HJAR Mar/Apr 2023

58 MAR / APR 2023 I  HEALTHCARE JOURNAL OF ARKANSAS PAIN MEDICINE COLUMN PAIN MEDICINE ABDOMINAL PAIN is among the main rea- sons for physicians’visits, withmore than 12 million consultations occurring each year in the United States. 1 The patients with visceral pain present unique challenges because the pain is poorly localized and is associated with strong autonomic reactions and chang- es in visceral function as well. Pain management, in turn, may further alter visceral function with opioid effects in the gastrointestinal tract. These unintended treatment effects on visceral function can exacerbate the pain or lead to additional discomfort, thus showing that functional and effective pain management need to be based on an understanding of the anatomic and physiologic basis of visceral function and pain. For example, in irritable bowel syndrome (IBS), the abdominal pain tends to get better after a bowel movement. Opioids will cause constipation, making the abdomi- nal pain worse and longer lasting due to the slow peristalsis caused by the stimulation of the mu receptors (mu2 to be precise). 2 The complex innervation that provides sensation and motility to the gut and to the many organs encased in the abdominal wall and peritoneum makes it very difficult for the clinician to determine what pathology is the culprit of the abdominal discomfort and disease. For obvious reasons, this is more complicated and dangerous if undiagnosed. In the acute setting, something called “acute abdomen” becomes a real challenge for the ER doctor who, in many instances, will be the first doctor who would have to untangle this very puzzling clinical presentation. To make matters worse, depending on the age group and sex, the related co-morbidities would vary, meaning that those in a pediat- ric setting will be different from those in an adult setting. This does not mean that either one is exclusive for the different age groups — it means that either one can be present in all of them, but the odds of being present increase depending on age and sex (except for the female organs, e.g., endometriosis). To share an example: Acute abdominal pain is a common presenting complaint in older patients. Presentation may differ from that of the younger patient and is often complicated with coexisting diseases, de- lays in presentation, and physical and social barriers. The physical examination can be misleadingly benign, even with catastrophic conditions such as abdominal aortic aneu- rysm rupture andmesenteric ischemia (lack of appropriate blood perfusion). Changes that occur in the biliary system because of aging make older patients vul- nerable to acute cholecystitis, the most com- mon indication for surgery in this popula- tion. 3 In older patients with appendicitis, the initial diagnosis is correct only half of the time, and there are increased rates of per- foration and mortality when compared with younger patients. Medication use, gallstones, and alcohol misuse increase the risk of pan- creatitis, and advanced age is an indicator CHRONIC Abdominal Pain