Chronic continuous abdominal pain: evaluation of diagnostic features, iatrogenesis and drug treatments in a cohort of 103 patients

Abstract

Summary Background Chronic continuous abdominal pain (CCAP) is characteristic of centrally mediated gastrointestinal pain disorders. It consumes significant healthcare resources yet is poorly understood, with minimal cohort‐specific data in the literature. Aims To examine in a large cohort of CCAP patients, (a) diagnostic features, (b) iatrogenic impact of opioids and surgery, (c) drug treatment effects and tolerance. Methods Consecutive tertiary CCAP referrals to a neurogastroenterology clinic (2009‐2016) were reviewed for Rome IV and neuropathic pain criteria. Medical, surgical and drug histories, interventions and outcomes were correlated with clinical diagnosis and associated opioid use. Results Of 103 CCAP patients (mean age 40 ± 14, 85% female), 50% had physiological exacerbations precluding full Rome IV Centrally Mediated Abdominal Pain Syndrome criteria. However, there were no significant differences between patients who satisfied Rome IV criteria and those who did not. Overall, 81% had allodynia (a nonpainful stimulus evoking pain sensation). Opioid use was associated with allodynia (P = 0.003). Prior surgery was associated with further operations post CCAP onset (P < 0.001). Although 68% had undergone surgical interventions, surgery did not resolve pain in any patient and worsened pain in 35%. Whilst duloxetine was the most effective neuromodulator (P = 0.003), combination therapy was superior to monotherapy (P = 0.007). Conclusions This is currently the largest cohort CCAP dataset that supports eliciting neuropathic features, including allodynia, for a positive clinical diagnosis, to guide treatment. Physiological exacerbation of CCAP may represent visceral allodynia, and need not preclude central origin. Use of centrally acting neuromodulators, and avoidance of detrimental opioids and surgical interventions appear to predict favourable outcomes.

An international survey on clinicians' perspectives on the diagnosis and management of chronic intestinal pseudo‐obstruction and enteric dysmotility

“…Indeed opioids can be detrimental in this setting due to their antimotility effects, worsen pain due opioid induced hyperalgesia, 30 and potentially increase infection risk, 31 which is particularly important when considering HPN 32 . The current survey data are thus in accordance with an increasing body of evidence 33 and recently published clinical guidelines to support use of centrally acting gut‐brain neuromodulators rather than the standard use of opioid medications to target this type of neuropathic pain 34,35 . Notably, respondents highlighted the importance of the multidisciplinary care including clinical psychology.…”

British Society of Gastroenterology guidelines on the management of irritable bowel syndrome

“…226 Evidence from a large cohort of patients with severe chronic continuous abdominal pain showed that combinations of neuropathic analgesics (eg, duloxetine plus gabapentin) were more efficacious than monotherapy. 287 Vigilance for the development of the serotonin syndrome for some combinations, especially those involving both SSRIs and SNRIs, is required. Symptoms include fever, hyperreflexia, tremor, sweating and diarrhoea.…”

Evaluation of the short-term efficacy of local analgesic (lidocaine) and opioid analgesic (sufentanil) on patients with centrally mediated abdominal pain syndrome: a randomized controlled trial

“…For example, a study reported 81% allodynia was found in patients with chronic continuous abdominal pain (CCAP). 14 It can be further explained that if afferent pathways between allodynia and abdominal pain can converge in the posterior horn of the spinal cord or if they can enhance afferent signals, two types of pain will interact with each other. It means visceral pain can be presented as somatogenic pain, and vice versa.…”