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Pain Management in Functional Gastrointestinal Disorders

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Pain Management in Functional Gastrointestinal Disorders REVIEW Pain management in functional gastrointestinal disorders ANTONIO VIGANO MD,EDUARDO BRUERA MD N INTERNATIONAL WORKING AVIGANO,EBRUERA. Pain management in functional gastrointestinal dis- panel recently defined functional orders. Can J Gastroenterol 1995;9(2):85-90. Pain is a common feature in A gastrointestinal disorders (FGID)asa functional gastrointestinal disorders (FGID). An abnormally low visceral sensory threshold, as well as a number of central, spinal and peripheral pain-modulating “variable combination of chronic or re- abnormalities, have been proposed for this syndrome. Clinical aspects of pain as- current gastrointestinal symptoms not sociated with irritable esophagus, functional dyspepsia, biliary dysmotility, in- explained by structural or biochemical flammatory bowel syndrome and proctalgia fugax are reviewed. Because of its abnormalities. FGID include symptoms unclear pathophysiology, pain expression is the main target for the successful as- attributed to the pharynx, esophagus, sessment and management of symptomatic FGID. The sensory, cognitive and af- stomach, biliary tree, small and large fective components of pain intensity expression need to be addressed in the intestine or anorectum” (1). The com- context of a good physician-patient rapport. A multidisciplinary team approach mon symptom among FGID is pain, is ideal for the smaller subset of patients with severe and disabling symptoms. Al- while other specific symptoms charac- though pharmacotherapy may target specific functional disorders, the role of be- terize the different functional symptom havioural techniques and psychotherapy appears much more important for pain complexes. management in FGID. Functional performance and quality of life improvement, rather than pain intensity, are the main therapeutic goals in these patients. Irritable bowel syndrome (IBS)isthe prototype of FGID in terms of preva- Key Words: Functional gastrointestinal disorders, Pain assessment and management, lence, physiopathology, clinical find- Quality of life ings and therapeutic opportunities (2). The description of IBS is beyond this Traitement de la douleur dans la maladie gastro-intestinale paper’s purposes. However, IBS will be fonctionnelle considered a model to describe the cur- RÉSUMÉ : La douleur est une caractéristique fréquente des troubles gastro- rent understanding of the physiopa- intestinaux fonctionnels (TGIF). Un seuil sensoriel viscéral anormalement bas, thology and treatment of pain in FGID. de même qu’un nombre d’anomalies sensorielles au niveau central, spinal et pé- riphérique ont été avancées pour expliquer ce syndrome. Les aspects cliniques de PHYSIOPATHOLOGY la douleur associés à l’oesophage irritable, à la dyspepsie fonctionnelle, à la dys- In an attempt to understand the motilité biliaire, au syndrome inflammatoire intestinal et à la proctalgie fugace causes and the mechanism of pain in sont passés en revue. À cause de sa physiopathologie imprécise, l’expression de la IBS, the features of visceral sensation douleur est la principale cible d’une évaluation et d’un traitement réussis des and clinical evidences for altered pain voir page suivante perception in the gastrointestinal tract have been extensively reviewed. Vis- Palliative Care Program, Edmonton General Hospital, University of Alberta, Edmonton, ceral sensation can be subdivided into Alberta two functional categories: nonpainful Correspondence: Dr Antonio Vigano, Fellow in Clinical Research, Palliative Care Program, Edmonton General Hospital, 11111 Jasper Avenue, Edmonton, Alberta T5K 0L4. Telephone conscious sensation which informs the (403) 482-8531 individual about the state of the gastro- Received for publication July 14, 1994. Accepted August 15, 1994 intestinal tract with sensations of full- CAN JGASTROENTEROL VOL 9NO 2MARCH/APRIL 1995 85 VIGANO AND BRUERA TGIF symptomatiques. Les composantes sensorielles, cognitives et affectives qui conditions is the frequent association caractérisent l’expression de la douleur dans son intensité doivent être abordées with psychiatric illness, especially dans le contexte d’un bon rapport médecin-patient. Une approche pluridiscipli- mood changes, anxiety or somatization naire est idéale chez un sous-groupe de patients plus restreint atteints de disorders (7). Life threatening events, symptômes graves et invalidants. Bien que la pharmacothérapie puisse s’attaquer loss of a job or loved one, long-standing à certains troubles fonctionnels spécifiques, le rôle de techniques comportemen- stress and severe emotional upset ap- tales et de la psychothérapie semble beaucoup plus important pour le traitement pear to precede the development of de la douleur associée aux TGIF. L’amélioration du rendement fonctionnel et de la functional abdominal pain more fre- qualité de vie plutôt que le soulagement de la douleur sont donc les principaux quently than the onset of organic gas- objectifs thérapeutiques chez ces patients. trointestinal disease (8). Furthermore, a history of sexual and physical abuse was particularly common in women suffering from FGID (9). Those events ness, hunger, satiety and nausea; and modulating mechanisms the deregula- also seem to enhance symptom report- painful visceral sensation which in- tion may take place. ing and health care utilization espe- forms the individual about potentially An increased visceral sensitivity has cially for pain management. A psycho- noxious events such as irritation of the been shown by intraluminal balloon logical similarity has been found mucosa or serosa, gross distension of distension of the stomach in functional between persons having IBS who do not the viscus, torsion or traction on the dyspepsia. Similar findings have been consult a physician and normal indi- mesentery, forceful contractions and extensively reported in the colon and viduals (10). So far, psychosocial dis- ischemia. Nociceptors have not been in the esophagus for IBS patients. The turbances appear to influence, rather identified in viscera; noxious and non- distension-induced pain was never re- than directly cause, the greater sympto- noxious stimuli are identified within lated to an abnormal visceral compli- matic and physiological response to the central nervous system (CNS)by ance (5). In IBS patients, stressful stressor in FGID patients compared with their intensity of discharge. Further- stimuli seem to influence intestinal normal individuals (1). more, there is no specific pathway for motility and pain perception to a visceral afferents in the spinal cord. greater extent than in normal individu- CLINICAL ASPECTS OF THE Visceral and somatic inputs converge als. Conversely, those gut disturbances PAIN SYNDROMES in the same second-order neurons of so- may influence the central nervous sys- A description of all the symptoms matic sensory. Subsequently, visceral tem. IBS patients with balloon disten- characterizing FGID with the related di- pain is poorly localized and is accompa- sion in the colon experienced pain at agnostic approaches is beyond the nied by autonomic and somatic reflexes many extracolonic sites such as the scope of this paper. Only pain manifes- as frequently seen in FGID. shoulder, back and thigh. These find- tations in the major FGID, such as irrita- Pain modulation is accomplished by ings may suggest an alteration in vis- ble esophagus, functional dyspepsia, central, spinal and peripheral mecha- ceral pain discrimination and a biliary dysmotility, IBS and proctalgia nisms. The central structures play an facilitation of referred pain mecha- fugax, will be reviewed. important role in the processing of the nisms (3). Chest pain resulting from irritable sensory experience of pain. Descending Pain in FGID may be partly caused by esophagus may fall into three clinical inhibitory pathways can be activated a hypoactive CNS antinociceptive sys- manifestations: pyrrhosis or heart burn; by endorphins from the periaqueductal tem. A decreased level of cerebrospinal odynophagia or pain on swallowing; grey area of the brain. The conver- fluid beta-endorphins has been found and spontaneous pain. While pyrrhosis gence of various sensory inputs into the in patients with long-lasting functional or odynophagia may easily be attrib- same second-order neuron within the lower abdominal pain (6). However, uted to an esophageal disorder, sponta- spinal cord can facilitate or inhibit the the pain sensitivity for ischemia in this neous chest pain of esophageal origin is pain transmission as suggested in the population was not found to be signifi- more difficult to diagnose. In the ab- gate-control theory by Melzak and cantly increased as previously shown sence of other specific symptoms, be- Wall. Finally, inflammatory mediators, for upper abdominal pain in functional sides the irritable esophagus syndrome, neuropeptides released from afferent dyspepsia. The possible effect of a low one should consider gastrointestinal terminals (antidromic nerve stimula- level of beta-endorphins on pain (eg, peptic ulcer disease), cardiac (eg, tion) and smooth muscle tone may threshold may be enhanced or counter- angina pectoris) or musculoskeletal modulate the sensory function of vis- balanced by neuropsychological (eg, costochondritis) organic disease ceral receptors (3). mechanisms such as level of attention, (11). It has become apparent that pain in anxiety, depression and mood. Burning or gnawing pain at the epi- FGID is related to an abnormally low Even though the role of psychologi- gastrium is present in the majority of visceral sensory threshold
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