Neurogenic abdominal pain

Neurogenic abdominalgia include abdominal pain that is not associated with organic diseases of the gastrointestinal tract and the gynecological area.

The main causes of neurogenic abdominal pain:

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

Vertebral, vertebrogenic and myofascial pain syndromes

Diseases of the spine (vertebral syndrome), which take place without compression of roots and spinal cord membranes (various spinal deformities, spondylosis, spondylitis, tumors, traumas, 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 lumbar and sacral vertebrae or vertebral-motor segments. This is confirmed by the patient's complaints and an objective examination revealing local muscle tension, soreness with percussion and compression of the corresponding vertebrae or joints, and limitation of mobility. Non-neurovisual research allows in detail to assess the nature and prevalence of the pathological process in the spine.

Vertebrogenic syndromes in the D8-D12 region are characterized by reflex muscular-tonic and compression syndromes and are manifested by circumcision bilateral or (more often) one-sided pains in the abdominal region (usually in the zone of one or the other root), sometimes - by local changes in muscle tone. Characteristic is the association of pain syndrome with movements in the spine and changes in intra-abdominal pressure (vertebrogenic abdominal syndrome).

Myofascial pain syndromes, accompanied by abdominal pain, are characteristic of local muscle hypertension in the area of the rectus abdominis muscle, oblique abdominal muscles, transverse abdominal muscle, iliac-ribus muscle of the breast, dividing muscles and pyramidal muscle. In this case, patients can complain about "burning in the abdomen", "overflow", "bloating", "swelling", etc. ("Pseudovisceral pain"), sometimes with the irradiation of pain in the groin and testicle. Often, myofascial pains mimic visceral disease. Characterized by trigger points, palpable painful thickening of the muscles, the connection of pain with movement or with a pose. 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 zone, etc.).

Differential diagnosis is carried out with atypical manifestations of coronary heart disease, lower-grade pneumonia, herpes zoster.

Vertebrogenic and myofascial pains in the abdominal region are amplified by coughing, sneezing, straining, flexing of the neck, and movements of the spine. Sensory disorders are often not convincing or absent. Pain syndrome is provoked by excessive physical exertion, a long stay in an uncomfortable position, or timed to a strictly defined movement or position of the body.

A full-fledged paraclinical examination is always necessary to eliminate somatic diseases.

Neurological diseases

Epilepsy. Paroxysmal attacks of abdominal pain in children can be observed in the form of aura of a large convulsive fit or be the only manifestation of an epileptic attack. These abdominal pains usually have a papular localization with irradiation into the epigastric region. In most cases, they last for several minutes (but can persist up to 24-36 hours). They are usually accompanied by a disorder of consciousness. These pains do not depend on the intake of food, they are often accompanied by post-prick sleep, sometimes - amnesia of attack.

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 a good effect of finlepsin, valproic acid or diphenin.

Abdominal migraine is typical for children who develop a typical migraine in the future. These 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. Characterized by the same type of diffuse or peripump pain, which can be accompanied by nausea, vomiting, blanching and cold extremities. 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 definite effect of antimigraine therapy and the presence of a typical migraine in an anamnesis.

Differential diagnosis is carried out with epileptic abdominal seizures.

Neurogenic tetany can sometimes be manifested by crimpial painful cramps in the abdominal muscles, but these convulsions are revealed in the picture of more widespread tetanic convulsions in the limbs ("hand of an obstetrician," carpopedic spasms) and other typical manifestations of tetany (paresthesia, symptoms of increased neuromuscular excitability, EMG- signs of tetany).

Spinal cord lesions (tumors, spinal cord with abdominal tabetic crises, syringomyelia, etc.) are manifested by characteristic segmental and conductive neurologic symptoms, in the context of which pain in the abdomen is not difficult to relate to the underlying disease.

Periodic illness (paroxysmal Janeyey-Mosental syndrome, Reimann's disease, Sigal-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 a picture of an "acute abdomen") and joints accompanied by fever (up to 40-42 ° C). Possible cutaneous erythema, reminiscent of an erysipelas. Attacks last for several days and spontaneously terminate, but after a while they are repeated in the same form.

Porphyria is a large group of diseases of various etiology (hereditary and acquired), which is based on the violation of porphyrin metabolism. One of the most common variants of the disease is acute intermittent porphyria. Its main manifestation is abdominal syndrome (a periodically occurring severe colicky abdominal pain lasting from several hours to several days, vomiting, constipation or diarrhea is possible), which is accompanied by tachycardia, hypertension and fever. Less common is hypotension, urinary retention and hyperhidrosis (symptoms of involvement of the segmental nervous system), psychopathological disorders. Pathognomonic symptom is the allocation of urine of red color (a symptom of "Burgundy wine"). Some drugs (for example, barbiturates, glucocorticoids, sulfonamides and many others) cause an exacerbation of the disease. With its progression, signs of peripheral nervous system (polyneuropathy) are added in about 50% of cases, epileptic seizures are possible. Stool analysis reveals a positive reaction to porphobilinogen; in urine there is uroporphyrin and an increase in the excretion of d-aminolevulinic acid.

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

Psychogenic abdominalgia

Psychogenic abdominalgias manifest themselves as "unexplained" abdominal pains against a background of personality anomalies or behavioral disorders within the framework of neurotic or (rarely) psychotic disorders. In a history of such patients, in addition to psychotraumatic events (often the death of loved ones), often repeated operations, pain episodes (in women often abortions or extirpation of the uterus) and unexplained (from the point of view of general oomatic medicine) symptoms. Characteristic is obvious or latent depression, hypochondriacal manifestations (depressive-hypochondriacal sensopathic disorder), or hysterical personality characteristics, as well as signs of "pain-prone", sleep disorders, fear of a serious illness or confidence in its presence. Often, abdominalgia fit into the picture of hyperventilation syndrome, when the air is literally swallowed by the patient (aerophagia) with subsequent pains in the abdomen, or are observed in the picture of panic attacks. Sometimes Münchhausen's syndrome (often with multiple laparotomies in an anamnesis about "adhesions") is the basis of stubborn complaints of pain; less obvious psychotic disorders, to manifestations of which includes a bright pain syndrome with conspicuous absurdity and inadequate behavior. Currently, patients with symptoms reminiscent of pregnancy (false pregnancy) are rare in the picture of Alvarez syndrome. However, in about 40% of patients with psychogenic abdominal disorders, the above personality characteristics are not found. This difficult category of patients who need the most thorough somatic (ultrasound, endoscopy, computer tomography studies, etc.) and informal psychological examination. As a rule, a syndrome of psycho-vegetative disorders is revealed on the background of the absence of somatic and organic neurological diseases (pains of an "inorganic" nature).

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

[1], [2], [3], [4], [5], [6], [7], [8]