Visceral Pain Syndromes
Treating Visceral Pain:
Integrating the Management of Visceral Pain:
Conditions That May Coexist with Visceral Pain Syndromes:
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Visceral Pain Syndromes
Some common conditions associated with chronic visceral pain include endometriosis, interstitial cystitis, chronic pancreatitis, chronic prostatitis, chronic pelvic pain, gastroparesis, irritable bowel syndrome and inflammatory bowel disease such as Crohn’s and Ulcerative Colitis.
Understanding Visceral Pain
The pain associated with internal organs and tissues is referred to as “visceral” pain. It tends to be diffuse, intermittent, and difficult to localize. It is often perceived in a different location than where the problem originates ( “referred pain” ). For example, the pain associated with a heart attack is often perceived down the left (or right) arm. An obstruction of the distal esophagus by food can cause pain in the neck and the pain of a gallstone may be perceived in the shoulder while the pain of a kidney stone can refer to the flank, abdomen or groin.
Visceral pain is usually perceived as dull, aching or cramping although it may be burning or sharp and stabbing. As a result of mechanical variables such as stretching, symptoms may included feeling bloated, distended or uncomfortably full. Nausea and vomiting may accompany visceral pain.
While all pain experience is subject to modification by an associated emotional response, visceral pain is known to have a significantly stronger degree of emotional response. This fact may make the perception of visceral pain to be more severe and/or more disruptive to quality of life.
Hypersensitivity to Pain and Central Sensitization
Development of chronic visceral pain is thought to result from changes that begin with hypersensitivity of the primary sensory neurons that innervate the GI tract, which is then maintained or magnified by changes in the central nervous system. This heightened response to visceral sensations, leads to an increase in pain perception. The changes associated with central sensitivity lead to a spread of symptoms beyond the specific organs involved in the primary condition.
Hyperalgesia is an exaggerated, increased painful response to a stimulus which is normally painful. Hyperalgesia often accompanies visceral pain syndromes and can be a consequence of central sensitization.
Central Sensitization is a process of hyper-responsiveness to sensory stimuli which is a result of chronic pain-induced changes in the spinal cord and brain. It can be an important contributing process to many chronic pain experiences, including the visceral pain syndromes.
For more information: Assessment and Management of Central Sensitization
The neurobiological interplay between pain, emotion and psychological stress and depression is complex but pronounced in visceral pain syndromes, more so than in somatic (musculoskeletal) pain syndromes. Visceral pain syndromes have a relatively high association with anxiety and depression and these conditions impact the severity of perceived pain. Adequate management of psychological conditions is a key element to controlling visceral pain.
Treating Visceral Pain
While the management of conditions associated with visceral pain is generally deferred to the appropriate specialist and is beyond the scope of this web site, there are common denominators relative to the management of the visceral pain in these conditions.
NSAIDs (Non-Steroid Anti-inflammatory Drugs)
While some visceral pain may respond well to NSAIDs, especially menstrual pain, NSAIDs are usually ineffective or counter-productive in gastrointestinal disorders such as inflammatory bowel diseaes and interstitial cystitis, causing increased pain and relapse.
When bowel pain results from spasm, the use of hyoscine (hyoscyamine) can be very effective. However,potential side effects, include bowel obstruction in an already partially obstructed gut or worsening dysmotility in a gut that is already prone to motility problems secondary to inflammation.
Neuromodulators – Gabapentinoids
Visceral pain conditions may respond to neuropathic pain agents such as gabapentin (Neurontin), pregabalin (Lyrica). There are likely multiple mechanisms by which these agents work, but one likely mechanism is a reduction in the hypersensitivity to pain and central sensitization of visceral pain.
Tricyclic antidepressants such as amitriptyline (Elavil), desipramine and doxepin have shown effectiveness for visceral pain, but one should start with low doses to avoid side effects of drowsiness and dry mouth. Duloxetine (Cymbalta) may also be effective for visceral pain and is better tolerated than the tricyclic antidepressants. In visceral pain syndromes accompanied by anxiety and/or depression, visceral pain has also been shown to respond to SSRIs such as fluoxetine (Prozac) and citalopram (Celexa).
Celiac plexus nerve blocks can be effective treatment for pain associated with chronic pancreatitis and pancreatic cancer and have been used for many years. The use of nerve blocks for the management of intractable abdominal pain are offered by interventional pain management specialists.
Integrative Management – Complementary and Alternative Medicine (CAM) Treatment
CAM treatments with evidence for effectiveness in the visceral pain of IBS include the use of the essential oil of peppermint (Menta piperita). Multiple studies have supported the safety and effectiveness of peppermint oil for reducing pain and other symptoms of IBS. Curcumin has also been suggested due to its anti-inflammatory benefits thought to be beneficial in Leaky Gut, but definitive evidence is lacking.
Because visceral pain syndromes, even more than somatic (musculoskeletal) pain syndromes, are strongly affected by stress and psychological distress or dysfunction, an integrative approach that incorporates means of improving coping skills and reducing stress is a key element to successful pain management. Several approaches have been shown to be effective.
See Using the Mind
Cognitive behavioral therapy (CBT) teaches people to recognize the relationship between thoughts, feelings, and behaviors. The goal of CBT is to train an individual to examine his or her negative cognitions (thought patterns), understand how they may impact his or her behavior and emotions, and ultimately work to change maladaptive or detrimental thought patterns. Typical CBT counseling interventions are brief, lasting from 4 to 12 individual or group sessions. A downloadable introductory course in CBT is also available.
Hypnotherapy, or the use of medical hypnosis, includes techniques that can be easily learned and very effective in reducing stress and it’s impact on pain and other symptoms related to visceral pain syndromes.
Stress management is particularly important in the management of most visceral pain syndromes.
Diet clearly plays a role in the management of most visceral pain syndromes, particularly IBS, Chrohn’s and Ulcerative Colitis, but also in Interstitial Cystitis. The specifics of dietary management of these individual conditions is deferred to elsewhere but of interest are the emerging concepts of the gut microbiome and of “leaky gut syndrome.”
The Gut Microbiome
The term “microbiome” was originally used to refer to the collection of the genomes (genetic materials) of the microbes in a particular ecosystem, in this case the gut. The term “microbiota” was originally used to refer to the actual organisms. These terms are now used somewhat synonymously, although not correctly. The intestines, or gut, contains trillions of microbes, mostly bacteria, and the balance of different species is believed to influence the health of an individual as well as to impact the integrity of the lining of the gut.
Probiotics are live microorganisms that are used as non-digestible food ingredients that enhance the growth of certain strains of bacteria in the colon. Probiotics are thought to suppress inflammation in the gut, reduce impaired permeability of the intestines (see “Leaky Gut,” below) or reduce visceral hypersensitivity by balancing the composition of bacteria in the intestines. They may lead to improvement of symptoms of IBS. In one study, the use of the probiotic “Bifidobacterium infantis” improved global IBS symptoms by more than 20%. Another study showed that after a four week-treatment of IBS patients with “Lactobacillus acidophilus,” another probiotic found in yogurt, abdominal pain and discomfort were reduced by more than 20%. However, in another recent randomized, double-blind, placebo-controlled trial, in which IBS patients received a probiotic mixture of Lactobacillus paracasei ssp paracasei F19, Lactobacillus acidophilus La5 and Bifidobacterium Bb12 over six months, no differences in GI symptoms were noticed. There are a number of conflicting studies regarding the benefits of use of probiotics though they do appear to be well tolerated.
When this integrity is compromised, the permeability of the gut is altered which allows substances to penetrate the lining of the gut and enter the blood stream, a condition referred to as “leaky gut.” The “inappropriate” entry of these substances is thought to possibly trigger the immune system in ways that contribute to the symptoms of IBS, Crohn’s and Ulcerative Colitis as well as many psychiatric conditions.
The healthy balance of microorganisms in the gut is related to many factors, including diet. This is an emerging field of study with far more questions than answers. There is early evidence for the role of prebiotics and probiotics in the management of visceral pain syndromes but it is still too early to make definitive recommendations based on current research.
See “Leaky Gut.”
Visceral Pain – Overviews
Visceral Pain – Endometriosis
Visceral Pain – Inflammatory Bowel Diseases
Visceral Pain – Irritable Bowel Syndrome (IBS)
Visceral Pain – Interstitial Cystitis
- Interstitial Cystitis – Diet, CAM & Supplements – Summary handout
Visceral Pain – Pancreatitis
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