Abdominal wall pain

organdonor · Mar 6, 2012

One subject that I have had great interest in lately is that of pain from the abdominal wall. According to the literature I have reviewed this is a very common -and very commonly missed- cause of abdominal pain. Would anyone be willing to comment on either

1. How you treat pain from the abdominal wall- I've seen dry needling, local anesthetic, and other options

2. Who should be able to detect pain from the abdominal wall, and contrast that with who actually does. I understand these patients often get caught up between family doctors, GI, surgeons, and pain management and many go through unnecessary tests/procedures looking for intraabdominal causes.

drf · Mar 6, 2012

I see a lot of these. Typically still have abdominal pain with either negative $1 million work up or return of pain a bit after a surgical correction for some real visceral disease. Pts who have a diagnosis and get better with GI or surgical treatment don't come to see me.

Sometimes I can palpate a scar neuroma if superficial or use US if deep. Often they get worse with a crunch or leg lift. TAP block for more diffuse pain or simply deep TP injection using US if very pinpoint. If either helps then its somatic pain. Muscle fascia or thoracoabdominal nerve entrapment or injury.

Steroids, Botox, RF and PT.

I should add I also have a plastic surgeon who likes to dissect out abdominal scar neuromas. He has a fair volume from panniculectomy s/p gastric bypass. A

powermd · Mar 6, 2012

organdonor said:
One subject that I have had great interest in lately is that of pain from the abdominal wall. According to the literature I have reviewed this is a very common -and very commonly missed- cause of abdominal pain. Would anyone be willing to comment on either

1. How you treat pain from the abdominal wall- I've seen dry needling, local anesthetic, and other options

2. Who should be able to detect pain from the abdominal wall, and contrast that with who actually does. I understand these patients often get caught up between family doctors, GI, surgeons, and pain management and many go through unnecessary tests/procedures looking for intraabdominal causes.

1. Regarding treatment of abdominal wall pain-
I do a technique with US selectively injecting layers of muscle until I figure out which one seems to be most closely associated with pain relief. Usually I can achieve excellent results by hydrodissecting the painful layer of muscle from the superficial or deep fascia. I typically inject local and steroids, but I'm beginning to doubt the need for steroids. We'll see if the generally good results change.

For scar/neuromas, I'll try local/steroids first, then RF. There's a guy at the local hospital here who will do alcohol for these. He gives them a slug of propofol first, since it hurts a lot. He says he gets good results.

2. If it's in the abdominal wall, this should be our domaine. You really need US to treat these effectively while avoiding puncture of the peritoneum. Most pain docs don't have US. All docs should learn how to do Carnett's test. It's an easy way to distinguish abdominal wall from visceral pain.

clubdeac · Mar 6, 2012

Not to hijack this thread but I'm looking into learning US for peripheral joint and nerve blocks. Anyone know of any good courses?

PinchandBurn · Mar 6, 2012

powermd said:
1. Regarding treatment of abdominal wall pain-
I do a technique with US selectively injecting layers of muscle until I figure out which one seems to be most closely associated with pain relief. Usually I can achieve excellent results by hydrodissecting the painful layer of muscle from the superficial or deep fascia. I typically inject local and steroids, but I'm beginning to doubt the need for steroids. We'll see if the generally good results change.

For scar/neuromas, I'll try local/steroids first, then RF. There's a guy at the local hospital here who will do alcohol for these. He gives them a slug of propofol first, since it hurts a lot. He says he gets good results.

2. If it's in the abdominal wall, this should be our domaine. You really need US to treat these effectively while avoiding puncture of the peritoneum. Most pain docs don't have US. All docs should learn how to do Carnett's test. It's an easy way to distinguish abdominal wall from visceral pain.

Power MD...I'm noticing thsi exact phenomenon. I have a lady that does great with just local aneshtetic blocks w/o steroids. She's reduced her opioid use about 50%. The thing is I have had to repeat them about every 1.5-2months. I think that's reasonable. I wish there was somethign else that would 'last longer'...something like phenol...but the issue arises (phenol isnt for non-CA pain). Unfortunatley this lady is one of those patients that had EGD/colonoscopies x10, various intestinal resections, and multiple CT/MRIs (all of which are normal). I really believe abodminal wall pain is underdiagnosed. Unfortunately, primaries and surgeons wont think of us if they have a patient with "abdominal pain". Instead they send to GI. GI then scopes/scans ad nauseum......

organdonor · Mar 7, 2012

PinchandBurn said:
Power MD...I'm noticing thsi exact phenomenon. I have a lady that does great with just local aneshtetic blocks w/o steroids. She's reduced her opioid use about 50%. The thing is I have had to repeat them about every 1.5-2months. I think that's reasonable. I wish there was somethign else that would 'last longer'...something like phenol...but the issue arises (phenol isnt for non-CA pain). Unfortunatley this lady is one of those patients that had EGD/colonoscopies x10, various intestinal resections, and multiple CT/MRIs (all of which are normal). I really believe abodminal wall pain is underdiagnosed. Unfortunately, primaries and surgeons wont think of us if they have a patient with "abdominal pain". Instead they send to GI. GI then scopes/scans ad nauseum......

Intestinal resection for what ended up being abdominal wall pain? I hope I'm missing something!

So in your opinion (or with reference to any evidence) who should be diagnosing/treating abdominal wall pain? Should primaries more aggressively screen for it, should GI and surgeons rule it out before proceeding with invasive testing/procedures? All of the above? UpToDate references that up to 20% of patients referred to GI practices have abdominal wall pain, so that seems like a promising place to screen and treat it.

I am just an M3 researching the topic so I have much to learn. However, I was surprised that the one neurologist I had a chance to talk to was unfamiliar with this. I figured that since the pain can be caused by a nerve entrapment that he would have at least heard of it. I suppose I was being more specific than I meant to be when I explained it as anterior cutaneous nerve entrapment, but he mistook it for compartment syndrome of an extremity.

Ligament · Mar 7, 2012

Guys, consider high volume TAP blocks with at least 60cc volume and the addition of Wydase. The high volume will hydrodissect the muscle planes and ostensibly break adhesions. The Wydase will help spread the local and steroid.

Having been stumped with great but short term results with regular TAP blocks this may be the long term solution.

Aether2000 · Mar 7, 2012

Have used phenol for years in treating nerve entrapment abdominal pain esp after surgical procedures. Without any prior surgical procedure, I have found nerve entrapment or response to local anesthesia blocks to be much less than those cases with prior abdominal wall penetration via surgery. Completely agree with US.....you would be astonished how close the peritoneum is to the wall in places and how many of the blocks such as LFCN have probably been partially delivered unknowingly through the abdominal wall.....

Ducttape · Mar 7, 2012

ive had good success in some patients with ICNB - generally T10-T11 - for patients who fail local injections, if it is more a discrete dermatomal distribution. i do them under US too. dont worry as much about volume as TAP block.

i have done a paravertebral also, +/- success...

Jcm800 · Mar 7, 2012

PinchandBurn said:
Power MD...I'm noticing thsi exact phenomenon. I have a lady that does great with just local aneshtetic blocks w/o steroids. She's reduced her opioid use about 50%. The thing is I have had to repeat them about every 1.5-2months. I think that's reasonable. I wish there was somethign else that would 'last longer'...something like phenol...but the issue arises (phenol isnt for non-CA pain). Unfortunatley this lady is one of those patients that had EGD/colonoscopies x10, various intestinal resections, and multiple CT/MRIs (all of which are normal). I really believe abodminal wall pain is underdiagnosed. Unfortunately, primaries and surgeons wont think of us if they have a patient with "abdominal pain". Instead they send to GI. GI then scopes/scans ad nauseum......

You guys are better men and women than me, these get referrals to someone who can "stomach" this stuff, pun intenteded.

DOctorJay · Mar 7, 2012

clubdeac said:
Not to hijack this thread but I'm looking into learning US for peripheral joint and nerve blocks. Anyone know of any good courses?

AAPM just did this and there was a great turnout and I thought the hands on portion was excellent. They covered hip, knee, shoulder, paraverts, intercostal, LFCN, Ilioing/iliohyp, piriformis, SI, caudal, and GON block prior to it's division (Narouze taught this).

another great course is AIUM but this focuses more on MSK. held annually at Mayo in July.

DOctorJay · Mar 7, 2012

we see a lot of these abdominal wall patients referred from GI after a negative workup in both the PM&R msk ultrasound inj clinic and in pain clinic. they typically get an ultrasound guided tpi. we're looking into a study to compare TAPs vs. TPIs for these patients.

drf · Mar 7, 2012

algosdoc said:
Have used phenol for years in treating nerve entrapment abdominal pain esp after surgical procedures. Without any prior surgical procedure, I have found nerve entrapment or response to local anesthesia blocks to be much less than those cases with prior abdominal wall penetration via surgery. Completely agree with US.....you would be astonished how close the peritoneum is to the wall in places and how many of the blocks such as LFCN have probably been partially delivered unknowingly through the abdominal wall.....

Sounds exciting! Please be more specific in how you use neurolytics in these folks. 1 ml into any trigger point? High volume in a fascial plane?

powermd · Mar 7, 2012

PinchandBurn said:
Power MD...I'm noticing thsi exact phenomenon. I have a lady that does great with just local aneshtetic blocks w/o steroids. She's reduced her opioid use about 50%. The thing is I have had to repeat them about every 1.5-2months. I think that's reasonable. I wish there was somethign else that would 'last longer'...something like phenol...but the issue arises (phenol isnt for non-CA pain). Unfortunatley this lady is one of those patients that had EGD/colonoscopies x10, various intestinal resections, and multiple CT/MRIs (all of which are normal). I really believe abodminal wall pain is underdiagnosed. Unfortunately, primaries and surgeons wont think of us if they have a patient with "abdominal pain". Instead they send to GI. GI then scopes/scans ad nauseum......

Totally agree with you here.

If everyone learned Carnett's test, I'd bet millions of dollars in unnecessary workup and complications would be avoided.

The thing is, we're really the only specialty that takes myofascial pain seriously. We do because we have to tools to prove where the pain is coming from (or at least discern the tissue of origin). Ultrasound takes this to the next level. I've figured out all kinds of weird pain syndromes that nobody else was able to diagnose simply because they lack the tools and experience using them. I've got a guy with interclavicular ligament pain (right along the superior aspect of the manubrium). How excited would you be to do an injection 1-2 cm deep right there without image guidance?

Aether2000 · Mar 7, 2012

10% phenol in glycerin 5%; the amount total is usually 1cc diluted with varying amounts of bupivicaine but keeping the concentration of phenol above 3%.

Abdominal wall pain

organdonor

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drf

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powermd

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clubdeac

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PinchandBurn

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organdonor

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Ligament

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