David S. Greenbaum

Chronic abdominal wall pain: a frequently overlooked problem. Practical approach to diagnosis and management.

Chronic abdominal wall pain is frequently misdiagnosed as arising from a visceral source, often resulting in inappropriate diagnostic testing, unsatisfactory treatment, and considerable cost. Its prevalence in general medical practice is unknown, although it may account for about 10% of patients with chronic idiopathic abdominal pain seen in gastroenterological practices. The most common cause appears to be entrapment of an anterior cutaneous branch of one or more thoracic intercostal nerves; myofascial pain and radiculopathy are less frequent. Sharply localized pain and superficial tenderness are suggestive of abdominal wall origin. Carnetts test (accentuated localized tenderness with abdominal wall tensing) is a helpful diagnostic sign, especially when incorporated with other findings. Early exclusion of a parietal source should increase diagnostic accuracy when evaluating patients with chronic abdominal pain. Reassurance of patients by the correct diagnosis and avoidance of precipitating causes is often sufficient treatment. However, accurately placed anesthetic/corticosteroid injections give substantial pain relief to more than 75% of patients, often for prolonged periods, and may be confirmatory for the source of the complaint. The probability of missing visceral disease is small (probably less than 7%) with strict adherence to diagnostic criteria and diligent observation of patients.

Chronic abdominal wall pain - Diagnostic validity and costs

Chronic abdominal wall pain (CAWP) is common and frequently mistaken for visceral pain. We determined the stability of this diagnosis with Main Outcome Measures of: (a) change of pain intensity after local anesthetic-corticosteroid injection, (b) pain relief after three or more months follow-up, and (c) costs of diagnostic procedures for visceral causes of abdominal pain in patients with confirmed CAWP. Seventy-nine patients fulfilled tentative criteria for CAWP; 72 (91%) experienced ≥50% pain relief with anesthetic injection and were followed for at least three months (mean=13.8 months). Abdominal pain in four patients was later diagnosed as caused by visceral disease. CAWP was confirmed in 56 of remaining 68 patients; 12 of 19 patients with recurrent pain were unavailable for re-injection of anesthetic. Thirty patients with confirmed CAWP had had diagnostic procedures to exclude visceral disease costing almost

Probable Gastrointestinal Toxicity of Kombucha Tea: Is This Beverage Healthy or Harmful?

700 per patient. CAWP is usually easily identified and treated; greater awareness should minimize misdiagnosis.

Metronidazole-Associated Pancreatitis

Kombucha tea is a health beverage made by incubating the Kombucha “mushroom” in tea and sugar. Although therapeutic benefits have been attributed to the drink, neither its beneficial effects nor adverse side effects have been reported widely in the scientific literature. Side effects probably related to consumption of Kombucha tea are reported in four patients. Two presented with symptoms of allergic reaction, the third with jaundice, and the fourth with nausea, vomiting, and head and neck pain. In all four, use of Kombucha tea in proximity to onset of symptoms and symptom resolution on cessation of tea drinking suggest a probable etiologic association.

A controlled therapeutic study of the irritable-bowel syndrome: effect of diphenylhydantoin.

Excerpt Metronidazole is a widely used antiprotozoal drug prescribed for infections withTrichomonas vaginalis, Giardia lamblia, Entamoeba histolytica, andGardnerella vaginalisas well as for general...

Psyllium and the irritable bowel syndrome.

Abstract Treatment of the irritable-bowel syndrome has not been subjected to adequately controlled studies. Diphenylhydantoin has been reported to be effective. Twelve patients were treated for 20 weeks with 300 mg of diphenylhydantoin daily and with placebo in a randomized double-blind crossover study. Six manifestations scored daily were used as assessment criteria. Psychologic tests were performed. No significant differences (p less than 0.05) between diphenylhydantoin and placebo in any of these manifestations were found. There were positive correlations between frequency and severity of pain and disability but not between frequency, and consistence of stools and pain or disability. These manifestations were strikingly consistent for each patient between biweekly periods. Six of seven patients with the most pain had abnormal scores for neuroticism. There appears to be a rationale for dealing with psychologic factors as well as gut pain in the syndrome. This experimental design should be useful for eva...

Effects of Desipramine on Irritable Bowel Syndrome Compared with Atropine and Placebo

Excerpt To the editor: The prevalence and generally unsatisfactory treatment of irritable bowel syndrome make it a legitimate and necessary target for research. In a recent article (1) on psyllium ...