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

Abstract

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.

Bilateral distribution of anterior cutaneous nerve entrapment syndrome (ACNES): are clinical features and outcomes comparable to unilateral ACNES?

“…As a result, ACNES is still often neglected as a possible cause of abdominal pain and discomfort and is considered a frequently overlooked diagnosis 3. The diagnosis itself relies entirely on undertaking a thorough medical history combined with searching for sensitive clues at physical examination (circumscript pain localization, positive Pinch test, Carnett’s test and abnormal sensory mapping).…”

“…We have also evaluated a number of patients with such a symmetrical bilateral pain syndrome at the umbilical level (T10) who were referred following an unsuccessful umbilical hernia repair elsewhere. Moreover, it may very well be that an initial neglect for the contralateral side could lead to this specific type of pain being overlooked, as is observed in ACNES in general 3. Therefore, a physician should be aware of these bilateral presentations by frequently repeating ACNES-tests on the contralateral side 7…”

“…However, in up to 30% of patients with CAP, pain is found to originate from the abdominal wall rather than from a viscus 2. CAP in these individuals often results from anterior cutaneous nerve entrapment syndrome (ACNES) although this diagnosis is frequently not considered 3. Wrongfully attributing CAP to intra-abdominal disorders could lead to unnecessary consultations, testing, and even futile abdominal surgery.…”

Multidisciplinary Approach to Chronic Pelvic Pain

“…The characteristic feature of chronic abdominal wall pain is localization of pain to a highly discrete region of the abdomen. The cause of the pain is cutaneous nerve entrapment from the neurovascular bundles of T7 to T12 caused by intra-or extra-abdominal pressure or localized scarring [22]. Cyclic abdominal wall pain in reproductive-aged women with prior abdominal surgery may suggest abdominal wall endometriosis.…”

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

“…ACNES is caused by entrapment of branches of intercostal nerves (Th 8–12) causing severe CAP. Myofascial pain and radiculopathy are considered less frequent causes of abdominal wall pain 7 8. As a tertiary referral centre, our research group is especially interested in CAP due to ACNES.…”