functional abdominal pain - inpatient management · 2018. 1. 18. · •commenced duloxetine: may...
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Functional Abdominal Pain- Inpatient management
Dr Peter Paine
Salford Royal Foundation Trust
2016
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“I’m afraid that your irritable bowel syndrome has progressed. You now have furious and vindictive bowel syndrome.”
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Definitions:
Rome or “real life”? Gastro 2016
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CAPS or “severe IBS” or?• Overlapping symptoms
– Bloating
– Constipation
– Nutrition (Nausea/vomiting)
– Dysmotility
• Overlapping nosology– Chronic (burnt out?) pancreatitis
– Previous IBD/surgery/gastroenteritis
– Overlap with other functional syndromes and psychiatric disorders
– Confounding pharmacology (NBS)
• Obscure pathophysiology– Neuropathic abdominal pain?
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Aug 2013
C. Small bowel involvement
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• Charibdis (whirlpool)“iatrogenesis”– investigation morbidity
• Cost• Reinforcement• Institutionalisation• Injury• NBS
– intervention morbidity• Surgery/short
bowel/TPN/death
Primum non nocere(first do no harm) .…..steer well clear!!
• Scylla (many headed)
“missing the diagnosis”
Is it cancer?
Is it crohn’s?
Is it FMF?
Is it porphyria?
Is it lead poisoning?
Is it C1 esterase deficiency?
Is it vasculitis?
Is it…………..?
Scylla or Charibdis?
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Adapted from Kroenke and Mangelsdorff 1989
How big is the problem?
“I hate IBS”
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0.00% 1.00% 2.00% 3.00% 5.00%4.00%
Per cent of patients consulting
Appendicitis
Malignant neoplasms of the digestive system
Duodenal ulcer
Noninfective colitis and enteritis
Other disorders of intestines
Other hernia
Hernia of abdominal cavity
Gastritis & duodenitis
Diseases of oesophagus
Disorders of function of stomach
Functional disorders not elsewhere classified
Infectious intestinal disease
Gastrointestinal disease (not liver)
Excludes hepatic/pancreaticobiliary
“I hate IBS even more!”
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IBS - Psychosocial
Drossman DA, Thompson WG., Ann Intern Med. 1992; 116:1009
Self-selection into Clinical Practice
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IBS - Psychosocial
Drossman DA, et al. Gastroenterology International. 1995; 8:47
Psychosocial Disturbances in Referral Practices
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Mixed up with surgeons
Mixed up with opiates
Malnutrition (disordered eating)Psychological distress – maladaptive coping/beliefsSymptom severity
Common CAPS pitfalls
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Case 1
• H 35yo ♀ - tertiary referral Yorkshire surgeon to IFU
• Teenager in social care: abdominal pains and bowel disturbance “IBS” – self managed, settling
• Miscarriage mid-20s. Recurrent severe lower abdominal pains. Gynae: “blocked tubes” TAH and BSO.
• Post-surgery progressively worsening abdo pains recurrent lap adhesiolysis
• Increasing doses of opiates:- fentanyl patch and lozenges for breakthrough. Doses escalating.
• Severe constipation digitates intermittently. One episode severe impaction anal tear and manual evac under GA (York)
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• Main pain = RIF. Barium small bowel “fixed” in RIF but no obstruction/strictures.
• Bloated & distended “like 6/12 pregnant”• Eating worsened pains PEG.• Drip feeding by PEG also worsened pains and some
peri-PEG discomfort. • Avoiding food but at other times “binge eats”. • “Wants TPN” IFU• Normal “nutrition bloods” high normal BMI. AXR left
sided faecal loading +++. • O/E Mildly tender peri-PEG but rest of abdomen
non-tender except RIF.• RIF exquisitely tender to light touch feels deep
pain, nauseous.
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Assessment
I think she exhibits several problems:
1. hypersensitivity in the right iliac fossa
• allodynia
• hyperalgesia"neuropathic pain”
2. sitophobia3. severe constipation
• element longstanding • exacerbated by opioid bowel dysfunction
4. possible element of "narcotic bowel syndrome”5. Mechanical element SB adhesional matting but also
abdominophrenic dysinergia
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How does NP differ from ACNES?
Diffuse vs focalCarnett’s sign – rectus sheath pain on tensing
Glissen Brown, J Clin Gastro 2016
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2013
allodynia
PS
CS
vscPS
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Surgeons: friend or foe?
• “all the operations
were necessary -
except the first”
Sir Miles Irving
Prof of surgery
IFU, Hope Hospital
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• Neuropathic pain prevalence post-op– Post-thoracotomy 35%
– Post-inguinal hernia 7-20%
– C-Section 10%
• Laparotomy 18%– Re-ops increased pain intensity
– Mostly moderate-severe neuropathic pain
– Lap adhesiolysis 5% serious complications, 1% mortality
– Most studies adhesion & pain recurrence
Oscar deLeon Casasola, PGM 2014
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• 3x cholecystectomy rate
• 2x hysterectomy rate
• 2x appendicectomy rate – (IBS OR 2.17 for negative appendicectomy)
• Increased colon resection
• Increased back surgery
Gut 2007
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Sites & mechanisms of chronic
post-surgical neuropathic pain
1. Peripheral sensitisation (distal
chemicals)
2. Neuroma at injury site (ectopic
excitability)
3. DRG gene expression
(excitiability)
4. Central sensitisation (dorsal horn
gene expression, inhibitory
interneurone loss, microglia
activation)
5. reduced DNIC (brainstem)
6. Limbic & hypothalamus
(emotion, behaviour, ANS)
7. Cortex (cognitive-evaluative)
8. Genomic DNA predisposition
& Rx responsiveness?
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Diffuse Noxious Inhibitory Controls (DNIC)
Wilder-Smith, Gut 2011
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Wilder-Smith, 2011
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Fear Avoidance Model in chronic abdominal pain
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Shifting the
balance in
endogenous
pain modulation
Wilder-Smith;
2011 Gut
“brakes”
“accelerator”
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The broken fire alarm: a wiring problem
It’s on a “hair trigger”:-Peripheral sensitisation & allodynia
The volume is turned right up/amplified:-Central sensitisation &Hyperalgesia
The “off switch” is broken:-Faulty CNS gaiting and descending inhibition &Continuous
It’s driving me mad!:-Coping strategies over-whelmed –for any sane person
NP agents: Cushions up a step-ladderdimmer switches not off switchesOpiates turn up the dialMay deaden/burn out over years
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APD “guttering”
Whorwell P Neurogastroenterol Motil (2012) 24, 301–304
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Is it mechanical, CIPO or enteric dysmotility or APD?
Functional bloaters CIPO
Accarino et al Gastro, 2009
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Management
• Explained: problems = – “wiring” nerve & muscle > “plumbing” pipes (CNS
element/opioid exacerbated-driven). (broken fire-alarm)– Pain on eating but not true “nutritional” problem.– TPN will not help and could be dangerous. – I do not think further surgery will help either. – Unrealistic to expect complete/quick resolution. – She would benefit additionally from psychological support in
coping with her chronic refractory symptoms
• Commenced duloxetine: may help neuropathic pain less constipation than tricyclics.
• Plan to commence: Methylnaltrexone s/c to help opioidbowel dysfunction
• Explained: “Rehabilitative” chronic pain team approach & possible controlled opiate reduction
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Outcome
• Discharged + clinic f/u 6/52• 2/52 post-discharge: Went cold turkey!• BO <q 4days, Weight increasing, PEG out• Chronic pain team shared care• 6months later on targinact improved bowel
function than previously• Not engaging initially with psychological approaches
but 1 year later “significant help” • 3 year follow up – remained out of hospital and back
into work. Discharged.
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CGH 2016
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Opiates: friend or foe?• Opiates and the gut:–
clinical scenarios– Opioid bowel dysfunction– Narcotic bowel syndrome– Opiate
dependency/addiction– Opiophobia– PN deaths (?immune
paresis)• Is it the opiates (pseudo-
obstruction) or is it pseudo-pseudo-obstruction?
• Are some opiates better?– Methadone (NMDA antag)– Tapentadol (NA reuptake
inhibition)– Tramadol– Long acting transdermal
(reduce soar and crash)
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33
IBS - Narcotic Bowel Syndrome
Rogers, J Clin Gastroenterlogy
1989;11:132
Pain &
Narcotic Vicious
Cycle
Narcotics pain relief Delayed
Transit
Constipation
/ Ileus
DistensionIncreased intestinalspasm / pain
Narcotics
Nausea /
VomitingWithdrawal
Narcotic Bowel – Pain and the Narcotic Vicious Cycle
Soar and Crash
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Drossman CGH 2008
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Opioid tolerance
Clin J Pain 2008
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Opioid induced Hyperalgesia
Clin J Pain 2008
allodyniahyperalgesia
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Salford data 2009-2016
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Hutchinson and Watkins, 2014 Neuropharmacology
TLR4 mediated pain intensification AND activation of the mesolimbic dopaminergic reward circuits drug-seeking behaviour
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Treatment of NBS• Recognition• Relationship• Replacement
– TCA, a2d ligands, NSRI (SSRI)– Linaclotide?– u-opioid antagonists (naloxegol?)– Pyschological therapies
• Reduction– Rapid? (GA, drug & alcohol team)– Slow controlled patient driven
• Prevention? TLR4 antagonists
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Drossman, Am J G, 2012
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Drossman, Am J G, 2012
“Buy in”Boundaries“Opioid aware”
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Salford data 2009-2016
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Linaclotide audit SRFT to Jan 2015
• Responder (34/79 = 43%) IBS SSS baseline = 390/500
• Equivocal response (4/79) = 5%– Average score
reduction at 4 weeks = 165
– Average score reduction at 12 weeks = 201 (n=25)
• non-responders (41/79 = 52%) IBS SSS baseline = 404/500
6
3
18
11
Reductions in other drug usage(4 stopped/ reduced drugs in 2 categories)
Stopped or reducedanalgesia (eg opiates,TCAs, Gabapentin)Stopped anti-spasmodics
Stopped or reduced otherlaxatives
No reduction in otherdrugs
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Salford data 2009-2016
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• KODIAC: laxative inadequate responders• Not injected• Not combined with opiate• Pegylation should prevent crossing BBB and
withdrawal• May help motility BUT will it help opiate induced
hyperalgesia?
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Overall Pain Phenotypes in Health & Disease
Farmer et al Pain 2013
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Modulating vagal tone
1. Deep Breathing…
2. HRV feedback…
Also, Zautra et al Pain 2010, Bonaz NGM, 2016
r = 0.54 p0.018 for increased vagal tone
r = 0.62 p0.004 for increased vagal tone
P <0.001P <0.001
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• 26 male STC for pancolitis (ileostomy, mucus fistula)
• developed neuropathic pain syndrome on lots of opiates almost immediately protracted readmission (slow penny drop!)
• Settled well with opiate reduction and gabapentinand TCA over next several months
• Weaned off all analgesics but now wants pouch!
Prevention is better than cure?..... Case 2
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• Option 1 To minimise the chances most -Do not have the operation
• Or if he does he has to accept there is a risk that he will have on going pain which may not settle second time around
• Option 2 600mg gabapentin as a premed higher doses have greater side effects (and so if admitted DOS then this can be a problem).
• Chose option 2 and successful pouch with no post-op pain
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