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Origin of right upper quadrant pain
Abstract
We have studied 22 consecutive patients referred for investigation of severe chronic right upper quadrant pain. The majority were women whose symptoms had been present for many years. All had undergone repeated investigations of the pancreatico-biliary, gastro-intestinal, urinary, and even gynaecological systems without a satisfactory diagnosis. Most had undergone at least one abdominal operation in an unsuccessful attempt to cure their pain. In 21 of 22 patients the customary pain was completely and reproducibly mimicked by balloon distension of the small or large intestine in at least one site. The trigger sites were jejunum (15), ileum (12), right colon (nine), and duodenum (six). In 12 more than one trigger site was found. Close questioning revealed features of the irritable bowel syndrome in the majority and depression in many though the symptoms were not spontaneously volunteered. Reproduction of pain has provided a convincing demonstration to this difficult group of patients that they have a sensitive gut and allows appropriate management.
... Upper abdominal pain can also be experimentally induced. For example, Kingham and Dawson [58] describe a study in which a latex balloon was swallowed and inflated, producing a pain sensation similar to that reported in naturally occurring GI pain. Bradette, Pare, Douville and Morin [10] also examined upper GI stimulation, by inserting a balloon at the gastric side of the lower oesophageal sphincter, which was found to successfully induce pain in both patients and healthy participants. ...
Methods for investigating human pain have been developed over the last 100years. Typically, researchers focus on people with clinical pain, or on healthy participants undergoing laboratory-controlled pain-induction techniques focussed mostly on exogenously generated skin nociception. Less commonly investigated are acute pain experiences that emerge naturally. Six common painful complaints were identified: headache, muscular pain, visceral pain, menstrual pain, dental pain, and pain associated with upper respiratory tract infection. Methods used to recruit participants with the natural occurrence of each pain complaint were identified, and features of their use reviewed. Also reviewed were experimental analogues designed to mimic these pains, with the exception of menstrual pain. Headache and menstrual pain appear to be most effectively researched in their naturally occurring form, whereas muscle and dental pain may be more easily induced. Upper respiratory tract infection and abdominal pain provide further challenges for researchers. Summary guidance is offered, and directions for methods development outlined.
Proton pump inhibitor (PPI)-refractory non-cardiac chest pain (NCCP) is often resolved when constipation was relieved. This study aimed to investigate the clinical features of patients with both NCCP and constipated functional bowel disorders (FBD).
Among 692 consecutive patients diagnosed with functional constipation or irritable bowel syndrome with constipation and underwent anorectal manometry (ARM) in our hospital, PPI-refractory NCCP was present in 37. The clinical course of various torso symptoms including NCCP and ARM findings were retrospectively evaluated.
The mean age was lower in the NCCP than in the non-NCCP group (57.4 vs 61.3 years, respectively, P = .042). Back pain (16.2% vs 2.0%, P < .001) and sharp abdominal pain (13.5% vs 0.9%, P < .001) were more common in the NCCP group. Increased resting pressure (16.2% vs 6.9%, P = .036) and squeezing pressure (62.2% vs 50.7%, P = .049) of the anal sphincter, increased urgency volume (40.5% vs 23.2%, P = .004), and maximal volume (25.7% vs 15.0%, P = .032) for rectal sensation were more frequently observed in the NCCP group. After taking laxatives for 1 to 3 months, 81.1% of patients with NCCP reported improvement.
Subjects with NCCP showed decreased rectal sensation more frequently at anorectal manometry. Majority of patients with NCCP reported improvement of symptom upon relief of constipation. Constipation might be a therapeutic target in patients with NCCP related to constipated functional bowel disorders.
Chronic, undiagnosed abdominal pain may pose difficult and frustrating problems in diagnosis and management. Imprecise diagnosis is disappointing to both patient and physician. Terms like “abdominal pain not yet diagnosed,” “functional,” or “psychogenic abdominal pain” may sustain the physician’s mystique but may do little to clarify the cause or indicate useful treatment. Patients seeking help for chronic pain risk two harmful extremes of management. In one extreme, the physician, unable to understand the nature of the complaint, may minimize its importance and force the patient to seek advice elsewhere. Regrettably, there are charlatans who prey on such patients. At the other extreme, repeated complaints of abdominal pain may generate costly consultations, hazardous investigations, and futile treatments (even surgery), which serve only to exaggerate the importance of the pain and the patient’s concern. The chronic abdomen is the most difficult gut reaction to understand or treat.
Right upper quadrant and epigastric pain in a patient without gallstones or structural alterations in the pancreatico-biliary tract may yet be related to the biliary system. Functional gallbladder and sphincter of Oddi disorders are evaluated using the Rome III diagnostic criteria. Further testing may then include a cholecystokinin (CCK)-stimulated hepatobiliary iminodiacetic acid (HIDA) excretion study to measure the patient’s gallbladder ejection fraction (GBEF). Patients with reduced GBEF may benefit from cholecystectomy. If a patient’s gallbladder has already been removed, the disorder may lie with the sphincter of Oddi. A patient can be stratified according to the Milwaukee Criteria (Type I–III). Sphincter of Oddi function can be evaluated using manometry or a fatty meal ultrasound. Type I and Type II patients will likely benefit from sphincterotomy, though treatment for Type III remains unclear.
Frau Biliardi leidet seit mehreren Jahren an episodischen Schmerzen im rechten Oberbauch. Die Schmerzattacken treten häufig nach dem Essen auf und dauern in der Regel 2–3 Stunden. In letzter Zeit haben die Schmerzen an Häufgkeit und Intensität so stark zugenommen, daß Frau Biliardi zur stationären Abklärung eingewiesen werden mußte.
Motor dysfunction of the gastrointestinal tract without discernible structural alteration is suspected frequently in patients with episodic or chronic abdominal pain. The biliary tract [gallbladder/sphincter of Oddi (SO)] assumes a “leadership” role in this clinical arena when the patient with “biliary-type” pain fails conventional diagnostic testing. A convincing relationship between dysmotility and pain is often difficult or impossible to establish. A motility disorder may simply be an epiphenomenon without meaningful clinical correlation or relevance to the patient’s symptoms. On the other hand, a valid relationship may exist between smooth muscle dysfunction in the biliary tract and the patient’s “biliary-like” pain complaints. Theoretically, functional disorders of bile flow may arise from a disturbance in motor function anywhere within the biliary tract. Similar speculation has persisted since the late 19th century, in fact.1 To help deal with this dilemma and to focus on the more meaningful clinical issues, a brief review of biliary flow dynamics, the mechanisms of biliary-type pain, and the spectrum of functional biliary tract disorders is useful.
Dyspepsia is a term which covers a multitude of symptoms and has no commonly agreed definition. It is often used interchangeably with indigestion, but has a pseudo scientific ring to it which may be useful in reassuring the patient that his condition is taken seriously, but may unfortunately delude the doctor into believing he has a greater understanding of the patient’s condition than is actually the case. A survey1 conducted recently amongst groups of senior hospital doctors and patients with a variety of gastroenterological and nongastroenterological disorders showed that there was much confusion as to what dyspepsia and indigestion implied. It seems that doctors by and large consider both terms to describe those symptoms typically associated with peptic ulceration. Most patients, on the other hand, though sometimes using the term dyspepsia, are uncertain what it means and are more conversant with indigestion. Unlike their medical counterparts, they are not familiar with the classical symptoms of peptic ulcer and give a less fettered account of what indigestion entails. Many of the symptoms which patients in that survey listed as indigestion, whether they were perennial or only occasional sufferers, more closely resembled irritable bowel syndrome than peptic ulceration. In this study1 we were careful not to bias our findings in favour of the hypothesis that indigestion may equate with a functional bowel disorder by excluding patients with such a diagnosis. The study revealed that 80% of those questioned suffered occasional indigestion. Only half of the patients understood what dyspepsia meant, but most of the doctors considered that indigestion and dyspepsia were synonymous. Not surprisingly, around four-fifths of the patients and doctors included upper abdominal pain, wind, heartburn and acid regurgitation as typical indigestion/dyspepsia symptoms. More surprisingly, over half of the patients listed lower abdominal pain and irregular bowel habit, especially constipation, as characteristic features of indigestion and just less than half also included headache and backache. The majority considered that predominant causes were heavy meals, over spiced food, alcohol and worry. A similar proportion felt that relief was best achieved by taking antacids or laxatives, particularly if the preparation induced belching. Interestingly the patients, unlike the doctors, did not accept that drinking milk was likely to give relief.
Most of the patients who suffer from illness of the digestive tract do not show any signs of lesion after a careful examination. They are classified as “dyspentic” or of “psychosomatic” patients; many cases seem to have a functional disorder somewhere in the digestive tract. Our aim is to show that some patients have a mucosal defect which we shall call “mucosal barrier weakness.” The rationale of this hypothetic mechanism is:
1.
Experimental cytoaggression by different drugs is clearly established.
2.
The major symptom of many dyspeptic patients is epigastric heartburn (quite different from pyrosis, which is a retrosternal and ascending pain), which appears shortly after ingestion of some beverages (white wine, coffee) or meals (jam or spices). These nutrients may possibly act as cytoaggressors.
3.
We have found [2] in normal subjects that montmorrillonnite, an inert and neutral clay, reduces the aggressive effect of aspirin not only when they are both ingested at the same time, but also when aspirin is ingested 24 h after the clay (Tarnasky et al. have observed the same with glucagon [8]).
4.
According to the general law linking pathological and physiological mechanisms (the first being either an enhancement or a diminution of the second), one may hypothesize that if some substances are able to increase the resistance of the mucosa, some others could produce the opposite: a weakening of the mucosal barrier.
Fibromyalgia syndrome (FM) is a common, often debilitating and intractable, chronic, generalized pain condition. The development of effective therapies to treat FM has been hindered by a lack of understanding of fundamental mechanisms in the etiology of FM. In view of prominent characteristics that FM shares with other generalized pain conditions, we suggest that a key mechanism in such disorders may be that of altered activity in the subdiaphragmatic vagus nerve. Specifically, we propose that activity in vagal afferents, arising from the gastrointestinal tract, and sympathoadrenal function mediate a contribution of stress to FM and its strong association with irritable bowel syndrome. An important prediction of the proposed mechanism is that interventions that selectively modulate activity in specific populations of subdiaphragmatic afferents might be used to treat the symptoms of FM and other generalized pain syndromes.
Background: The drivers of conventional and, especially, alternative health care use for irritable bowel syndrome and functional dyspepsia are not clear. Aim: To determine the predictors of conventional and alternative health care use for irritable bowel syndrome and functional dyspepsia. Methods: Two hundred and seven subjects with irritable bowel syndrome or functional dyspepsia, identified from a previous population survey, were included in the study. Individuals with irritable bowel syndrome/functional dyspepsia were defined as consulters (n = 103) if they had visited their doctor for gastrointestinal symptoms more than once in the past year. Controls (n = 100) did not report having any abdominal pain. Subjects were given structured interviews to assess the Diagnostic and Statistical Manual - version IV (DSM-IV) and International Classification of Disorders - version 10 (ICD-10) psychiatric diagnosis for anxiety, depression, somatization or any psychiatric diagnosis, aspects of health care use and symptom factors. Results: About one-half (n = 103, 49.8%) of community subjects with irritable bowel syndrome/functional dyspepsia had sought conventional care for gastrointestinal symptoms in the past 12 months. Lifetime rates for alternative health care use for gastrointestinal symptoms were 20.8% (n = 43). Independent predictors of conventional health care use were more frequent abdominal pain, greater interference of gastrointestinal symptoms with work and activities and a greater satisfaction with the physician-patient relationship. Being female independently predicted alternative health care use. Conclusions: Psychological morbidity did not predict conventional or alternative health care use for gastrointestinal symptoms. Other factors were more important.
Visceral hypersensitivity is highly prevalent in all functional bowel disorders. Most also demonstrate wider patterns of somatic referral of intestinal pain or discomfort. This hypersensitivity may explain the symptoms as the sensitive gut can be more easily provoked by normal or abnormal motor events in the gut. Visceral hypersensitivity may increase during psychosocial stress and during periods of symptom exacerbation, although this requires confirmation. Pharmacological therapy to reduce visceral hypersensitivity is now possible using antagonists to neurotransmitters, opening up an exciting new era for the treatment of functional gastrointestinal disorders.
The irritable colon syndrome is a common cause of visits to a physicians’s office and time lost from work in the United States. The number of such patients who present to a physician appears to be the tip of the iceberg, since approximately a third of otherwise healthy persons have similar symptoms.1,2 The subgroup of patients who present to a physician may be selected by factors other than their symptoms. These patients have increased numbers of negative life events which may alter their psychologie makeup and their ability to cope with their symptoms.3,4 There is also evidence that during their childhood, many of these many of these patients received positive reinforcement for their symptoms.5 This explains why patients with increased bowel complaints in childhood may have similar complaints as adults.6,7 However, it is unclear if there is a genetic predisposition to the irritable colon, or if the symptoms are learned behavior.
This chapter is an attempt to make some sense out of the effects of diet and eating habits on the intestine with special reference to functional disorder of the intestine, commonly called irritable bowel syndrome (IBS). The chapter does not cover the role of diet in causing and treating organic gastrointestinal disease nor the effects on the gut of under-nutrition including specific deficiencies.
This paper discusses the definition of non-ulcer dyspepsia and its relationship to other functional bowel disorders. The research on the prevalence, outcome, aetiology and management of this condition is reviewed with particular emphasis on its multifactorial nature. Future research will need to concentrate on the inter-relationship of physical and psychosocial factors including the health beliefs of the individual patient.
Abstract Functional upper gut symptoms, such as nausea, vomiting and abdominal pain, are a continuing challenge in gastroenterological practice. This article considers the approaches applied in recent years to evaluate motor function in the upper gut including manometry and radio-nuclide transit studies, and symptom-provocation tests such as balloon distension and pharmacologic stimulation.
An approach is proposed that is based on positive symptomatic diagnosis of the disturbed pathophysiologic state, followed by treatment of this disturbance of function after a minimum of confirmatory investigations.
Medically unexplained symptoms and somatisation are the fifth most common reason for visits to doctors in the USA, and form one of the most expensive diagnostic categories in Europe. The range of disorders involved includes irritable bowel syndrome, chronic widespread pain and chronic fatigue syndrome. This book reviews the current literature, clarifies and disseminates clear information about the size and scope of the problem, and discusses current and future national and international guidelines. It also identifies barriers to progress and makes evidence-based recommendations for the management of medically unexplained symptoms and somatisation. Written and edited by leading experts in the field, this authoritative text defines international best practice and is an important resource for psychiatrists, clinical psychologists, primary care doctors and those responsible for establishing health policy.
The role psychologic factors play in the aetiology of peptic ulcer disease and the irritable bowel syndrome is discussed on the basis of data from the literature. Although much remains to be established, psychopathology, personality factors, and environmental stress may be involved, in addition to genetic and physiologic factors, in the causation of peptic ulcer disease. However, the role of these psychologic factors is generally not very important, and they do not appear to influence current therapeutic regimens. In the irritable bowel syndrome psychologic factors appear not to be related to the causation of the bowel symptoms. However, psychologic distress and psychiatric disease may induce illness behaviour. In patients with chronic inexplicable bowel symptoms illness behaviour, rather than bowel symptoms per se, frequently prompts patients to seek medical attention. These patients might benefit more from psychiatric therapy than from medical treatment.
Ninety patients with irritable bowel syndrome (IBS) who did not respond to medical treatment were randomly assigned to four treatment conditionstwo experimental groups: stress management and contingency management; and two control groups: medical treatment and placebo. The subjects underwent 12 individual sessions which were specific for each condition. All the subjects completed symptom-monitoring diaries. Thirty-three dropped out during the assessment or treatment. The subjects who received training in contingency management experienced significant reductions in all the characteristic digestive symptoms: abdominal pain (p<0.001), diarrhoea (p<0.05), constipation (p<0.05) and dyspepsia (p<0.001). At the end of the treatment, 50 per cent of the patients remained asymptomatic and 37.5 per cent reduced their symptoms by at least 50 per cent. Among the patients assigned to the condition stress management, 33 per cent got rid of their symptomatology and the subjects showed significant reductions in the following digestive symptoms: abdominal pain (p<0.05), diarrhoea (p<0.05) and dyspepsia (p<0.05). The changes in the placebo group are not representative. The subjects assigned to this condition showed a high dropout rate. Significant changes were not observed in symptomatology in the medical treatment group. The results are maintained after a year of follow-up. Possible predictive parameters of the progress of the patients are explored. © 1998 John Wiley & Sons, Ltd.
A new type of ultrasound signal processing (“FM sonography”) appears to be beneficial compared to conventional ultrasound (“AM sonography”) in some applications (e.g., diffuse liver disease and prostatic carcinoma). Despite these possible advantages, it is doubtful FM sonography will be widely used unless it is at least as useful as conventional (AM) sonography in all common applications.
Fifty-five patients with suspected gallbladder disease were independently evaluated with both AM and FM sonography. The two modalities were blindly and prospectively compared for accuracy in detecting gallstones and for image quality. No statistically significant difference was found between images produced by FM and conventional signal processing. FM had an accuracy of detecting gallstones of 98.1%, compared to 96.2% for AM. Overall, FM accuracy was 97.7%, while AM had an overall accuracy of 97.3%. Other useful sonographic signs were evaluated (gallbladder wall thickness, diameter of common duct). No AM/FM difference was noted.
Our data suggest that FM-only imaging could be performed in patients with suspected gallbladder disease without loss of accuracy.
Regional differences in colonic motility may be responsible for the orderly transit of intraluminal contents through the colon. The aims of this study were to compare the effect of stretch on active and passive stress development in colonic muscle from the proximal and distal colon and to compare the responses of these tissues to KC1 or bethanechol stimulation. Strips of taenia or circular smooth muscle were obtained from the disease-free segment of the colon removed for adenocarcinoma. Passive, active, and total isometric stress were measured on full-thickness strips of circular or longitudinal taenial muscle stimulated with bethanechol (10−4 M) as the muscles were stretched to 120% of the length of optimum tension (Lo.) The tissues then were stimulated with increasing concentrations of KCI and bethanechol while being stretched at Lo. The active stress in the proximal circular muscle was greater at all levels of stretch than in distal circular or longitudinal muscle (p <.001). The resting and passive stress were greater in distal circular and longitudinal taenial muscle than in proximal circular muscle (p < .05). There was a dose-dependent increase in stress development to bethanechol and KCl in each type of muscle. Proximal circular muscle had the greatest response. The EDSO was shifted to the right in distal circular muscle (2.6 ± 0.1 × 10−5 M) compared to proximal circular muscle (1.1 ± 0.1 × 10−5 M) (p < .001). These studies suggest that muscle stress differs in different locations of the colon and the role of active and passive stress development must be considered in models explaining in vivo colonic motility disturbances.
Visceral hypersensitivity is highly prevalent in all functional bowel disorders. Most also demonstrate wider patterns of somatic referral of intestinal pain or discomfort. This hypersensitivity may explain the symptoms as the sensitive gut can be more easily provoked by normal or abnormal motor events in the gut. Visceral hypersensitivity may increase during psychosocial stress and during periods of symptom exacerbation, although this requires confirmation. Pharmacological therapy to reduce visceral hypersensitivity is now possible using antagonists to neurotransmitters, opening up an exciting new era for the treatment of functional gastrointestinal disorders.
The irritable bowel syndrome (IBS) is a common condition consisting of abdominal pain, abdominal distension and an altered bowel habit in the absence of underlying organic pathology. Most people can be helped by conventional medical treatment but a small proportion (15%) run a chronic course with disabling symptoms that are unresponsive to medical intervention. This paper briefly describes a recent randomised, controlled trial of brief psychotherapy in 102 patients with refractory irritable bowel syndrome. The trial showed that two-thirds of people with chronic symptoms of IBS show significant improvement following brief therapy. Six cases of patients seen during the trial are presented to illustrate the nature of the therapy employed and the range of people who can be helped by such an approach. The advantages and inevitable limitations of brief dynamic therapy with IBS patients are then discussed.
The sphincter of Oddi has a cyclic motility that is closely associated with the duodenal migrating motor complex during fasting.
This close association affects the bile flow mechanism and may play several roles in keeping the intestine clean and maintaining
the migrating motor complex. The cyclic motility of the sphincter of Oddi changes after surgery and abnormal motility causes
biliary dyskinesia. In this article, the gastrointestinal migrating motor complex and cyclic motility of the sphincter of
Oddi are reviewed for better understanding of biliary and gastrointestinal physiology and the relationship between the two
phenomena.
Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder, characterized by recurrent abdominal pain or discomfort in combination with disturbed bowel habits in the absence of identifiable organic cause. Visceral hypersensitivity has emerged as a key hypothesis in explaining the painful symptoms in IBS and has been proposed as a "biological hallmark" for the condition. Current techniques of assessing visceral perception include the computerized barostat using rectal distensions, registering responses induced by sensory stimuli including the flexor reflex and cerebral evoked potentials, as well as brain imaging modalities such as functional magnetic resonance imaging and positron emission tomography. These methods have provided further insight into alterations in pain processing in IBS, although the most optimal method and condition remain to be established. In an attempt to give an overview of these methods, a literature search in the electronic databases PubMed and MEDLINE was executed using the search terms "assessment of visceral pain/visceral nociception/visceral hypersensitivity" and "irritable bowel syndrome." Both original articles and review articles were considered for data extraction. This review aims to discuss currently used modalities in assessing visceral perception, along with advantages and limitations, and aims also to define future directions for methodological aspects in visceral pain research. Although novel paradigms such as brain imaging and neurophysiological recordings have been introduced in the study of visceral pain, confirmative studies are warranted to establish their robustness and clinical relevance. Therefore, subjective verbal reporting following rectal distension currently remains the best-validated technique in assessing visceral perception in IBS.
OBJECTIVES:Health care use is a costly outcome of the irritable bowel syndrome (IBS) and nonulcer dyspepsia (NUD), but the predictors of this behavior remain poorly defined. We aimed to systematically review the literature to determine which symptoms and psychosocial factors drive health care seeking in these disorders.METHODS:A broad based MEDLINE and Current Contents search between 1966 and 2000 identified 44 relevant publications. References from these articles were also reviewed.RESULTS:The literature suggests that symptom severity is an important factor, but only explains a small proportion of the health care seeking behavior associated with these disorders in population-based studies. Psychosocial factors including life event stress, psychological morbidity, personality, abuse and abnormal illness attitudes and beliefs have been found to characterize those that seek help versus those that do not. The role of other psychosocial factors such as social support, coping style and knowledge about illness are as yet undetermined.CONCLUSIONS:A model for health care seeking for IBS and NUD, with an emphasis on psychosocial factors is presented, but remains to be tested.
Fifty cases of chronic non-specific abdominal pain were studied prospectively. All patients were subjected to a detailed clinical examination and investigations related to gastrointestinal system. A full psychiatric assessment was done with application of Goldberg's 60 item's General Health Questionnaire. Thirty four (68%) patients had psychiatric symptoms, of whom twenty six (52%) had a definite psychiatric illness while the remaining eight patients had organic illness. Sixteen patients (32%) had a pure organic illness. Dysthymic disorder constituted the main (22%) psychiatric illness.
Thirty patients with the Irritable Bowel Syndrome (IBS) were evaluated for personality profiles and psychiatric morbidity. In comparison with normal controls, these patients were more neurotic, showed more anxiety and had a higher incidence of neurotic depression, anxiety neurosis and alcoholism. IBS was found to be more common in young, urban males and sedentary workers.
The occurrence of fatigue in primary sclerosing cholangitis (PSC), its impact on quality of life and the role of concomitant inflammatory bowel disease (IBD) and coexisting irritable bowel syndrome (IBS) is unexplored.
Ninety-three patients with PSC, associated with IBD in 80% of cases and 77 patients with IBD alone, were enrolled in the study. The patients completed the following questionnaires: the Fatigue Impact Scale (FIS), the Psychological General Well-Being Index (PGWB), the Gastrointestinal Symptom Rating Scale (GSRS), the Beck Depression Inventory (BDI) and diagnostic criteria for IBS. Questionnaire data were related to liver tests and the latest liver biopsy in the PSC patients. Two sex- and age matched controls from the general population (GP) were assigned to each PSC patient and these controls completed the FIS and the BDI.
Total fatigue score did not differ significantly between patients with PSC and IBD alone. Median total fatigue score among GP subjects was 39 (13-72), which was higher than in PSC (19 (6-52) (P = 0.02)) and in IBD patients (19 (5-35) (P < 0.0001)). PGWB and GSRS scores did not differ between patients with PSC and IBD alone. Depression and general health (PGWB) were independent predictors for total fatigue score in PSC. No correlation was observed between fatigue in PSC and the severity of the liver disease.
Fatigue in patients with PSC is related to depression but not to the severity of the liver disease. Both the PSC and IBD patients had lower total fatigue scores than subjects from the general population. This argues against fatigue as a specific symptom of PSC and IBD patients.
Many of the ideas on irritable bowel syndrome (IBS) are derived from studies conducted in Western societies. Their relevance to Asian societies has not been critically examined. Our objectives were to bring to attention important data from Asian studies, articulate the experience and views of our Asian experts, and provide a relevant guide on this poorly understood condition for doctors and scientists working in Asia.
A multinational group of physicians from Asia with special interest in IBS raised statements on IBS pertaining to symptoms, diagnosis, epidemiology, infection, pathophysiology, motility, management, and diet. A modified Delphi approach was employed to present and grade the quality of evidence, and determine the level of agreement.
We observed that bloating and symptoms associated with meals were prominent complaints among our IBS patients. In the majority of our countries, we did not observe a female predominance. In some Asian populations, the intestinal transit times in healthy and IBS patients appear to be faster than those reported in the West. High consultation rates were observed, particularly in the more affluent countries. There was only weak evidence to support the perception that psychological distress determines health-care seeking. Dietary factors, in particular, chili consumption and the high prevalence of lactose malabsorption, were perceived to be aggravating factors, but the evidence was weak.
This detailed compilation of studies from different parts of Asia, draws attention to Asian patients' experiences of IBS.
Los objetivos de estudio de esta tesis son, en primer lugar, evaluar si las características psicológicas se relacionan con los factores sensitivos y biomecánicos en pacientes diagnosticados de Síndrome de Intestino Irritable. En segundo lugar, evaluar si la Fisiología Rectal permite distinguir la existencia de distintos patrones biomecánicos en el Síndrome de Intestino Irritable. Y por último, en caso de confirmarse este hecho, conocer si dichos patrones son diferentes desde el punto de vista clínico y/o psicológico.
In a case-control study in adult men from The Netherlands, the associations of work stressors with both exhaustion prior to first acute myocardial infarction (AMI) and with first AMI itself were explored. The 133 AMI-cases reported more exhaustion, work stressors, and smoking than the controls (i.e. 133 neighborhood controls and 192 hospital controls). After controlling for smoking, exhaustion constituted a firm risk indicator for first AMI; it was also positively associated with work stressors, in particular conflicts at work. Work stressors that may disrupt one's occupational career, and increased responsibility (in younger AMI-cases), were directly associated with elevated risk for first AMI. Conflicts at work were conducive to first AMI through their associations with exhaustion.
Ninety-three consecutive patients referred to a gastroenterology unit with unexplained dyspeptic symptoms were sent a postal questionnaire 6-12 months after endoscopy. It inquired into their current physical symptoms and subjective improvement since investigation, satisfaction with treatment, past history and current psychological well-being. A comparison group of 47 patients with peptic disease were similarly surveyed. Those with unexplained dyspepsia reported more current physical symptoms, more dissatisfaction with their treatment and less subjective improvement than those with peptic disease. The two groups were similar in terms of psychological distress but previous consultation for abdominal and other somatic complaints were more common in those with unexplained dyspepsia. The implications for management of dyspeptic patients are discussed.
In this study, our aim was to test the hypothesis that colonic tone is abnormal in patients with irritable bowel syndrome (IBS). We studied eight patients with IBS and eight age-matched asymptomatic control subjects, in whom tone and motility were measured by an electronic barostat and by pneumohydraulic perfusion manometry, respectively. Tone and motility were recorded from the descending colon for a 14-hour period--3 hours awake, 7 hours asleep, 2 hours fasting after awakening, and 2 hours postprandially. In patients with IBS and in healthy subjects, colonic tone decreased by up to 50% during sleep and increased promptly on awakening. Fasting colonic tone (as quantified by the volume in the barostat balloon) in the awake state was not significantly higher in patients with IBS than it was in healthy subjects (125 +/- 13 versus 152 +/- 15 ml; P = 0.19). Tone increased postprandially in both study groups, and the increase was greater in healthy subjects than it was in patients with IBS (P < 0.05). The motility index during fasting was greater in patients with IBS than it was in healthy control subjects (3.2 +/- 0.6 versus 1.6 +/- 0.4; P = 0.05), and the postprandial increase in motility index was greater in the healthy subjects. Preprandially and postprandially, we noted a trend for high-amplitude prolonged contractions to be more frequent in patients with IBS than in healthy subjects. We conclude that colonic tone in patients with IBS showed the same nocturnal and postprandial variations as it did in healthy subjects.(ABSTRACT TRUNCATED AT 250 WORDS)
Pain site and radiation and the effect of various foods were studied prospectively in a consecutive series of patients with chronic upper abdominal pain. Patients followed for less than one year were excluded unless peptic ulcer or abdominal malignancy had been diagnosed or laparotomy had been carried out. A total of 632 patients were eligible for the first study and 431 for the second. Gastric ulcer pain was more likely to be left hypochondrial (17%) compared with pain from duodenal ulcer (4%) or from all other conditions (5%). It was less likely to be epigastric (54%) compared with duodenal ulcer pain (75%). Oesophageal pain was more likely to be both retrosternal and epigastric (25%) compared with non-oesophageal pain (2%). Radiation to the back was more common in peptic ulcer (31%) and biliary pain (35%) compared with functional pain (20%). Pain precipitation by fatty foods was commoner in biliary disease (40%) than in duodenal ulcer (11%), peptic ulcer (9%), or non-ulcer dyspepsia (19%). Orange, alcohol, and coffee precipitated pain more frequently in duodenal ulcer (41%, 50%, and 43% respectively) than in biliary disease (17%, 0%, and 14% respectively). Chilli precipitated pain in one quarter to one half of subjects regardless of diagnosis. Approximately one tenth of all subjects avoided chilli, curry, coffee, and tea because of medical or other advice.
The development of liaison psychiatry services over the last 20 years is briefly reviewed--sophisticated liaison services have been confined to teaching hospitals. Limited manpower and other resources have prevented the development of liaison services in most district general hospitals; further developments are unlikely unless these deficiencies are corrected and psychiatrists take a more active role in developing links with physicians and surgeons. The time is right for such development as physicians are keen to extend our understanding of psychological and social factors in causing non-organic disorders, reduce unnecessary investigations and provide more comprehensive care. Increased collaboration between physicians and psychiatrists will provide a better service for many patients and this should be extended to all district general hospitals.
The irritable bowel syndrome is characterized by the presence of abdominal pain associated with disturbed defecation; certain symptoms are able to discriminate the irritable bowel syndrome from organic disease. Functional dyspepsia is also common in patients with symptoms otherwise compatible with the irritable bowel syndrome. Approximately one-third of patients with functional dyspepsia have symptoms thought to be of colonic origin. Despite this, functional dyspepsia can be distinguished from the irritable bowel syndrome on the basis of symptom criteria. A generalized motility disturbance may explain the presence of dyspepsia in patients with the irritable bowel syndrome. Whether a specific type of dyspepsia occurs in this syndrome is not established.
Fifty-two consecutive patients referred to a psychiatrist with somatic symptoms of underlying psychiatric disorder were studied. The costs of investigations performed in the general hospital prior to referral to the psychiatrist were assessed. The median cost was pounds 286 but the range was pounds 25-2300. Those costs were determined by the physician's original assessment of the likelihood of organic disease and were independent of the view expressed in the general practitioner's referral letter. This preliminary study indicates the need to understand more fully the determinants of early or late referral of somatization patients to a psychiatrist. The determinants include the diagnostic difficulties of the presenting symptom, patient factors including resistance to adopting a psychological view of the symptoms, and physician factors determining the number of investigations performed to exclude organic disease.
One hundred two patients with irritable bowel syndrome were studied in a controlled trial of psychological treatment involving psychotherapy, relaxation, and standard medical treatment compared with standard medical treatment alone. Patients were only selected if their symptoms had not improved with standard medical treatment over the previous 6 months. At 3 months, the treatment group showed significantly greater improvement than the controls on both gastroenterologists' and patients' ratings of diarrhea and abdominal pain, but constipation changed little. Good prognostic factors included overt psychiatric symptoms and intermittent pain exacerbated by stress, whereas those with constant abdominal pain were helped little by this treatment. This study has demonstrated that psychological treatment is feasible and effective in two thirds of those patients with irritable bowel syndrome who do not respond to standard medical treatment.
The prevalence of gall stone disease in a stratified random sample of 1896 British adults (72.2% of those approached) was established using real time ultrasound. The prevalence rose with age, except in women of 40-49 years, so that at 60-69 years, 22.4% of women and 11.5% of men had gall stones or had undergone cholecystectomy. The cholecystectomy rate of people with gall stone disease was higher in women than in men (43.5% v 24%, p less than 0.05). Very few subjects with gall stones had convincing biliary symptoms. In women, 10.4% had symptoms according to a questionnaire definition of biliary pain and 6.3% according to conventional history taking, while no men at all admitted to biliary pain. Nevertheless, cholecystectomy in men had nearly always been preceded by convincing biliary symptoms. The age at cholecystectomy was, on average, nine years less than the age at detection of silent gall stones in both sexes. It is concluded that either gall stones are especially prone to cause symptoms in younger people or that there are two kinds of cholelithiasis - symptomatic and silent. The lack of symptomatic gall stones in cross sectional surveys is probably due to their rapid diagnosis and treatment.
Because functional bowel disorders have no reliable markers, they must be defined by their symptoms. The various constellations of symptoms (syndromes) may have different mechanisms, differential diagnoses, and treatments. Therefore, precise classification is important on clinical and scientific grounds. Functional bowel disorders are a subset of functional gastrointestinal disorders attributed to the intestine. By symptoms they may be subclassified as IBS, burbulence, functional constipation and functional diarrhea. "Orphan" symptoms insufficient to qualify as one of these syndromes may be classified as unspecified functional bowel disorder. There may be overlap in symptoms among the disorders. A more careful definition of these symptom complexes will permit a logical approach to their study, investigation, and management.
This paper reviews clinical and basic science research reports and is directed toward an understanding of visceral pain, with emphasis on studies related to spinal processing. Four main types of visceral stimuli have been employed in experimental studies of visceral nociception: (1) electrical, (2) mechanical, (3) ischemic, and (4) chemical. Studies of visceral pain are discussed in relation to the use and 'adequacy' of these stimuli and the responses produced (e.g., behavioral, pseudoaffective, neuronal, etc.). We propose a definition of an adequate noxious visceral stimulus and speculate on spinal mechanisms of visceral pain.
Psychophysiological experiments were performed in 9 humans using constant-pressure, phasic, graded distention (30 sec, 20-70 mm Hg) of the sigmoid colon as a visceral stimulus. Reliable cardiovascular (pressor), respiratory and visceromotor responses in addition to reports of pressure/pain sensations were evoked by colonic distension in 8 of the 9 subjects. The pressure/pain sensations were referred to the lower abdomen, lower back and perineum and their intensity quantified using a visual analogue scale. Responses to colonic distension were graded and increased with repeated distensions at the same intensity (60 mm Hg). The area of referral as indicated by subject drawings increased with repeated distensions as did the intensity of the subjects' sensory and affective descriptors of the sensation. Five of the subjects differentiated between 'pressure' and 'pain' sensations evoked by colonic distension; the intensity of the 'pain' sensation accelerated during the distending stimulus whereas the 'pressure' sensation was typically stable or adapting during the distending stimulus.
Psychological treatments are increasingly being used to help patients with the irritable bowel syndrome (IBS), but the efficacy of such treatments is still debated. This review indicates that there are three ways in which they might have been effective in published studies to date; relating bowel symptoms to stress, specific help with psychosocial problems/relationships and relaxation to decrease anxiety and tension. A close doctor-patient relationship is regarded as central to these therapeutic tasks but the time required to maximise the effectiveness of this therapeutic role means that intensive psychological treatment should be reserved for those IBS patients who do not respond to first line standard medical treatment. There are insufficient data to indicate at present which patients are best suited to each form of psychological treatment.
A 12 month follow up study to assess the impact of symptoms suggestive of irritable bowel syndrome in women presenting to gynaecology clinics with pelvic pain is reported. Of 71 women 37 (52%) had symptoms suggestive of irritable bowel syndrome at presentation. A firm gynaecological diagnosis was reached in only three (8%) women positive for irritable bowel syndrome compared with 15 (44%) without (p = 0.002). After 12 months 24 (65%) women with irritable bowel syndrome were still symptomatic compared with 11 (32%) without (p = 0.01). This study shows that women with irritable bowel syndrome frequently attend gynaecological clinics but rarely have gynaecological pathology and the prognosis is poor in terms of resolution of their pain.
Over a 6-year period 264 cholecystokinin (CCK) provocation tests have been performed in 174 patients with undiagnosed right upper quadrant pain. All were carried out by one person (T.W.J.L.) as part of a prospective placebo-controlled crossover study. Following infusion of CCK but not saline, 103 patients developed pain (CCK + ve). These patients were offered cholecystectomy and 90 accepted. Seventy patients developed no pain during either infusion (CCK - ve), and one patient experienced pain with both CCK and saline infusions. Of the 90 patients who underwent cholecystectomy, 81 (90 per cent) have been followed up for a mean of 35 months (range 12 months to 5 1/2 years), 67 per cent have had complete resolution of symptoms and a further 24 per cent have had a marked improvement in symptoms. Only 9 per cent of patients did not benefit from cholecystectomy. This compares well with patients undergoing cholecystectomy for uncomplicated calculous gallbladder disease, 88 per cent of whom, in our study, were improved by surgery. Patients with a positive CCK test have an excellent chance of symptomatic improvement following cholecystectomy.
To determine whether motor activity of the stomach and proximal small intestine is a factor in recurrent abdominal pain in adolescents, we prospectively investigated eight patients with recurrent abdominal pain and compared them with seven normal adolescents. All patients underwent a detailed examination to exclude other known organic causes of the pain. The gastroduodenal motor activity during fasting was studied with a semiconductor recording probe. The recordings were analyzed for periodicity, duration, and propagation velocity of the activity front of the migrating motor complex. The amplitude of the antral and duodenal contractions was also determined. The patients with recurrent abdominal pain had more frequent migrating motor complexes, but these were shorter in duration and moved more slowly down the intestine (slower propagation velocities). The patients also had high-pressure duodenal contractions that were associated with abdominal pain during the study period. These studies suggest that altered intestinal motility may be the underlying mechanism of recurrent abdominal pain in some children.
Synopsis
Seventy patients presenting to the gastroenterologist with upper abdominal pain were examined by a psychiatrist to establish the presence of psychiatric disorder, illness behaviour and to record in detail their symptom pattern. The 37 patients who had no organic cause for their abdominal complaints were subdivided into those with and without psychiatric disorder. The former (21 patients) demonstrated more illness behaviour, they complained of more abdominal symptoms and their pain was both more severe and more persistent than in the patients with organic disease and those with non-organic illness who did not have psychiatric disorder. The latter group reported no symptoms of ‘psychoneurosis’ and should probably be regarded as a separate group if the aetiology of functional abdominal pain is to be clarified. Those with non-organic abdominal complaints who had psychiatric illness could be distinguished by the presence of three symptoms, namely depression, anxiety and fatigue. Detection and treatment of their psychiatric disorder might lead to a decrease in their symptomatic complaints and illness behaviour.
EDITORIALCOMMENT A study ofthepsychiatric background ofpatients withabdominal pain without demonstrable physical disease. Thepatients came fromsignificantly larger sibships than a control population andscored highfor'neuroticism'. Thepatients' symptomsoften beganina setting ofbereavement orsome other upheaval intheir lives. Anumber ofpatients wereconsiderably depressed whenseenandtreatment fordepression was followed bydisappearance ofpain. This offers an important therapeutic approach inmany patients. A considerable proportion ofthepatients atany medical out-patient clinic havenoorganic lesion to account fortheir symptoms (see review byMcClay, 1965). Oneofthecommonest complaints inthis category ispain andwhenthis occurs intheabdomen itmaywellgive rise todifficulty indiagnosis and treatment. Theabsence oforganic disease insuchapatient implies anincreased likelihood thatpsychological factors mayplay animportant partintheaetiology ofthepatient's symptoms. Inorder toexplore this possibility andalso toattempt totrytodefine the clinical picture ofabdominal painoccurring inthe absence ofstructural change, a groupofthese patients wascarefully investigated bothfromthe clinical andpsychological points ofview. STUDYAND METHOD
The effects of inflating a balloon introduced through a sigmoidoscope to 35 cm in the pelvic colon have been observed and compared in 67 patients with the irritable colon syndrome and in 16 normal and constipated subjects acting as controls.
Inflation to 60 ml caused pain in 6% of the controls at a mean diameter of 3·8 cm and in 55% of patients with the irritable colon syndrome (diameter 3·4 cm). An estimate of gut wall tension at this volume of inflation showed it to be normal in patients with the irritable colon syndrome; the incidence of pain in relation to wall tension was increased nearly tenfold in the irritable colon group.
Inflation of the balloon to different volumes was normally painless to a maximum acceptable diameter which remained constant for each study under constant conditions; continued inflation eventually gave rise to pain without increasing the diameter. The pain was felt in the hypogastrium in 40%, in one or both iliac fossae in 31%, and in the rectum in 21%; the other 8% felt pain in the back or elsewhere and there were no significant differences between clinical groups. Exceptionally, in 6% of the controls, and in 52% of patients with the irritable colon syndrome, pain occurred at balloon diameters that could still be increased by 10% or more with further inflation. This was probably the outcome of a low threshold for visceral pain in the section of bowel in contact with the balloon. Colonic hyperalgesia of this kind, possibly a random occurrence, may be an important contributory factor in the aetiology of the irritable colon syndrome.
The symptom complex of gallstone dyspepsia is defined and then analysed before and after cholecystectomy in 108 patients. Only 46% of patients were symptom-free after operation and 30% were no better. When pyloric function was studied patients with these symptoms before or after cholecystectomy and those with normal radiographs showed duodenogastric reflux, often precipitated by intraduodenal fat. Symptomless matched control subjects showed no reflux. Synchronous radiology and pressure recordings demonstrated that the pylorus in these patients failed to contract in response to a duodenal contraction, whereas the normal pylorus could prevent the reflux produced by an isolated duodenal contraction. The effect of metoclopramide on gastroduodenal contractions and in treating the symptoms was assessed. Gallstone dyspepsia is essentially a functional disease--a disorder of gastroduodenal motility.
Ninety-six patients complaining of recurrent or persistent abdominal pain were referred consecutively to a surgical clinic and a medical clinic, respectively. They were examined psychiatrically after their initial physical investigation. The psychiatric examination included rating scales for depression and anxiety, a personality inventory, life-events schedule, scale of verbal expressivity, and family and personal patterns of pain and invalidism. Only 15 patients (15-6%) had organic disorders that could be responsible for their symptoms. In the remainder, psychiatric factors were considered primarily responsible for their abdominal pain: 31 were depressed; 21 had chronic tension; in 17 hysterical mechanisms were prominent; and 12 were found to be unrecognised alcoholics. Follow-up at three and six months and recognition by 80% of the psychogenic group that a psychological explanation was plausible, confirmed the diagnoses, and over half responded favourably to psychiatric management. Features distinguishing the organic and psychogenic groups were delineated. Psychiatric assessment has a place among the investigations of non-acute abdominal pain; certainly it should not be condisered simply as "a last resort."
A washout technic with intestinal infusion of an inert gas mixture was used to study the relation of gas to functional abdominal symptoms. The volume of gas in the intestinal tract (176 plus or minus 28 ml S.E.M.) of 12 fasting patients with chronic complaints of excess gas did not differ significantly (P greater than 0.10) from that of 10 controls (199 plus or minus 31 ml). Similarly, there was no difference in the composition or accumulation rate of intestinal gas. However, more gas tended to reflux back into the stomach in patients who complained of abdominal pain during infusion of volumes of gas well tolerated by controls. Six patients with severe pain during the study had intestinal transit times of gas (40 plus or minus 6 minutes S.E.M.) that were significantly (P less than 0.05) longer than those of the control group (22 plus or minus 3 minutes). Thus, complaints of bloating, pain and gas may result from disordered intestinal motility in combination with an abnormal pain response to gut distention rather than from increased volumes of gas.
Twenty-nine consecutive outpatients with irritable bowel syndrome were given structured psychiatric interviews, as were 33 consecutive medical controls who did not have irritable bowel syndrome. All were from an internal medicine group practice. Seventy-two percent of irritable bowel syndrome subjects had psychiatric illness, with hysteria and depression the most prevalent syndromes. Only 18% of controls had psychiatric illness. The primary physician made an accurate psychiatric assessment in only 28% of the subjects. An awareness of his patient's psychiatric illness is necessary for the physician to provide effective treatment, as for depression, and to spare the patient needless medications, hospitalizations, and surgery, as with hysteria.
In a weighted random sample of the specially enumerated population of a South Wales industrial town, examined by cholecystography for gallstones, the overall prevalence rates were 6.2 per cent for men 45 to 69 years of age and 12.1 per cent for women of the same ages. Contrary to our expectation there was no marked increase in prevalence with age in either sex. Symptoms of dyspepsia said to be suggestive of gallstones were found with approximately equal frequency in those with and without gallbladder disease.
Intravenous injection of cholecystokinin (C.C.K.) in twenty patients with the irritable-bowel syndrome resulted in increased colonic motor activity. This increase was especially pronounced in eight patients who complained of attacks of abdominal pain after food. In four of these eight patients a typical attack of their usual pain developed after the injection, at a time when there was markedly increased colonic motor activity. It is suggested that " functional " abdominal pain after food may be due to an exaggerated intestinal motor response to C.C.K.
26 out of 50 patients with cholelithiasis gave evidence of gastric hyposecretion with the augmented histamine test. With the pyloric-regurgitation test, 16 out of 18 patients with cholelithiasis showed persistent reflux of dudodenal contents. Gastric hyposecretion is common in patients with gallstones, and pyloric incompetence is usual with gallstones. When gallstones form, duodenal reflux may be an associated factor that produces dysfunction and destruction of oxyntic cells. These changes are likely to cause hyposecretion, and the presence of bile and pancreatic juices in the stomach may cause the flatulent dyspepsia. If, in addition, the cardia is incompetent, heartburn may well be produced by the passage of duodenal contents, with or without gastric juices, into the œsophagus. The commonly accepted mechanism of flatulent dyspepsia is pylorospasm. In fact, the reverse appears to be the case.
The effects of inflating a balloon introduced through a sigmoidoscope to 35 cm in the pelvic colon have been observed and compared in 67 patients with the irritable colon syndrome and in 16 normal and constipated subjects acting as controls. Inflation to 60 ml caused pain in 6% of the controls at a mean diameter of 3.8 cm and in 55% of patients with the irritable colon syndrome (diameter 3.4 cm). An estimate of gut wall tension at this volume of inflation showed it to be normal in patients with the irritable colon syndrome; the incidence of pain in relation to wall tension was increased nearly tenfold in the irritable colon group. Inflation of the balloon to different volumes was normally painless to a maximum acceptable diameter which remained constant for each study under constant conditions; continued inflation eventually gave rise to pain without increasing the diameter. The pain was felt in the hypogastrium in 40%, in one or both iliac fossae in 31%, and in the rectum in 21%; the other 8% felt pain in the back or elsewhere and there were no significant differences between clinical groups. Exceptionally, in 6% of the controls, and in 52% of patients with the irritable colon syndrome, pain occurred at balloon diameters that could still be increased by 10% or more with further inflation. This was probably the outcome of a low threshold for visceral pain in the section of bowel in contact with the balloon. Colonic hyperalgesia of this kind, possibly a random occurrence, may be an important contributory factor in the aetiology of the irritable colon syndrome.
The effects of exogenous cholecystokinin (CCK) and secretin on motor activity of the sigmoid colon and rectum were studied in 10 subjects. CCK stimulated and secretin inhibited basal motor activity of the sigmoid. In addition, CCK induced motor activity of the sigmoid colon was inhibited by secretin. Neither CCK nor secretin influenced motor activity of the rectum.
Sixty-seven patients with the irritable colon syndrome are reported. The symptom complex is considered to be a concomitant of an affective disorder, and the psychological factors associated with the genesis of the illness are discussed. Fifty-six patients received treatment with anti-depressant therapy, of whom 80% reported significant improvement.
This is an account of further work on a rating scale for depressive states, including a detailed discussion on the general problems of comparing successive samples from a ‘population’, the meaning of factor scores, and the other results obtained. The intercorrelation matrix of the items of the scale has been factor-analysed by the method of principal components, which were then given a Varimax rotation. Weights are given for calculating factor scores, both for rotated as well as unrotated factors. The data for 152 men and 120 women having been kept separate, it is possible to compare the two sets of results. The method of using the rating scale is described in detail in relation to the individual items.
The distribution of pain from the colon was examined in normal subjects and in patients with irritable bowel syndrome (IBS). Colonic pain was induced by inflating a balloon (introduced during colonoscopy) at several sites throughout the colon. The pain was felt predominantly in the central, lower, and left abdomen in nine patients presenting with rectal bleeding and no spontaneous pain. Pain was felt in any part of the abdomen in 48 patients with painful IBS. Distension of the ascending and transverse colon often produced right-sided or upper abdominal pain in patients with IBS and in 29 of the 48 the pain induced was the same in quality and site as their presenting complaint. In addition pain was referred to several, previously undescribed, extra-abdominal sites. Wider recognition of the distribution of colonic pain could prevent unnecessary investigations including laparotomy.
The distribution and referral of abdominal pain in 21 patients with functional abdominal pain were investigated by performing balloon distension of the ileum, proximal jejunum, second part of the duodenum, and distal oesophagus. Pain was perceived not just in classically described sites but throughout the abdomen and was referred to several unusual extra-abdominal sites. The presenting pain was reproduced by this technique in 14 patients, in three of whom it was also reproduced by colonoscopic distension. This study emphasises the protean presentation of functional abdominal pain and demonstrates the existence of potentially tender "trigger" areas for the production of abdominal pain in the proximal as well as the distal gut.
Of 100 consecutive patients treated in a program for management of chronic pain, 25 were definitely depressed, 39 were probably depressed, and 36 were not depressed. Comparisons between the definitely depressed and nondepressed groups showed them to have strikingly similar characteristics as well as treatment outcome. Nearly 90% of the definitely depressed patients showed resolution of their depression without use of antidepressant medication.
Chronic pain of obscure origin, a widespread problem, represents a distinct psychopathologic condition for which the authors propose the term “pain-prone Disorder.” Pain-prone persons present with continuous pain and a desire for surgery. Based on an evaluation of 234 patients at the Massachusetts General Hospital, the authors describe the profile of such patients. They have engaged in excessive activity (ergomania) before the onset of pain and after its onset, they become excessively passive (anergic). Interviews and psychological tests show that their pain is related to a denial of emotional and interpersonal difficulties and that they tend to idealize their family relationships. The disorder appears to be a “depression-spectrum disease,” and treatment with antidepressants is often effective.
The clinical experience of a psychiatrist working in a pain clinic is described. One hundred and seventy two patients were assessed over a 4-year period. The modal age was 45-54 years with a male : female ratio of 7 : 10. The model duration of pain was 1-5 years, the back being the commonest site. Depression was diagnosed in 30% of cases. PErsonality disorder, traumatic neurosis, anxiety, hysteria and drug dependence were the next most common diagnoses. Treatment was instituted in half of the patients seen and half of the treated patients improved or recovered. Drug withdrawal, EMG feedback and brief psychotherapy were associated with more improvement than pharmacotherapy or treatment at a psychiatric unit. The response to antidepressant medication was particularly disappointing and possible reasons for this are discussed.
Summary1. The term "irritable colon syndrome" is used to embrace a variety of colonic functional disturbances which can be divided into two main clinical groups, (a) spastic colon, (b) chronic simple diarrhoea.2. Aetiological factors which appear to be of importance in the condition include psychological disturbances, an attack of dysentery, dietary habits, specific sensitivity to certain foods and abuse of purgatives.3. The outstanding symptom of spastic colon is pain. This may occur over any part of the colon but is most common over the descending and sigmoid colon. When the pain occurs over the hepatic flexure, gall-bladder disease is often suspected; when over the transverse colon, a peptic ulcer, and when over the splenic flexure, disease of the heart, oesophagus or left lung. The pain may be either continuous or intermittent and is often partly relieved by defaecation. The bowel action is often normal, but there may be constipation alternating with short bursts of diarrhoea. When constipation is present, clear mucus is often passed per rectum and the term "mucous colitis" has been applied to these cases, but it is a misnomer as there is no histological evidence of disease and should therefore be abandoned.4. The patients with chronic simple diarrhoea as their sole gastro-intestinal symptom may have either continuous or intermittent symptoms over the course of many months or years.5. The diagnosis of irritable colon syndrome depends upon both positive and negative evidence. On the negative side, exclusion of major organic disease is an essential. On the positive side, both sigmoidoscopy and a barium enema examination may yield evidence favouring the diagnosis.6. The radiological aspects of the disorder are considered in detail. A barium enema examination plays an essential part in diagnosis and it fulfils two separate functions. On the one hand, it assists in the exclusion of organic disease. On the other, it can yield valuable positive evidence to support the diagnosis. To obtain reliable positive evidence it is necessary to avoid heavy preparation of the patient with purgatives and colon washouts with irritating solutions; and the examination itself should be made with a plain barium enema suspension free from agents which stimulate the colon. Under these conditions, a reduced size of lumen, and increased number of haustral markings and (in more severe cases) actual segmental spasms, are strong evidence in support of the diagnosis. The post-evacuation appearances may also yield positive support.7. The radiological findings have been correlated with the results of a colonic motility study of these patients. Under resting conditions, patients with spastic colon have evidence of excessive colonic motility on their pressure tracings, while those with chronic diarrhoea display somewhat less motor activity than normal subjects, yet on barium enema examination these two classes of patient yield appearances which are closely similar and which, in the great majority of cases, give evidence of "irritability." This similarity of the barium enema appearances corresponds with the motility patterns observed after an injection of prostigmine, when patients with the irritable colon syndrome are likely to show excessive motor activity, irrespective of whether their symptomatology is that of spastic colon or of chronic diarrhoea and also irrespective of whether they are in a stage of symptoms or are symptom-free at the time of observation.
IT is commonly believed that gastrointestinal symptoms may be produced in otherwise healthy people by the ingestion of certain foods. In addition specific foods are often thought to initiate or aggravate symptoms of various gastrointestinal disorders. Some of these beliefs are so widely held that they have attained the status of "knowledge" and form the basis for dietary therapy. Thus, everyone "knows" that foods rich in fats cause distressing symptoms in patients with biliary-tract disease and that proper management of such patients includes a diet low in fat content. Neither the popularity nor the intensity of such convictions, however, appears . . .
Sites of pain referred from common bile duct
- Fsa Doran
- Doran, F.S.A.
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Prognosis in the irritablebowel syndrome
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Waller SL, Misiewicz JJ. Prognosis in the irritablebowel syndrome. Lancet 1969: 2: 753-5.
- Wh Price
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Sensibility of the rectum and colon
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Experimental referred pain from the gastro-intestinal tract. Part 1. The oesophagus
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Duodenogastric reflux and gastritis in non-ulcer dyspepsia
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Digestive tract pain
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Supradiaphragmatic reference of pain
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