Differential Diagnosis and Treatment of Visceral Pain in the Pelvis and Abdomen

Author(s): Ameet S Nagpal, MD, MS, MEd, Darrell Vydra, DO, DPT, Caleb Seale, MD

Originally published:09/08/2015

Last updated:11/19/2019

1. DISEASE/DISORDER:

Definition

True 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 dull1. It is usually associated with autonomic features (e.g. sweating, nausea and vomiting) and highly emotional (e.g. anxious, feeling of impending doom).

Patho-anatomy/physiology

The 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 effect2.

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.

Etiology

Anatomical:

Foregut

  1. Stomach
  2. Duodenum
  3. Liver
  4. Gallbladder
  5. Bile ducts
  6. Pancreas

Midgut

  1. Small bowel
  2. Proximal colon
  3. Appendix

Hindgut

  1. Distal colon
  2. Genitourinary tract

Retroperitoneal

  1. Aorta
  2. Kidneys
  3. Ureters

Pelvis4

  1. Muscular endopelvic fascial lining
    • Levator ani
    • Coccygeus
  2. Organs
    • Rectum
    • Bladder
    • Uterus
    • Ovaries
    • Prostate
    • Vulva/Scrotum
    • Urethra
    • Perianal region

Physiological:

Organ Inflammation

  1. Chemical irritation
    • Enzymatic
      • Gastric
      • Biliary
      • Pancreatic
      • Duodenal
    • Infection
      • Parenchymal
      • Organ capsule
      • Interstitium
    • Mechanical irritation
      • Nephrolithiasis, cholelithiasis
      • Neoplasm
      • Fibroids

Disruption of normal mechanical processes

  1. Organ obstruction and distention
    • Neoplasm
      • Benign
      • Malignant
    • Calculi
    • Stenotic ducts
    • Increased peristalsis
    • Decreased peristalsis
    • Muscle spasm

Ischemia

  1. Impaired circulation:
    • Thrombus
    • Embolism
    • Hypotension

Clinical Variants of Abdominal and Pelvic Visceral Pain

  1. True Visceral Pain
    • Nociception arises from pain fibers in deep lying abdominal or pelvic organs
    • (+) tissue injury
  2. Visceral Hyperalgesia
    • Slow, poorly localized i.e. colic
    • Proposed Mechanisms:
      • Sensitization of primary sensory afferents innervating the viscera (e.g., direct tissue injury via PEG tube placement)
      • Hyperexcitability of spinal ascending neurons (central sensitization) receiving synaptic input from the viscera (e.g., irritable bowel syndrome)
      • Dysregulation of descending pathways that modulate spinal nociceptive transmission (e.g., SCI, TBI, CVA)
      • Alternation in sensory neurons so that they are more responsive to naturally occurring stimuli. (peripheral) An enhanced sensitivity of the sensory pathways in the brain (central). (e.g., TBI, CVA)
  1. Viscero-Viscero Hyperalgesia
    • Sensory interaction between two different organs that share the same sensory pathway
  2. Viscero-Somatic Pain
    • Pain experienced in a somatic portion of the body secondary to organ irritation due to shared somatic and visceral innervation (e.g., Left shoulder pain secondary to a ruptured spleen)

Epidemiology including risk factors and primary prevention

Chronic 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 year3.

Risk factors

Surgery

  1. Distorted/altered anatomy
  2. Increased risk of visceral hyperalgesia
  3. Adhesions
    • Surgical approach
      1. Use of peritoneal mesh
    • Age
    • Type of procedure

Smoking

  1. Malignancy
  2. Organ ischemia

Alcohol

  1. Malignancy
  2. Pancreatitis
  3. Cholelithiasis
  4. Cirrhosis

Diet

  1. Periabdominal fat
  2. Gastritis
  3. Low fiber diet (i.e., constipation)

Diabetes

  1. Hypomotility
  2. Diabetic neuropathy (i.e., gastroparesis)

Trauma

  1. Childbirth (i.e., organ prolapse)

Infection

Psychosocial factors

  1. History of sexual abuse
  2. Somatoform disorder

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 symptoms4.

Specific secondary or associated conditions and complications

Can be associated with autonomic phenomena such as:

  1. Pallor
  2. Profuse sweating
  3. Nausea
  4. Gastrointestinal disturbances
  5. Changes in body temperature
  6. Hypotension
  7. Tachycardia

2. ESSENTIALS OF ASSESSMENT

History

  1. The onset is often insidious
  2. Pain is poorly localized. Exceptions include biliary, pancreatic, renal, appendix
  3. True visceral pain is dull/colicky pain, but depending on the etiology the pain can transform to sharp
  4. Exacerbating factors
    • Abdomen
      • Commonly worse with eating
    • Pelvis
      • Worse with urination, sexual intercourse, or defecation
  5. Dysautonomia
    • Nausea
    • Vomiting
    • Pallor
    • Diaphoresis
    • Restlessness
  6. Medical history
    • Diabetes
    • Anxiety/depression
    • Post-traumatic stress disorder
    • Cancer
    • Female patients: menstrual cycle, pregnancy
  7. Surgical history
    • Abdominal/pelvic surgeries
  8. Social history
    • Tobacco, alcohol, illicit substance use
    • Sexual trauma
    • Living situation

Physical examination

  1. Review the vital signs prior to seeing the patient: looking for tachycardia, tachypnea, fever
  2. Assessment of patient’s appearance, position on the exam table, and degree of discomfort
  3. Perform and cardiac and pulmonary exam
  4. Inspect for surgical scars and skin discoloration
  5. Auscultate the abdomen listening for increase/decreased activity and pitch of bowel sounds and bruits
  6. Percuss the abdomen for detection of hepatomegaly, tympany, shifting dullness
  7. Palpation of the abdomen/pelvis for areas of tenderness, signs of peritoneal inflammation (pain out of proportion to exam), masses, pulsations, hernias, ascites
  8. Abdominal special tests
    • Abdominal wall pain: Carnett’s sign (sensitivity 78% specificity 88%)- with the patient supine, palpate the tender area, then ask them to tense their abdomen by either raising their head/shoulder off the table or lifting both straightened legs off the table5. The test is positive if the pain worsens.
    • Renal pathology: Flank percussion (Murphy’s punch)
    • Biliary pathology: Murphy’s sign
    • Appendicitis: psoas, obturator, Rovsing’s signs
    • Ascites: shifting dullness, fluid wave
  9. Rectal examination if complaining of peri-anal pain
    • Manual prostate examination
      • Pain
      • Bogginess
      • Mass
  10. Pelvic examination if complaining of dyspareunia or vulvodynia
    • External examination
      • Inspection of external genitals for scars, uterine/rectal prolapse, sexual transmitted diseases
      • Palpation of pelvic floor assessing for trigger points in the ischiocavernosus, bulbocavernosus, superficial transverse perineal, external anal sphincter, and the anterior/posterior levator ani mucles
    • Internal Examination
      • The cervix is inspected for discharge, uterine prolapse, and cervical stenosis or lesions. Bimanual examination should assess cervical motion tenderness, adnexal masses or tenderness, and uterine enlargement or tenderness.
        1. Trigger points can be assessed during the bimanual exam. Specific muscles include ischiocavernosus, bulbocavernosus, superficial/deep transverse perineal, coccygeous, piriformis, obturator internus, and the anterior/posterior levator ani mucles

Clinical functional assessment: mobility, self-care and cognition/behavior/affective state

  1. Chronic abdominal/pelvic pain has strong association with psychological comorbidities
    • Depressed mood
    • Anorexia
    • Poor Focus
    • History of sexual abuse
    • Postprandial pain, pain with defecation, dyspareunia
    • Validated Measures
      • Functional Bowel Disease Severity Index
      • Inflammatory Bowel Severity Scale
      • Pelvic Girdle Questionnaire
      • Chronic Prostatitis Symptom Index

Laboratory studies

  1. Blood
    • Lactate
    • ESR/CRP
    • Amylase/lipase/calcium
    • Bilirubin
    • Beta hCG
    • Auto-immune labs if there is clinical suspicion as many conditions can present with visceral pain6
  2.  Urine
    • Infectious
      • Bacteria/WBC/Leukocyte esterase/Nitrite/Culture
    • Vasculitis
      • RBC/WBC/Casts
  3. Stool
    • Blood
    • Leukocytes
    • Lipids
    • Parasites
    • Bacteria
  4.  Semen/Vaginal
    • Infectious
      • Chlamydia/Gonorrhea
  5. Malignancy
    • CEA (Gut)
    • CA 195 (Gut)
    • Gastrin (Gastrinoma)
    • CA19-9 (Ovarian/Pancreatic)
    • CA 125 (Ovarian)
    • TPA (Non-specific for gynecologic, bladder, lung)
    • PSA (Prostate)
    • AFP (Liver/Reproductive)

Imaging

A 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.

  1. Ultrasound
    • Neoplasm
    • Cholecystitis
    • Cholelithiasis
    • Calculi
    • Cysts
    • Free fluid/air
    • Varicosities
  2. Radiograph
    • Gastric/Colon Paresis
    • Calculi
    • Masses
  3. Barium GI Series
    • Obstruction
      • Mechanical
      • Metabolic
        1. Decreased peristalsis
  4. CT
    • Inclusive of US findings and:
    • Appendicitis
    • Organ distension
    • Aortic aneurysm
    • Organ wall thickening
    • Diverticulitis
    • Nephrolithiasis
    • Cystitis
    • Prostatitis
    • Proctitis
    • Fistula
    • Adhesions
  5. MRI
    • Inclusive of CT findings and:
      • Active inflammation
      • Organ blood flow analysis
    • Magnetic Resonance Cholangiopancreatography (MRCP)
  6. Invasive
    • Endoscopy/Colonoscopy
      • Lumen analysis
        1. Mass
        2. Ulceration
        3. Polyps
        4. Biopsy
    • ERCP
      • Foregut duct obstructions
    • Cystoscopy
      • Ulcer
      • Glomerulations
      • Cancer

Supplemental assessment tools

  1. Pelvic EMG- evaluate for pelvic floor dysfunction
  2. Vaginal manometry
  3. Pap smear – to evaluate for possible malignancy
  4. Rectal manometry
  5. Diagnostic celiac plexus block for evaluation of foregut dysautonomia
  6. Barium contrast studies
  7. Diagnostic superior hypogastric plexus block for evaluation of pelvic visceral etiology
  8. Behavioral evaluation
  9. Psychologic evaluation
    • Depression Questionnaire (i.e. PHQ-2, PHQ-9, Geriatric Depression Scale)

Early prediction of outcomes

Early 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.

Environmental

Chronic 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 system

Many 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 issues

Many 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 overdose8.

3. REHABILITATION MANAGEMENT AND TECHNIQUES

Available or current treatment guidelines

Generally 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 stages

New 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.].

  1. Intravenous analgesia (inpatient only, typically post-operatively):
    • Ibuprofen
    • Acetaminophen
    • Opiates
    • Ketamine
  2. Oral analgesia:
    • Nonsteroidal anti-inflammatories
    • Acetaminophen
    • Antiseizure medications
    • Nonselective serotonin reuptake inhibitors
    • Antispasmodics
    • Opioids as a last line therapy
  3. Topical:
    • Lidocaine
    • Prilocaine/lidocaine
    • Capsaicin
      • not to be used on mucosal surfaces
    • Rehabilitation- involves early mobilization, transfers, bed mobility, wound care. May require stay in acute rehabilitation setting depending on diagnosis and surgical intervention performed.
  4. Percutaneous Sympathetic Blocks:
    • Few reports have evaluated optimal timing for celiac plexus neurolysis, some suggest for those with malignant disease, neurolysis may be more effective when performed early before development of a substantial viscero-somatic component, leading some authors to advocate for its use as a first-line treatment modality9.
    • Idiopathic coccydynia, though not a true visceral etiology, is another indication as the coccygeal plexus or its branches can be involved2.

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.

  • Chronic abdominal pain associated with malignancy secondary to direct invasion or mass effect on viscera and surrounding structures by pancreatic, biliary, and gastric cancers, or metastases from hematogenous or lymphatic spread is a common indication for sympathetic blocks.
  • Nonmalignant sources of chronic abdominal pain include chronic pancreatitis from inflammatory processes or from biliary pathology like common bile duct stenosis10 and is composed of pre- and postganglionic sympathetic, parasympathetic and visceral sensory afferents fibers.
    • For pelvic viscera-associated pain, possible interventions include superior hypogastric plexus (SHP) blocks, inferior hypogastric plexus (IHP) blocks, and the ganglion impar block11.
    • For patients with successful sympathetic blocks, neurolytic blocks are a mainstay in the management of cancer pain and may be performed with either phenol or alcohol for longer lasting relief2.
      • The complication rate from celiac plexus neurolysis (CPN) or splanchnic nerve neurolysis (SNN) with either treatment is low, estimated to be 1 – 2%12.
    • Radiofrequency ablation of the splanchnic nerves is an option, though infrequently performed for cancer pain.

Coordination of care

  1. Development of acute pain service for management of postoperative pain.
  2. Providing multimodal analgesia to improve postoperative pain treatment.
  3. Patients should be managed by an extended multidisciplinary team (pain, GI/Ob/gyn, surgery, rehabilitation, psychiatry) and enrolled in psychologist-administered support groups specific to the etiology of pain.

Patient & family education

Visceral 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 the patient’s family to 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 based

The 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

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

  1. Spectrum of care includes education, activity modification, medication management, and surgery if the inciting agent is operable.. The WHO stepladder for analgesia may be a useful tool to aid with medication management. Once conservative treatment is fully utilized, interventional procedures should be considered to help reduce intractable pain. However, in patients with terminal diagnoses with significant pain, these procedures should be considered as early as possible.
  2. Physical therapy offers multiple non to minimally invasive modalities for treatment which are generally well-tolerated. More research is needed to prove the efficacy of the listed modalities in a multitude of pain etiologies.
    • Myofascial induction/manual manipulation/ therapy: has been shown to decrease pain related to scar formation13,14.
    • Auricular acupuncture: possible therapy for acute abdominal pain3
    • Yoga: proposed to improve pain associated with irritable bowel syndrome in children15.
    • Neuromuscular therapy: suggested as an alternate therapy for women with dysmenorrhea16.
    • Dry needling: has been shown to improve pain related to trigger points17,18.
    • Dry cupping: minimally invasive, however has not reliably demonstrated improvement of pain specifically related to trigger points14,17.
    • Transcutaneous electrical nerve stimulation: improvement in pain related to many abdominal/pathologies including chronic pelvic pain and constipation related abdominal pain19,20.

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

Cutting edge concepts and practice

  1. Ablation of abdominal and pelvic tumors
    • Investigational procedures
    • Demonstrated preliminary efficacy.
  2. Spinal cord, vagus, and splanchic stimulation technology have produced variable successful reports for abdominal pain.
    • Conus medullaris and sacral stimulation products (dorsal root ganglion stimulation) are currently being improved for refractory sacral pain indication but have thus far produced marginal success in the literature21.
  3. Radiofrequency ablation (RFA) techniques:
    • Conventional RFA carries a risk of inadvertent damage to motor nerves secondary to the thermocoagulation effect.
    • Pulsed radiofrequency (PRF) treatment is carried out in similar fashion as conventional RFA; however, the current is typically carried out in 20-ms pulses every 0.5 s at a temperature that does not exceed 42 °C22,23. This lower temperature allows for a non-ablative, neuromodulatory treatment, thus sparing motor or sensory destruction.
  4. Spinal Cord Stimulation
    • Traditional Frequency:
      • 50-100 Hz
      • Produces paresthesias in the abdomen and pelvis, altering pain transduction
      • Support for successful symptom control with lead placement at the conus medullaris or the mid‐thoracic region21.
      • Further studies are needed to explore this as a reliable and viable option in specific etiologies of visceral pain.
      • While dorsal column stimulation has shown great promise, alternative technology outside the dorsal column focused on concentrating current in the dorsal root ganglion or targeting individual nerves as demonstrated through peripheral nerve stimulation has demonstrated efficacy in case series24.
  5. Intrathecal Therapy
    • May be used after failure of oral medical management
      • Opiates
        1. Morphine
        2. Fentanyl
        3. Sufentanyl
        4. Dilaudid
        5. Methadone
      • Local Anesthetics
        1. Bupivacaine
        2. Lidocaine
      • Other
        1. Clonidine
        2. Ketamine
        3. Baclofen
        4. Ziconitide

5. GAPS IN THE EVIDENCE BASED KNOWLEDGE

Gaps in the Evidence Based Knowledge

There 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.

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Original Version of the Topic

Sayed E. Wahezi, MD, Sunil Thomas, MD. Differential diagnosis and treatment of visceral pain in the pelvis and abdomen. 09/08/2015.

Author Disclosure

Ameet S Nagpal, MD, MS, MEd
Nothing to Disclose

Darrell Vydra, DO, DPT
Nothing to Disclose

Caleb Seale, MD
Nothing to Disclose

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