Differential diagnosis and treatment of visceral pain in the pelvis and abdomen

Author(s): Sayed E. Wahezi, MD, Sunil Thomas, MD

Originally published:09/08/2015

Last updated:09/08/2015

1. DISEASE/DISORDER:

Definition

Visceral pain is a poorly localized ‘achy and dull’ sensation of the abdomen or pelvis. It is thought to be an autonomic nociceptive response of the abdominal or pelvic viscera to organ distension or hypermuscular contraction. Stretching, distension, or ischemia of abdominal or pelvic organs may cause visceral pain.1

Etiology

Organ Inflammation

  1. Chemical irritation
    • Enzymatic
      • Gastric
      • Biliary
      • Pancreatic
      • Duodenal
    • Infection
      • Parenchymal
      • Organ capsule
    • Mechanical irritation
      • Kidney Stones
      • Neoplasm

Disruption of normal mechanical processes

  1. Organ obstruction
    • Neoplasm
      • Benign
      • Malignant
    • Increased peristalsis
    • Decreased peristalsis

Visceral Neuropathy

  1. Postoperative pain
    • Hypersensitive visceral nociceptors
      • Alpha 1-R upregulation2
    • Ischemia

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. Adhesions
    • Surgical approach
      1. Use of peritoneal mesh
    • Age
    • Type of procedure

Smoking

  1. Malignancy
  2. Organ ischemia

Alcohol

  1. Malignancy
  2. Pancreatitis

Diet

  1. Periabdominal fat
  2. Gastritis

Diabetes

  1. Hypomotility

Trauma

  1. Pelvic Organ Prolapse

Infection

  1. H. Pylori

Psychosocial factors

  1. History of sexual abuse
  2. Somatoform disorder

Patho-anatomy/physiology

Most commonly infection, inflammation and neoplasms of hollow organs, fascia, and fascial lining of the following structures.

Foregut

  1. Stomach
  2. Duodenum
  3. Liver
  4. Pancreas

Midgut

  1. Small bowel
  2. Proximal colon
  3. Appendix

Hindgut

  1. Distal colon
  2. GU tract

Retroperitoneal

  1. Aorta
  2. Kidneys
  3. Ureters

Pelvis4

  1. Muscular endopelvic fascial lining
    • Levator ani
    • Coccygeus
  2. Organs
    • Rectum
    • Prostate
    • Bladder
    • Uterus
    • Ovaries
    • Prostate

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 or radiation/chemotherapy treatment commonly improves symptoms5

Specific secondary or associated conditions and complications

Can be associated with autonomic phenomena such as:

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

2. ESSENTIALS OF ASSESSMENT

History

  1. “Dull/colicky” pain.
  2. Exacerbating factors
    • Abdomen
      • Commonly worse with eating
    • Pelvis
      • Worse with urination, sexual intercourse, or defecation
  3. Poorly localized
  4. History of abdominal/pelvic surgery
  5. Dysautonomia
    • Nausea
    • Vomiting
    • Pallor
    • Diaphoresis
    • Restlessness
  6. Psychosocial
    • Depression
    • Introversion
    • History rape/abortion

Physical examination

  1. Assessment of patient’s appearance, position and degree of discomfort
  2. Vital signs
  3. Surgical scars
  4. Percussion of the abdomen for detection of hepatomegaly, splenomegaly, abdominal masses, ascites, masses, pulsations or aneurysms or hernias
  5. Palpation of the abdomen/pelvis for areas of tenderness, signs of peritoneal inflammation.
  6. Flank percussion (Murphy’s punch) to evaluate for renal pathology
  7. Rectal examination if complaining of peri-anal pain
    • Manual prostate examination
      • Pain
      • Bogginess
      • Mass
  8. Pelvic examination if complaining of dyspareunia or vulvodynia
    • Pelvic examination includes inspection of external genitals, speculum examination, and bimanual 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.

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
    • Pain with eating, defecation, sex
    • Validated Measures
      • Functional Bowel Disease Severity Index
      • Inflammatory Bowel Severity Scale
      • Pelvic Girdle Questionnaire
      • Chronic Prostatitis Symptom Index

Laboratory studies

  1. Urinalysis
    • Infectious
      • Leukocytes/Nitrite/Nitrate/Culture
    • Varices
      • RBC
  2. Stool
    • Blood
    • Leukocytes
    • Parasites
  3. Blood
    • Ectopic
      • HCG
    • Midgut
      • Elevated Amylase/lipase
      • Elevated Calcium
    • Celiac
      • ESR/CRPAnti-gliadin
  4. Semen/Vaginal
    • Infectious
      • Chlamydia/Gonorrhea
    • E. Coli
  • Maligancy
    • CEA (Gut)
    • CA19-9 (Ovarian/Pancreatic)
    • CA 125 (Ovarian)
    • PSA (Prostate)
    • AFP (Liver/Reproductive)

Imaging

  1. Xray
    • Gastric/Colon Paresis
    • Calculi
    • Mass
  2. Barium GI Series
    • Obstruction
      • Mechanical
      • Metabolic
        • Decreased peristalsis
  3. Ultrasound
    • Neoplasm
    • Cholecystitis
    • Cholelithiasis
    • Calculi
    • Cysts
    • Free fluid
    • Varicosities
  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 Cholangeopancreatography (MRCP)
      • Biliary Tree analysis when ERCP contraindicated
  6. Invasive
    • Endoscopy/Colonoscopy
      • Lumen analysis
        • Mass
        • Ulceration
        • Polyps
        • Biopsy
    • ERCP
      • Foregut duct obstuctions
    • Cystoscopy
      • Ulcer
      • Glomerulations
      • Biopsy

Supplemental assessment tools

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

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 utilized 6.

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 households that 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 both from a professional standpoint as well as from a patient safety standpoint.

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, dysautonomia is thought to be the cause and percutaneous sympathetic blocks and ablations are performed, such as at the celiac and superior hypogastric plexus.

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, a surgical evaluation may be necessary for certain diagnoses [e.g. Bowel Obstruction, cholecystitis, appendicitis (both visceral and somatic), etc.]

Postoperative period (up to one month)

  1. Intravenous analgesia (inpatient only)
    • Ibuprofen
    • Acetaminophen
    • Opiates
    • Ketamine
  2. Oral analgesia
    • Nonsteroidal anti-inflammatories
    • Acetaminophen
    • Opiates
    • Antiseizure medications
    • Nonselective serotonin reuptake inhibitors
    • Antispasmotics
  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.

Subacute (Recovery phase)- Involves transition to home setting as well returning to work and normal daily activities. Patient may need ongoing outpatient rehabilitation focusing on mobility, scar management, desensitization techniques, TENS. May require continued need for oral/topical analgesic therapy as listed above.

  1. Chronic (maintenance therapy)/ End of life care- includes all of the above as well as use of possible interventional procedures such as ganglion blocks to help treat intractable pain.
    • Celiac ganglion block- Celiac ganglion block is applied most commonly to patients with pancreatic, gastric, or biliary cancer who have severe intractable abdominal pain.
    • Splanchnic nerve block- For patients in whom celiac ganglion block has failed, splanchnic nerve block may provide a viable alternative.7

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 cancer survivor support groups.

Patient & family education

Patient education is very important throughout the stages of recovery. Patients as well as family members must be educated on the disease process, treatments as well as possible complications

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

Spectrum of care includes education, activity modification, physical therapy, 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.

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

Cutting edge concepts and practice

  1. Ablation of abdominal and pelvic tumors
    1. Investigational procedures
    2. Demonstrated preliminary efficacy.
  2. Spinal cord, vagus, and splanchic stimulation technology have produced variable successful reports for abdominal pain.
    1. 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 literature.
  3. Spinal Cord Stimulation
    1. Traditional Frequency
      1. -40-60 Hz
      2. Produces paresthesias in the abdomen and pelvis, altering pain transduction o High frequency spinal cord stimulation
      3. 1200-10,000 Hz
      4. No paresthesias but believed to stimulate the medial thalamus, causing altered emotional response to pain
      5. May be the future of chronic refractory abdominal/pelvic visceral pain treatment as well but this technology is new and there are few reports supporting this as a current abdomen/pelvis treatment modality. 8
  4. Intrathecal Therapy
    1. May be used after failure of oral medical management
      1. Opiates
        1. Morphine
        2. Fentanyl
        3. Sufentanyl
        4. Dilaudid
        5. Methadone
      2. Local Anesthetics
        1. Bupivicaine
        2. Lidocaine
      3. Other
        1. Clonidine
        2. Ketamine
        3. Baclofen
        4. Ziconitide

In comparison to conventional or low frequency spinal cord stimulation, high frequency stimulation is unique in that it provides paresthesia free analgesia by stimulating beyond the physiologic frequency range. The preliminary results have been mixed and a large randomized control trial is underway to evaluate the future of this technology.9

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

NA

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 ambiguitiy, 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

1 Dahl JL. Effective pain management in terminal care. Clin Geriatr Med. 1996;12:279-300.

2 Mellar P. Davis. Drug Management of Visceral Pain: Concepts from Basic Research. Pain Research and Treatment, vol. 2012, Article ID 265605, 18 pages, 2012. doi:10.1155/2012/265605

3 Origoni, M; Maggiore, U. Neurobiological Mechanisms of Pelvic Pain. Biomed Res Int. 2014; 903848.

4 Bailey, A; Bernstein, C; Pain in Women: A Clinical Guide (2013) pp 17-58, Springer-Verlag New York.

5. Sikandar S, Dickenson AH. Visceral Pain – the Ins and Outs, the Ups and Downs. Curr Opin Support Palliat Care. 2012; 6: 17–26.

6. Mystakidou, K., Katsouda, E., et al. (2004). “Use of the Greek McGill Pain Questionnaire in cancer patients.” Expert Rev Pharmacoecon Outcomes Res 4(2): 227-233

7. Tam, A; Ahrar, K. Palliative Interventions for Pain in Cancer Patients. Semin Intervent Radiol. 2007 Dec;24(4):419-29.

8. Qin,C; Martinez, M,. Is constant current or constant voltage spinal cord stimulation superior for the suppression of nociceptive visceral and somatic stimuli? A rat model. Neuromodulation. 2012 Mar-Apr;15(2):132-42.

9. Song, JJ; Popescu,A. Present and potential use of spinal cord stimulation to control chronic pain. Pain Physician. 2014 May-Jun;17(3):235-46.

Author Disclosure

Sayed E. Wahezi, MD
Nothing to Disclose

Sunil Thomas, MD
Nothing to Disclose

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