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Abdominal pain is one of the most common presenting complaints in the primary care physician’s office and often a diagnostic dilemma for surgeons. Despite recent technologic advances, the diagnosis and treatment of chronic, recurrent abdominal pain remain a challenge. Pain is a subjective sensation that patients often find difficult to describe. By contrast with other areas of the body, the abdominal organs have poorly developed sensory systems that also may contribute to the patient’s difficulty when trying to describe and localize the pain. In the majority of clinical scenarios, no physical course is apparent and symptoms are transient. The purpose of pain is to protect the organ and the patient from injury. After the source of the pain is found, every effort should be made to control or eliminate it. In chronic pancreatitis or diffuse malignancy, for example, pain control may become as much a challenge as in instances where no underlying cause can be found.

For a patient to perceive pain, the autonomic nervous system must be intact. The anatomy and physiology of pain have been described in detail in previous chapters. Abdominal viscera are relatively insensitive to many stimuli compared with a more sensitive organ such as the epidermis. In addition to the relative paucity of sensory nerve endings, the same group of nerves may innervate several viscera. There are a few well-known nociceptive triggers in the abdominal cavity. These include abnormal distention or contraction of hollow organ walls, ischemia of the visceral musculature, direct action of chemical substances on the mucosa, formation of allogenic mediators, and traction or compression of ligaments, vessels, or mesentery. Pain patterns are not well differentiated as to their location or the cause. Nevertheless, there are some recognizable pain patterns, and a careful history often can lead to the correct diagnosis. The history and physical examination provide diagnosis in two thirds of clinical presentations. Laboratory and radiologic tests are important auxiliary tools for investigative workup. The invasiveness and cost-effectiveness of the proposed tests should always be considered.

There is either a physical (organic) or psychogenic (nonorganic) cause to pain, with one or more elements dominating. Abdominal pain can be classified by the duration of the symptoms, etiology, primary diagnosis, anatomic localization, and its response to treatment. It can be either acute or chronic; chronic pain being arbitrary, based on symptoms persisting for more then 6 months or after the healing process is completed. Some clinicians divide pain into nociceptive (somatic or visceral), neuropathic, psychogenic, or referred.

Visceral pain is transmitted from nociceptors found on the walls of the abdominal viscera via sympathetic (thoracic branches and lumbar splanchnic nerves synapsing in subsidiary plexuses: celiac, splenic, hepatic, aorticorenal, superior mesenteric, adrenal) and parasympathetic (vagus and nervi erigentes S2–4; motor and sensory) pathways. This pain is nonspecific because of wide divergence and relatively small number of afferent fibers innervating a large area with extensive ramification. Patients usually have difficulty localizing the source of pain ...

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