Abdominal Wall Pain: Clinical Evaluation, Differential Diagnosis, and Treatment

 

Abdominal wall pain is often mistaken for intra-abdominal visceral pain, resulting in expensive and unnecessary laboratory tests, imaging studies, consultations, and invasive procedures. Those evaluations generally are nondiagnostic, and lingering pain can become frustrating to the patient and clinician. Common causes of abdominal wall pain include nerve entrapment, hernia, and surgical or procedural complications. Anterior cutaneous nerve entrapment syndrome is the most common and frequently missed type of abdominal wall pain. This condition typically presents with acute or chronic localized pain at the lateral edge of the rectus abdominis that worsens with position changes or increased abdominal muscle tension. Abdominal wall pain should be suspected in patients with no symptoms or signs of visceral etiology and a localized small tender spot. A positive Carnett test, in which tenderness stays the same or worsens when the patient tenses the abdominal muscles, suggests abdominal wall pain. A local anesthetic injection can confirm the diagnosis when there is 50% postprocedural pain improvement. Point-of-care ultrasonography may help rule out other abdominal wall pathologies and guide injections. The management of abdominal wall pain depends on the etiology. Reassurance and patient education can be helpful. Local injection with an anesthetic and a corticosteroid is an effective treatment for anterior cutaneous nerve entrapment syndrome, with an overall response rate of 70% to 99%. For refractory cases that require more than two injections, surgical neurectomy generally resolves the pain.

Pain originating from the abdominal wall has been described for nearly 100 years 1 but did not receive much attention until 1926, when a simple bedside test was proposed.2 Case reports in the early 1970s suggested that nerve entrapment could be the cause of abdominal wall pain and was able to be successfully treated with local injections.3,4 More recently, the consensus has been that abdominal wall pain is commonly unrecognized, overlooked, underdiagnosed, and understudied.511

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Anterior cutaneous nerve entrapment syndrome should be suspected in patients with a localized small tender spot at the lateral edge of the rectus abdominis.

C

4, 16, 18, 21, 38

The Carnett test is useful to support the diagnosis of abdominal wall pain.

C

2, 28, 32

Local anesthetic injection with or without corticosteroids can diagnose and treat abdominal wall pain caused by nerve entrapment.

B

10, 3336


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Anterior cutaneous nerve entrapment syndrome should be suspected in patients with a localized small tender spot at the lateral edge of the rectus abdominis.

C

4, 16, 18, 21, 38

The Carnett test is useful to support the diagnosis of abdominal wall pain.

C

2, 28, 32

Local anesthetic injection with or without corticosteroids can diagnose and treat abdominal wall pain caused by nerve entrapment.

B

10, 3336


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The prevalence of abdominal wall pain in the general population and primary care settings is not known, but it ranges from 5% to 67% in patients referred to subspecialists.1214 A study of 100 consecutive patients referred to a pain clinic by gastroenterologists for chronic abdominal pain management found that 43 had abdominal wall pain, and that many were initially misdiagnosed with functional abdominal pain, irritable bowel syndrome, or a psychiatric disorder.13

Abdominal wall pain is an umbrella term that comprises many etiologies, the most common of which is benign nerve entrapment. Because of physicians' unfamiliarity with abdominal wall pain and concern about the consequences of missing serious pathology, evaluation is often misdirected toward costly and unnecessary laboratory tests, advanced imaging studies, consultations, and frequent clinic visits. Patients may be exposed to unwarranted invasive procedures such as endoscopy, laparoscopy, or cholecystectomy. These procedures have a high cost: one study calculated that the typical patient had abdominal wall pain for 25 months before diagnosis, with an annual direct health care cost of more than $1,100.12 This highlights the importance of early consid

The Authors

show all author info

BRIAN SHIAN, MD, is a clinical associate professor of family medicine at the University of Iowa Carver College of Medicine, Iowa City....

SCOTT T. LARSON, MD, is a clinical assistant professor of family medicine at the University of Iowa Carver College of Medicine.

Address correspondence to Brian Shian, MD, University of Iowa Carver College of Medicine, 200 Hawkins Dr., 01291-E PFP, Iowa City, IA 52242 (e-mail: brian-shian@uiowa.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Cyriax EF. On various conditions that may stimulate the referred pain of visceral diseases and a consideration of these from the point of view of cause and effect. Practitioner. 1919;102:314–322....

2. Carnett JB. Intercostal neuralgia as a cause of abdominal pain and tenderness. Surg Gynecol Obstet. 1926;42:625–632.

3. Ranger I, Mehta M, Pennington M. Abdominal wall pain due to nerve entrapment. Practitioner. 1971;206(236):791–792.

4. Applegate WV. Abdominal cutaneous nerve entrapment syndrome. Surgery. 1972;71(1):118–124.

5. Koop H, Koprdova S, Schürmann C. Chronic abdominal wall pain. Dtsch Arztebl Int. 2016;113(4):51–57.

6. van Assen T, de Jager-Kievit JW, Scheltinga MR, Roumen RM. Chronic abdominal wall pain misdiagnosed as functional abdominal pain. J Am Board Fam Med. 2013;26(6):738–744.

7. Lindsetmo RO, Stulberg J. Chronic abdominal wall pain—a diagnostic challenge for the surgeon. Am J Surg. 2009;198(1):129–134.

8. Suleiman S, Johnston DE. The abdominal wall: an overlooked source of pain. Am Fam Physician. 2001;64(3):431–438.

9. Gallegos NC, Hobsley M. Abdominal wall pain: an alternative diagnosis. Br J Surg. 1990;77(10):1167–1170.

10. Shute WB. Abdominal wall pain—the primary diagnosis. Zentralbl Gynakol. 1984;106(5):309–313.

11. Srinivasan R, Greenbaum DS. Chronic abdominal wall pain: a frequently overlooked problem. Practical approach to diagnosis and management. Am J Gastroenterol. 2002;97(4):824–830.

12. Costanza CD, Longstreth GF, Liu AL. Chronic abdominal wall pain: clinical features, health care costs, and long-term outcome. Clin Gastroenterol Hepatol. 2004;2(5):395–399.

13. McGarrity TJ, Peters DJ, Thompson C, McGarrity SJ. Outcome of patients with chronic abdominal pain referred to chronic pain clinic. Am J Gastroenterol. 2000;95(7):1812–1816.

14. Mui J, Allaire C, Williams C, Yong PJ. Abdominal wall pain in women with chronic pelvic pain. J Obstet Gynaecol Can. 2016;38(2):154–159.

15. Anterior abdominal wall. In: Morton DA, Foreman KB, Albertine KH, eds. The Big Picture: Gross Anatomy. New York, NY: McGraw Hill Medical; 2011: 85–96.

16. Clarke S, Kanakarajan S. Abdominal cutaneous nerve entrapment syndrome. Contin Educ Anaesth Crit Care Pain. 2015;15(2):60–63. https://academic.oup.com/bjaed/article/15/2/60/248606. Accessed May 3, 2018.

17. Mol FM, Lataster A, Scheltinga M, Roumen R. Anatomy of abdominal anterior cutaneous intercostal nerves with respect to the pathophysiology of anterior cutaneous nerve entrapment syndrome (ACNES): a case study. Translational Res Anat. 2017;8–9:6–10.

18. Applegate WV, Buckwalter NR. Microanatomy of the structures contributing to abdominal cutaneous nerve entrapment syndrome. J Am Board Fam Pract. 1997;10(5):329–332.

19. Sippo WC, Gomez AC. Nerve-entrapment syndromes from lower abdominal surgery. J Fam Pract. 1987;25(6):585–587.

20. Cavalli M, Bombini G, Campanelli G. Pubic inguinal pain syndrome: the so-called sports hernia. Surg Technol Int. 2014;24:189–194.

21. Towfigh S, Anderson S, Walker A. When it is not a Spigelian hernia: abdominal cutaneous nerve entrapment syndrome. Am Surg. 2013;79(10):1111–1114.

22. Khan Z, Zanfagnin V, El-Nashar SA, Famuyide AO, Daftary GS, Hopkins MR. Risk factors, clinical presentation, and outcomes for abdominal wall endometriosis. J Minim Invasive Gynecol. 2017;24(3):478–484.

23. Ding Y, Zhu J. A retrospective review of abdominal wall endometriosis in Shanghai, China. Int J Gynaecol Obstet. 2013;121(1):41–44.

24. Heinz GJ, Zavala DC. Slipping rib syndrome. JAMA. 1977;237(8):794–795.

25. Meuwly JY, Wicky S, Schnyder P, Lepori D. Slipping rib syndrome: a place for sonography in the diagnosis of a frequently overlooked cause of abdominal or low thoracic pain. J Ultrasound Med. 2002;21(3):339–343.

26. Cherry WB, Mueller PS. Rectus sheath hematoma: review of 126 cases at a single institution. Medicine (Baltimore). 2006;85(2):105–110.

27. Karaca B, Tarakci H, Tumer E, Calik S, Sen N, Sivrikoz ON. Primary abdominal wall actinomycosis. Hernia. 2015;19(6):1015–1018.

28. Thomson H, Francis DM. Abdominal-wall tenderness: a useful sign in the acute abdomen. Lancet. 1977;2(8047):1053–1054.

29. Longstreth GF. Diabetic thoracic polyradiculopathy. Best Pract Res Clin Gastroenterol. 2005;19(2):275–281.

30. O'Connor RC, Andary MT, Russo RB, DeLano M. Thoracic radiculopathy. Phys Med Rehabil Clin N Am. 2002;13(3):623–644, viii.

31. Howell JM. Xiphodynia: a report of three cases. J Emerg Med. 1992;10(4):435–438.

32. Baker HW. The abdominal wall as a source of pain. J Ky Med Assoc. 1973;71(5):309–310.

33. Boelens OB, Scheltinga MR, Houterman S, Roumen RM. Randomized clinical trial of trigger point infiltration with lidocaine to diagnose anterior cutaneous nerve entrapment syndrome. Br J Surg. 2013;100(2):217–221.

34. Alnahhas MF, Oxentenko SC, Locke GR III, et al. Outcomes of ultrasound-guided trigger point injection for abdominal wall pain. Dig Dis Sci. 2016;61(2):572–577.

35. Kuan LC, Li YT, Chen FM, Tseng CJ, Wu SF, Kuo TC. Efficacy of treating abdominal wall pain by local injection. Taiwan J Obstet Gynecol. 2006;45(3):239–243.

36. Bourne IH. Treatment of painful conditions of the abdominal wall with local injections. Practitioner. 1980;224(1347):921–925.

37. Chrona E, Kostopanagiotou G, Damigos D, Batistaki C. Anterior cutaneous nerve entrapment syndrome: management challenges. J Pain Res. 2017;10:145–156.

38. Oor JE, Ünlü Ç, Hazebroek EJ. A systematic review of the treatment for abdominal cutaneous nerve entrapment syndrome. Am J Surg. 2016;212(1):165–174.

39. Boelens OB, van Assen T, Houterman S, Scheltinga MR, Roumen RM. A double-blind, randomized, controlled trial on surgery for chronic abdominal pain due to anterior cutaneous nerve entrapment syndrome. Ann Surg. 2013;257(5):845–849.

 

 

Copyright © 2018 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Dec 15, 2018

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article