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Chronic visceral pain

Presented at: EFIC Virtual Pain Education Summit

Speakers

Asbjørn Mohr Drewes

Professor, Department of Gastroenterology, Aalborg University Hospital, Denmark
BIOGRAPHY
Tim Vanuytsel

Professor, Belgium
Monique Steegers

Professor, Anesthesiologist, Pain and Palliative Specialist, Amsterdam University Medical Centers, The Netherlands
BIOGRAPHY

Abstract

Chair: Asbjørn Mohr Drewes, Denmark

Basic concepts of visceral pain
Asbjørn Mohr Drewes, Denmark

Visceral pain is common and diagnosis and management is often complicated. The learning objectives is to outline the symptoms, epidemiology, assessment and management strategies of visceral pain. Due to the organisation of the visceral nervous system, symptoms often differ from what is expected, and referred pain to somatic structures, cross-organ sensitization and autonomic symptoms may dominate the clinical presentation (for details see Drewes et al. 20230). The discussion of basic mechanisms will pave the road for an up-to-date outline of management of functional and organic visceral disorders. In general treatment of visceral pain follows the guidelines from the somatic counterpart. Hence, management is multi-factorial and combination of pharmacological and non-pharmacological management is beneficial for a mechanism-orientated approach to treatment.

Patients can frequently become disengaged with healthcare providers leading to a need for repeated consultations. Thus, a key aspect of management is to prevent this from happening by validating patients’ symptoms, adopting an empathic approach and taking time to educate patients. To optimize treatment in patients with chronic visceral pain, we need to move towards by use of more holistic strategies that involves knowledge about alterations in central pain processing. Practical guidelines as well as mechanism based treatment options will be presented and clinical useful take-home-messages will help and stimulate the participants to better diagnosis and management of visceral pain.

Chronic primary (functional) abdominal pain
Tim Vanuytsel, Belgium

Management of pain secondary to visceral diseases
Asbjørn Mohr Drewes, Denmark

Is there a role for interventions in chronic visceral pain?
Monique Steegers, Netherlands

Chronic visceral pain is a common pain-syndrome which is associated with a lot of different diseases and syndromes. It is often diffuse, poorly localized and associated with autonomic and emotional reactions plus alterations in visceral function. Often the first treatment is done with opioids which can lead to a lot of problems.

Autonomic sympathetic blocks are being performed since World War I for pain relieve with the idea to block the adrenergic hypersensitivity and to limit opioid use. In various conditions where hyperactivity of the sympathetic nervous system influences this pain condition as in chronic visceral pain, an effect was seen of a sympathetic block longer than the duration of the agents that were applied. Suggesting that blocking of these sympathetic fibers interrupts some kind of a feedback system leading to hyperexcitability. For this reason, sympathetic ganglia have been the target of local anaesthetic blocks to determine the sympathetic role in the transmission of pain. If analgesia is reached with local anaesthetics, chemical or thermal neurolysis have been done to attempt to provide long-term pain relief.

Despite frequent use of minimally invasive sympathetic blocks, their efficacy for providing pain relief has been sparsely reported in the literature. The evidence is based on case reports and case series, very few placebo-controlled studies have been published, especially for chronic visceral pain.

The learning objectives is discussing the (limited) indications of invasive pain-procedures in chronic visceral pain of non-malignant causes. Diverse ganglion blocks are being considered, its indications, effectiveness and side effects/complications. Also, epidural stimulation and medication intrathecally for chronic visceral pain is being debated.

Q&A