrasound guided TPI and predictors of a successful TPI. Methods: Patients receiving TPI between July 1 2010-June 30 2011 for presumed CAWP were mailed a questionnaire. Primary endpoint was measured using the Treatment Efficacy Questionnaire (TEQ), consisting eight items (scored 1-5). Other outcome measures and the Somatic Symptom Checklist (SSC) score were also completed. Medical records were reviewed to ascertain patient, pain and TPI characteristics. The associations of TEQ score with clinical features and demographics were assessed using linear regression models. Results: Of the 218 patients contacted, 120 (55%) responded to the survey. Females, elderly, and married had greater odds of responding to the survey. Among the 120 patients, median pain duration was 12 months and right upper quadrant was the commonest site of pain (35%). Pain was rated as 8-10 (on a 1-10 scale) by 57%, 4-7 by 35% and 1-3 by 8% of patients. Majority (77%) described pain as an ache and 33% complained of a constant, daily pain. Narcotic use was reported in 46 (38%) and 88 (73%) had a history of at least one abdominal surgery. Most (94%) patients received a combination of anesthetic and corticosteroid for the TPI. The median (Interquartile range) TEQ score was 23 (18 to 30) with 44 of the 120 (37%) meeting the criteria for responder (successful TPI, TEQ ≥ 28). Compared to before treatment, 36% reported being “significantly better” and 22% “slightly better.” 37 of the 120 (30%) noted a response within 24 hrs of TPI, 23 (19%) in 1-3 days and 27 (22%) after three days and 35 (29%) never responded. Pain relief lasted >12 weeks in 43% of patients. The SSC score was univariately associated with TEQ score, but not age or BMI. Multiple linear regression analyses identified only SSC score as a significant negative predictor of the TEQ score (partial R-square of 5%, p<0.05) and the overall model R-square values were all <12%. Conclusion: Ultrasound guided TPI can provide significant, long-term symptom relief in a third of patients with chronic abdominal pain attributed to CAWP. Lower degree of somatization was modestly predictive of an increased response. CAWP should be considered in a patient with chronic abdominal pain and TPI should be offered, however, better predictors of response are needed.

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

ObjectiveThe 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...

Endometriosis of the abdominal wall. A rare, under-recognized entity causing chronic abdominal wall pain

Endometriosis is a common gynaecological condition which affects women during their reproductive years. It is characterized by ectopic endometrial tissue responding to hormonal changes associated with menstrual cycle. Aetiology is unknown and symptoms are quite aspecific (dysmenorrhoea, pelvic pain, infertility or pelvic mass). Here we report the case of a 43-year-old woman, who presented with complaints of chronic abdominal wall pain and lower abdominal discomfort during menstruation. Symptoms persisted for more than nine months. Clinical and ultrasound evaluation raised the suspicion of abdominal wall endometriosis; surgical exploration confirmed diagnosis. The patient progressed satisfactorily and is free of symptoms 20 months after surgery.

The Diagnosis and Differential Diagnosis of Chronic Abdominal Wall Pain

Objective To study the clinical character , diagnosis and differential diagnosis procedures of chronic abdominal wall pain( CAWP ).Methods:Observe and analysize on 27 CAWP patients and tell its difference from the pain resulted from the abdominal internals. Results 1.The main reasons of CAWP is neurogenic( n=18,67% ) , such as the entrapment of intercoastal nerve , postherpetic pain , neuritis caused by diabetic, etal.2.Myofascial pain of abdominal wall is secondatory ( n=7, 26% ).3.the other reasons is rare ( n=2, 7% ).The characteristics of CAWP were local abdominal pain related to posture, positive Carnette,Hover, Tinel s signs, local pain point blocking is effective.Conclusion The diagnosis and differential diagnosis of CAWP depended mostly the health record, clinical expression and radiology. The doctors were required to have better medical knowledge. Key words: Chronic abdominal wall pain; Diagnosis; Differential diagnosis

Chronic Abdominal Wall Pain and Ultrasound-Guided Abdominal Cutaneous Nerve Infiltration: A Case Series

Chronic abdominal wall pain occurs in about 10-30% of patients presenting with chronic abdominal pain. Entrapment of abdominal cutaneous nerves at the lateral border of the rectus abdominis muscle has been attributed as a cause of abdominal wall pain. We report our experience of treating such patients using ultrasound-guided abdominal cutaneous nerve infiltration. We conducted a retrospective audit of abdominal cutaneous nerve infiltration performed in the period between September 2008 to August 2009 in our center. All patients had received local anesthetic and steroid injection under ultrasound guidance. The response to the infiltration was evaluated in the post-procedure telephone review as well as in the follow-up clinic. Brief pain inventory (BPI) and numerical rating scale pain scores were collated from two points: the initial outpatient clinic and the follow up clinic up to 5 months following the injection. Nine patients had abdominal cutaneous nerve injections under ultrasound guidance in the period under review. Six patients reported 50% pain relief or more (responders) while three patients did not. Pain and BPI scores showed a decreasing trend in responders. The median duration of follow-up was 12 weeks. Ultrasound can reliably be used for infiltration of the abdominal cutaneous nerves. This will improve the safety as well as diagnostic utility of the procedure.

Use of ultrasound‐guided subcostal transversus abdominis plane blocks in a pediatric patient with chronic abdominal wall pain

Use of ultrasound‐guided subcostal transversus abdominis plane blocks in a pediatric patient with chronic abdominal wall pain

Rectus sheath block: successful use in the chronic pain management of pediatric abdominal wall pain

Seven pediatric patients (aged 11-16 years) with chronic abdominal wall pain are presented who gained significant relief from a rectus sheath block (RSB). We describe the case histories and review the relevant literature for this technique. The etiology of the abdominal wall pain was considered to be abdominal cutaneous nerve entrapment, iatrogenic peripheral nerve injury, myofascial pain syndrome or was unknown. All patients showed significant initial improvement in pain and quality of life. Three patients required only the RSB to enable them to be pain-free and return to normal schooling and physical activities. Two children received complete relief for more than 1 year. In the majority of cases, the procedure was carried out under general anesthesia as a daycase procedure. Local anesthetic and steroids were used. This is the first report of the successful use of this technique in the chronic pain management setting in children.

Does laparoscopy used in open exploration alleviate pain associated with chronic intractable abdominal wall neuralgia?

This study aimed to assess the efficacy of diagnostic laparoscopy and open exploration of trigger points (scar revision and neurectomy) in the treatment of intractable chronic abdominal wall pain. This prospective nonrandomized study enrolled 24 patients (21 women) with an average age of 59 +/- 11 years. Abdominal wall pain was diagnosed by excluding other causes of pain and using multiple injections of bupivacain. The patients' demographic data and long-term postoperative course (37 +/- 13 months) were carefully recorded. Using laparoscopy, intraabdominal adhesions close to trigger points were found and lysed in 15 patients (63%). Next, a subcutaneous nerve resection was performed. After 1 month, 33% of the patients were completely pain free, and 42% reported alleviation of pain. After 3 years, chronic abdominal pain was totally healed in 25%, diminished in 50%, and unchanged or increased in 25% of the patients. A total of 23 patients (96%) reported that surgery was beneficial for their intractable pain. Laparoscopy used in open exploration is beneficial for 75% of carefully selected patients with chronic abdominal wall pain.

Abdominal wall reconstruction using biological tissue grafts: present status and future opportunities

Surgeons often encounter the challenge of treating acquired abdominal wall defects following abdominal surgery. The current standard of practice is to repair most defects using permanent synthetic mesh material. Mesh augments the strength of the weakened abdominal wall fascia and enables the hernia repair to be performed in a tension-free manner. However, there is a risk of acute and/or chronic infection, fistula formation and chronic abdominal wall pain with the use of permanent mesh materials, which can lead to more complex operations. As a means to avoid such problems, surgeons are turning increasingly to the use of xenogenic and allogenic materials for the repair of abdominal wall defects. Their rapid evolution and introduction into the clinical operating room is leading to a new era in abdominal wall reconstruction. There are promising, albeit limited, clinical data with short-term follow-up for only a few of the many biological tissue grafts that are being promoted currently for the repair of abdominal hernias. Additional clinical studies are required to better understand the long-term efficacy and limitations of these materials.

Functional Bowel Disorders

Employing a consensus approach, our working team critically considered the available evidence and multinational expert criticism, revised the Rome II diagnostic criteria for the functional bowel disorders, and updated diagnosis and treatment recommendations. Diagnosis of a functional bowel disorder (FBD) requires characteristic symptoms during the last 3 months and onset > or =6 months ago. Alarm symptoms suggest the possibility of structural disease, but do not necessarily negate a diagnosis of an FBD. Irritable bowel syndrome (IBS), functional bloating, functional constipation, and functional diarrhea are best identified by symptom-based approaches. Subtyping of IBS is controversial, and we suggest it be based on stool form, which can be aided by use of the Bristol Stool Form Scale. Diagnostic testing should be guided by the patient's age, primary symptom characteristics, and other clinical and laboratory features. Treatment of FBDs is based on an individualized evaluation, explanation, and reassurance. Alterations in diet, drug treatment aimed at predominant symptoms, and psychotherapy may be beneficial.

Chronic abdominal wall pain: Clinical features, health care costs, and long-term outcome

Background & Aims: Chronic abdominal wall pain (CAWP) often is misdiagnosed. We evaluated CAWP patients regarding diagnosis accuracy, clinical features, comorbidity, referral frequency, use of care, and long-term outcome. Methods: We reviewed the records of all outpatients referred to a gastroenterologist in 5 years, recorded referral indications, and identified patients initially diagnosed with CAWP or irritable bowel syndrome (IBS). Charts of all CAWP patients were reviewed, and direct costs were estimated for abdominal pain-related physician visits and imaging studies during the 12 months before and 12 months after consultation. We appraised long-term pain status by telephone. Results: Of 2709 patients, CAWP was diagnosed by physical examination in 137 patients; the diagnosis remained unchanged after 47.3 ± 17.7 (mean ± SD) months in 133 (97.1%) patients. Women predominated over men 4 to 1, pain was usually upper abdominal, had lasted 25.3 ± 46.3 months, and obesity and painful comorbidities and depression were common. CAWP and IBS comprised 7.8% and 16.3% of symptomatic referrals, respectively. Prereferral, physicians rarely suspected CAWP and often prescribed therapy for acid-peptic disease. Postconsultation, primary care, emergency and specialist visits, and radiologic examinations markedly decreased ( P < 0.001), and estimated annual costs decreased from $1133.87 ± 953.37 to $541.33 ± 989.04 ( P < 0.0001). Therapy varied, and 44 (47.3%) patients had no pain at follow-up evaluation. Conclusions: CAWP is a common underrecognized disorder. Comorbidities are frequent, and health care use is high. Diagnosis is accurate and reduces health care costs. Over the long term, pain disappearance and persistence occurs in approximately equal proportions of patients.

Chronic abdominal wall pain in referral practice: long-term outcome

Chronic abdominal wall pain in referral practice: long-term outcome

Chronic abdominal wall pain: a frequently overlooked problem. Practical approach to diagnosis and management.

Chronic abdominal wall pain is frequently misdiagnosed as arising from a visceral source, often resulting in inappropriate diagnostic testing, unsatisfactory treatment, and considerable cost. Its prevalence in general medical practice is unknown, although it may account for about 10% of patients with chronic idiopathic abdominal pain seen in gastroenterological practices. The most common cause appears to be entrapment of an anterior cutaneous branch of one or more thoracic intercostal nerves; myofascial pain and radiculopathy are less frequent. Sharply localized pain and superficial tenderness are suggestive of abdominal wall origin. Carnett's test (accentuated localized tenderness with abdominal wall tensing) is a helpful diagnostic sign, especially when incorporated with other findings. Early exclusion of a parietal source should increase diagnostic accuracy when evaluating patients with chronic abdominal pain. Reassurance of patients by the correct diagnosis and avoidance of precipitating causes is often sufficient treatment. However, accurately placed anesthetic/corticosteroid injections give substantial pain relief to more than 75% of patients, often for prolonged periods, and may be confirmatory for the source of the complaint. The probability of missing visceral disease is small (probably less than 7%) with strict adherence to diagnostic criteria and diligent observation of patients.