Neurogenic abdominal pain

Neurogenic abdominalgia includes abdominal pain not associated with organic diseases of the gastrointestinal tract and gynecological sphere.

The main causes of neurogenic abdominal pain are:

1. Vertebral, vertebrogenic and myofascial syndromes: spinal deformities, hormonal spondylopathy, excessive physical activity involving the abdominal muscles (rowing, etc.), syndromes of the rectus abdominis and oblique abdominal muscles.
2. Neurological diseases: epilepsy, abdominal migraine, neurogenic tetany, syringomyelia, brain tumors, herpes zoster, neurosyphilis (tabes dorsalis), reflex sympathetic dystrophy, periodic disease, porphyria.
3. Psychogenic abdominalgia: depressive syndrome, hypochondriacal syndrome, Alvarez syndrome in hysteria, psychotic disorders.

Vertebral, vertebrogenic and myofascial pain syndromes

Diseases of the spine (vertebral syndrome) occurring without compression of the roots and membranes of the spinal cord (various deformations of the spine, spondylosis, spondylitis, tumors, injuries, hormonal spondylopathy, etc.) may be accompanied at some stages of the disease by reflected pain in the abdomen, but they are usually characterized by a simultaneous and more pronounced pain syndrome directly in the area of the lumbar and sacral vertebrae or spinal-motor segments. This is confirmed by the patient's complaints and an objective examination that reveals local muscle tension, pain during percussion and compression of the corresponding vertebra or its joints, and limited mobility. Neuroimaging research allows for a detailed assessment of the nature and prevalence of the pathological process in the spine.

Vertebrogenic syndromes in the D8 - D12 segments are characterized by reflex muscle-tonic and compression syndromes and are manifested by encircling bilateral or (more often) unilateral pain in the abdomen (usually in the area of one or another root), sometimes by local changes in muscle tone. The pain syndrome is typically associated with movements in the spine and changes in intra-abdominal pressure (vertebrogenic abdominal syndrome).

Myofascial pain syndromes accompanied by abdominal pain are characterized by local muscle hypertonicity in the area of the rectus abdominis muscle, oblique abdominal muscles, transverse abdominal muscle, iliac-costal muscle of the chest, multifidus muscles and pyramidal muscle. In this case, patients may complain of "burning in the abdomen", "overflow", "bloating", "swelling", etc. ("pseudovisceral pain"), sometimes with irradiation of pain to the groin area and testicle. Myofascial pain often imitates visceral disease. Trigger points, palpable painful muscle thickening, pain associated with movement or posture are characteristic. There is information in the literature that myofascial pain in the abdominal muscles can sometimes lead to reflex visceral disorders (diarrhea, vomiting, colic, dysmenorrhea, pain in the bladder area, etc.).

Differential diagnosis is carried out with atypical manifestations of ischemic heart disease, lower lobe pneumonia, herpes zoster.

Vertebrogenic and myofascial pain in the abdominal area increases with coughing, sneezing, straining, bending the neck, and movements of the spine. Sensory disturbances are often unconvincing or absent. The pain syndrome is provoked by excessive physical exertion, prolonged stay in an uncomfortable position, or is associated with a strictly defined movement or body position.

A full paraclinical examination is always necessary to exclude somatic diseases.

Neurological diseases

Epilepsy. Paroxysmal attacks of abdominal pain in children may be observed as an aura of a grand mal seizure or be the only manifestation of an epileptic seizure. These abdominal pains are usually located near the umbilicus with irradiation to the epigastric region. In most cases, they last for several minutes (but can persist for up to 24-36 hours). They are usually accompanied by disturbances of consciousness. These pains do not depend on food intake, they are often accompanied by post-seizure sleep, sometimes by amnesia of the seizure.

The diagnosis of epilepsy is based on the presence of other epileptic manifestations (usually complex partial seizures), epileptic activity on the EEG during or between seizures, and sometimes on the good effect of finlepsin, valproic acid, or diphenin.

Abdominal migraine is typical for children who later develop typical migraine. Such children usually have a family history of migraine. In adolescents and adults, discomfort and abdominal pain during a migraine attack alternate with attacks of the same abdominal pain, but without a headache. The same type of diffuse or periumbilical pain is typical, which can be accompanied by nausea, vomiting, paleness and coldness of the extremities. The duration of pain varies from half an hour to several hours (rarely - up to several days). Somatic examination does not reveal any pathology. The diagnosis is confirmed by a certain effect of anti-migraine therapy and the presence of typical migraine in the anamnesis.

Differential diagnosis is carried out with epileptic abdominal seizures.

Neurogenic tetany can sometimes manifest itself as cramping painful spasms in the abdominal muscles, but these spasms are revealed in the picture of more widespread tetanic spasms in the extremities (“obstetrician’s hand”, carpopedal spasms) and other typical manifestations of tetany (paresthesia, symptoms of increased neuromuscular excitability, EMG signs of tetany).

Lesions of the spinal cord (tumors, tabes dorsalis with abdominal tabetic crises, syringomyelia, etc.) are manifested by characteristic segmental and conductive neurological symptoms, in the context of which pain in the abdominal region is easily associated with the underlying disease.

Periodic disease (paroxysmal Janeway-Mosenthal syndrome, Reimann disease, Segal-Kattan-Mamu syndrome) is a hereditary disease that occurs among people of Armenian, Arab and Jewish nationality. The disease is characterized by recurrent attacks of pain in the abdomen (they resemble the picture of "acute abdomen") and joints, which are accompanied by fever (up to 40-42 ° C). Skin erythema, resembling erysipelas, is possible. The attacks last for several days and spontaneously stop, but after some time they recur again in the same form.

Porphyria is a large group of diseases of various etiologies (hereditary and acquired), which are based on the disorder of porphyrin metabolism. One of the most common variants of the disease is acute intermittent porphyria. Its main manifestation is abdominal syndrome (periodically occurring severe colicky abdominal pain lasting from several hours to several days, vomiting, constipation or diarrhea are possible), which is accompanied by tachycardia, hypertension and fever. Less common are hypotension, urinary retention and hyperhidrosis (symptoms of involvement of the segmental nervous system), psychopathological disorders. The pathognomonic symptom is the release of red urine (the "Burgundy wine" symptom). Some drugs (for example, barbiturates, glucocorticoids, sulfonamides and many others) provoke an exacerbation of the disease. As it progresses, signs of damage to the peripheral nervous system (polyneuropathy) join in approximately 50% of cases, and epileptic seizures are possible. Stool analysis reveals a positive reaction to porphobilinogen; uroporphyrin and increased excretion of d-aminolevulinic acid are detected in the urine.

Other rare neurological causes. Abdominal pain has been described in multiple sclerosis, brain tumors (IV ventricle tumors, temporal and upper parietal tumors), acute encephalitis, vascular lesions of the nervous system, and other diseases. Their genesis is not entirely clear.

Psychogenic abdominal pain

Psychogenic abdominalgias manifest themselves as "unexplained" abdominal pains against the background of personality anomalies or behavioral disorders within the framework of neurotic or (less often) psychotic disorders. In the anamnesis of such patients, in addition to psychotraumatic events (often the death of loved ones), repeated operations, painful episodes (in women, often abortions or extirpation of the uterus) and unexplained (from the point of view of general somatic medicine) symptoms are often revealed. Characteristic are overt or latent depression, hypochondriacal manifestations (depressive-hypochondriacal senestopathic disorder), or hysterical personality traits, as well as signs of a "pain personality" ("pain-prone"), sleep disorders, fear of a serious illness or confidence in its presence. Abdominalgias are often included in the picture of hyperventilation syndrome, when air is literally "swallowed" by the patient (aerophagia) with subsequent abdominal pain, or are observed in the picture of panic attacks. Sometimes persistent complaints of pain are based on Munchausen syndrome (often with multiple laparotomies in the anamnesis due to "adhesions"); less common are obvious psychotic disorders, the manifestations of which include a bright pain syndrome with striking absurdity and inadequate behavior. Currently, patients with symptoms resembling pregnancy (false pregnancy) in the picture of Alvarez syndrome are rare. However, in about 40% of patients with psychogenic abdominalgias, the above personality traits are not detected. This is a difficult category of patients who need the most thorough somatic (ultrasound, endoscopy, computed tomography, etc.) and informal psychological examination. As a rule, a syndrome of psychovegetative disorders is detected against the background of the absence of somatic and organic neurological diseases (pain of a “non-organic” nature).

The diagnosis of neurogenic abdominalgia requires the most thorough somatic examination to exclude somatic causes of abdominal pain (irritable bowel syndrome, gastric dyspepsia syndrome and other diseases of the visceral organs).

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