Chronic Abdominal and Visceral Pain: Theory and Practice

552 Pages·2006·6.68 MB·English

by  Pankaj Jay Pasricha

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Chronic Abdominal
and Visceral Pain
Theory and Practice
edited by
Pankaj Jay Pasricha
University of Texas Medical Branch
Galveston, Texas, U.S.A.
William D. Willis
University of Texas Medical Branch
Galveston, Texas, U.S.A.
G. F. Gebhart
University of Pittsburgh
Pittsburgh, Pennsylvania, U.S.A.
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Preface
Ifanythingailaman,sothathedoesnotperformhisfunctions,ifhehaveapaininhisbowelseven,—forthatis
theseatofsympathy,—heforthwithsetsaboutreforming—theworld.–HenryDavidThoreau(1817–1862)
There is almost no physician who has not encountered the problem of chronic visceral
painatsomepointinhisorhercareer.Visceralandabdominalpainisamajorclinicalproblem,
affectingupto25%ofthegeneralU.S.population.Itmaybepartofawell-definedsyndrome
such as irritable bowel syndrome or chronic pancreatitis or be the sole or dominant clinical
manifestationasinfunctionalabdominalpainanddyspepsia.Patientswithsuchpainpresent
to a variety of medical specialists including gastroenterologists, cardiologists (noncardiac
chest pain), gynecologists (pelvic pain syndromes) or urologists (interstitial cystitis etc.),
anesthesiologists.Thelasttwodecadeshaveseenimpressiveprogressintheneurobiologyof
somaticpainandthisisnowbeginningtobetranslatedintoclinicalpracticewiththeadvent
of several new classes of analgesics, particularly for neuropathic syndromes. By contrast,
despiteitsprevalence,chronicvisceralpainremainspoorlyunderstood,leadingtosignificant
difficulty in diagnosis and management. Much of modern medicine has tended to dismiss
chronic visceral pain, in part because changes in function and structure of visceral organs
are more subtle than those seen in somatic structures (a deformed and swollen knee for
instance). Indeed, the term ‘‘functional pain’’ is often used (pejoratively) for these patients,
generally in association with a referral to a clinical psychologist.
The editors of this book feel fortunate and privileged to be able to assemble leading
expertsfromacrosstheworldtowritethefirstdefinitiveandcomprehensiveworkonthissub-
ject and one that is truly ‘‘bench to bedside.’’ Conceptually, this book is divided into four
sections. The first deals with a global overview of visceral pain, its distinctive features and
socialimpact.Thesecondsection,writtenbymanyoftheauthorswhohavedefinedthepara-
digms in this field, provides a detailed discussion of the neurobiological, immunological,
andpsychologicalbasisofvisceralpain,asprovidedbythestudyofbothanimalmodelsand
humansubjects.The nextsection dealswith thegrowingarrayof molecular targetsfor treat-
ment of visceral pain as well as current conventional and alternative approaches used in the
clinic. The final section consists of a detailed discussion of individual syndromes covering
the gamut ofproblemsencounteredbythe practicing physician.In most instances, two lead-
ing authorities in the field have provided a state-of-the-art summary of the pathophysiology
and management of these conditions, often bringing unique insight as well as practical tips.
The reader can approach this book in many different ways. For the novice clinician or
researcher, if read as written, it will be an easily understood journey of discovery from basic
anatomic and physiological principles to an understanding of the complex balance of patho-
physiological factors that make up a given clinical syndrome and rational approaches to
treatment of the same. For the expert, individual chapters can be perused with ease for an
in-depthandup-to-datereviewofthetopic.Eitherway,weareconfidentthattheexperience
will be rewarding and stimulating.
Itisclearthatvisceralpainsyndromesarecomplex,possiblymoresothantheirsomatic
counterparts. The editors of this book hope that we have been able to put together a compi-
lation of work that will provide the beginning of a rational approach to this symptom and
the recognition of the real suffering it causes.
Painisrealwhenyougetotherpeopletobelieveinit.Ifnoonebelievesinitbutyou,yourpainismadnessor
hysteria.–NaomiWolf(b.1962)
Pankaj Jay Pasricha
William D. Willis
G. F. Gebhart

Contents
Preface . . . . iii
Contributors . . . . xiii
SECTION I:INTRODUCTION ANDOVERVIEW OFVISCERAL AND
ABDOMINALPAIN
1. Distinctive Clinical andBiological Characteristics ofVisceral Pain 1
T.J.Ness
Introduction . . . . 1
ClinicalVisceralPain . . . . 1
ClinicalSuperficialPain . . . . 2
PsychophysicalStudiesofVisceralSensation . . . . 3
NeuroanatomyofVisceralPain . . . . 4
DifferencesinSpinalPathways . . . . 5
FunctionalImagingofVisceralSensation . . . . 6
EffectsofStressonVisceralPain . . . . 6
SilentAfferentsintheViscera . . . . 7
AreAllVisceralPainstheSame? . . . . 7
References . . . . 8
2. EpidemiologyandSocioeconomic Impact ofVisceral and
AbdominalPain Syndromes 11
SmitaL. S.Halder and G.Richard Locke III
Introduction . . . . 11
AbdominalPain . . . . 11
SpecificVisceralandAbdominalPainSyndromes . . . . 12
Conclusions . . . . 15
References . . . . 15
SECTION II:THE NEUROBIOLOGYAND PSYCHOBIOLOGY
OFCHRONICVISCERAL PAIN
3. Overview ofPainand Sensitization 17
MichaelS. Gold
WhatisPain? . . . . 17
PainTerminology . . . . 18
SummaryandConclusions . . . . 27
References . . . . 27
4. NeuroanatomyofVisceralPain: PathwaysandProcesses 33
ElieD. Al-Chaer and William D. Willis
PeripheralPathways . . . . 33
CentralPathways . . . . 34
RepresentationofVisceralSensationintheBrain . . . . 38
References . . . . 39
5. TheNeurobiologyofVisceralNociceptors 45
StuartM.Brierley and L.Ashley Blackshaw
Introduction . . . . 45
IrritableBowelSyndrome . . . . 45
SensoryInnervationoftheGastrointestinalTract . . . . 46
Conclusions . . . . 60
References . . . . 60
vi Contents
6. Neurochemical andMolecular BasisofPeripheral Sensitization 67
Klaus Bielefeldt
Introduction . . . . 67
IonChannelsasTransducers . . . . 67
SynapticTransmission . . . . 75
Nerve-ImmuneInteractionsandPeripheralSensitization . . . . 76
PeripheralSensitizationandVisceralPainSyndromes . . . . 77
References . . . . 78
7. SpinalMechanisms ofVisceral Pain andSensitization 85
Richard J.Traub
Introduction . . . . 85
VisceralAfferentOrganizationContributingto
VisceralPainandHyperalgesia . . . . 86
ReferredPainandHyperalgesia:Convergenceofthe
SomaticandVisceralBody . . . . 88
MeasurementofExperimentalVisceralPainandHyperalgesia . . . . 91
PharmacologyofSpinalProcessingofVisceralPain . . . . 95
GonadalHormoneModulationofVisceralPain . . . . 97
ConclusionsandaHypothesis . . . . 97
References . . . . 98
8. Animal Modelsof Visceral Pain 107
David R.Robinson and G.F.Gebhart
Introduction . . . . 107
TheCardiopulmonarySystem . . . . 109
TheGastrointestinalTract . . . . 111
TheGenitourinaryTract . . . . 116
ClosingNotes . . . . 121
References . . . . 121
9. Measuring PainandHyperalgesia inPersistent Pain Conditionswith a Special
Emphasis onIrritable Bowel Syndrome 127
Donald D.Price, Michael E.Robinson, and G.Nicholas Verne
Introduction . . . . 127
GeneralConsiderationsConcerningPainMeasurement . . . . 127
PsychophysicalCharacterizationofPathophysiologicalPain . . . . 128
TestingVisceralandCutaneousHyperalgesiain
IrritableBowelSyndromePatients . . . . 132
ConclusionsandFutureImplications . . . . 137
References . . . . 138
10. Mechanisms ofVisceralSensitization inHumans 141
Abhishek Sharmaand Q. Aziz
Background . . . . 141
TheModulationofPainPerception . . . . 141
VisceralHypersensitivity . . . . 141
VariabilityintheDevelopmentofSensitizedStates . . . . 149
MechanismsofVisceralSensitizationinFunctionalGastrointestinalDisorder . . . . 150
Summary . . . . 154
References . . . . 155
11. Visceral Pain:LessonsfromFunctional Brain Imaging 161
EmeranA.Mayer and BruceNaliboff
Introduction . . . . 161
ReviewofPublishedStudiesonBrainResponsesto
VisceralStimuli . . . . 161
ConclusionsandFutureDirections . . . . 171
References . . . . 172
Contents vii
12. The NeuralBasisofReferredVisceralPain 177
MariaAdele Giamberardino and FernandoCervero
Introduction . . . . 177
ReferredPainPhenomenaintheClinicalContext . . . . 177
ReferredPainPhenomenaintheExperimentalContext . . . . 180
NeurophysiologicalBasisofReferredPain . . . . 183
Conclusion . . . . 189
References . . . . 189
13. FromSensation to Perception: The Gut–Brain Connection 193
FernandoAzpiroz
GeneralOverview . . . . 193
EvaluationofVisceralSensitivityinHumans . . . . 194
ModulationofVisceralPerception . . . . 197
DysfunctionoftheSensorySystem:FunctionalGutDisorders . . . . 198
References . . . . 201
14. Stress,VisceralPain, andthe Brain–GutConnections 205
Yvette Tache´ and MulugetaMillion
Introduction . . . . 205
Stress-InducedVisceralHyperalgesia . . . . 205
Stress-InducedSomaticandVisceralHypoalgesia . . . . 208
CRF/CRF ReceptorsandtheBiochemicalCodingofStress . . . . 209
1
BrainCRF/CRF-SignalingPathwaysinStress-Related
1
VisceralHyperalgesia . . . . 210
Conclusions . . . . 213
References . . . . 213
15. The Biopsychosocial Continuum inVisceral Pain inChronicAbdominaland
Visceral Pain:Theory andPractice 221
DouglasA.Drossman
Introduction . . . . 221
TheBiopsychosocialContinuum . . . . 222
Pathophysiology . . . . 223
ClinicalPresentationBasedonSeverityofPainand
ImplicationsforTreatment . . . . 227
Conclusion . . . . 228
References . . . . 229
16. ChronicPainandAddiction 231
HowardHeitand Douglas Gourlay
Introduction . . . . 231
BinaryConceptofPainandAddiction . . . . 231
PainandOpioidAddiction—AContinuumApproach . . . . 232
BasicScienceofAddiction . . . . 233
Addiction . . . . 234
PhysicalDependence . . . . 234
Tolerance . . . . 234
BasicConceptsintheUseofOpioids . . . . 236
Modified-ReleaseDeliverySystems . . . . 237
Long-actingDrugs . . . . 238
OpioidsforAnalgesiaorOpioidStabilizingEffect? . . . . 238
UniversalPrecautionsinPainMedicine . . . . 239
GroupIPrimaryCareManagement . . . . 239
GroupIIPrimaryCarewithConsultativeSupport . . . . 239
GroupIIISpecialtyReferral . . . . 240
ClassificationofPain . . . . 240
SpecificPainCondition . . . . 241
FederalRegulationsforPrescribingaScheduled
ControlledSubstance . . . . 241
Conclusion . . . . 242
References . . . . 243