abdominal pain

Understanding Pain Centralization States

/ Thomas Cohn, MD

One of the newer ideas that is gaining better understanding in the pain community is the concept of pain centralization. This is the general category that a lot of other pain problems fall under. The most common condition is Fibromyalgia, but other conditions such as TMJ, irritable bowel syndrome and some tension headaches are similar. The main characteristic is that the disturbance is processed differently by the brain, and a diffuse increase to pain fiber stimulation then occurs. There are an altering of levels of neurotransmitters affecting pain transmission.

The key finding in all the conditions characterized by centralized pain states is a significant increased sensitivity to sensory stimuli. Chronic pain is often found in multiple regions of the body over a period of time. Multiple other types of symptoms also occur including fatigue, sleep difficulties, mood changes and memory problems. Symptoms are often triggered by a stressful event, such as an infection, brain injury or trauma. Multiple discrete areas of pain are found, and can be present with other diseases such as rheumatoid/osteoarthritis and hyper-laxity conditions like Ehlers-Danlos or Marfans Syndromes.

These conditions are a continuum of pain problems starting from acute peripheral pain to chronic centralized diffuse pain. It affects from 2-8% of the population, and is about twice as common in females. There is a strong familial correlation and it can be worsened with stress and anxiety.

New Understanding of Centralized Pain

Research has now shown there are definite abnormalities present in these patients. Functional MRI scans have shown an increased connectivity in regions of the brain that sense pain signals and decreased activity in areas that inhibit signals. Along with this is a change in the balance of neurotransmitters, those that facilitate pain reception including Substance P, Glutamate, Serotonin, and Nerve Growth Factor are elevated. Those transmitters that inhibit pain are decreased, such as Norepinephrine and GABA.

Pain Brain

Treatment of these conditions is difficult. Nothing works in everyone; it is a matter of using multiple strategies. Medications that have have proven effective include some antidepressants like tricyclic’s, cymbalta and cyclobenzaprine, and seizure medications like gabapentin and lyrica. Tramadol, low dose naltrexone and cannabinoids have shown modest benefits, but they aren’t typically as effective. What absolutely does not work and sometimes makes things worse are opioids. Other beneficial treatments with strong evidence include aerobics, strength training and cognitive behavioral therapy. There is little benefit from acupuncture, massage, chiropractic and manual therapy, and most injections including trigger points.

In a lot of chronic pain conditions, a common thread is emerging. There appears to be a short circuit in the brain and the volume control for pain sensitivity is turned to high. Normal signals become overly amplified in the brain and are considered painful. The normal ability of the brain to inhibit pain signals for the periphery is also decreased. The brain then becomes stuck in a state of hypersensitivity. The new directions of research is to find ways to correct the changes seen in these centralized pain states.

When to Seek Medical Attention for Abdominal Pain

/ Thomas Cohn, MD

abdominal painAbdominal pain is fairly common and is usually not cause for alarm. Every structure in the abdomen can cause pain, including:

  • Stomach
  • Intestines
  • Liver
  • Spleen
  • Kidneys
  • Bladder
  • Appendix
  • Sexual organs
  • Blood vessels
  • Muscles

Since every organ and structure tends to have some type of sensory innervation, they can all be sources of pain.

Almost everyone has experienced pain from the stomach and intestines.  From overeating, to acid reflux and indigestion, to constipation or diarrhea, the problems are common.  Most of these issues are short lived, inconvenient, and not serious.  When they are intense and do not resolve quickly, sometimes they do require medical intervention.

When to Seek Medical Help

The main concern with abdominal pain is when to seek medical attention to help determine the cause.  Signs that indicate a need for further attention include:

  • Fever
  • Inability to eat or drink fluids for over a day
  • Ongoing vomiting
  • Vomiting blood
  • Severely painful abdomen and not being able to touch it
  • Painful urination
  • Passing blood in urine or stools
  • Difficulty breathing due to pain
  • Acute traumatic injury

Since there are so many different organs and structures linked to the abdomen, diagnosing the cause of pain may be difficult.  The starting point is always the history and story provided by the patient. A physical exam gives the next set of information.  With this basic information, the clinician then can determine the best tests to help find the answers to the cause of the pain.  Tests may include blood and urine analysis, X-rays, CT scans, ultrasounds, and sometimes invasive scopes of various systems.

Treating Abdominal Pain

Treatment options for abdominal pain are as variable as the causes.  Since the vast majority of causes are not life threatening, treatment is often simple.  Serious problems often require the intervention of medical specialists to guide the evaluation and treatment.  Self-diagnosis and treatment for minor problems is fine.  But when the symptoms are more serious, find a medical specialist who you can trust.  If looking up information on the Internet, stick to respected medical sites like WebMD, Mayo Clinic, and the NIH (National Institutes of Health).  Do not panic about information you read on the Internet but use it to discuss concerns with your provider.

How to Identify & Treat Abdominal Pain

/ Thomas Cohn, MD

abdominal painMost everyone has had abdominal pain at some point in his or her lives.   Thankfully, the most common causes of abdominal pain are not serious. Every structure in the abdomen can cause pain. The organs and structures in the abdomen include:

  • Stomach
  • Intestines
  • Liver
  • Spleen
  • Kidneys
  • Bladder
  • Appendix
  • Sexual organs
  • Blood vessels and muscles

Since each of these structures tends to have some type of sensory innervation, they can all be a source for pain.

Almost everyone has had pain from the stomach and intestines.  From overeating, to acid reflux and indigestion, to constipation or diarrhea, the problems are not unusual.  Most of the problems are short-lived, inconvenient, and not serious.  When they are intense and not resolving, sometimes they do require medical intervention.

When to Seek Medical Attention

The main concern with abdominal pain is when to seek medical attention to help determine the cause.  Signs that indicate a need for further medical attention include:

  • Fever
  • Inability to eat or drink fluids for over a day
  • Ongoing vomiting
  • Vomiting blood
  • Severely painful abdomen and not being able to touch it
  • Painful urination
  • Passing blood in urine or stools
  • Difficulty breathing due to pain
  • Acute traumatic injury

Since there are so many different organs and structures linked to the abdomen, the diagnosis of the cause of pain may be difficult.  The starting point is always the history and story provided by the patient. After the history, a physical exam gives the next set of information.  With the basic information, the clinician then can determine the best tests to help find the answers to the cause of the pain.  Tests may include blood and urine analysis, X-rays, CT scans, ultrasounds, and sometimes invasive scopes of various systems and possibly surgery.

Treatment for Abdominal Pain

Treatment of abdominal pain is as variable as the causes.  Since the vast majority of causes are not life threatening, treatment is often simple.  Serious problems often require the intervention of medical specialists to guide the evaluation and treatment.  Self-diagnosis and treatment for minor problems is fine.  When the problems are more serious, find a medical specialist who you work well with and can trust.  If looking up information on the internet, stick to respected medical sites, including WebMD, Mayo Clinic, and the NIH (National Institutes of Health).  Do not panic about information on the Internet but use it to discuss concerns with your provider.