Online Health Chat with Joseph Abdelmalak, MD.
August 21, 2013
Chronic abdominal pain and chronic pelvic pain (CPP) can arise from many contributing factors or medical conditions. When the cause of the pain is known, your primary care physician, gastroenterologist or surgeon may treat the condition and, subsequently, the pain. But other times, 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, whether from a known or unknown cause.
Chronic abdominal pain, also known as chronic functional abdominal pain, is pain caused by an unexplained source. Chronic abdominal pain is the diagnosis when appendicitis, aortic dissection, aortic aneurysm, ulcers, Crohn’s disease, colon cancer, irritable bowel syndrome (IBS), diverticulitis and other diagnoses have been ruled out.
Chronic pelvic pain (CPP) is defined as nonmenstrual pelvic pain of more than three months’ duration that is severe enough to cause functional disability, and require medical or surgical treatment. Its hallmark is deep-seated, aching pain that often interferes with sleep and work, leads to urinary urgency and frequency, and causes pain with sex and/or urination. Some sources of chronic pelvic pain that can be diagnosed include endometriosis and interstitial cystitis.
Let’s Chat About Chronic Abdominal and Pelvic Pain
Moderator: Dr. Vrooman, thank you for joining the chat today. Let's begin with some of the questions that have been submitted.
Joseph_Abdelmalak_MD: Thank you for having me here today to discuss the various treatment options for abdominal pain. I enjoyed discussing this topic last year and look forward to questions this year. Some of the questions last year were quite specific to a person's medical condition. As you would expect, it is difficult to diagnose a condition without a complete history and physical exam, although I hope to touch base on a number of topics that may be helpful to the webchat participants.
naturelady: Since the end of May, I have been having sporadic pain about two inches below my navel, slightly to the right. Have also lost 20 lbs. My primary physician at first thought it was irritable bowel syndrome. He ran numerous tests, including blood work, abdominal and pelvic scan, and a colonoscopy. All were normal. The gastroenterologist thought that it may be a nerve entrapment or adhesions due to two prior cesarean sections. (The first was an emergency surgery with a vertical incision.) I also had a laparotomy. I also have many spinal issues and attend pain management. My latest MRI showed increased thoracic dextroscoliosis (side-to-side scoliosis) and kyphosis. I also have numerous issues in the lumbar area with the worst being moderate-to-severe grade1 anterolisthesis and severe right foraminal stenosis. Last week, the doctor at pain management suggested that this pain may be due to an abdominal neuroma—most likely from all the abdominal surgeries. He said that he could do cortisone injections to relieve it. Could you please give your opinion on abdominal neuromas.
Joseph_Abdelmalak_MD: It is fortunate that your laboratory work, imaging studies, and colonoscopy do not necessarily reveal conditions that merit further study or additional surgery. The spine issues you are having (dextroscoliosis, kyphosis, anterolisthesis, and foraminal stenosis) are likely contributing to your back pain and, depending upon the vertebral levels involved, radicular pain traveling down your leg. As you mentioned, this is being treated by your pain management physician. Physical therapy and possibly epidural steroid injections could help.
If your pain is very specific to one area, tender to palpation (pressing your finger against the abdominal wall at this area), and close to the location where you had an incision, it could be due to a neuroma, which is essentially a collection of nerve fibers. This pain is considered somatosensory (specific and discrete) rather than visceral (vague and diffuse) pain. The pain could be reduced by means of injecting a steroid and local anesthetic mixture at that site—with or without the use of ultrasound. If the results are temporary, it could be repeated. Cryoablation, or freezing of the neuroma, could also be considered with the use of a small probe that is inserted to that specific site with the use of local anesthetic in the skin to make the procedure more comfortable.
Spinal Sources of Abdominal Pain
naturelady: My gynecologist stated that numerous spinal problems may also contribute to abdominal pain. What is your opinion on that statement?
Bruce_Vrooman,_MD: Her statement is true. Nerve impingement in the spine, depending upon the level, may be contributing to pain. Occasionally, thoracic epidural steroid injections could help if it a protruding intervertebral disk or foraminal stenosis is contributing to the patient's pain.
Pain from Adhesions
Erin: I have had numerous abdominal surgeries (both laparoscopic and open) for gynecologic and urologic issues. I am assuming that I have many adhesions. Occasionally I have pain that occurs out of the blue or when I press on my abdomen. I have had an MRI to rule out any mass. Can adhesions actually cause pain? And is there anything that can be done?
Joseph_Abdelmalak_MD: You have had multiple surgeries. Surgeries may result in adhesions that could be contributing to pain. Occasionally, surgeons may perform lysis (separation) of adhesions to reduce the number of adhesions present. However, additional surgery increases the likelihood of more adhesions. The diffuse, vague abdominal pain that occurs sporadically may diminish over time or respond to treatment with a trial of medications such as membrane-stabilizing medications. There are risks and potential benefits associated with all medications including this class. A celiac plexus block or a splanchnic plexus block are procedures we perform in the pain management clinic that may help in the treatment of vague and diffuse visceral pain. (Plexus means a nerve network.) If this does help in the treatment, the block can be repeated or radiofrequency ablation could possibly be considered.
liesel: I am a 74-year-old female. I am dealing with a lot of lower abdominal pain, mainly on my lower left side. I also have rectal bleeding issues when going to the bathroom three or four times per week. I did have a sigmoidoscopy in 2008 and a colonoscopy in 2011. The gastroenterologist said nothing was wrong, but I possibly had a fistula I would have to live with.
I had a rectocele (the tissue separating the rectum and vagina) repair in 2001. A pelvic examination by my gynecologist two weeks ago did not reveal any problems. Should I worry about the constant rectal bleeding and the lower abdominal pain? What should my next step be since I already had the colonoscopy?
Joseph_Abdelmalak_MD: Rectal bleeding warrants a thorough evaluation by your gastroenterologic or colorectal surgery team. It is important to note when you are having the bleeding, the color of the blood, and if this coincides with when you are having pain. As with any pain condition, if there is an underlying active medical problem causing pain, it merits a full investigation into this problem. Treatment of the problem may understandably reduce the pain. In your particular situation, it is difficult to tell what is contributing to the bleeding given that you have had a quite thorough work-up. I would ensure that your colorectal surgeon also knows about this bleeding and inquire if, in fact, you do have a fistula that can be treated with surgery.
Undiagnosed Abdominal Pain Treatment
UndiagnosedPain: My wife, who has scheduled an appointment with you, has had undiagnosed abdominal pain for over one and one half years. She has had many diagnostic tests (endoscopies, endoscopic ultrasounds, stomach emptying studies, blood work, and imaging services) performed by primary care doctors and gastroenterologists. Pain doctors even tried an abdominal injection once, and a celiac plexus block at a later date, but it offered with no help. The consistent theme has thought to have been some sort of nerve damage issues, possible developing many years after gall bladder removal. What additional options might you offer? We have heard about more aggressive nerve block procedures or trying additional abdominal injections.
Joseph_Abdelmalak_MD: Patients frequently see me with a known diagnosis, such as chronic pancreatitis, that may be causing them pain. Here, the treatment options may be quite specific and include changes in lifestyle, avoiding alcohol, changing a diet, or performing procedures such as celiac plexus blocks, splanchnic radiofrequency ablation, and neurostimulation. (Plexus means a nerve network.)
In your wife's situation, it sounds that the diagnosis is unknown. Her pain is very real though. There is a procedure called a ‘differential epidural block’ that has shown to be helpful in identifying the pain that is centralized, visceral, or somatosensory. It is quite reliable in helping to identify the type of pain, and may suggest treatment options for the pain. We may consider this block after discussing her symptoms during her visit. After the differential epidural block, we may have a better sense of whether the pain is centralized, somatosensory or visceral.
Centralized pain may benefit from conservative therapies and medication management. Of note, there is no role for opioid medications in the treatment of chronic, nonmalignant abdominal pain, but other medications from other classes of medications may help.
Somatosensory pain may respond to specific nerve blocks performed under ultrasound along the abdominal wall. Visceral pain may respond to celiac plexus or splanchnic plexus blocks.
UndiagnosedPain: Thanks for the advice and encouragement. It is nice to know that at least you have ideas. My wife is here with me, and reminded me that she is scheduled for an electromyogram (EMG) at The Ohio State University Hospitals, in Columbus, the day before we see you. Would you recommend that she still have the EMG?
Bruce_Vrooman,_MD: No problem! Yes, please have the EMG to rule out any specific nerve entrapment or injury that could be contributing to her pain.
Gynecologic Sources of Pain
Fs: I have a very severe pain on my right side under the chest and above the belly. I had a CAT scan, and the results were fine, However, the left ovarian vein is dilated, and there are multiple large venous structures on the left side of my pelvis. There is a corpus luteum cyst in the right ovary, but the uterus is normal. Apart from this I'm having continuous diarrhea for about one and one half months. All of my blood work and stool tests are normal. The ultrasound also showed that the pain isn't caused by the cyst. I don't know what the cause is or how to treat this pain. I'm scheduled for an endoscopy and colonoscopy soon. I don't know if this would help to find the cause of pain. I have to pass gas and burp, after I eat but the pain still doesn't go away. It's always there even if am hungry or full. It gets worse and worse by the end of the day, or if I stand or walk for long periods of time. I took the Plan B pill (the ‘morning after’ birth control pill) two months ago and the pain started almost four days after I had that pill. But I never had such experience before whenever I took this pill before. What do you think might be the cause of the pain? And how should I get it treated?
Joseph_Abdelmalak_MD: It is difficult to identify the specific cause of your pain as there could be multiple causative factors. I would be interested in finding the results of the endoscopy and colonoscopy. I also would discuss with your gynecologist your particular response to the Plan B pill. Like with any medication, there can be side effects, although I would need to see if such pain has been described previously in the medical literature.
Centralization of Pain and Psychological Connection
cpatton84: I have been in disabling pain since I was 16 years old. I've had many tests and work ups. I have undergone a partial hysterectomy, and since then the pain has gotten worse. I am now being told it is in my head, and this is how my body handles stress. I am feeling hopeless. Do you have any suggestions on what route— if any— I should take?
Joseph_Abdelmalak_MD: When a person experiences pain, such as after a surgery, there can be ‘centralization’ of pain in the nervous system. Thus, pain may continue unabated (at original intensity) long after the original acute pain. We wish to use all possible treatment options to reduce this pain. Frequently, I work in conjunction with an abdominal pain psychologist who can train patients to use biofeedback, relaxation strategies, and other options to help in reducing the pain. The pain is not in your head, per se, but all pain pathways do involve the brain. Training the individual to help reduce pain can be very effective. Fortunately, counseling may help in the treatment of depression that frequently accompanies chronic pain. Also, very fortunately, there are antidepressants in the category called SNRIs (serotonin and norepinephrine reuptake inhibitors) that help treat both pain and depression. You are not alone in feeling both pain and depression. You may benefit from being treated in a multidisciplinary pain clinic.
bfc: What do you do when the doctors are telling you that it is all in your head? I have had many diagnostic tests with no results. I can't believe that this pain is not real. I have an appointment with a psychiatrist to see if he can offer me any relief. Do I just give up and believe them, or do I keep trying to find an answer?
Joseph_Abdelmalak_MD:Your pain is real, although frequently it is difficult to identify the specific cause of the pain. It may be due to the centralization of pain that I mentioned in response to an earlier question. Pain can be exasperating because of the hurt caused by pain, but also by a lack of control a patient seems to have in treating the pain. Patients I see used to be fully engaged in work, life at home exercise, and other activities until their particular pain affected all of these things, contributing to worsening pain and despair. Do not give up! Treatment can be very effective. It just depends on the particular treatment needed, either with a pain psychologist or a team approach toward treatment.
Several pain psychologists at Cleveland Clinic have a particular focus on helping patients with chronic abdominal pain of unknown origin. When patients have become dependent on controlled medications or have lost control and functionality, they may benefit from an interdisciplinary team rehabilitation program such as in the Cleveland Clinic Chronic Pain Rehabilitation Program, involving individual and group therapies.
It is worth the time to have an initial evaluation with a pain psychologist and then to continue with this therapy or consider the interdisciplinary approach.
Spinal Cord Stimulation for Abdominal Pain
Baldedemiel: Has there been success with the spinal cord stimulator for abdominal pain?
Joseph_Abdelmalak_MD: Yes. I have a number of patients who have excellent relief from abdominal pain with spinal cord stimulation. However, it is best chosen for patients who have appropriate expectations for such neurostimulation. I have found that patients who benefitted from blocks have obtained longer duration of relief from stimulators in the treatment of their pain. Peripheral nerve stimulators may be helpful for specific peripheral nerve injury whereas spinal cord stimulators have been helpful with diffuse, visceral abdominal pain. As mentioned regarding chronic pancreatitis, spinal cord stimulation can be helpful for this pain condition. We need more prospective randomized controlled trials in the field of neurostimulation to be able to predict success from this treatment option.
Pancreatitis Pain Treatment
Baldedemiel: What is the recommended course of treatment for someone with debilitating chronic pancreatitis pain?
Joseph_Abdelmalak_MD: There are different factors that may contribute to chronic pancreatitis (CP). Reducing triggers is the first step. A celiac or splanchnic plexus block may help. (Plexus refers to a nerve network.) Splanchnic radiofrequency may help if the initial block results were temporary. Neurostimulation may be very helpful in the treatment of this condition for the appropriate patient. We have performed a retrospective trial on patients implanted with neurostimulators at Cleveland Clinic, and found the results to be impressive. (We look forward to a prospective randomized controlled trial for evaluating neurostimulation in the treatment of CP.) There are surgical options including total pancreatectomy and auto islet cell transplantation, which is performed in our department of surgery, although this is for refractory CP (pancreatitis that can be treated alternatively) in the properly selected patient.
Moderator: I'm sorry to say that our time is now over. Thank you again, Dr. Abdelmalak, for taking the time to answer our questions today about chronic abdominal and pelvic pain.
Joseph_Abdelmalak_MD: Thank you for your excellent questions and for your patience in waiting for me to type responses! I look forward to this webchat again next year and I welcome new patients to visit Cleveland Clinic’s Pain Management Center for abdominal pain or other pain conditions.
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.
For More Information
On Cleveland Clinic
When chronic pain disrupts your quality of life and does not improve with standard treatment, Cleveland Clinic’s Department of Pain Management is here to help. There are many safe, proven treatments available that can eliminate or reduce chronic pain. Using the latest diagnostic technology, paired with medical and interventional therapeutics, our specialists will work with you to identify the source of the pain, eliminate or reduce the pain, and teach you to manage it. The sooner you seek effective treatment, the sooner you can start enjoying life again.
On Chronic Abdominal and Pelvic Pain
To learn more about the different treatment options for chronic pain related to any type of disease, injury or accident, download Cleveland Clinic free pain management guide.
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