Chronic continuous abdominal pain: evaluation of diagnostic features, iatrogenesis and drug treatments in a cohort of 103 patients.

Published on May 1, 2019in Alimentary Pharmacology & Therapeutics7.515
· DOI :10.1111/APT.15241
Eleesia Kilgallon1
Estimated H-index: 1
(Salford Royal NHS Foundation Trust),
Dipesh H. Vasant10
Estimated H-index: 10
(University of Manchester)
+ 4 AuthorsPeter Paine15
Estimated H-index: 15
(University of Manchester)
Sources
Abstract
BACKGROUND: Chronic continuous abdominal pain (CCAP) is characteristic of centrally mediated gastrointestinal pain disorders. It consumes significant healthcare resources yet is poorly understood, with minimal cohort-specific data in the literature. AIMS: To examine in a large cohort of CCAP patients, (a) diagnostic features, (b) iatrogenic impact of opioids and surgery, (c) drug treatment effects and tolerance. METHODS: Consecutive tertiary CCAP referrals to a neurogastroenterology clinic (2009-2016) were reviewed for Rome IV and neuropathic pain criteria. Medical, surgical and drug histories, interventions and outcomes were correlated with clinical diagnosis and associated opioid use. RESULTS: Of 103 CCAP patients (mean age 40 ± 14, 85% female), 50% had physiological exacerbations precluding full Rome IV Centrally Mediated Abdominal Pain Syndrome criteria. However, there were no significant differences between patients who satisfied Rome IV criteria and those who did not. Overall, 81% had allodynia (a nonpainful stimulus evoking pain sensation). Opioid use was associated with allodynia (P = 0.003). Prior surgery was associated with further operations post CCAP onset (P < 0.001). Although 68% had undergone surgical interventions, surgery did not resolve pain in any patient and worsened pain in 35%. Whilst duloxetine was the most effective neuromodulator (P = 0.003), combination therapy was superior to monotherapy (P = 0.007). CONCLUSIONS: This is currently the largest cohort CCAP dataset that supports eliciting neuropathic features, including allodynia, for a positive clinical diagnosis, to guide treatment. Physiological exacerbation of CCAP may represent visceral allodynia, and need not preclude central origin. Use of centrally acting neuromodulators, and avoidance of detrimental opioids and surgical interventions appear to predict favourable outcomes.
📖 Papers frequently viewed together
2017
1 Author (Tarek Shams)
1998
1 Author (M. Zenz)
1 Citations
References28
Newest
#1Eva Szigethy (University of Pittsburgh)H-Index: 38
#2Mitchell R. Knisely (University of Pittsburgh)H-Index: 9
Last. Douglas A. Drossman (UNC: University of North Carolina at Chapel Hill)H-Index: 103
view all 3 authors...
Chronic opioid use is increasing worldwide and has negative effects in the gastrointestinal and central nervous systems. This Review summarizes the evidence and consequences of opioid misuse in gastroenterology, as well as alternative pharmacological and nonpharmacological strategies for pain management in patients with gastrointestinal disorders.
48 CitationsSource
#1Douglas A. Drossman (UNC: University of North Carolina at Chapel Hill)H-Index: 103
#2Jan Tack (Katholieke Universiteit Leuven)H-Index: 126
Last. Lukas Van Oudenhove (Katholieke Universiteit Leuven)H-Index: 39
view all 6 authors...
Background & Aims Central neuromodulators (antidepressants, antipsychotics, and other central nervous system−targeted medications) are increasingly used for treatment of functional gastrointestinal disorders (FGIDs), now recognized as disorders of gut−brain interaction. However, the available evidence and guidance for the use of central neuromodulators in these conditions is scanty and incomplete. In this Rome Foundation Working Team report, a multidisciplinary team summarized available research...
113 CitationsSource
#1Katja Kovacic (MCW: Medical College of Wisconsin)H-Index: 10
#2Keri R. Hainsworth (MCW: Medical College of Wisconsin)H-Index: 15
Last. Adrian Miranda (MCW: Medical College of Wisconsin)H-Index: 20
view all 8 authors...
Summary Background Development of safe and effective therapies for paediatric abdominal pain-related functional gastrointestinal disorders is needed. A non-invasive, US Food and Drug Administration-cleared device (Neuro-Stim, Innovative Health Solutions, IN, USA) delivers percutaneous electrical nerve field stimulation (PENFS) in the external ear to modulate central pain pathways. In this study, we evaluated the efficacy of PENFS in adolescents with abdominal pain-related functional gastrointest...
48 CitationsSource
#1W Harley Sobin (United Hospital)H-Index: 1
#2Thomas W. Heinrich (MCW: Medical College of Wisconsin)H-Index: 10
Last. Douglas A. DrossmanH-Index: 103
view all 3 authors...
Patients with functional GI disorders (FGIDs) are commonplace in the gastroenterologist's practice. A number of these patients may be refractory to peripherally acting agents, yet respond to central neuromodulators. There are benefits and potential adverse effects to using TCAs, SSRIs, SNRIs, atypical antipsychotics, and miscellaneous central neuromodulators in these patients. These agents can benefit mood, pain, diarrhea, constipation, nausea, sleep, and depression. The mechanisms by which they...
26 CitationsSource
#1Marijke J. Molegraaf (EUR: Erasmus University Rotterdam)H-Index: 2
#2Bart Torensma (LUMC: Leiden University Medical Center)H-Index: 8
Last. Dingeman J. SwankH-Index: 3
view all 6 authors...
Background Laparoscopic adhesiolysis as a therapy for chronic pain is still controversial, and long-term effects are not known; therefore, our aim was to evaluate long-term effects of laparoscopic adhesiolysis for the treatment of chronic abdominal pain believed to be related to intraperitoneal adhesions. Methods A total of 100 patients with abdominal pain attributed to adhesions were randomized to laparoscopic adhesiolysis or a placebo group with laparoscopy alone. Pain relief was assessed afte...
11 CitationsSource
#1Jeremy R. Glissen Brown (TU: Temple University)H-Index: 6
Last. Adam C. EhrlichH-Index: 10
view all 4 authors...
Chronic abdominal wall pain (CAWP) refers to a condition wherein pain originates from the abdominal wall itself rather than the underlying viscera. According to various estimates, 10% to 30% of patients with chronic abdominal pain are eventually diagnosed with CAWP, usually after expensive testing h
19 CitationsSource
#1Douglas A. Drossman (UNC: University of North Carolina at Chapel Hill)H-Index: 103
#2William L. HaslerH-Index: 62
480 CitationsSource
#1Laurie Keefer (ISMMS: Icahn School of Medicine at Mount Sinai)H-Index: 40
#2Douglas A. Drossman (UNC: University of North Carolina at Chapel Hill)H-Index: 103
Last. Peter J. WhorwellH-Index: 83
view all 7 authors...
Centrally mediated abdominal pain syndrome, formerly known as functional abdominal pain syndrome, can be distinguished from other functional gastrointestinal disorders by its strong central component and relative independence from motility disturbances. Centrally mediated abdominal pain syndrome is a result of central sensitization with disinhibition of pain signals rather than increased peripheral afferent excitability. A newly described condition, narcotic bowel syndrome/opioid-induced gastroi...
58 CitationsSource
#1Stefan A. W. Bouwense (Radboud University Nijmegen)H-Index: 2
#1Stefan A.W. Bouwense (Radboud University Nijmegen)H-Index: 23
Last. Oliver H.G. Wilder-Smith (Radboud University Nijmegen)H-Index: 46
view all 5 authors...
BACKGROUND: Pain control in chronic pancreatitis is a major challenge; the mechanisms behind analgesic treatment are poorly understood. This study aims to investigate the differences in pain sensitivity and modulation in chronic pancreatitis patients, based on their clinical response (responders vs nonresponders) to placebo or pregabalin treatment. METHODS: This study was part of a randomized, double-blind, placebo-controlled trial evaluating the analgesic effects of pregabalin and placebo in ch...
15 CitationsSource
#1Laurie Keefer (NU: Northwestern University)H-Index: 40
#2S. Mandal (Albany Medical College)H-Index: 1
Last. S. Mandal (Albany Medical College)H-Index: 1
view all 2 authors...
Background Chronic abdominal pain carries a substantial health care burden but little is known about best practices for it management across ambulatory, hospital, and emergency room settings. This is especially true when abdominal pain presents in the absence of peripheral triggers like tissue injury (e.g. appendicitis) or altered bowel movements (e.g. IBS). Unfortunately, once central sensitization has occurred, pain can present wiithout any stimulation or with minimal peripheral stimulation (f...
18 CitationsSource
Cited By8
Newest
#1Umair Akbani (University of Manchester)
#2Dipesh H. Vasant (University of Manchester)H-Index: 10
Source
PURPOSE OF REVIEW To provide an update on the recent evidence underpinning the approach to nutritional care in patients with severe primary chronic small bowel dysmotility. RECENT FINDINGS Patients with severe chronic small intestinal dysmotility suffer nutritional and nonnutritional morbidity, both as a result of their underlying polysymptomatic, poorly understood condition and the interventions required. A proportion require artificial nutrition support; however, this is associated with impair...
Source
#1Hang Yang (Sichuan University)
Last. Bing Hu (Sichuan University)H-Index: 20
view all 3 authors...
Background null Centrally mediated abdominal pain syndrome (CAPS) is characterized by continuous or frequently recurring abdominal pain and can result in functional loss across several life domains. The efficacy of the present management methods has not been established yet. We performed a prospective randomized controlled trial to explore the short-term efficacy of local analgesic (lidocaine) and opioid analgesic (sufentanil) in patients with CAPS. null Methods null We consecutively enrolled 13...
Source
#1Dipesh H. Vasant (University of Manchester)H-Index: 10
#2Simon Lal (University of Manchester)H-Index: 33
Severe gastrointestinal motility disorders with small bowel involvement continue to pose a major clinical challenge to clinicians, particularly because of the limitations of diagnostic tests and the lack of efficacious treatment options. In this article, we review current understanding and the utility of diagnostic modalities and therapeutic approaches, and describe how their limitations may potentially exacerbate prolonged suffering with debilitating symptoms, diagnostic delays, the risk of iat...
Source
#1Dipesh H. Vasant (University of Manchester)H-Index: 10
#2Peter Paine (University of Salford)H-Index: 15
Last. Alexander C. Ford (St James's University Hospital)H-Index: 86
view all 13 authors...
Irritable bowel syndrome (IBS) remains one of the most common gastrointestinal disorders seen by clinicians in both primary and secondary care. Since publication of the last British Society of Gastroenterology (BSG) guideline in 2007, substantial advances have been made in understanding its complex pathophysiology, resulting in its re-classification as a disorder of gut-brain interaction, rather than a functional gastrointestinal disorder. Moreover, there has been a considerable amount of new ev...
4 CitationsSource
Source
#1Peter Paine (Salford Royal NHS Foundation Trust)H-Index: 15
#2Marie McMahon (Salford Royal NHS Foundation Trust)H-Index: 2
Last. Simon Lal (Salford Royal NHS Foundation Trust)H-Index: 33
view all 5 authors...
The decision to commence jejunal feeding in patients with structural abnormalities, which prevent oral or intragastric feeding, is usually straightforward. However, decisions surrounding the need for jejunal feeding can be more complex in individuals with no clear structural abnormality, but rather with foregut symptoms and pain-predominant presentations, suggesting a functional origin. This appears to be an increasing issue in polysymptomatic patients with multi-system involvement. We review th...
2 CitationsSource
#1J.M.D. NightingaleH-Index: 21
#2P Paine (University of Salford)H-Index: 2
Last. Simon Lal (University of Salford)H-Index: 33
view all 6 authors...
Adult patients with severe chronic small intestinal dysmotility are not uncommon and can be difficult to manage. This guideline gives an outline of how to make the diagnosis. It discusses factors which contribute to or cause a picture of severe chronic intestinal dysmotility (eg, obstruction, functional gastrointestinal disorders, drugs, psychosocial issues and malnutrition). It gives management guidelines for patients with an enteric myopathy or neuropathy including the use of enteral and paren...
5 CitationsSource
#1Dipesh H. Vasant (University of Manchester)H-Index: 10
#2Loris Pironi (UNIBO: University of Bologna)H-Index: 37
Last. Simon Lal (University of Manchester)H-Index: 33
view all 13 authors...
BACKGROUND Chronic intestinal pseudo-obstruction (CIPO) and enteric dysmotility (ED) are small intestinal motility disorders defined by radiological and manometric criteria. In the absence of consensus guidelines, we surveyed opinions on the diagnosis and management of CIPO and ED among experts from different countries. METHODS A survey questionnaire was circulated electronically to members of the European society for Clinical Nutrition and Metabolism, European Society of Neurogastroenterology a...
3 CitationsSource