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Chronic Abdominal Pain: What You Should Know

Online Health Chat with Bruce Vrooman, MD

August 21, 2012

Introduction

Cleveland_Clinic_Host: Chronic abdominal pain may arise from many contributing factors. Frequently the cause for the pain is known and treatments by a primary care, gastroenterology or surgical team may be directed toward treating the cause and, subsequently, the pain. Sometimes, despite an extensive work-up by these teams, the cause of the pain may not be clear, but the pain may be debilitating just the same. Patients with abdominal pain may then be referred to a pain management clinic for evaluation and treatment of their pain, whether from a known or unknown cause.


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A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult


For Appointments

To make an appointment with Bruce Vrooman, MD, or any other specialist in our Department of Pain Management at Cleveland Clinic, please call 216.444.PAIN. You can also visit us online at www.clevelandclinic.org/painmanagement


About the Speakers

Bruce Vrooman, MD is board-certified in pain management and anesthesiology. His specialty interests include abdominal and pelvic pain, back and neck pain, cancer pain, complex regional pain syndrome, interventional pain management for back and neck pain, management of chronic pain, neuropathic, pelvic pain, reflex sympathetic dystrophy, and spine pain. Dr. Vrooman is a member of the following professional associations: American Society of Anesthesiology, American Society of Interventional Pain Physicians, American Medical Association, and American Society of Regional Anesthesia and Pain Medicine. Dr. Vrooman completed his fellowship in pain management at the Cleveland Clinic. He completed his residency in pain management at Boston University Medical Center after graduating from medical school at Eastern Virginia Medical School, in Norfolk, Va.


Let’s Talk About Chronic Abdominal Pain

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic expert Dr. Bruce Vrooman. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.


Chronic Pelvic Neuropathy
Jechse: I have been diagnosed with chronic pelvic neuropathy. A nerve block was performed, which was unsuccessful, along with two unsuccessful attempts with a spinal cord stimulator. I have been seen by several specialists, including two pain management providers. None of the providers have been able to offer any hope of treatment with the exception of pain medications. I am currently taking Neurontin®, oxycodone, amitriptyline and Opana®. The medications barely help with pain management. I would greatly appreciate your input on this disease and treatment. Thank you very much for your time.
Dr__Vrooman: Thank you for your question. There can be many different causes of this type of pain condition. Treatment of the underlying cause is clearly the best treatment option. However, the underlying cause is sometimes not readily apparent. I am assuming that this has been the case for you. A nerve block may be helpful to identify the specific nerve that may be irritated. It seems that this has not helped. Another nerve, such as the pudendal nerve, may be involved, depending upon your symptoms. Perhaps this could be performed if it has not been done already. If the pain is visceral (frequently a deep and dull pain) in origin, a superior hypogastric plexus block could be considered. Regarding medications, chronic opioid therapy is rarely useful for a neuropathy such as yours. Membrane stabilizing medications, such as gabapentin, need to be at a therapeutic level in order to be effective. This could be tried, though side effects may occur, particularly at higher doses.

 

Gastroparesis with Severe Obstructive Vasovagal Syndrome
Sita: I have been dealing with disabling gastroparesis for three years now. I, also, have severe obstructive vasovagal syndrome. I have been told to live on a liquid diet. I have been told that I will have to live with the attacks that I have with every bowel movement. Basically, I try not to eat at all. What I do eat builds up over about six weeks and then leads to a bowel movement. My body reacts as if I have a bowel obstruction and I end up in the emergency room for a day or two. No one here has been able to help.  My cardiologist said that he thinks your clinic is my only chance at a normal life. I have fibromyalgia and mitral valve prolapse as well. I am only 41 years old. My husband and I are about to start a foster family. I can't live like this anymore. I appreciate any help or information that you can provide to me about this. Thank you so much
Dr__Vrooman: Gastroparesis clearly can lead to constipation and visceral pain that is caused by dilating the abdominal organs, such as the stomach and the loops of bowel. I would recommend having a thorough evaluation with a gastroenterologist who could consider treatment for the underlying gastroparesis. There are medications that could possibly help. Technology has come a long way as well in the evaluation of gastroparesis, including a capsule that measures transit time, pressure, temperature and pH in the digestive tract. Technology has also been helpful in the treatment, such as with what is known as a ‘gastric pacemaker’ or ‘gastric stimulator.’ This may help in reducing gastrointestinal transit time.

This may be a good opportunity to describe the Chronic Abdominal Pain Clinic (CAPC) at Cleveland Clinic. This involves an evaluation with a gastroenterologist, a pain psychologist and a pain physician that can be coordinated through the CAPC. Patients come from around the country to be evaluated in this clinic.

 

Irritable Bowel Syndrome and Possible Endometriosis
mw2000: I've had constant low-intensity abdominal pain for 12 years, caused by irritable bowel syndrome or possibly endometriosis. So far, I've been told to live with it, but it's waking me up at night, leaving me fatigued. Is there any hope for pain management?
Dr__Vrooman: I'm sorry to hear about this pain condition. Irritable bowel syndrome is a painful and aggravating condition. This may be quite amenable to treatment strategies advocated by our pain psychologist. These include relaxation strategies, biofeedback and other treatment options. Biofeedback is particularly interesting, and may be helpful for abdominal pain as well as chronic back pain or extremity pain. Some patients find that this and other pain conditions are disabling. Working with a pain psychologist or in an interdisciplinary rehabilitation program can sometimes be helpful, particularly for those patients who have become dependent upon opioid medications.

In regard to endometriosis, this may be treated surgically if indicated. Given that the pain may be visceral, a nerve block such as a superior hypogastric plexus block may be helpful for pain that has not responded to medications or other therapies.


Pediatric Pain Management
jch: My 12-year-old daughter has had chronic abdominal pain for three years, and while her gastroenterologist has been able to assist with some of the pain, she is still uncomfortable. Is she too young to be treated by a pain management doctor?
Dr__Vrooman: I would recommend that she come in for an evaluation, given that her pain is very real for her. We have specialists within our pain management department for the various specialties in our field, including pediatric pain management as well as other fields of pain management, such as back pain, complex regional pain syndrome and cancer-related pain to name a few.


Gynecological Issues with Abdominal Pain
dark_waters: I am 31 years old and have had three children. Not long after my last delivery, I started having severe abdominal pains as well as painful intercourse. My doctors have done laparoscopies, an MRI and an ultrasound and found nothing. Endometriosis has been ruled out. I have been trying Lupron Depot®. If this last shot doesn’t help or work, my doctor says the next best thing may be a hysterectomy. That scares me and seems kind of drastic without a definitive diagnosis. What are your thoughts?
Dr__Vrooman: Prior to considering a hysterectomy, I would recommend scheduling an office visit for evaluation in a pain management clinic. These symptoms may be indicative of visceral pain that may possibly be treated more conservatively, with a diagnostic and then a potentially therapeutic nerve block.


Small Bowel Obstruction
A_blank: I have had minor and major small bowel obstructions (SBOs) since megasurgery last year that are unresolved. The test only shows distension of the small intestine, no kinks, twists, adhesions or tumors. How do I cope with the strong cramps and abdominal pain that accompany mild SBOs?
Dr__Vrooman: Symptoms such as cramps may be indicative of a small bowel obstruction. This is good to know in case the obstruction worsens, in which case you should have close observation with your primary team. If the symptoms persist despite no evidence of obstruction, you could consider a muscle relaxant medication possibly, though these are not without possible side effects such as sedation. It is important to identify the cause of symptoms, such as cramping, prior to treatment with medications that may lessen the effect of the symptoms, such as cramping. In your case, you have identified that this may be related to a small bowel obstruction that you seem to have investigated quite thoroughly.


Unidentified Abdominal Pain
boondocks: What are the treatment options for abdominal pain when you can't find a cause?
Dr__Vrooman: Abdominal pain is usually from one of three sources: somatosensory, visceral or central. Somatosensory usually involves the abdominal wall and the nerves that course through the muscles of the abdominal wall. Visceral pain involves the abdominal organs themselves. Central pain may result from chronic pain that has existed for a long period of time and may, in a sense, result from the ‘plasticity’ of the abdominal nervous system. Frequently a cause is identified for abdominal pain, and treatment may range from medication to injections or to surgery. When the cause is not known, as is also quite often the case, we try to identify if the pain is from one of the three main causes above. We may perform a diagnostic test to help identify the cause. Treatment may help improve pain management and functionality, as these are our main goals.

Dr__Vrooman: Treatment may involve physical therapy, injections performed under ultrasound or fluoroscopy in our pain clinic, and to more advanced treatments.

larryg: What do you do with undiagnosed abdominal pain? The doctors have done every test and can not find anything. When do you as a physician give up and just try and treat the pain (so far little has helped on that front either!) and no longer look for a cause?
Dr__Vrooman: Clearly, this is a common question, as it is very similar to the last one and one that patients often pose in the clinic. It is important to work with a primary care physician and a gastroenterologist first to help identify a cause. We first look for a cause as well, but can frequently identify a nerve that is involved by performing a nerve block early in our diagnosis and treatment paradigm. A specific nerve block, such as an ilioinguinal nerve block, genitofemoral nerve block or a transversus abdominis plane blockade may be helpful in diagnosis and potential therapy. If the pain seems visceral in nature by the history and examination, a block such as a celiac plexus block may be helpful if more conservative approaches have not been effective.

johnny: I have severe stomach pains that also can go around to my back, and down to my groin. The physician’s test came out negative. It was suggested that it was constipation. I have taken laxatives, but it has not helped. Could this still be constipation, or should I keep looking for another answer?
Dr__Vrooman: It is difficult to diagnose your pain based on your description alone. I would recommend an evaluation with a pain physician for your specific concern. However, given that the pain has not resolved with laxatives, there could be other causes for your pain. The pain could be due to nerve irritation in your back that is causing pain to travel toward your abdomen and your groin. This merits further investigation if the pain has been this debilitating.

ring_a_ling: What are some of the possible causes of abdominal pain?
Dr__Vrooman: Some common causes are conditions such as thoracic disc displacement as well as neuralgias from intercostal, iliohypogastric, ilioinguinal and genitofemoral neuralgias. There are numerous conditions contributing to visceral pain, including gastritis, chronic pancreatitis, Crohn's disease, ulcerative colitis, appendicitis, cholecystitis and malignancies as well, to name a few conditions. Sometimes patients have chronic pain after multiple surgeries in the past. Clearly, work-up with your primary care physician or gastroenterologist should precede a visit to a pain physician.

Lauren: I am 45 years old and for the past two years, I have been suffering with chronic abdominal pain with severe intestinal inflammation. I have had a CT scan, gastrointestinal series, lactose test (scored 8-6-7), bacterial overgrowth test (12 -66), colonoscopy, endoscopy and blood work done. All came back negative. The endoscopy showed mild gastritis. H. pylori and celiac disease all came back negative as well. I was put on omeprazole for 30 days and rifaximin  550 mg and had no relief. I have seen four different gastroenterologists, and have basically been dismissed because they cannot pinpoint the cause of the intestinal inflammation. The only test that has not been done is either an X-ray or CT Scan to check for pneumatosis intestinalis. The only thing I'm currently taking is probiotics. Can you please give me your opinion as what else I should be tested for, and what can possibly be causing the severe intestinal inflammation? I can't take the pain & discomfort anymore. Thank you.
Dr__Vrooman: Your pain condition has been challenging, most certainly for you, as well as your physicians from what I understand from your question. I would recommend a thorough evaluation at our Chronic Abdominal Pain Clinic to consider all of the possible pain generators including those you mentioned. A thorough, interdisciplinary approach is often best.


Psychology of Pain
sweetness: When they say the pain is all in your head, how can this be? Why and how would a psychological issue manifest itself as pain in the abdomen?
Dr__Vrooman: Pain is real. No question about it. There may be conservative measures that can help, including cognitive behavioral therapy or biofeedback as an adjunct to nerve blocks if pain has contributed to depression, anxiety or disability. Frequently, one nerve block alone may not cure a chronic pain condition, but may be helpful in combination with counseling, only if indicated.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic expert Bruce Vrooman, MD is now over. Thank you Dr. Vroonan for taking your time to answer our questions today about Chronic Abdominal Pain.

Dr__Vrooman: Thank you for your questions today. For more information about our services, please consider going to our website at clevelandclinic.org/painmanagement or call 216-444-PAIN for an appointment.


Contact Information

For Appointments
To make an appointment with Bruce Vrooman, MD, or any other specialist in our Department of Pain Management at Cleveland Clinic, please call 216.444.PAIN. You can also visit us online at www.clevelandclinic.org/painmanagement

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