# Chronic functional abdominal pain



## eric (Jul 8, 1999)

FYIwith permissionCHRONIC FUNCTIONAL ABDOMINAL PAINReprinted with permission from the IFFGD.Originally printed in Participate -- Vol 7 No 1, Spring 1998.Go to the IFFGD website for Information on subscribing to Participate (and becoming anIFFGD member).People with functional gastrointestinal (GI) disorders can have a variety of symptoms thatrange from painless diarrhea or constipation, to pain associated with diarrhea and/orconstipation (usually called irritable bowel syndrome). There is another, less commoncondition of abdominal pain that is chronic or frequently recurring; it is not associatedwith changes in bowel pattern. This condition is called chronic functional abdominal pain(CFAP).CFAP is a functional GI disorder. There are no abnormal x-rays or laboratory findings toexplain the pain. It occurs because of altered sensitivity to nerve impulses in the gut andbrain, and it is not associated with altered motility in the intestines.For people with CFAP, the pain can be so all-consuming that it becomes the main focusof their lives. Not only does it impact on quality of life, but it has a major economicimpact as well. The US Householders Survey of Functional GI Disorders published in1993 found that people with CFAP missed an average of 12 days of work annually due toillness compared to 4 missed days for people without gastrointestinal symptoms. Also,the number of doctor visits in a year averaged 11 for those with CFAP compared withonly 2 for those without CFAP.PATHOPHYSIOLOGY -- UNDERSTANDING WHY PEOPLE GET CFAPTo understand the basis for chronic functional abdominal pain it is helpful to understandhow the body experiences pain. Nerve impulses travel from the abdomen to the spinalcord, and then to various areas of the brain. There are many different areas of the braininvolved in the sensation of abdominal pain. One of these connected areas is concernedwith the location and intensity of the pain, while another connected area is concernedwith memories or emotions. Because of this interconnection, the perception of pain canbe affected by emotions or life experiences.While symptoms of CFAP can appear without apparent cause, they can also occur aftertraumatic life events like the death of a loved one, divorce, or a history of sexual orphysical abuse. During times of added stress, symptoms can worsen.Repeated injury can cause abdominal nerve receptors to become overly sensitive. Forinstance, if someone has had multiple abdominal surgeries or an infection, a later painfuloccurrence may be experienced as more painful than previously. Even normal abdominalactivity may be experienced as being painful. It is as if the volume has been turned up ona stereo receiver. This condition is called visceral hypersensitivity (i.e., increasedsensitivity of the intestines).Understanding how the brain can modify the pain experience (for better or worse) isessential to beginning any treatment. When someone is feeling anxious or depressed, orfocuses attention on the pain, it is experienced as more severe. The use of relaxationtraining or other techniques can divert attention away from the pain.If a person has previously had a bad encounter with pain, the fear of having the painagain can actually make the pain worse the next time. If a person takes steps to feel incontrol of the pain, symptoms will improve. In addition, the amount of support a personreceives from family, friends, and other sources can affect how a person responds to pain.TREATMENT STRATEGIESGiven what we currently know about CFAP the aim of treatment is to help you gaincontrol over your symptoms and improve daily function, rather than totally eliminatesymptoms, which usually is not possible. One way to start is to keep a diary to recordsymptom flare- ups, and to identify possible triggers (emotional and situational). Thiskind of information may be used by you or your physician to help develop betterstrategies to control the symptoms (IFFGD created a Personal Daily Diary for use bypeople with functional GI disorders).The brain not only affects how you sense pain, it is also able to block pain. Think aboutthe basketball player who sprains his ankle during a game and continues to play withoutawareness of pain. Then, when the game ends, he collapses to the floor, unable towalk. He was able to block the pain by focusing his attention on the game.When nerve impulses travel up from the abdomen to the spinal cord, some of them gothrough a kind of "gate" that is controlled by nerve impulses coming down from thebrain. These impulses from the brain can block or inhibit pain signals going from theabdomen to the brain by "closing" the gate. Alternatively, they can increase signals to thebrain by opening the gate.Because the brain has such a strong influence on the sensation of pain, psychologicaltreatments can relieve symptoms of CFAP by sending signals that close thegate. Different techniques include relaxation, imagery, hypnosis, and cognitivebehavioraltherapy.Medications may also be used in the treatment of CFAP. For continuous or severeabdominal pain, your doctor might prescribe an antidepressant. It is important tounderstand that these medications are not just used to treat patients who have depressionbut also act as pain relievers (central analgesics) for treatment of CFAP and many otherpainful conditions.Antidepressant medications can help stimulate the brain to increase the signals whichblock pain transmission from the abdomen to the brain. It may take several weeks beforea difference is noticed.Some people will experience side effects from antidepressant medications. Usually theside effects will go away after a few days so it is important to stay with the medicationuntil treatment benefit is obtained. The tricyclic antidepressants (TCAs) can cause drymouth and drowsiness. Another group of antidepressants is called selective serotoninreuptake inhibitors (SSRIs). These can cause side effects like agitation, sleep disturbance,vivid dreams, and diarrhea.It is important to realize that narcotics are not indicated -- and can even be harmful andneed to be avoided -- in treating chronic abdominal pain. Over long periods of time,narcotics may produce more pain causing a condition called "Narcotic Bowel Syndrome."THE PATIENT-DOCTOR PARTNERSHIPIt is important that you work with a physician who demonstrates empathy toward you andan understanding of the symptoms of CFAP. It is a disorder where treatment requires theparticipation of both you and your physician.Treatments for CFAP are most effective when the patient and the doctor work as a team,each having a role. Your doctor has the responsibility to educate you about CFAP. He orshe should answer your questions and provide you with an understanding of what yoursymptoms are about and what your treatment options are.You need to express your views about your treatment goals, work with your doctor todevelop the treatment plan, and work toward putting the plan into action. If you followthe treatment plan closely, you and your doctor will be better able to track yourresults. This will allow you to achieve the best possible relief of abdominal pain. http://www.med.unc.edu/wrkunits/2depts/med.../fgidc/cfap.pdf


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