Abdominal pain: update on emergency department management of appendicitis and diverticulitis.

Abdominal pain is one of the most common presenting complaints to the emergency department, and appendicitis and diverticulitis are common causes. Intra-abdominal infections have historically been managed with admission to the hospital, antibiotics, and surgical interventions, and best-practice pathways are an important part of quality programs. Advances in diagnostics and management, supported with outcome data, are impacting care pathways. This review provides an update on best practices related to the management of appendicitis and diverticulitis, with the goal of improving patient care, minimizing risk, and maximizing the patient experience.

Efficacy of botulinum toxin injection using the right-sided unilateral retrocrural approach for celiac plexus in a cancer survivor with persistent abdominal pain: a case report.

Cancer survivors often face persistent abdominal pain, necessitating optimal pain management. While celiac plexus block (CPB) and botulinum toxin (BT) injection are viable options, traditional methods may encounter challenges due to patient-specific concerns and anatomical complexities. Here, the case of a cancer survivor in his 70 s experiencing recurrent abdominal pain, who declined conventional percutaneous CPB approaches due to anxiety related to aortic puncture, is presented. Following a pancreaticoduodenectomy, the patient developed chronic abdominal pain attributed to adhesions leading to small bowel obstruction. Concurrently, there was notable psychological distress, including anxiety, depression, and heightened concerns regarding tumor recurrence. Considering the patient's specific concerns, a right-sided unilateral retrocrural single-needle technique was proposed, aimed at alleviating pain, while avoiding conventional CPB approaches. Initial right-sided retrocrural CPB offered short-term relief, prompting a subsequent BT injection using the same approach. Following BT injection, the patient reported significant and sustained pain reduction (from 8 to 1 on an 11-point numerical rating scale) at both 12 and 20 weeks post-procedure. Right-sided retrocrural BT injection offers an alternative approach, addressing patient concerns and demonstrating prolonged pain relief. This may benefit cancer survivors with upper abdominal pain, emphasizing the importance of personalized and innovative pain management strategies.

Diagnosing and managing irritable bowel syndrome with predominant diarrhoea in clinical practice: online survey among gastroenterologists and general practitioners.

Introduction: Irritable bowel syndrome (IBS) represents the most common disorder of gut-brain interaction encountered in clinical practice. The Rome IV criteria define the disorder. Over the years, many guidelines proposed guidance during the diagnostic and therapeutic approach of patients with presumed IBS. Aim: This study investigates the management of IBS with predominant diarrhoea (IBS-D) by Belgian gastroenterologists (GE) and general practitioners (GP) in daily practice. Methods: An online vignette-based survey was conducted exploring the diagnostic and therapeutic approach of patients suffering from IBS with predominant diarrhoea (IBS-D) in primary and secondary care. Results: 64 GE and 31 GP completed the survey. Abdominal pain and discomfort led to an IBS diagnosis in 88% and 84% of cases, respectively. The diagnosis rate dropped to 58.3% with diarrhoea as main presentation and 26.8% for patients aged 65. Additional tests were ordered by 89.5% of physicians, including biochemistry (77.9%), stool culture and parasites (59.3%), iFOBT (60.5%), breath testing (17.4%), imaging (12.8%), and endoscopy (9.3%). Upon normal results, 57% of physicians did not order further investigations. Both GP and GE preferred spasmolytics (64.3%) and dietary interventions (23.9%) as first-line treatment for IBS. Second-line treatment options included referral to a specialist or colleague (19.4%), dietary intervention (22.6%), neuromodulators (19.4%), and spasmolytics (14.5%). No GP initiated neuromodulators. Conclusion: In Belgium, abdominal pain or discomfort are equivalent cardinal symptoms when diagnosing IBS. During the further diagnostic and therapeutic approach most physicians order only limited additional non-invasive testing. Spasmolytics and dietary interventions are favoured in first-line. Upon failure, only GE prescribe neuromodulators, while GP opt for referral. These findings are consistent with the general principles and recommendations outlined in the recently published Belgian guideline for IBS.

Ricin intoxication by lethal dose of castor seeds ingestion: a case report.

INTRODUCTION: Ricin intoxication is a serious condition with symptoms ranging from mild gastroenteritis to fatal outcomes due to shock and multi-organ failure. Intoxication from the ingestion of castor seeds is uncommon. However, its diagnosis is crucial, particularly with a clear history of exposure to castor seeds, regardless of the route of exposure (enteral or parenteral). Prompt diagnosis is essential to monitor and manage the patient effectively and to prevent potentially fatal outcomes. We report a case where ingestion of castor seeds resulted in gastroenteritis severe enough to necessitate emergency medical care. CASE REPORT: We present the case of a 47-year-old Belgian woman of Moroccan descent, previously healthy who was admitted to the emergency department with symptoms of colicky abdominal pain, diarrhea, and vomiting following the ingestion of six castor beans. The patient was diagnosed with ricin intoxication, admitted for observation, and received symptomatic treatment. She was discharged home after a complete recovery three days later. CONCLUSION: Our report underscores the clinical manifestations, hemodynamic changes, laboratory findings, and treatment of intoxication due to castor seed ingestion. It contributes to the limited literature on castor seed poisoning in humans, with a specific focus on cases in Belgium. This report aims to raise awareness among clinicians about this condition and emphasizes the importance of a comprehensive history-taking to prevent misdiagnosis and malpractice.

Navigating through 65 years of insights: lessons learned on functional abdominal pain in children.

In 1958, Apley and Naish authored a groundbreaking paper in Archives of Disease in Childhood, elucidating the epidemiology and risk factors of recurrent abdominal pain in children-a subject that had confounded clinicians of their time. Surprisingly, even after 65 years, there are several unanswered questions regarding the etiology, pathophysiology, and management of pediatric abdominal pain. Contrary to the prevailing notion that children naturally outgrow functional abdominal pain, compelling evidence suggests it's possible these children develop a number of clinically significant psychological issues that could profoundly impact their quality of life and, consequently, future health and educational outcomes. In this light, we aimed to comprehensively review the current literature to update the knowledge of practicing clinicians on functional abdominal pain, summarizing the evidence from the last 65 years.Conclusion: The enduring unanswered questions surrounding childhood abdominal pain continue to challenge clinicians, resulting in unnecessary investigations, thereby contributing to substantial healthcare expenditures. It is also evident that children with long-standing symptoms would progress to adulthood with the potential to develop irritable bowel syndrome and many psychological disturbances. Several key interventions using pharmacological agents, such as amitriptyline, showed that some of these drugs are no more effective than the placebo in clinical trials. Several research during the recent past suggest that psychological interventions such as gut-directed hypnotherapy alleviate symptoms and ensure better prognosis in the long run. Therefore, clinicians and researchers must join hands to explore the pathophysiological mechanisms underpinning functional abdominal pain and novel therapeutic strategies to ensure the well-being of these children. What is Known: • Functional abdominal pain disorders are common among children, with a worldwide prevalence of 13.5% of children suffering from at least one of these disorders • These disorders contribute to a significant reduction in the quality of life of affected children and their families and lead to an array of psychological problems What is New: • The biological basis of functional abdominal pain is becoming more explicit, including complex interactions between altered microbiome, deranged motility, and psychological dysfunction with gut-brain interactions • Novel approaches giving minimal emphasis on pharmacological interventions and exploring psychological interventions are showing promising results.

Irritable bowel syndrome: Clinical practice update.

ABSTRACT: Irritable bowel syndrome (IBS) is a common and burdensome disorder characterized by chronic recurrent abdominal pain and altered bowel habits. IBS remains misunderstood, leading to delayed diagnosis, impaired quality of life, and substantial healthcare costs. Advancing clinicians' understanding of this complex biopsychosocial process, using a positive diagnostic strategy rather than a diagnosis of exclusion, and incorporating a multimodal treatment approach expedite time to diagnosis, facilitate symptom relief, and reduce financial expenditure.

[The prospect of using virtual reality technology in combination with psychotherapeutic methods in children with functional abdominalgia]. / Perspektiva primeneniya tekhnologii virtual'noi real'nosti v sochetanii s psikhoterapevticheskimi metodami u patsientov detskogo vozrasta s funktsional'noi abdominalgiei.

OBJECTIVE: The literature review addresses the effectiveness of psychotherapeutic methods in the treatment of functional abdominal pain syndrome and studying the prospects for using virtual reality technology in combination with psychotherapeutic methods according to the available literature. MATERIAL AND METHODS: A search was conducted for available literature in the eLibrary and PubMed databases, published for the period 2017-2022, using the keywords: abdominalgia, psychotherapeutic methods, gut-brain axis, virtual reality technology. RESULTS: Currently, the biopsychosocial concept of the etiopathogenesis of abdominal pain syndrome, which is not associated with an organic disease of the gastrointestinal tract, is used. A significant contribution to the formation of the disease is made by genetic, neuropsychological, neurophysiological factors, and disruption of the interaction of the gut-brain axis. Cognitive behavioral therapy, yoga, and hypnotherapy are applicable as effective psychotherapeutic methods in the complex treatment of abdominal pain syndrome in children. A promising direction is the use of virtual reality technology to increase the effectiveness of psychotherapeutic methods and reduce chronic abdominal pain syndrome by influencing the gut-brain axis. Practical research work devoted to this issue is currently rare. CONCLUSION: In the complex treatment of functional abdominal pain syndrome in children, various psychotherapeutic methods are used, the most effective are cognitive behavioral therapy and hypnotherapy. It is necessary to stimulate domestic research work studying the joint use of virtual reality technology and psychotherapeutic methods in children aged 7 to 18 years.

Dorsal Root Ganglion Stimulation for the Management of Inflammatory Bowel Disease: A Case Report.

This case report presents the successful use of dorsal root ganglion stimulation (DRGS) in a 30-year-old female patient with Crohn's disease. Despite extensive treatments, the patient experienced chronic abdominal pain, diarrhea, bloating, cramping, fatigue, and other debilitating symptoms. After a successful DRGS trial with leads placed on the right T6 and T10, she was implanted with a permanent system. At 18 months she continues to experience significant improvement in symptoms, including reduced abdominal pain, decreased defecation frequency, better stool consistency, less pain with eating and bowel evacuation, and enhanced quality of life.

Sympathetic nerve blocks for persistent pain in adults with inoperable abdominopelvic cancer.

BACKGROUND: Persistent visceral pain is an unpleasant sensation coming from one or more organs within the body. Visceral pain is a common symptom in those with advanced cancer. Interventional procedures, such as neurolytic sympathetic nerve blocks, have been suggested as additional treatments that may play a part in optimising pain management for individuals with this condition. OBJECTIVES: To evaluate the benefits and harms of neurolytic sympathetic nerve blocks for persistent visceral pain in adults with inoperable abdominopelvic cancer compared to standard care or placebo and comparing single blocks to combination blocks. SEARCH METHODS: We searched the following databases without language restrictions on 19 October 2022 and ran a top-up search on 31 October 2023: CENTRAL; MEDLINE via Ovid; Embase via Ovid; LILACS. We searched trial registers without language restrictions on 2 November 2022: ClinicalTrials.gov; WHO International Clinical Trials Registry Platform (ICTRP). We searched grey literature, checked reference lists of reviews and retrieved articles for additional studies, and performed citation searches on key articles. We also contacted experts in the field for unpublished and ongoing trials. Our trial protocol was preregistered in the Cochrane Database of Systematic Reviews on 21 October 2022. SELECTION CRITERIA: We searched for randomised controlled trials (RCTs) comparing any sympathetic nerve block targeting sites commonly used to treat abdominal pelvic pain from inoperable malignancies in adults to standard care or placebo. DATA COLLECTION AND ANALYSIS: We independently selected trials based on predefined inclusion criteria, resolving any differences via adjudication with a third review author. We used a random-effects model as some heterogeneity was expected between the studies due to differences in the interventions being assessed and malignancy types included in the study population. We chose three primary outcomes and four secondary outcomes of interest. We sought consumer input to refine our review outcomes and assessed extracted data using Cochrane's risk of bias 2 tool (RoB 2). We assessed the certainty of evidence using the GRADE system. MAIN RESULTS: We included 17 studies with 1025 participants in this review. Fifteen studies with a total of 951 participants contributed to the quantitative analysis. Single block versus standard care Primary outcomes No included studies reported our primary outcome, 'Proportion of participants reporting no worse than mild pain after treatment at 14 days'. The evidence is very uncertain about the effect of sympathetic nerve blocks on reducing pain to no worse than mild pain at 14 days when compared to standard care due to insufficient data (very low-certainty evidence). Sympathetic nerve blocks may provide small to 'little to no' improvement in quality of life (QOL) scores at 14 days after treatment when compared to standard care, but the evidence is very uncertain (standardised mean difference (SMD) -0.73, 95% confidence interval (CI) -1.70 to 0.25; I² = 87%; 4 studies, 150 participants; very low-certainty evidence). The evidence is very uncertain about the risk of serious adverse events as defined in our review as only one study contributed data to this outcome. Sympathetic nerve blocks may have an 'increased risk' to 'no additional risk' of harm compared with standard care (very low-certainty evidence). Secondary outcomes Sympathetic nerve blocks showed a small to 'little to no' effect on participant-reported pain scores at 14 days using a 0 to 10 visual analogue scale (VAS) for pain compared with standard care, but the evidence is very uncertain (mean difference (MD) -0.44, 95% CI -0.98 to 0.11; I² = 56%; 5 studies, 214 participants; very low-certainty evidence). There may be a 'moderate to large' to 'little to no' reduction in daily consumption of opioids postprocedure at 14 days with sympathetic nerve blocks compared with standard care, but the evidence is very uncertain (change in daily consumption of opioids at 14 days as oral milligrams morphine equivalent (MME): MD -41.63 mg, 95% CI -78.54 mg to -4.72 mg; I² = 90%; 4 studies, 130 participants; very low-certainty evidence). The evidence is very uncertain about the effect of sympathetic nerve blocks on participant satisfaction with procedure at 0 to 7 days and time to need for retreatment or treatment effect failure (or both) due to insufficient data. Combination block versus single block Primary outcomes There is no evidence about the effect of combination sympathetic nerve blocks compared with single sympathetic nerve blocks on the proportion of participants reporting no worse than mild pain after treatment at 14 days because no studies reported this outcome. There may be a small to 'little to no' effect on QOL score at 14 days after treatment, but the evidence is very uncertain (very low-certainty evidence). The evidence is very uncertain about the risk of serious adverse events with combination sympathetic nerve blocks compared with single sympathetic nerve blocks due to limited reporting in the included studies (very low-certainty evidence). Secondary outcomes The evidence is very uncertain about the effect of combination sympathetic nerve blocks compared with single sympathetic nerve blocks on participant-reported pain score and change in daily consumption of opioids postprocedure, at 14 days. There may be a small to 'little to no' effect, but the evidence is very uncertain (very low-certainty evidence). There is no evidence about the effect on participant satisfaction with procedure at 0 to 7 days and time to need for retreatment or treatment effect failure (or both) due to these outcomes not being measured by the studies. Risk of bias The risk of bias was predominately high for most outcomes in most studies due to significant concerns regarding adequate blinding. Very few studies were deemed as low risk across all domains for any outcome. AUTHORS' CONCLUSIONS: There is limited evidence to support or refute the use of sympathetic nerve blocks for persistent abdominopelvic pain due to inoperable malignancy. We are very uncertain about the effect of combination sympathetic nerve blocks compared with single sympathetic nerve blocks. The certainty of the evidence is very low and these findings should be interpreted with caution.

[Beware of labels]. / 5 minutes pour apprendre. Gare aux étiquettes.

A 50-year-old individual identified as a 'frequent user' of emergency services due to chronic abdominal pain was transported to the emergency department by ambulance during a new episode of abdominal pain. Despite being initially deemed stable by paramedics, the patient was not reassessed by the triage nurse upon arrival. Subsequently, the patient presented with severe pain, arterial hypotension, and tachycardia. Following a multidisciplinary protocol for pain management, analgesic treatment was initiated. Despite several hours of management and repeated assessments, an abdominal CT-scan was eventually conducted, revealing a perforated small intestine. The application of the 'frequent user' label may have contributed to a delay in the provision of timely care for this patient.

Manual & exercise therapy for treatment of chronic abdominal pain and diarrhea, a case report.

A 34-year-old male with a 9+ year history of right sided abdominal pain, associated diarrhea and a diagnosis of irritable bowel syndrome was referred for physical therapy and chiropractic care at a multidisciplinary primary care clinic. Multiple evaluations by various providers resulted in multiple tests and numerous medications without substantial relief in symptoms. Five physical therapy visits and three sessions of chiropractic care resulted in 90% improvement in subjective pain report and 60-70% reduction in diarrhea frequency. At a 6 month follow up phone visit, his symptoms had continued to decrease. While limited as a case study, this report may illustrate a potential somatovisceral relationship and subsequent reduction in gastrointestinal symptoms that can be addressed with conservative care.

Gastrointestinal Conditions: Pancreatitis.

Acute pancreatitis is among the most common gastrointestinal disorders requiring hospitalization. The main causes are gallstones and alcohol use. Patients typically present with upper abdominal pain radiating to the back, worse with eating, plus nausea and vomiting. Diagnosis requires meeting two of three criteria: upper abdominal pain, an elevated serum lipase or amylase level greater than 3 times the normal limit, and imaging findings consistent with pancreatitis. After pancreatitis is diagnosed, the Atlanta classification and identification of the systemic inflammatory response syndrome can identify patients at high risk of complications. Management includes fluid resuscitation and hydration maintenance, pain control that may require opioids, and early feeding. Feeding recommendations have changed and "nothing by mouth" is no longer recommended. Rather, oral feeding should be initiated, as tolerated, within the first 24 hours. If it is not tolerated, enteral feeding via nasogastric or nasojejunal tubes should be initiated. Antibiotics are indicated only with radiologically confirmed infection or systemic infection symptoms. Surgical or endoscopic interventions are needed for biliary pancreatitis or obstructive pancreatitis with cholangitis. One in five patients will have recurrent episodes of pancreatitis; alcohol and smoking are major risk factors. Some develop chronic pancreatitis, associated with chronic pain plus pancreatic dysfunction, including endocrine failure (insulin insufficiency) and/or exocrine failure that requires long-term vitamin supplementation.

Functional dyspepsia: How to manage the burn and the bloat.

Functional dyspepsia is defined as persistent symptoms of postprandial bloating, early satiety, or pain in the center of the upper abdomen, without findings on upper endoscopy such as peptic ulcer disease to explain these symptoms. It is common, affecting up to 30% of the global population, but it often goes undiagnosed for years. There are 2 subtypes: epigastric pain syndrome (burning and pain) and postprandial distress syndrome (bloating and satiety). The authors discuss how to diagnose and treat both subtypes.

Older age and risk for delayed abdominal pain care in the emergency department.

BACKGROUND AND IMPORTANCE: Suboptimal acute pain care has been previously reported to be associated with demographic characteristics. OBJECTIVES: The aim of this study was to assess a healthcare system's multi-facility database of emergency attendances for abdominal pain, to assess for an association between demographics (age, sex, and ethnicity) and two endpoints: time delay to initial analgesia (primary endpoint) and selection of an opioid as the initial analgesic (secondary endpoint). DESIGN, SETTING, AND PARTICIPANTS: This retrospective observational study assessed four consecutive months' visits by adults (≥18 years) with a chief complaint of abdominal pain, in a UK National Health Service Trust's emergency department (ED). Data collected included demographics, pain scores, and analgesia variables. OUTCOME MEASURES AND ANALYSIS: Categorical data were described with proportions and binomial exact 95% confidence intervals (CIs). Continuous data were described using median (with 95% CIs) and interquartile range (IQR). Multivariable associations between demographics and endpoints were executed with quantile median regression (National Health Service primary endpoint) and logistic regression (secondary endpoint). MAIN RESULTS: In 4231 patients, 1457 (34.4%) receiving analgesia had a median time to initial analgesia of 110 min (95% CI, 104-120, IQR, 55-229). The univariate assessment identified only one demographic variable, age decade ( P = 0.0001), associated with the time to initial analgesia. Association between age and time to initial analgesia persisted in multivariable analysis adjusting for initial pain score, facility type, and time of presentation; for each decade increase the time to initial analgesia was linearly prolonged by 6.9 min (95% CI, 1.9-11.9; P = 0.007). In univariable assessment, time to initial analgesia was not associated with either detailed ethnicity (14 categories, P = 0.109) or four-category ethnicity ( P = 0.138); in multivariable analysis ethnicity remained non-significant as either 14-category (all ethnicities' P ≥ 0.085) or four-category (all P ≥ 0.138). No demographic or operational variables were associated with the secondary endpoint; opioid initial choice was associated only with pain score ( P = 0.003). CONCLUSION: In a consecutive series of patients with abdominal pain, advancing age was the only demographic variable associated with prolonged time to initial analgesia. Older patients were found to have a linearly increasing, age-dependent risk for prolonged wait for pain care.

Effect of Brain-Gut Behavioral Treatments on Abdominal Pain in Irritable Bowel Syndrome: Systematic Review and Network Meta-Analysis.

BACKGROUND & AIMS: Some brain-gut behavioral treatments (BGBTs) are beneficial for global symptoms in irritable bowel syndrome (IBS). United States management guidelines suggest their use in patients with persistent abdominal pain, but their specific effect on this symptom has not been assessed systematically. METHODS: We searched the literature through December 16, 2023, for randomized controlled trials (RCTs) assessing efficacy of BGBTs for adults with IBS, compared with each other or a control intervention. Trials provided an assessment of abdominal pain resolution or improvement at treatment completion. We extracted data as intention-to-treat analyses, assuming dropouts to be treatment failures and reporting pooled relative risks (RRs) of abdominal pain not improving with 95% confidence intervals (CIs), ranking therapies according to the P score. RESULTS: We identified 42 eligible randomized controlled trials comprising 5220 participants. After treatment completion, the BGBTs with the largest numbers of trials and patients recruited demonstrating efficacy for abdominal pain, specifically, included self-guided/minimal contact cognitive behavioral therapy (CBT) (RR, 0.71; 95% CI, 0.54-0.95; P score, 0.58), face-to-face multicomponent behavioral therapy (RR, 0.72; 95% CI, 0.54-0.97; P score, 0.56), and face-to-face gut-directed hypnotherapy (RR, 0.77; 95% CI, 0.61-0.96; P score, 0.49). Among trials recruiting only patients with refractory global IBS symptoms, group CBT was more efficacious than routine care for abdominal pain, but no other significant differences were detected. No trials were low risk of bias across all domains, and there was evidence of funnel plot asymmetry. CONCLUSIONS: Several BGBTs, including self-guided/minimal contact CBT, face-to-face multicomponent behavioral therapy, and face-to-face gut-directed hypnotherapy may be efficacious for abdominal pain in IBS, although none was superior to another.

Postprandial symptoms in disorders of gut-brain interaction and their potential as a treatment target.

Postprandial, or meal-related, symptoms, such as abdominal pain, early satiation, fullness or bloating, are often reported by patients with disorders of gut-brain interaction, including functional dyspepsia (FD) or irritable bowel syndrome (IBS). We propose that postprandial symptoms arise via a distinct pathophysiological process. A physiological or psychological insult, for example, acute enteric infection, leads to loss of tolerance to a previously tolerated oral food antigen. This enables interaction of both the microbiota and the food antigen itself with the immune system, causing a localised immunological response, with activation of eosinophils and mast cells, and release of inflammatory mediators, including histamine and cytokines. These have more widespread systemic effects, including triggering nociceptive nerves and altering mood. Dietary interventions, including a diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols, elimination of potential food antigens or gluten, IgG food sensitivity diets or salicylate restriction may benefit some patients with IBS or FD. This could be because the restriction of these foods or dietary components modulates this pathophysiological process. Similarly, drugs including proton pump inhibitors, histamine-receptor antagonists, mast cell stabilisers or even tricyclic or tetracyclic antidepressants, which have anti-histaminergic actions, all of which are potential treatments for FD and IBS, act on one or more of these mechanisms. It seems unlikely that food antigens driving intestinal immune activation are the entire explanation for postprandial symptoms in FD and IBS. In others, fermentation of intestinal carbohydrates, with gas release altering reflex responses, adverse reactions to food chemicals, central mechanisms or nocebo effects may dominate. However, if the concept that postprandial symptoms arise from food antigens driving an immune response in the gastrointestinal tract in a subset of patients is correct, it is paradigm-shifting, because if the choice of treatment were based on one or more of these therapeutic targets, patient outcomes may be improved.

Extracorporeal Shock-Wave Lithotripsy and Endoscopy for the Treatment of Pain in Chronic Pancreatitis : A Sham-Controlled, Randomized Trial.

BACKGROUND: No randomized controlled trials have substantiated endoscopic decompression of the pancreatic duct in patients with painful chronic pancreatitis. OBJECTIVE: To investigate the pain-relieving effect of pancreatic duct decompression in patients with chronic pancreatitis and intraductal stones. DESIGN: 24-week, parallel-group, randomized controlled trial (ClinicalTrials.gov: NCT03966781). SETTING: Asian Institute of Gastroenterology in India from February 2021 to July 2022. PARTICIPANTS: 106 patients with chronic pancreatitis. INTERVENTION: Combined extracorporeal shock-wave lithotripsy (ESWL) and endoscopic retrograde pancreatography (ERP) compared with sham procedures. MEASUREMENTS: The primary end point was pain relief on a 0- to 10-point visual analog scale (VAS) at 12 weeks. Secondary outcomes were assessed after 12 and 24 weeks and included 30% pain relief, opioid use, pain-free days, questionaries, and complications to interventions. RESULTS: 52 patients in the ESWL/ERP group and 54 in the sham group were included. At 12 weeks, the ESWL/ERP group showed better pain relief compared with the sham group (mean difference in change, -0.7 [95% CI, -1.3 to 0] on the VAS; P = 0.039). The difference between groups was not sustained at the 24-week follow-up, and no differences were seen for 30% pain relief at 12- or 24-week follow-up. The number of pain-free days was increased (median difference, 16.2 days [CI, 3.9 to 28.5 days]), and the number of days using opioids was reduced (median difference, -5.4 days [CI, -9.9 to -0.9 days]) in the ESWL/ERP group compared with the sham group at 12-week follow-up. Safety outcomes were similar between groups. LIMITATION: Single-center study and limited duration of follow-up. CONCLUSION: In patients with chronic pancreatitis and intraductal stones, ESWL with ERP provided modest short-term pain relief. PRIMARY FUNDING SOURCE: Asian Institute of Gastroenterology and Aalborg University Hospital.

Case Series of Multicontact Peripheral Nerve Stimulation in the Transversus Abdominis Plane for Chronic Abdominal Wall Pain.

OBJECTIVES: Managing abdominal pain can be difficult. This is due to the nonspecific nature of the pain, the multiple etiologies, and the different mechanisms underlying this type of pain. Abdominal wall pain in particular poses its own challenges. Traditionally, chronic abdominal wall pain has been managed with nonopioid analgesics, and in severe cases, opioid therapy has been considered. For patients with chronic abdominal wall pain refractory to medication management, peripheral nerve blocks and spinal cord stimulation also have been trialed with some success. In this study, we present a case series in patients with chronic abdominal wall pain who were treated with a multicontact peripheral nerve stimulation (PNS) system in the transversus abdominis plane (TAP). MATERIALS AND METHODS: This was a single-center, retrospective case series. Data were included from adults with chronic abdominal wall pain whose symptoms were refractory to standard medical management and who underwent a multicontact PNS system placement in the TAP. RESULTS: Four patients met the inclusion criteria. All four patients underwent a multicontact PNS trial lead placement in the TAP. One patient reported no benefit from the trial. The remaining three patients underwent a permanent multicontact PNS system placement in the TAP. CONCLUSIONS: In patients with chronic abdominal wall pain whose symptoms are refractory to conservative medical management, PNS may be an alternative treatment option. As the use of PNS for chronic abdominal wall pain and other fascial planes continues to develop, additional research is necessary to determine optimal placements and specific stimulation parameters.