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Abdominal pain

Published: 16 June 2013

IASP year of visceral pain

This year is the International Association for the Study of Pain (IASP) year of visceral pain so there are lots of resources about pain associated with GI disorders. Most reviews of GI pain mainly cover functional disorders such as IBS.
 
Qasim Aziz, one of the two IASP co-chairs for this year has written an article for the British Journal of Pain on pain associated with functional GI disorders. In that issue Mike Goulden also wrote a review which may be of more interest on pain associated with the pancreas.

Assessment/treatment strategies 
 

There do not seem to be any specific guidance documents about the management of abdominal pain in patients with neuroendocrine tumours (NET). A few guidance documents on pain in children exist but this was general abdominal pain of all aetiologies but no mention of analgesia! Just avoidance strategies such as laxative use, diet, avoiding stressors etc.  There are only a few primary research publications and most of these relate to functional bowel disorders (IBS, UC etc). 
 
The management of acute pain associated with an acute abdomen would be no different in a patient with NET. Consensus from the world of pain appears to be that opioids in general are not indicated for chronic (persistent) non-malignant pain (APA, BPS etc).  The British Pain Society has published numerous documents on opioids for persistent pain which can be accessed here. NSAIDs also need to be used with caution.
 
The management of pain say from an intestinal obstruction with a carcinoid tumour would be very similar to someone with a functional bowel disorder and a pseudo obstruction. Macaluso’s article provides a good structure on which to base your guidance document’s assessment of pain and associated signs (but only provides one short paragraph on analgesia).

Article abstracts

 

Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain


Roger Chou, Gilbert J. Fanciullo, Perry G. Fine, Jeremy A. Adler, Jane C. Ballantyne, Pamela Davies, Marilee I. Donovan, David A. Fishbain, Kathy M. Foley, Jeffrey Fudin, Aaron M. Gilson, Alexander Kelter, Alexander Mauskop, Patrick G. O'Connor, Steven D. Passik, Gavril W. Pasternak, Russell K. Portenoy, Ben A. Rich, Richard G. Roberts, Knox H. Todd, Christine Miaskowski, American Pain Society–American Academy of Pain Medicine Opioids Guidelines Panel

The Journal of Pain; Volume 10, Issue 2 , Pages 113-130.e22, February 2009.

Abstract

Use of chronic opioid therapy for chronic noncancer pain has increased substantially. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the evidence on chronic opioid therapy for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations. Although evidence is limited, the expert panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. The recommendations presented in this document provide guidance on patient selection and risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; monitoring of patients on chronic opioid therapy; dose escalations, high-dose opioid therapy, opioid rotation, and indications for discontinuation of therapy; prevention and management of opioid-related adverse effects; driving and work safety; identifying a medical home and when to obtain consultation; management of breakthrough pain; chronic opioid therapy in pregnancy; and opioid-related polices.

Perspective

Safe and effective chronic opioid therapy for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion. Although evidence is limited in many areas related to use of opioids for chronic noncancer pain, this guideline provides recommendations developed by a multidisciplinary expert panel after a systematic review of the evidence.

Key words: Clinical practice guideline, opioids, opioid analgesics, risk assessment, monitoring, chronic pain

 

Recurrent abdominal pain in adolescents: initial evaluation of an interdisciplinary pain rehabilitation program

D. Henry, A. Wojtowicz, G. Banez, T. Frazier, K. McDonald, K. Buchannan, S. Ali

The Journal of Pain; Volume 12, Issue 4, Supplement, Page P72, April 2011.

Article outline
Recurrent abdominal pain in adolescents is common, with a prevalence of 20% in middle school and high school students. A subset of these patients experiences a downward spiral of increasing functional disability. They do not attend school, interact with peers, and/or participate in sports/extracurricular activities. Their dysfunction profoundly affects activities of other family members. Though advances have been made on pharmacological and psychological treatments, unidisciplinary and symptom-focused strategies may not lead to an acceptable resolution. For severely affected patients, an interdisciplinary rehabilitation approach provides a useful model of care. The purpose of this research is to describe the effectiveness of interdisciplinary pain rehabilitation for adolescents with recurrent abdominal pain. Twenty-two adolescents (mean age = 15.54 years) with recurrent abdominal pain and associated disability were treated in a three-week, combined inpatient/day hospital pain rehabilitation program. Mixed model regression analyses revealed significant improvements made during and after the program. At admission, surveyed patients rated their pain a ‘7.25’ on a ‘0'-‘10’ scale. They averaged 4.0 missed school days in a week, and their parents reported an average of 2.40 missed work days in a week. At both 2- and 3-year follow-up points, surveyed patients rated their pain a ‘3.0’. Patients surveyed 2 years following the program averaged 0.13 missed school days/week, and their parents reported no missed work days. Those surveyed 3 years after program reported no missed school days/week, and their parents reported no missed work days. These results suggest that interdisciplinary pain rehabilitation is a promising approach to the management of recurrent abdominal pain and associated disability. Enduring improvements on real-world indices of pain and functioning were found two and three years following program completion. Ongoing research will examine program effectiveness on a broader range of self-report, parent report, and objective measures.

 

Manterola C, Vial M, Moraga J, Astudillo P. Analgesia in patients with acute abdominal pain. Cochrane Database Syst Rev

2007;3:CD005660