Rev Dor.

São Paulo, 2013 oct-dec;14(4):311-4 REVIEW ARTICLE

Abdominal visceral pain: clinical aspect*

Dor visceral abdominal: aspectos clínicos
Telma Mariotto Zakka1, Manoel Jacobsen Teixeira1, Lin Tchia Yeng1

*Received from the Interdisciplinary Pain Center, Clinicas Hospital, School of Medicine / University of São Paulo. São Paulo, SP, Brazil.

ABSTRACT são subtratados e subdiagnosticados. O tratamento interdisci-

plinar visa minimizar o sofrimento do paciente, aliviar a dor e
BACKGROUND AND OBJECTIVES: Abdomen is the most melhorar sua qualidade de vida.
frequent site for acute or chronic painful syndromes, for re- CONTEÚDO: Como as doenças viscerais podem determinar
ferred pain from distant structures or for pain caused by sys- dores de vários tipos e, habitualmente, desafiam os médicos no
temic injuries. Abdominal visceral pain is induced by hollow seu diagnóstico e tratamento, os autores descreveram de for-
viscera or parenchymal viscera walls stretching or by peritoneal ma prática, as características dolorosas e as associações com as
stretching. Complex diagnosis and treatment have motivated doenças mais incidentes.
this study. Patients with chronic abdominal pain are usually CONCLUSÃO: O tratamento interdisciplinar com a associa-
undertreated and underdiagnosed. The interdisciplinary treat- ção das medidas farmacológicas aos procedimentos de medicina
ment aims at minimizing patients’ distress, relieving pain and física e reabilitação e ao acompanhamento psicológico diminui
improving their quality of life. o sofrimento e as incapacidades e melhora a qualidade de vida.
CONTENTS: Since visceral diseases may determine pain of Descritores: Dor abdominal, Dor miofascial, Dor visceral,
different types and, usually, challenge physicians with regard to Tratamento interdisciplinar.
their diagnosis and treatment, the authors have described in a
practical way painful characteristics and associations with more INTRODUCTION
common diseases.
CONCLUSION: The interdisciplinary treatment, with the Visceral pain may be induced by tension or stretching of hol-
association of pharmacological measures to physical medicine low viscera or of the capsule of parenchymal viscera and by
and rehabilitation procedure and to psychological follow up, peritoneal traction or stretching. Abdomen is one of the most
decreases distress and inabilities and improves quality of life. frequent sites for acute or chronic painful syndromes caused by
Keywords: Abdominal pain, Interdisciplinary treatment, Myo- visceral diseases, caused by referred pain coming from adjacent
fascial pain, Visceral pain. structures and/or as a consequence of systemic injuries. Annual
chronic abdominal pain incidence is 15 cases out of 1 thousand
RESUMO individuals.
Visceral diseases may determine different types of pain: true
JUSTIFICATIVA E OBJETIVOS: O abdômen é o local mais visceral, referred visceral, localized parietal or referred parietal.
frequente das síndromes dolorosas agudas ou crônicas, de dor True visceral pain – not referred – is manifested in the ab-
referida de origem em estruturas distantes ou de dor decorrente dominal midline, without precise location in the epigastrium,
de lesões sistêmicas. A dor visceral abdominal ocorre por tensão periumbilical region or mesograstrium, in general described as
ou estiramento da parede das vísceras ocas ou da cápsula das colic and associated to nausea, vomiting, sweating or paleness1.
vísceras parenquimatosas e pela tração ou estiramento perito- Referred visceral pain is located in myotomes and dermatomes
neal. O diagnóstico e o tratamento complexos motivaram este supplied by neurons which project from the same medullar seg-
estudo. Os pacientes com dor abdominal crônica usualmente ments of the affected viscera2.
Localized or non-referred parietal pain results from the irrita-
tion of the parietal peritoneum and is located in the abdominal
wall corresponding to the injury site. Referred parietal pain is
1. University of São Paulo, School of Medicine, Clinicas Hospital, São Paulo, SP, Brazil.
manifested distant from the nociceptive stimulation site1,2.
Submitted in May 02, 2013. Among the most frequent causes of abdominal pain there are
Accepted for publication in August 12, 2013. infectious or chemical inflammatory processes, ischemic dis-
Conflict of interests: None
eases, dysfunctional diseases and tumors3.
Correspondence to: In general, visceral pain is not evoked by solid viscera and or-
Telma Mariotto Zakka
R Antonio Valente da Silva, 141 gans, such as liver, kidneys, and lung parenchyma, among oth-
12080-230 São Paulo, SP, Brasil. ers, and is not necessarily associated to visceral injury; it is in
E-mail: [email protected]
general diffuse and poorly located, may be referred distant from
© Sociedade Brasileira para o Estudo da Dor the affected viscera and is followed by autonomic and motor

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Rev Dor. São Paulo, 2013 oct-dec;14(4):311-4 Zakka TM, Teixeira MJ and Yeng LT

reflexes which act as pain transmission maintaining and facili- neuralgia, pos-cholecystectomy syndrome and pneumonia1,5,7,8.
tating system4,5. Liver pain is located in the right hypochondrium, epigastrium
Peripheral neuropathic abdominal pain is located in the dis- or distal chest region, worsens with expirations and may be
tribution region of one or more caudal thoracic roots (D8 to referred to right shoulder and scapula1,8,9.
D12), is characterized as burning, flashing, jumping or tingling, Left hypochondrium pain is induced by spleen and colon
is associated to hyperalgesia, hyperesthesia, hyperpathia and/or splenic flexure diseases, left hemothorax and tail of pancreas
other sensory and motor abnormalities, including wall laxity injury, neurological and musculoskeletal diseases. Thrombo-
and/or neurovegetative changes1. embolism or thrombosis of splenic nerves, splenic infarction,
This study aimed at analyzing anatomic, clinical and therapeu- splenic abscess, splenomegaly, colitis, spleen rupture, colon
tic aspects of visceral abdominal pain. splenic flexure carcinoma, pneumonia, intercostal neuralgia,
diaphragmatic hernia, pericarditis and angina pectoris are the
ANATOMIC ASPECTS most frequent injuries1,5. Pancreatic visceral pain is character-
ized by constant abdominal discomfort, with irradiation to
The abdominal cavity is clinically divided in regions: right and lumbar or distal dorsal regions.
left hypochondrium, epigastric, umbilical, hypogastric, right Lumbar pain is induced by kidneys, ureters, head and tail of
and left lumbar regions, right and left inguinal6. It may also pancreas or colon injuries. Major causes are peri-renal abscess-
be divided in quadrants: upper right (URQ) and left (ULQ) es, pyelitis, pyelonephritis, renal abscesses, renal tumor, renal
quadrant, and lower right (LRQ) and left (LLQ) quadrant. The tuberculosis, post-nephrectomy pain syndrome, intercostal
URQ lodges right liver lobe, gallbladder, pylorus, part of the neuralgia of one or more nerves (T8-T11), radicular compres-
duodenum, head of pancreas, right adrenal gland, right kidney, sion by tumor, vertebral diseases and herpes zoster1,5.
right colic flexure (hepatic), upper component of the ascending Periumbilical pain is induced by small intestine, appendix, cae-
colon and right half of the transverse colon. cum and body of pancreas injury, musculoskeletal or neurolog-
ULQ lodges left liver lobe, spleen, stomach, jejunum, proximal ical diseases, especially by acute intestinal obstruction, Meckel’s
ileum, body and tail of pancreas, left kidney, left adrenal gland, diverticulitis, superior mesenteric artery thromboembolism,
left colic flexure, left half of transverse colon and upper seg- enterocolitis, umbilical hernia, intercostal neuralgia (T9-T11) or
ment of descending colon. myofascial pain syndrome1,5.
LRQ lodges caecum, appendix, most part of the ileum, lower Right iliac region pain is induced by appendix, small intes-
segment of ascending colon, ovary, right oviduct, abdomi- tine, caecum, right kidney and ureter, right oviduct or ovary
nal segment of ureter, right spermatic cord, uterus (when in- injuries, musculoskeletal or neurological diseases, such as acute
creased) and bladder (when very full). appendicitis, chronic salpingitis, ovarian follicle rupture, renal
LLQ lodges sigmoid colon, distal segment of descending colon, colic, acute pyelitis, caecum carcinoma, inguinal hernia, acute
ovary, left oviduct, abdominal segment of ureter, left spermatic epididymitis and psoitis1,5.
cord, uterus (when increased) and bladder (when very full)6. Right iliac region pain is caused by sigmoid colon, left urinary
tract or internal female genitalia injuries, musculoskeletal or
CLINICAL CHARACATERISTICS OF VISCERAL PAIN neurological diseases. Common causes are acute salpingitis,
ectopic pregnancy, ulcerative colitis, psoitis, diverticulitis, sig-
Epigastric pain is caused by stomach, gallbladder, duodenum, moid volvo, intestinal intussusception, intestinal obstruction,
pancreas, liver, esophageal distal region, heart and lungs inju- inguinal hernia, epididimitis, segmental neuropathy (herpes
ries, especially by peptic ulcer, perforated ulcer, gastritis, py- zoster, disc hernia, medulary tumor), iliohypogastric or ilio-
loric spasm, gastric carcinoma, chronic or acute pancreatitis, inguinal nerves neuralgias and lumbar myofascial pain syn-
cholecystitis, biliary lithiasis, lower esophageal perforation, drome1,5,9.
chemical or bacterial esophagitis, myocardial infarction, peri- Hypogastric pain is due to bladder and internal genitalia inju-
carditis, congestive heart failure or epigastric hernia1,5. Stomach ries, intestinal diseases, musculoskeletal or neurological disor-
visceral pain is in general located in the mid-epigastric region. ders. Acute cystitis, bladder distention (bexigoma), prostatitis,
The involvement of peritoneum parietal layer by gastric dis- prostatic hypertrophy, bladder carcinoma, retosigmoid tumor,
eases may determine pain only in the upper left abdominal chronic constipation and internal female genitalia diseases are
quadrant. Diseases involving duodenal bulb cause visceral pain the most frequent causes1,5.
in the epigastric region and possibly in abdominal URQ. Distal Colic periumbilical pain, coming from the small intestine, may
duodenum diseases induce pain in the periumbilical region1. be triggered by visceral lumen distension or by excessive motor
Right hypochondrium pain is induced by liver, gallbladder activity. Infiltrative and inflammatory processes affecting pa-
and colon hepatic flexure diseases, right hemithorax and right rietal peritoneum may induce somatic pain and periumbilical
hemidiafragm disorders, musculoskeletal or nervous system visceral pain9,10. Ascending colon and right half of transverse
diseases. Most frequent injuries are chronic or acute cholecysti- colon distension may result in periumbilical and/or suprapubic
tis, biliary colic, liver and biliary system cancer, liver and pan- pain. Left half of transverse colon and descending colon dis-
creas abscesses, chronic or acute hepatitis, right hemidiafrag- tension determines pain in mid infraumbilical and suprapubic
matic pleurisy, subphrenic abscess, duodenal ulcer, intercostal portion10.

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Sigmoid colon injuries induce abdominal LRQ or LLQ pain relations, worsening and improving factors and circumstances
and in the suprapubic region when there is peritoneal involve- generating its installation and maintenance5,11,12. One should
ment due to mesenteric stimulation1,2. also evaluate pain relation with menstrual cycle, traumas or ab-
Peritoneal abdominal pain in the acute stage may be associ- dominal scars; evaluate triggering factors related to worsening
ated to nausea, vomiting, fever, tachycardia, hypertonia and of pain and/or improving pain factors such as cough, sneezing,
abdominal stiffness, sudden painful abdominal wall decom- elimination of flatus or feces, micturition, physical movements
pression and abolishing of bowel sounds. Parietal peritoneum and efforts. Check the use of drugs, such as angiotensin inhibi-
involvement in general causes pain in the region corresponding tors, beta-blockers, antibiotics, chemotherapeutic drugs, pro-
to the affected envelope. Musculoskeletal pain may be referred ton pump inhibitors and anti-inflammatory drugs.
to the same visceral pain reference regions10,11. During history, ask about weight loss, fever, anemia, adynamia,
Vertebral, ligamentous and/or muscular dysfunctions or chang- syncope, adenomegalies, abdominal masses, nausea, vomiting,
es of the thoracolumbar transition may generate pain or dis- diarrhea, obstipation, abdominal distension, belching, pirosis,
comfort in inguinal, pubic, gluteous and/or abdominal regions early satiety, postprandial fullness, anorexia, jaundice, choluria,
and/or lower limbs. Pain may simulate abdominal and/or pel- acholia, pruritus, hematemesis, melena, enterorrhagia, arthri-
vic visceral diseases and/or hip ligamentous or joint diseases11. tis, arthralgia, chest pain, urinary urgency, nighttime urination,
Visceral nociceptive pain is diffuse and deep, poorly located dispareunia, dysmenorrhea, low back pain, dorsal pain, fatigue,
and described as heavy, colic, jumping or pricking, has variable headaches, palpitations, insomnia, anorexia or increased appe-
intensity and may be constant or intermittent, disablilng or tite, presence of sexually transmitted diseases, habits, etc.1,9.
not. In association, there may be dispareunia and dysmenor- As to family history, evaluate factors related to abdominal pain,
rhea, as well as sleep disorders, difficulty to perform mild physi- such as acute intermittent porphyry, Mediterranean fever, di-
cal exercises and practical and daily life activities11. gestive tract cancer, diabetes mellitus, etc.
Clinical history should include background about abdominal
ABDOMINAL PAIN OF MYOFASCIAL ORIGIN surgeries, injuries, muscle fibers micro-trauma after physi-
cal exercises, repetitive or prolonged activities. Elements such
Myofascial pain syndrome (MPS), especially of abdominal as cough, body torsion, changes in position, physical activi-
rectus and oblique muscles, results in abdominal wall muscles ties, carrying heavy objects, which increase tension on muscle
pain and may mimic visceral diseases. Referred pain of abdomi- groups, may decondition patients and trigger or worsen ab-
nal muscles myofascial trigger points (TP) in general is located dominal pain. Visceral involvement symptoms, such as nau-
in the same quadrant and possibly in a different abdominal sea, vomiting, diarrhea, obstipation, fever and chills, are rare in
quadrant or in lumbar or dorsal region. Abdominal muscles such cases, except for the worsening period of painful crises1,5,9.
TPs activation may be caused by trauma or muscle stresses or At physical evaluation, abdominal palpation determines the
may represent visceral-somatic responses of visceral diseases presence of distension, tumor, ascitis, wall asymmetry, derma-
such as peptic ulcer, intestinal parasitosis, ulcerative colitis, co- tological spots or injuries. One should look for abdominal stiff-
lon diverticular disease or cholecystopathy. TPs may trigger so- ness, hepatomegaly or splenomegay, signs of peritonitis, motor
matovisceral responses, including vomiting, anorexia, nausea, deficits. Evaluate the presence and/or abnormalities of bowel
intestinal colic, diarrhea, vesical or sphincter spasm or dysmen- sounds. Physical evaluation should be complete, including rec-
orrhea. These symptoms associated to abdominal wall pain and tal and vaginal touch, and search for MPS-related TPs.
stiffness may mimic acute visceral disease, such as appendicitis A study13 has used Carnett test to evaluate the presence or ab-
or cholecistitis. sence of visceral diseases. Abdominal palpation of patients with
TPs activation may be perpetuated by emotional stress, adop- muscle contraction also results in pain and discomfort.
tion of inadequate postures and inadequate physical activities. Very often clinical findings are incompatible with complaints
MPS pain is worsened by movement, cough and is in general and additional exams may help the diagnosis. Such exams in-
associated to muscle reflex spasm and segmental and supra- clude blood count, erythrocyte sedimentation rate (ESR), glu-
segmental discrasic abnormalities1,2,6. cose, creatinine, bilirubin, a-amilase, lipase, alkaline phospha-
tase, urinary porphyrins (porphobilinogen), free T4 and TSH,
DIAGNOSIS serum calcium and phosphorus, hemoglobin electrophoresis,
feces parasitological exam, urine exam, Widal reaction (recent
Diagnosis is based on history and physical evaluation. Labo- diarrhea), tolerance to lactose test (diarrhea), etc.5,13,14.
ratory, imaging, endoscope and electrophysiological tests help Chest X-rays, total abdominal ultrasound (US), pelvic and/or
abdominal pain differential diagnosis. transvaginal ultrasound, CT, abdominal MRI, urinary tract scin-
During history one should consider gender, current patient’s tigraphy, proximal digestive endoscopy and colonoscopy, among
age, age at beginning of symptoms and its duration. Pain should other additional exams, should be tailored for each case. This
be characterized as to location, installation, irradiation, inten- way, for rostral abdominal pain one should request chest X-rays
sity, rhythm, periodicity, duration, interference with activities and for dorsalgia, thoracic and lumbar column X-rays13,14.
including sleep, ingestion of alcohol, spices, fatty food, fast- Total abdominal US for hypochondrium or epigastrium pain
ing, defecation and use of drugs. One should evaluate temporal discards biliopancreatic diseases and for mesogastric and dif-

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fuse pain without digestive symptoms it discards aneurysm Symptomatic drugs should be indicated and directed to the
or tumors. Pelvic or transvaginal US for pelvic pain helps the remission of predominant symptoms or primary abnormalities.
diagnosis of gynecological or urological diseases; kidney and Prokinetic agents, acid secretion inhibitors, 5-hidroxi-trip-
urinary tract US is indicated for flanks or lumbar region pain. tamine agonists13,17, antispasmodics, antidepressants, anxiolyt-
Proximal digestive endoscopy is indicated for epigastric pain or dis- ics, analgesics (opioids or not), Helicobacter pylory eradica-
comfort and colonoscopy is indicated for intestinal transit changes tion, acupuncture11, balanced diet, adequate ingestion of fibers
in patients above 45 years of age, with family history of colorectal and psychotherapy may be indicated for gastrointestinal dis-
cancer or polyposis, changes in pain or intestinal transit pattern, eases8-10,16.
short-duration recurrence symptoms and/or alarm signs (weight Due to the difficulty to locate the specific cause responsible for
loss, anorexia, rectal bleeding, anemia, nighttime symptoms). chronic abdominal pain, treatment is challenging. In these cases
Colonoscopy or opaque enema and/or anorectal manometry may there is peripheral and central sensitization as well as pain endog-
be useful for intestinal obstipation without organic injury13,14. enous modulation change. Analgesics, anticonvulsants and anti-
Laparoscopy is indicated for severe and disabling abdominal depressants are used to decrease sensitization and improve endog-
pain with undefined diagnosis or when abnormalities were enous pain modulation system. Non-pharmacological treatments
not explained by physical, laboratory or imaging evaluation. and additional treatment options may be indicated14,17.
Laparoscopy in chronic abdominal pain patients shows abnor-
malities in 53% of cases13,14. It is worth stressing that peritoneal CONCLUSION
adhesions are in general not related to chronic abdominal pain.
In females below 45 years of age with symptoms such as non- Patients with chronic visceral pain are usually undertreated
restorative sleep, low back pain, clinical presentation suggestive because they are underdiagnosed. Contributors to pain relief
of fibromyalgia, polaciuria, nicturia, dispaurenia, dysmenor- are symptoms control, normalization or restoration of patients’
rhea, etc., in the absence of alarm signs or symptoms or family physical, emotional and social components, elimination of fear
history of colorectal cancer and with normal physical evalua- of other diseases, correction of social, professional and family
tion, investigation should be judicious and progressive8. mismatches. The interdisciplinary treatment with association
When the investigation does not reveal structural and/or func- of pharmacological measures to physical and rehabilitation
tional changes related to visceral abnormalities, gastroentero- medicine and to psychological follow up decreases distress and
logical functional syndromes such as dyspepsia, nonspecific incapacities and improves quality of life.
dysmotility or irritable bowel syndrome, functional abdominal
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