HJAR Mar/Apr 2023

HEALTHCARE JOURNAL OF ARKANSAS I  MAR / APR 2023 59 Julio Olaya, MD President Pain Medicine Specialists of Arkansas related to the unpredictability of symptoms may have a greater effect on quality of life than the symptoms themselves. Patients in generally good health who have ongoing or recurrent gastrointestinal symptoms and abnormal stool patterns most likely have IBS or another gastrointestinal disorder. Pa- tients who meet symptom-based criteria and have no alarm features may be confi- dently diagnosed with few, if any, additional tests (e.g., fecal calprotectin is accurate and cost effective). Patients may not completely understand the diagnostic process; asking about expectations and carefully explain- ing the goals and limitations of testing leads to more effective care. There is no defini- tive treatment for IBS, and recommended treatments focus on symptom relief and improved quality of life. Trusting patient- physician interactions are essential to help patients understand and accept an IBS di- agnosis and to actively engage in effective self-management. 5 Obviously, to try to cover everything there is regarding chronic abdominal pain in this column would be extremely unrealistic. My intention is to discuss the cornerstone issues and the very particular profile of this pain. I would like to make sure we understand the difference between somatic pain and visceral pain. Nociceptive pain can originate from so- matic and/or visceral sources, or both. So- matic pain originates from skin, muscle, and fascia. It is mediated by the somatic nervous system; as innervation is highly specific, lo- calization of the pain is precise. Somatic pain is often described as sharp, aching, or throb- bing. Visceral pain originates from internal structures. It is mediated by the autonomic nervous system, and there is a lack of speci- ficity of innervation with considerable neu- ronal crossover. Visceral pain is typically difficult for the patient to localize or describe and may encompass an area that is much larger than might be expected for a single organ. Visceral pain is often characterized as diffuse and intermittent. Examples can include the abdominal pain experienced with bowel obstruction or bloating. So, in conclusion, due to its very particu- lar innervation, abdominal pain can be a challenge for the physician to localize and diagnose. But with a very thorough medical history, physical exam, labs, and imaging, we could determine the cause so we can treat it, our goal being to improve the quality of life, minimize the psycho-social impact, and help the patients to manage their pain. n REFERENCES 1 Russo, M.W.; Wei, J.T.; Thiny, M.T.; et al. “Digestive and liver diseases statistics, 2004.” Gastroenter- olo 125, no. 5 (May 2004): 1448-1453. 2 Atcheson, R.; Lambert, D.G. “Update on Opioid Receptors.” British Journal of Anaesthesia73, 2 (August 1994): 132-134. 3 Sanson, T.G.; O’Keefe, K. “Evaluation of abdomi- nal pain in the elderly.” Emergency Medical Clin- ics of North America 14, 3 (August 1996): 615-27. doi: 10.1016/s0733-8627(05)70270-4 4 Lyon, C.; Clark, D.C. “Diagnosis of Acute Ab- dominal Pain in Older Patients.” American Family Physician 74, no. 9. (Nov. 1, 2006): 1537-1544. 5 Wilkinson, J.M.; Gill, M.C. “Irritable Bowel Syn- drome: Questions and Answers for Effective Care.” American Family Physician 103, no. 12 (June 15, 2021): 727-736. of poor prognosis for this disease. Diver- ticulitis is a common cause of abdominal pain in the older patient; in appropriately selected patients, it may be treated on an outpatient basis with oral antibiotics. Small and large bowel obstruction, usually caused by adhesive disease or malignancy, are more common in the aged and often require sur- gery. Morbidity and mortality among older patients presenting with acute abdominal pain are high, and these patients often re- quire hospitalization with prompt surgical consultation. 4 Inflammation of the gastrointestinal (GI) tract may occur as a result of infec- tion, physical damage (radiation exposure and ischemia), or an idiopathic, chronic relapsing process commonly referred to as inflammatory bowel disease (IBD), in- cluding ulcerative colitis (UC) and Crohn’s Disease. These are among the chronic ab- dominal pain pathologies. More commonly manifested, we can also add irritable bowel syndrome (IBS), which is a heterogeneous group of conditions related to specific bi- ologic and cellular abnormalities that are not fully understood — a chronic functional colonic motility disorder manifested by re- current abdominal pain and bloating. Psy- chological factors do not cause IBS, but many people with IBS also have anxiety or depressed mood, a history of adverse life events, or psychological stressors. Physi- cians must understand the fears and expec- tations of patients and how they think about their symptoms and should also respond empathetically to psychosocial cues. Anxiety