Disease/ DisorderDefinitionTrue visceral pain is a physiologically and clinically separate entity from somatic pain. Visceral pain responses are provoked by ischemia, inflammation, and distention. Visceral pain is poorly defined and diffuse and commonly described as deep, gnawing, twisting, aching, colicky, or dull.1 It is usually associated with autonomic features (e.g., sweating, nausea and vomiting) and highly emotional (e.g., anxious, feeling of impending doom). Show
Patho-anatomy/physiologyThe cell bodies for the sympathetic nervous system originate from the intermediolateral column of the spinal cord between T1 and L2/3. The paravertebral sympathetic ganglia are arranged in two chains spanning from the skull to the coccyx along the anterior aspect of the vertebral column and terminate in the only unpaired ganglion of the sympathetic chain, the ganglion impar (ganglion of Walther) on the ventral surface of the coccyx. After synapsing in the sympathetic ganglia, post ganglionic C fibers can rejoin the spinal nerve via the gray rami communicates at any spinal level and continue onward as postganglionic fibers to exert their end effect.2 Visceral pain fibers, which are Aδ or C fibers, follow a similar path as described above with the sympathetics, but in an afferent manner. It is this overlapping pathway that generates the non-discrete pain from abdominal or pelvic viscera. EtiologyAnatomical: Foregut
Midgut
Hindgut
Retroperitoneal
Pelvis4
Physiological: Organ Inflammation
Disruption of normal mechanical processes
Ischemia
Clinical Variants of Abdominal and Pelvic Visceral Pain
Epidemiology including risk factors and primary preventionChronic pelvic pain (CPP) prevalence is estimated between 4 and 15%. 21% of healthy individuals and 24% in people of age 65 and older have a minimum of six episodes of abdominal pain and discomfort per year.4 Risk factorsSurgery
Smoking
Alcohol
Diet
Diabetes
Trauma
Infection Psychosocial factors
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)Clinical features have a temporal evolution and vary in different phases of pathology. Clinical courses vary with etiology. Infectious sources may present rapidly and improve rapidly as the source is treated. Postsurgical pain has a sudden onset but may worsen following surgery due to mechanical or neural disrepair of peri-surgical tissue. Treatment is usually conservative and involves multiple treatment modalities. Tumor invasion commonly presents insidiously and gradually worsens with tumor growth. Resection, radiation/chemotherapy treatment, and interventional pain procedures may improve symptoms.3 Specific secondary or associated conditions and complicationsCan be associated with autonomic phenomena such as:
Essentials of AssessmentHistory
Physical examination
Clinical functional assessment: mobility, self-care and cognition/behavior/affective state
Laboratory studies
ImagingA wide range of imaging are utilized based of the physician’s clinical suspicion. For example, a patient in an emergency setting presenting with acute severe visceral pain might be screened with an ultrasound then have CT if the ultrasound findings are inconclusive.
Supplemental assessment tools
Early prediction of outcomesEarly outcome predictors may include vocational status, psychologic status, motivation, medication consumption, family relationships, emotional distress, pain intensity, and objective initial physiotherapeutic response measures. Pain assessment scales such as the McGill Pain questionnaire can also be utilized7. EnvironmentalChronic visceral pain can lead to psychologic disability and may require a social worker to assist with frequent home assessments. It is important to evaluate home social dynamics as there is an association between chronic abdominal and pelvic pain in patients who suffer from physical and sexual abuse. Social role and support systemMany diagnoses can cause visceral pain that have their own support groups. On-line support groups exist for each condition. In addition, some hospitals have behavioral therapy groups that patients may enter for more intimate discussions. Professional issuesMany patients with chronic abdominal/pelvic pain are treated with opiate medications. Treatment of chronic visceral pain refractory to various interventions may lead to the misuse and abuse of these which can present as an ethical dilemma. Patient safety must also be considered when prescribing opioids. According to the Center for Disease Control & Prevention, opioids (both prescribed and illicit) were involved in 67.8% of deaths by drug overdose.8 Rehabilitation Management and TechniquesAvailable or current treatment guidelinesGenerally accepted treatment for visceral pain includes treating the underlying pathology. This pathology, in many cases of visceral pain, is either caused by infection, ischemia, inflammation or malignancy of the involved organ system. Treatment is directed at the pathology. In the cases of ischemia and inflammation and ischemia, surgical intervention is often times required. In cases where an organic pathology is not clear, diagnostic percutaneous sympathetic blocks can be performed. In malignant cases refractory to surgical or chemotherapeutic treatment, repeat therapeutic percutaneous sympathetic blocks or ablative procedures may be performed. At different disease stagesNew onset/acute: It is essential to confirm accurate diagnosis, as visceral pain is generally poorly localized and can mimic other pathologies within the abdomen and pelvis. Once confirmed, visceral and pelvic pain may improve or resolve with appropriate treatment. A surgical evaluation may be necessary for certain diagnoses [e.g., bowel obstruction, cholecystitis, appendicitis (both visceral and somatic), etc.].
Subacute and Chronic Phase: Involves transition to home setting as well returning to work and normal daily activities. Patients may need ongoing outpatient rehabilitation focusing on mobility, scar management, desensitization techniques, TENS. Includes all of the above as well as use of percutaneous sympathetic blocks.
Coordination of care
Patient & family educationVisceral pain can be ambiguous and difficult to understand. Therefore, it is very important for the patient to be educated on the disease process, treatments, and possible complications. It is especially important for the patient’s family to be well-versed on the patient’s disease to help foster a supportive environment for the patient. Measurement of Treatment Outcomes including those that are impairment based, activity participation-based and environmentally basedThe Pain Disability Questionnaire, 12-Item Short-Form Health Survey or Medical Outcomes Study 36-Item Short-Form Health Survey, and the Oswestry and McGill Pain Questionnaire can be used to monitor overall efficacy of treatments, functional improvement, and quality of life. The Functional Bowel Disease Severity Index, Inflammatory Bowel Severity Scale, Pelvic Girdle Questionnaire, Chronic Prostatitis Symptom Index are outcome measures specifically designed to measure pain and quality of life in patients with abdominal and pelvic pain. The Visual Analog Scale (VAS) can be used to rate an individual’s intensity of pain helping measure the effectiveness of treatments by comparing pre- and post-treatment VAS scores. Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
Cutting Edge/ Emerging and Unique Concepts and Practice
Gaps in the Evidence Based KnowledgeThere are many gaps in the evidence-based knowledge in visceral pain originating from the abdomen and pelvis. Chronic pelvic and abdominal pain may or may not have a clear organic etiology. Visceral pain, by definition of its local ambiguity, clouds identification of pain and can be challenging to accurately diagnose these patients. For patients without evident organic findings behavioral and psychologic comorbidities diagnosis may be even more difficult. Often complicated by a behavioral or psychologic diagnosis one cannot rule out concomitant somatoform or neuropathy (dysautonomia). Therefore, epidemiology, medical, interventional, rehabilitation, and psychologic treatment are very challenging. References
Original Version of the TopicSayed E. Wahezi, MD, Sunil Thomas, MD. Differential diagnosis and treatment of visceral pain in the pelvis and abdomen. 9/8/2015. Previous Revision(s) of the TopicAmeet S Nagpal, MD, MS, MEd, Darrell Vydra, DO, DPT, Caleb Seale, MD. Differential diagnosis and treatment of visceral pain in the pelvis and abdomen. 11/19/2019. Author DisclosureAmeet S Nagpal, MD, MS, MEd, MBA Aaron Yearsley, DO Which condition is characterized by lower abdominal or pelvic pain?Pelvic inflammatory disease (PID) is an infection of a woman's reproductive organs. It's usually caused by a sexually transmitted infection. Symptoms include stomach, lower abdominal pain and vaginal discharge.
Which disorder requires treatment with oral fluconazole?Fluconazole is used for many different fungal infections. If you have vaginal thrush, balanitis or oral thrush, your symptoms should be better within 7 days of taking fluconazole. If you have a serious fungal infection, ask your doctor how long it will take for fluconazole to start to work.
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