Abdominal Wall Pain. What is Abdominal Wall Pain?

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1 Abdominal Wall Pain What is Abdominal Wall Pain? Abdominal Wall Pain is a syndrome (an experience) of abdominal pain that can occur at any time of life and is not unique to children. It is diagnosed by a typical history of long-standing continuous, localized abdominal pain and a characteristic finding on physical exam of localized tenderness not relieved by abdominal tension. Abdominal Wall Pain is not associated with any abnormal findings on laboratory tests, x-rays and even at surgery. It is a real pain not imaginary or psychological. What are the typical symptoms of Abdominal Wall Pain? The pain tends to be more severe than other types of pain. It usually occurs every minute of every day. Abdominal Wall Pain can occur anywhere in the abdomen. Typically there is always a background pain, that suddenly gets severe, stays severe for half-an-hour or so and then slowly lessens back to the background pain. The pain occurs at any time of the day or night. Abdominal Wall Pain often is worse with muscular activity such as exercise coughing or vomiting. The pain is not related to what is called visceral function the working of the internal organs so there is usually no rhyme or reason to the pain. In other words, the pain is not usually related to meals (although it can be if the pain is high in the abdomen) it can occur before, during, shortly after or a long time after meals. It is not related to bowel movements in that is does not regularly occur before a bowel movement or after a bowel movement. It is not related to movement or activity. It is not related to urination. The child is otherwise well. How is Abdominal Wall Pain diagnosed? Abdominal Wall Pain is diagnosed on the description of the pain and the physical examination. The test that proves the diagnosis is the finding of tenderness in the abdomen on physical examination which is unaffected or made worse with tension of the abdominal pain. Figures 1 and 2 illustrate the finding. In figure 1 the patient is asked to lie relaxed on their backs. An area of tenderness is found by pressing on the abdomen. This painful area means that the pain is coming from the skin, the underlying fat, the

2 muscles or the organs within the abdominal cavity. The tenderness does not differentiate any of these layers other than it is very rare for pain to come from the fat, and skin tenderness is usually easily identified by the patient. In essence the pain is either coming from the internal organs or the abdominal muscles. The patient is then asked to elevate their shoulders and head of the table, or to elevate their legs in a straight leg raise. This tenses the abdominal muscles so they can t be dented by the examining finger as in figure 2. The area of tenderness is again checked to see if it still exists. If the tenderness is coming from inside the abdominal cavity from one of the internal organs, then the tenderness should no longer be there since no pressure is being placed on the organs. If the tenderness remains, and particularly if it is worse, then it is coming from the muscle or possibly, but much less likely, the skin or the abdominal fat. Laboratory tests can only rule out other possible diagnoses. However, if the child presents with the symptoms and signs described above, it highly likely that all tests will be normal, and if they are abnormal, probably don t relate to the pain. How can we sure that the pain is not coming from something else? In the assessment of the pain, each organ is carefully considered to make sure it is not contributing to the pain. This is relatively easy in that each organ tends to have a typical pain pattern. Let s consider each organ in the abdomen that could give rise to abdominal pain. Diseases of the esophagus that cause pain, give pain behind the chest bone, typically after eating or waking from sleep in the middle of the night. Typically there is the experience of acid material coming into the throat. Esophageal pain is relieved by drinking milk, taking antacids or taking acid-reducing drugs. Stomach or duodenal pain is experienced when there is a lot of acid in the stomach. It is felt above the belly button and is very meal related - tending to occur before meals - or in the middle of the night. Drinking milk or taking antacids rapidly relieves stomach or duodenal pain.

3 Small intestinal pain occurs when the small intestine is working. It is felt in the same mid-abdominal area (around the belly button) as does Recurrent Abdominal Pain of Childhood. However, small intestinal pain is very much meal related occurring 15 to 60 minutes after a meal and not occurring between meals. Colonic pain occurs when the colon is moving stool along. It is typically felt below the belly button, often on the left side, and occurs before and rarely after a bowel movement. It is relieved by a bowel movement. Gallbladder pain is a severe pain occurring above the belly button usually in the midline but also occurring to the right. It comes on infrequently (usually every few weeks or months), comes on severely, stays constantly for several hours often resulting in a visit to emergency. Pancreas pain is also a severe pain occurring above or around the belly button usually in the midline. It comes on infrequently (usually at least every few weeks), comes on severely, stays constantly for days often resulting in a visit to emergency. Kidney pain occurs to the back and rarely gives abdominal pain. Bladder pain is very low in the abdomen, gets worse prior to peeing and is relieved by peeing. Gynecological pain is extremely rare in girls who have not entered puberty, and if present is felt very low in the abdomen. As stated above, Abdominal Wall Pain is diagnosed in the setting of an otherwise well child, with the typical history and physical examination findings, without any of the above descriptions to the pain, Concern as to whether the problem is really Abdominal Wall Pain should be expressed if any of the following occurs: Weight loss

4 Significant occurrence at night Diarrhea especially with blood Constipation as evidenced by large, hard infrequent stools Vomiting An otherwise ill child Episodic occurrence to the pain with pain-free intervals in between. What tests should be done for Abdominal Wall Pain The test that makes the diagnosis is the physical examination findings described in detail above. There are no blood tests or imaging tests for Abdominal Wall Pain. Medical tests are done to rule other things out. How can the pain be so bad if it is only a muscle? This is perhaps the most common question asked by patients and parents in patients diagnosed with Abdominal Wall Pain. The reason is that there are a lot more pain fibres in the abdominal muscles than there are anywhere in the abdomen. The reason that I give is that the abdominal wall has two main functions as muscles keeping us upright and in helping us to sit up, and to protect the insides the vital organs. To do this these muscles have been endowed with lots of pain fibres. When we were cave people, if we were going to be poked with a spear, if the spear went through the abdominal muscles into the intestines, death was a sure thing due to infection. By having lots of pain fibres, the muscles can detect the spear, and let us fall back or protect ourselves, before the spear goes too deep. Therefore, given the huge amount of pain fibres in the abdominal wall compared to those in the vital organs, it is quite understandable that the pain is that bad! Why does the pain keep going on in Abdominal Wall Pain? The abdominal muscles are quite different from the muscles of the arms and legs. Rather that relaxing in response to pain like the arm and leg muscles, these muscles tense in response to pain. This results in a vicious circle which prolongs or worsens the injury, thus worsening the pain. Pain results in tensing or spasm of the muscle, which results in injury which results in pain, and the cycle continues.

5 What are the risks for Abdominal Wall Pain? The medical only risk is if another cause of pain arises that is passed off as Abdominal Wall Pain such as appendicitis. The rule here is that if a different pain arises, and particularly if it is severe, it should be evaluated by a physician and not considered Abdominal Wall Pain until diagnosed otherwise. The other major and common risk is that Abdominal Wall Pain might dominate the child s life. This pain is generally more severe than any of the usual causes of abdominal pain in children. Since it tends to be chronic, everything should be done to keep the child integrated into their school and activities. The pain will be there whether the child is at school or at home so nothing medical can be gained by staying home. How is Abdominal Wall Pain treated? First of all, it must be stated that abdominal wall is hard to treat. The main objective is to break the pain-spasm-injury cycle by either reducing the pain or by reducing the spasm. Four layers of therapy are used. If layer one does not work, layer 2 is added. If layer 1 and 2 don t work then layer 3 and or 4 may be added. Layer 1 should always be done even if layer 3 or 4 is being used. Layer 1: Heat, Stretching and Pain Prevention As with any muscular pain, physiotherapy is really helpful. Part of physiotherapy is muscle stretching, to improve the range of motion of the muscles and to prevent spasms. If anyone has ever had a Charlie-horse in their calves, they realize that stretching the calf is one of the only things that can bring relief. Therefore stretching the abdominal muscles is very important. Heat: To help stretch muscles they need to be warmed up. Therefore, the following is very helpful. A bath towel is placed under hot running tap water at the highest temperature that the hands can tolerate squeezing out the water. With the patient lying down, the hot compress is placed on the painful area.

6 Stretching: After the towel has cooled a bit and the abdomen is warmed (at least 3 minutes), then two stretching exercises are recommended. One is sometimes called the sloppy push-up. As illustrated with the stick figures in figure 3, in this exercise the patient, lies on their front and with the arms the shoulder are pushed up, while the hips stay on the floor or bed, bending the back and stretching the stomach. One should expect that this will cause some pain in the usual area of the Abdominal Wall Pain. One should stretch to a tolerable level of pain, holding that stretch for at least 30 seconds. It should be repeated once. The second exercise is the knee-over stretch. In this exercise, the patient lies on their back. While keeping both shoulders touching the bed or floor, the left leg is kept straight, the right leg is flexed at the hip letting the knee flex to a 90 degree angle. The right knee is then pushed over the straight left leg until the knee touches the floor or bed on the opposite side of the left leg, or until just before the pain becomes too much. The knee is kept at this distance for at least 30 seconds. It is repeated once. The stretch is then done on the opposite side. While keeping both shoulders touching the bed or floor, the right leg is kept straight, the left leg is flexed at the hip letting the knee flex to a 90 degree angle. The left knee is then pushed over the straight right leg until the knee touches the floor or bed on the opposite side of the right leg, or until just before the pain becomes too much. The knee is kept at this distance for at least 30 seconds. It is repeated once. Pain Prevention: It is much easier to prevent the pain rather than treating it once it is there. To do this, acetaminophen (Tylenol) is given at full dose whether the patient has pain or not. It is for preventing the pain that initiate the spasms, and therefore trying to prevent the ongoing injury that is taking place. The acetaminophen starts as soon as the patient wakes up and is continued at the intervals recommended on the acetaminophen bottle for the size of the patient. If the patient is able to swallow big pills then long acting acetaminophen 650 mg pills should be used since they have a more constant pain relieving quality. Level 2: The use of an anti-inflammatory

7 Non-steroidal anti-inflammatory drugs (known by doctors as NSAIDS) have both pain relieving properties and anti-inflammatory properties. They can reduce the inflammation that occurs in the muscle. Motrin and Advil are examples of ibuprofen which is a commonly used medication. Why they are not used as first-layer, is that they can bother the stomach and actually cause abdominal pain. The NSAIDs are used instead of the regularly administered acetaminophen above. Long-acting NSAIDs which require a prescription are preferred but Motrin or Advil can be used. The NSAIDs are given regularly at a dose and frequency recommended by the doctor. Tylenol can still be taken but is generally taken for bad pain rather than regularly. They should be continued until the pain has disappeared plus two weeks before stopping them. Level 3: Local Injection of the Tenderness Site Sometimes the patient has a trigger point one spot that can be identified with one finger that on pressure causes the typical pain. If this is so, this area can be injected much as one would inject a painful shoulder or knee. To do this, a long acting freezing (local anaesthetic) is mixed with a steroid in a syringe with a needle. The trigger point is identified. After sterilizing the skin with alcohol, the needles is pushed into the trigger point muscle and the steroid and anaesthetic are injected directly into the painful muscle. The muscle is then massaged to spread the medication around. This injection usually results in significant improvement of the pain for about 24 hours. The pain does come back since the anaesthetic disappears but the pain is usually less. The steroids then have an affect for several weeks. The main objective of the injection is not to get rid of the pain, but to lessen the pain enough to allow the patient to do the stretches more effectively. As with any injection into the body there are risks and are the same as any injection or vaccination. An allergy to the anaesthetic can occur. Although rare, the injection can make the pain worse by bothering the nerves. Done

8 too often, the injection can cause atrophy (a shriveling up) of the injected muscle. Level 4: Chronic Pain Management Medications and Psychological Support There are no specific drugs for Abdominal Wall Pain. As with any pain, there are pain pills that can help with the pain regardless of the cause. In addition to the acetaminophen and NSAIDS described above, narcotics are effective pain relievers. However, narcotics are exceedingly addictive and should not be used for this pain. Fortunately there are pain modifiers that can help. All of these change the perception of pain rather than affecting the cause of the pain. They can be a helpful adjunct to the control of the pain. Three medications are commonly used for the treatment of severe Abdominal Wall Pain. One can use a small does of amitriptyline an old antidepressant that has pain relieving properties and some antispasmodic activity. It does have side-effects including sleepiness, interference with learning and dryness. Gapabentin or pregabalin (Lyrica) can occasionally be used, but there are frequent side effects as well. Cymbalta is another antidepressant-type medication that has pain relieving properties. All of these medications should only be used in extreme cases and under close supervision. Psychological Support: There are four ways to treat people with a disease 1) physical treatment such as stretches and heat, 2) drugs, 3) Surgery and 4) Psychology. There is not surgery that can be done. If the physical treatment and drugs are unhelpful, then the only thing left is psychological support. This is not meant to mean that psychological support should be left to last, but rather it should be considered at every step of the way. However, in the absence of a definite psychiatric problem, it tends to be left to the last. Patients are often hesitant to receive psychological support since they perceive it as a weakness or they don t see how it can help. Quite the

9 contrary, psychological help has been very helpful in the management of any chronic pain syndrome and should be considered in every case of Abdominal Wall Pain that doesn t get better with level 1 therapy. Finding internal means and strength for dealing with the pain can be very effective in helping the pain and in getting rid of the pain. A psychology referral can definitely make the difference.