Psychogenic abdominal pain - Causes and symptoms

Abdominal migraine

Abdominal pain in abdominal migraine is most often found in children and adolescents, but is often detected in adult patients. As abdominal equivalents of migraine, abdominal pain may be accompanied by vomiting and diarrhea. Vomiting is usually persistent, imperative, with bile, does not bring relief; the pain is severe, diffuse, can be localized in the navel area, accompanied by nausea, vomiting, pallor, cold extremities. Vegetative concomitant clinical manifestations can be of varying severity, sometimes their bright manifestation forms a fairly clear picture of one or another variant of vegetative crisis. The duration of abdominal pain in these situations varies - from half an hour to several hours or even several days. The duration of vegetative concomitant manifestations can also vary. It is important to emphasize that the presence of hyperventilation components in the structure of vegetative manifestations can lead to the manifestation and intensification of such tetanic symptoms as numbness, stiffness, muscle contractions and spasms in the distal limbs (carpal, carpopedal spasms).

Analysis of the relationship between abdominal pain and cephalgic manifestations of migraine is of great importance for clinical diagnostics. Thus, various variants of the indicated relationships are possible: abdominal pain can be detected simultaneously with an attack of cephalgic migraine; cephalgic and abdominal paroxysms can alternate with each other; abdominal pain can be the leading one in the clinical picture. In the latter case, diagnostics of the migraine nature of abdominal pain is greatly complicated.

When making a diagnosis, it is necessary to take into account the following features of abdominal pain of this nature: the presence of a certain connection with a migraine headache (pulsating, provoked by emotions, meteorological factors, accompanied by photophobia, noise intolerance, etc.), predominantly young age, the presence of a family history of migraine, paroxysmal course, the relative duration (hours or even days) of the paroxysm, a certain effect of anti-migraine therapy, the detection of signs of discirculation in the vessels of the abdominal cavity (for example, acceleration of the linear velocity of blood flow in the abdominal aorta during Dopplerography), especially during the paroxysm.

Differential diagnosis is carried out with the visceral (abdominal) form of epilepsy.

It should also be noted that special studies conducted on such patients reveal signs of disturbances in the vegetative background, reactivity and support, hyperventilation-tetanic manifestations and subclinical disturbances in mineral metabolism.

Epilepsy with abdominal seizures

Abdominal pain, which has epileptic mechanisms at its core, despite being well-known, is extremely rarely diagnosed. The pain phenomenon itself, as in most forms of abdominal pain, cannot indicate the nature of the pain, therefore, the analysis of the clinical context, the "syndromic environment" is of fundamental importance for diagnosis. The most important thing in the clinical picture of abdominal pain of epileptic nature is paroxysmal nature and short duration (seconds, minutes). As a rule, the duration of pain does not exceed several minutes. Before the pain appears, patients may experience various unpleasant sensations in the epigastric region.

Vegetative and mental disorders with abdominal pain may be of varying intensity. The onset of a paroxysm may be manifested by pronounced panic (horror), which phenomenologically resembles the manifestation of a panic attack, but the suddenness and short duration make it easy to distinguish them from real panic disorders. Vegetative symptoms (pallor, sweating, palpitations, chest tightness, shortness of breath, etc.) are very vivid, but short-lived. Provoking factors for the occurrence of this paroxysm may be various stresses, overexertion, overfatigue, light stimuli (TV, light music). Sometimes the pain has a distinct cramping (painful spasms) character. During the paroxysm, in some cases, the patient experiences psychomotor anxiety, various, most often clinical, movements of the abdominal muscles, lower jaw. Sometimes there may be loss of urine and feces. In some cases, the period after the paroxysm is quite characteristic: a pronounced asthenic state, drowsiness, lethargy.

Diagnostic criteria of abdominal pain of epileptic origin: paroxysmal nature, short duration of the attack, other manifestations of epilepsy (other types of seizures), pronounced affective-vegetative manifestations, the presence of a number of epileptic phenomena in the structure of the attack itself, stupor after the attack of pain. Electroencephalographic examination with various methods of provocation (including sleep deprivation at night) can be of great help in clarifying the epileptic genesis of pain, as well as achieving a positive effect in the treatment with anticonvulsants or stopping the attack of pain with intravenous administration of seduxen.

For the purposes of clinical diagnosis, it is necessary to differentiate abdominal pain of an epileptic nature from the abdominal form of migraine, tetany, hyperventilation, and panic attacks.

The differential diagnosis of abdominal epilepsy and migraine is particularly difficult. However, the short duration of the attack, changes in the EEG, and a certain effect from the use of anticonvulsants allow us to distinguish these forms of the disease with a certain degree of probability.

The pathogenesis of abdominal pain of epileptic origin is associated with various situations. On the one hand, it may be a manifestation of a simple partial seizure with vegetative-visceral disorders within focal seizures (according to the latest international classification of epileptic seizures - 1981); on the other hand, a manifestation of vegetative-visceral aura.

Abdominal form of spasmophilia (tetany) The visceral, including abdominal, form of spasmophilia or tetany is based on the phenomenon of increased neuromuscular excitability, manifested by visceral spasms in organs with smooth muscles. In this regard, an important feature of abdominal pain is most often its periodic, spasmodic and painful (crampial) nature. Pain can manifest itself both paroxysmally (sometimes the intensity of pain is very pronounced) and permanently. In the latter case, patients complain of "colic", a feeling of contraction, compression, spasms in the abdomen. Painful abdominal paroxysms can be accompanied, in addition to characteristic pain, by nausea and vomiting. Frequent vomiting can lead to an even greater increase in visceral spasms as a result of the loss of fluid and electrolytes. Such an analysis of the structure of pain sensations, especially paroxysmal ones, can reveal, in addition to specific, cramping type of pain sensations, also other clinical phenomena that are of great importance in identifying the nature of abdominal pain: these are muscle-tonic phenomena in the extremities (obstetrician's hand phenomenon, pedal cramps or combined carpopedal spasms), sensations associated with breathing (lump in the throat, difficulty in breathing). Also characteristic is the presence of various types of distal paresthesia (numbness, tingling, crawling sensation) both during and outside of paroxysms. If the doctor thinks that the patient may have tetanic manifestations, symptoms indicating increased neuromuscular excitability should be established. There are certain diagnostic criteria for identifying tetanic syndrome.

1. Clinical symptoms:
   • sensory disorders (paresthesia, pain mainly in the distal parts of the extremities);
   • muscular-tonic phenomena (reduction, cramps, carpopedal spasms);
   • "background" symptoms of increased neuromuscular excitability, symptoms of Chvostek, Trousseau, Trousseau-Bonsdorf, etc.;
   • trophic disorders (tetanic cataract or clouding of the lens, increased fragility of nails, hair, teeth, trophic disorders of the skin);
2. Electromyographic signs (repetitive activity in the form of doublets, triplets, multiplets during ischemia of the arm in combination with hyperventilation).
3. Biochemical (in particular, electrolyte) disorders (hypocalcemia, hypomagnesemia, hypophosphatemia, imbalance of monovalent and bivalent ions).
4. The effect of the therapy aimed at correcting mineral imbalance (administration of calcium, magnesium).

It should be noted that the therapy of tetanic syndrome, the reduction of increased neuromuscular excitability, leading to a significant regression of abdominal pain, are, in our opinion, significant evidence of the presence of a pathogenetic connection between tetany and abdominal pain, while we are not talking about abdominalgia against the background of tetanic manifestations.

The pathogenesis of abdominal pain in tetany is associated with the main phenomenon underlying the clinical manifestations - increased neuromuscular excitability. A connection has been established between increased neuromuscular excitability and the occurrence of muscle contractions and spasms in both striated and smooth muscles (visceral form of spasmophilia or tetany), with a violation (purely subclinical) of the mineral balance, with autonomic dysfunction. In this case, various levels of the nervous system (peripheral, spinal, cerebral) can be the "generator" of increased neuromuscular excitability.

Abdominal pain in patients with hyperventilation syndrome has been noted by many researchers. Abdominal pain has been recently identified as a separate clinical manifestation within hyperventilation disorders. Abdominal pain is most often localized in the epigastric region, has the character of "gastric cramps", and in many ways resembles the pain described in tetany. It is important to emphasize that abdominal pain syndrome is inscribed in a specific clinical context, the consideration of which helps to identify the pathophysiological basis of suffering. Two variants of this clinical context are most often encountered in patients. The first is other gastrointestinal disorders (nausea, vomiting, rumbling in the abdomen, constipation, diarrhea, lump in the throat). A special place among them is occupied by a manifestation associated with the "invasion" of air into the gastrointestinal tract as a result of increased breathing and frequent swallowing, characteristic of patients with hyperventilation syndrome. This is a feeling of bloating, flatulence, belching of air or food, aerophagia, a feeling of distension in the stomach, in the abdomen, heaviness, pressure in the epigastric region. The second variant of clinical phenomena is a disorder of other systems: emotional disorders, respiratory (lack of air, dissatisfaction with inhalation, etc.), unpleasant sensations from the heart (pain in the heart, palpitations, extrasystoles) and other disorders.

In the structure of numerous manifestations of hyperventilation syndrome, signs of increased neuromuscular excitability (tetany) are often encountered. This is apparently associated with the identity of a number of features of the abdominal syndrome, namely, the cramping nature of pain. Of great importance is the analysis of the syndromic "environment" of pain manifestations, the hyperventilation test, which reproduces a number of complaints present in patients that are absent at the time of examination, a positive "breathing into a cellophane bag" test, the presence of symptoms of increased neuromuscular excitability, and a decrease in the concentration of carbon dioxide in the alveolar air.

The pathogenesis of abdominal pain in the context of hyperventilation disorders is associated with several mechanisms. Expressed vegetative dysfunction is naturally accompanied by impaired motility of the stomach and intestines, which leads to a sharp decrease in the threshold of vegetative perception. This factor, along with increased neuromuscular excitability and humoral changes as a result of hyperventilation (hypocapnia, alkalosis, mineral imbalance, etc.), determines the formation of powerful intraceptive impulses under conditions of reduced thresholds (vegetative perception, sensory, pain). The above mechanisms, primarily of a biological nature, in combination with a number of psychological characteristics of an affective and cognitive nature are, apparently, leading in the formation of abdominal pain in patients with hyperventilation disorders.

Periodic disease

In 1948, EMReimanl described 6 cases of the disease, which he called "periodic disease". The disease was characterized by periodically occurring attacks of acute pain in the abdomen and joints, accompanied by a rise in temperature to high numbers. Such conditions lasted for several days, after which they disappeared without a trace, but after some time they reappeared.

Periodic disease affects patients of almost all nationalities, but most often it manifests itself in representatives of certain ethnic groups, mainly in residents of the Mediterranean region (Armenians, Jews, Arabs). The abdominal variant of periodic disease is the main and most striking.

Paroxysms of abdominal pain in this disease, in addition to periodicity, have a certain stereotypy. The characteristic clinical picture is manifested by peculiar paroxysms of abdominal pain, the intensity of which resembles the picture of acute abdomen. In this case, a picture of diffuse serositis (peritonitis) develops. The localization of pain can be different (epigastric region, lower abdomen, right hypochondrium, around the navel or the entire abdomen) and change from attack to attack. A frequent concomitant symptom of abdominal pain is a rise in temperature, sometimes to high numbers (42 °C).

An abdominal attack may be accompanied by emotional and vegetative manifestations at the very beginning or even as precursors in 85-90% of patients. These are a feeling of anxiety, fear, general malaise, throbbing headache, pallor or hyperemia of the face, cold extremities, yawning, polyuria, fluctuations in blood pressure, pain in the heart, palpitations, sweating. During the height of the paroxysm, patients are bedridden due to severe pain, the slightest movements increase the pain. Palpation reveals a sharp tension of the muscles of the anterior abdominal wall; a sharply positive Shchetkin-Blumberg symptom is noted.

Considering that abdominal pain, in addition to fever, may also be accompanied by an increase in ESR and leukocytosis, patients with periodic disease often (47.8%) undergo surgical interventions, some of them (32.2%) - repeated. In such patients, the abdomen is covered with numerous surgical scars ("geographical abdomen"), which has a certain diagnostic value. From the gastrointestinal tract, patients are most often bothered by nausea, vomiting, profuse defecation and other manifestations. An important aspect of abdominal pain in periodic disease is the duration of the attack - 2-3 days. Most patients note a number of factors that can provoke an attack in them: negative emotions, overwork, suffering from any disease or surgery, menstruation, eating certain foods (meat, fish, alcohol), etc.

The main criteria for diagnosing abdominal pain in periodic disease are based on the analysis of the attack itself: rhythmically recurring pain attacks, their duration (2-3 days), the presence of diffuse serous peritonitis, pleurisy, complete disappearance of pain in the interictal period. Additional criteria for the disease include: onset of the disease in early childhood or during puberty, ethnic predisposition and hereditary burden, complications with amyloid nephrosis, frequent arthropathies, changes in the course of the disease during pregnancy and lactation, increased ESR, leukocytosis, eosinophilia, autonomic disorders, etc.

Periodic disease is differentiated from appendicitis, pancreatitis, cholecystitis, porphyria, etc.

The etiology and pathogenesis of periodic disease are still unknown. Numerous theories (infectious, genetic, immunological, endocrine, hypothalamic, etc.) apparently reflect various aspects of the pathogenesis of this disease. The mechanisms of symptom formation are based on periodic disruption of the vascular wall permeability and the formation of serous effusions, serositis (peritonitis, pleurisy, rarely pericarditis). A special study of the neurological aspects of periodic disease revealed signs of autonomic dysfunction in patients in the interparoxysmal period, organic microsymptomatology, which indicated the involvement of deep brain structures, the participation of hypothalamic mechanisms in the pathogenesis of the disease.

Abdominal pain associated with peripheral (segmental) autonomic disorders

Solar plexus lesions (solaritis) with the occurrence of well-known clinical manifestations, described in detail by domestic vegetologists, are currently extremely rare, practically being casuistry. Such descriptions (except for traumatic and oncological situations) are practically not found in the world literature. Many years of clinical experience of the All-Russian Center for Pathology of the Autonomic Nervous System indicate that in most patients diagnosed with "solaritis", "solaralgia", "solaropathy", etc., upon careful analysis, no conclusive signs of solar plexus lesions were established, as well as lesions of other vegetative plexuses. The overwhelming majority of such patients have abdominal pain of a psychogenic nature, suffer from abdominal migraine or myofascial pain, or have abdominal manifestations of hyperventilation and tetany. The listed causes of pain may be independent clinical syndromes, but most often they are components in the structure of a psychovegetative syndrome of a permanent or (more often) paroxysmal nature.

A special study of prolonged and persistent abdominal pain without signs of organic damage to the peripheral autonomic nervous system and without somatic organic disorders made it possible to establish a major role of the mental factor in the genesis of the said pain. In-depth analysis of the mental sphere, the autonomic nervous system and careful dynamic measurement of sensory and pain thresholds in the said group of patients, as well as in patients with organic diseases of the gastrointestinal tract and in the control group made it possible to identify a number of characteristic patterns in the pathogenesis of abdominal pain, proving the undoubted psychovegetative genesis of the so-called solarites. It should be added to this that an adequate study of damage to the peripheral autonomic nervous system should be modern special tests, described in detail in the section devoted to methods of studying peripheral autonomic insufficiency. Symptoms such as pain in the epigastric region (permanent or paroxysmal), painful “vegetative” points, “neuroinfections” suffered in the past, etc., cannot serve as a serious criterion for diagnosing “solaritis” or “solaralgia”, since they are natural situations in patients with a psychovegetative syndrome of a psychogenic nature.

In most cases, solar plexus lesions are essentially solar irritation syndromes resulting from various diseases of the abdominal organs and other systems. Cancer of the pancreas and other abdominal organs is often hidden behind the signs of solar plexus lesions. Another cause may be trauma to this area. Tuberculosis and syphilis can also affect the solar plexus both locally and through general toxic influence.

"Gastric" tabetic crises. Despite the fact that the late stage of syphilis - tabes darsalis - is quite rare, a neurologist should keep this pathology in mind as well. "Gastric crisis" usually imitates pain in a stomach ulcer, gallstone and kidney stone disease, or even intestinal obstruction. Abdominal pain usually begins without a prodromal period, suddenly and quickly reaches its maximum severity. The pain is very severe, excruciating, pulling, "tearing", cramping in nature. Most often, the pain is localized in the epigastric region, but can radiate to the left hypochondrium or lumbar region, and can be diffuse. Periodically intensifying, the pain can last for several days and suddenly stop. There is no connection between the pain and food intake, and conventional painkillers do not give an effect.

With the noted paroxysms of abdominal pain, other gastrointestinal disorders are also possible: nausea, vomiting, which does not alleviate the patient's condition. Palpation of the abdomen is painless, the abdomen is soft, however, during palpation there may be reflex, or more precisely, mental (anxiety) contractions of the abdominal muscles. In addition to abdominal pain, fleeting pains in the extremities may be detected.

Multidimensional general and vegetative disorders are also possible, such as asthenia, hyperthermia, tachycardia, hypotension, sometimes fainting, oliguria, etc. Serological studies and analysis of neurological symptoms are important for recognizing the nature of the described pains, which can indicate the presence of hidden or obvious signs of luetic damage to the nervous system in the patient.

The pathogenesis of paroxysms of pain in tabes dorsalis is not yet fully understood. Selective lesions of the posterior columns, posterior roots and membranes of the spinal cord are most often found at the lower thoracic, lumbar and sacral level (inferior tabes). The mechanism of involvement of the posterior columns of the spinal cord remains unclear. Among the existing hypotheses, the most common idea explains the mechanism of damage to the posterior columns by their compression at the sites of passage through the pia mater of proliferative processes of the affected posterior roots and membranes. It is possible that these organic processes disrupt the processes of the nociceptive-antinociceptive system (according to the gate control theory), forming a number of conditions for the occurrence of paroxysmal pain manifestations.

Porphyria is a large group of diseases of various etiologies, which are based on the disorder of porphyrin metabolism. One of the most common variants of porphyria is acute intermittent porphyria. The leading symptom of this form of the disease is abdominal syndrome: periodically occurring colicky pain in the abdomen lasting from several hours to several days. Vomiting, constipation, and, less often, diarrhea may soon join the pain.

Pathognomonic for porphyria is the excretion of red urine, the intensity of which depends on the severity of the disease. A special analysis reveals a positive reaction to porphobilinogen in feces and uroporphyrin in urine. Later, various signs of nervous system involvement appear.

The diagnosis of abdominal pain associated with porphyria is based on a combination of severe pain with mental and neurological manifestations, changes in urine color (red color in the absence of hematuria, positive qualitative reaction to porphobilinogen), the presence of skin changes, consideration of factors (taking a number of medications) that provoke attacks, and the presence of a family history.

Differential diagnosis is carried out with abdominal pain due to lead poisoning (lead colic), pre-comatose state due to diabetes mellitus, late periarteritis. The clinical picture of all these conditions is a combination of abdominal pain and damage to the nervous system (especially its peripheral part). However, a correct diagnosis is possible only taking into account the clinical features and paraclinical data.

The etiology and pathogenesis of porphyria have not been sufficiently studied. Genetically determined porphyrias are the most common. More diffuse lesions of the nervous system are also observed - in the form of polyradiculoneuropathy or even encephalomyelopolyradiculoneuropathy. A feature of neuropathies is their predominantly motor deficit. The upper limbs may be affected more severely than the lower, and the proximal muscles more than the distal. Paresis of the facial and ocular muscles is possible. In some cases, convulsive seizures develop. In some patients, the muscular system may be affected (myopathic porphyria).

Abdominal pain of vertebrogenic origin

Abdominal pain may be associated with damage to nerve formations (posterior roots) of spondylogenic origin. Most often, these are degenerative changes in the spine, but other various diseases may also occur (spondylosis, tuberculosis, tumors, traumatic changes in the spine, etc.).

Abdominal pain is not diffuse, but localized in the innervation zone of a particular segment of the spinal cord. Most often, pain is felt on the surface of the body, in the abdominal muscles, but it can also be deep, visceral. An important characteristic of the pain syndrome is its connection with the movement of the trunk. Getting out of bed, bending, unbending the trunk, turning can cause or exacerbate pain. Pain is also closely related to changes in intra-abdominal pressure, which manifests itself during coughing, defecation, straining. Often the pain can be one-sided, can be combined with pain in the lower back or in the back. As a rule, the pain is permanent, can be dull and becomes sharp when provoked, but the course of pain can also be paroxysmal.

Vertebrogenic abdominal syndrome is specially distinguished as one of the common syndromes of damage to the thoracic and lumbar spine. Its frequency fluctuates from 10 to 20% in patients with osteochondrosis of the spine. The main clinical manifestations are the same as described above. At the same time, attention is paid to the fact that the pain is aching, aching, bursting or boring in nature. In addition to abdominal pain, patients usually complain of limited movement in the affected section of the spine, a feeling of stiffness in it, and stiffness.

There are three types of vertebrogenic abdominal syndrome: thoracic, lumbar and lumbosacral. During objective examination of patients, certain changes in the abdominal wall muscles may be detected: change in tone (hypotonia, hypertension), zones of neuro-osteofibrosis. As a rule, spinal movements are limited in the frontal and sagittal planes, there may be vertebral deformities. Tension of the paravertebral muscles and soreness of the affected vertebral-motor segments are detected. Degenerative changes are revealed on radiographs. The diagnosis of abdominal pain of vertebrogenic origin is based on the clinical characteristics of the pain: limitation corresponding to certain segments, one-sidedness, close connection with movement and fluctuations in intra-abdominal pressure; the presence of signs of vertebrogenic disease - change in tone, configuration of the abdominal wall muscles and paravertebral region, limitation of movement. The results of the radiographic examination are important.

The occurrence of abdominal pain in osteochondrosis of the spine is realized through vegetative-irritative mechanisms, visceromotor reactions, which largely determine the appearance of neurodystrophic changes in the abdominal muscles.

The question of pathogenetic mechanisms of paroxysmal pain manifestations is important. In addition to local and reflex reactions, cerebral, in particular deep, structures of the brain are of great importance, which integrate mental, vegetative and endocrine-humoral functions involved in the phenomenon of chronic pain in these situations. Abdominal pain in organic diseases of the brain and spinal cord. Abdominal pain at some stage of development of a neurological disease can occupy an important place in the clinical manifestations of the disease. Most often, abdominal pain can occur in multiple sclerosis, syringomyelia and brain tumors. Acute abdominal pain has been described and also occurs in acute encephalitis, vascular lesions of the nervous system, encephalopathy and other diseases. In case of spinal cord damage of any etiology (tumor, myelitis, meningomyelitis, etc.), the involvement of the roots can lead to the appearance of abdominal pain, the characteristics of which were given in the corresponding section. Abdominal pain in tumors of the fourth ventricle is very intense, accompanied by spontaneous vomiting without preceding nausea (cerebral vomiting). Tumors of the temporal (especially in the insula) and upper parietal localization can cause severe visceral, most often epigastric pain in the abdominal localization. Abdominal pain in multiple sclerosis and syringomyelia rarely acts as the leading syndrome in clinical manifestations; most often it is part of fairly pronounced neurological disorders. The diagnosis is made based on the exclusion of a somatic disease and the detection of a disease of the nervous system. Treatment of abdominal pain is closely related to the treatment of the underlying disease.

Abdominal pain in gastrointestinal diseases of unclear etiology In recent years, it has become increasingly clear that mental factors and autonomic dysfunction play a key role in the pathogenesis of so-called inorganic (functional) gastrointestinal diseases. Analysis of modern literature on this issue reveals two situations in which abdominal syndrome may be the main or one of the main manifestations of the disease. These are irritable bowel syndrome and gastric dyspepsia syndrome. Although largely identical, these two pathological conditions still differ from each other. They are united by an unknown etiology and unclear pathogenesis. Given the undoubted role of psychovegetative mechanisms in the pathogenesis of both conditions, the presence of abdominal pain in their clinical manifestations suggests that modern vegetology should be included in the clinical and scientific analysis of these conditions.

Irritable bowel syndrome is a chronic pathological condition characterized by abdominal pain combined with bowel dysfunction (diarrhea, constipation) without loss of appetite and weight loss, lasting at least 3 months in the absence of organic changes in the gastrointestinal tract that could explain the existing disorders. In the American population, irritable bowel syndrome occurs in 8-17% of those examined, and among gastroenterological patients this percentage is significantly higher - 50-70. The ratio of women to men is 1.5:1. Most often, the syndrome occurs in the third decade of life, although cases of the disease in childhood and old age are not uncommon. Pain syndrome is characterized by a variety of manifestations: from diffuse dull pain to acute, spasmodic; from constant to paroxysmal abdominal pain. In adults, pain is most often localized in the left lower quadrant of the abdomen, but often in the left and right hypochondrium, around the navel (periumbilical pain is especially typical for children), pain can also be diffuse. The duration of painful episodes is from several minutes to several hours. Abdominal pain can bother the patient all day, but falling asleep and sleep are not disturbed. Paroxysmal pain is irregular in both duration and duration. In 90% of cases, pain is accompanied by intestinal dysfunction (diarrhea or constipation). Diarrhea is possible with increased pain and regardless of pain manifestations.

A number of authors even distinguish two variants of irritable bowel syndrome: with a predominance of pain and with a predominance of diarrhea. In the morning, patients empty their bowels several times (3-4 times). In the presence of constipation, the stool may resemble "sheep feces", have a small volume, and the act of defecation is painful. Appetite, as a rule, does not suffer, body weight does not change. Some patients have intolerance to a number of foods.

There are asthenic, mild depressive and anxiety disorders, signs of vegetative dysfunction. Endoscopic examinations reveal hyperalgesia of the mucous membranes of the sigmoid colon. X-ray examination reveals a spastic state of various parts of the intestine.

The diagnosis of irritable bowel syndrome is based on clinical and paraclinical studies. In modern publications devoted to this problem, the following diagnostic criteria are most popular among clinicians with a certain focus on finding the psychosomatic basis of suffering:

1. The presence of abdominal pain without organic changes in the gastrointestinal tract.
2. Bowel disorders (diarrhea with loose stools or constipation with small-volume, ball-shaped, pill-shaped stools, like “sheep feces”).
3. Clinical manifestations are constant or intermittent and last more than 3 months.
4. The absence of other diseases in the patient that could explain the genesis of the existing disorders.

The etiology and pathogenesis are not clear. Mental changes in the form of anxiety and depressive disorders occur in 70-90% of patients with irritable bowel syndrome. Signs of panic disorders in these patients disappear during treatment with antidepressants simultaneously with the normalization of gastrointestinal function, which indicates the existence of a connection between these two conditions. There is also some evidence on the role of hyperventilation mechanisms in the pathogenesis of irritable bowel syndrome.

Dyspepsia is defined as abdominal pain, discomfort, or nausea that occurs intermittently, lasts for at least a month, is not associated with exercise, and does not resolve within 5 minutes of rest [Talley N., Piper D., 1987].

Non-ulcer dyspepsia is dyspepsia in which detailed clinical examination does not reveal organic changes, and panendoscopy excludes acute or chronic peptic ulcer, esophagitis and malignant tumors.

Essential dyspepsia was defined as non-ulcer dyspepsia in which biliary tract disease was excluded by radiological examination, irritable bowel syndrome and gastroesophageal reflux were excluded by clinical criteria, and there were no other gastrointestinal diseases or disorders that could explain the clinical manifestations.

There are also other definitions of dyspepsia, such as considering it within the framework of the syndrome of indigestion - a disorder of the processes of cavity digestion in the stomach, small intestine or large intestine.

The pain syndrome in dyspepsia is largely identical to the pain in irritable bowel syndrome. They are usually combined with a feeling of heaviness, pressure and fullness after eating in the epigastric region, belching of air or food, an unpleasant metallic taste in the mouth, and sometimes a decrease in appetite. Patients are also bothered by rumbling, pouring, and increased peristalsis. Diarrhea and sometimes constipation develop more often. Such disorders, despite the fact that they bother patients, causing them numerous sufferings, causing asthenic and vegetative disorders, do not significantly affect the social activity of patients in general.

In addition to discussing the factors causing disturbances in enzymatic activity as a result of past illnesses (gastritis, duodenitis, enteritis, colitis), great importance is attached to psychogenic effects. It has been shown that psychosomatic mechanisms can affect the tone and motor functions of the gastrointestinal tract, causing disorders of various natures.

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