The Missed Diagnosis Series

PROF : Abdel Rahman A Mokhtar

Internist – Gastroenterologist
Mansoura University
 Introduction :
Diseased organs are frequently identified as the In contrast, the abdominal
source of chronic abdominal discomfort and pain. wall and pelvic floor often
are neglected as a cause of
If a patient’s history, physical examination, and chronic abdominal pain and
diagnostic evaluations are not abnormal, a common discomfort.
functional abdominal pain diagnosis, such as irritable
bowel syndrome (IBS), which has a 10% to 15%
prevalence in Europe and North America, may be considered.
 CAWP :
Chronic abdominal
wall pain syndrome.
Definition
Why CAWP ? [ Van Assen etal., 2013 ]

It is not surprising that doctors’ delay in diagnosing CAWP

syndromes is substantial and many patients with ACNES remain
undiagnosed. This situation is not only a Dutch issue; CAWP is a
globally undervalued medical problem and a diagnostic challenge.
Therefore, clinicians worldwide require education on abdominal wall
pain problems so that these clinical entities will be identified at an
earlier stage and treated accordingly.
Pathophysiology of CAWP

Myofascial pain and

radiculopathy are rare
examples
of a CAWP syndrome.

However, CAWP is
commonly caused by
the entrapment of an
anterior cutaneous
branch of one or more
thoracic intercostal
nerves.
Locations where pain in the abdominal wall might originate:
Locations where pain in the
abdominal wall might originate.

Epigastric hernias occur

along the linea alba.

Spegelian hernias occur below

the arcuate line where the inferior
epigastric vessels traverse the
fascia.
Nerve roots passing through or
around the lateral edge of the
rectus sheath are often subject to
irritation.
Pathophysiology of ACNES :
The thoracoabdominal nerves, which terminate as the cutaneous nerves, are
anchored at six points :
1) The spinal cord;
2) The point of the posterior branch origin .
3) the point at which the lateral branch originates.
4) the point at which the anterior branch makes
a nearly 90° turn to enter the rectus channel;
5) the point from which accessory branches are
given off in the rectus channel.
6) skin.
Patho physiology of ACNES :

The most common

site of nerve
entrapment
is the lateral
border of the
rectus muscle.

At these points the anterior twigs of the intercostal nerves

penetrate the rectus abdominal muscle (T7– 12).

The level of the umbilicus corresponds with intercostal nerve T10.

The most typical site is T11 on the right side.

Patho physiology of ACNES :

After turning at a 90º angle, the nerve passes

from the posterior sheath of the abdominal wall
muscle (rectus abdominis) through a fibrous
opening and then branches at right angles while
passing through its anterior sheath. It has been
thought that the underlying problem is nerve
compression with resulting ischemia or lack of
blood supply, explained by the nerve's course
through the muscle.
The entrapped nerve may also be pushed by
intra- or extra abdominal pressure or pulled by a
scar causing pain in the abdominal wall
 CLINICAL PRESENTATION
General features of musculoskeletal abdominal wall pain
 Symptomatology of ACNES 1

Symptoms of ACNES can be acute or chronic.

•The acute pain is described as localized, dull, or burning, with a sharp
component (usually on one side) .
•Radiating horizontally in the upper half of the abdomen and obliquely downward
in the lower abdomen.
•The pain may radiate when the patient twists, bends, or sits up.
•Lying down may help but sometimes worsens the pain.
Young women often express concern about their“ovaries,” “kidneys” or both.
Noting that between 30% and 76% of diagnostic laparoscopic procedures
done for pelvic pain show normal tissues, Slocomb ( 1984) expressed
concern about surgical exploration with removal of pelvic structures for
normal variants in women with chronic pelvic pain when the problem was
actually traceable to the abdominal wall.
Symptomatology of ACNES 2

Chronic complaints due to ACNES are

ACNES-related pain is well localized and usually affects only one side.

However, the pain can occur on both sides at the same level .
or at different levels.

Pain radiating into the scrotum or vulva suggests involvement at the

T12/L1 level, but inguinal or femoral hernia and pain arising from the
adductor muscles of the thigh must be ruled out.
Symptomatology of ACNES 3

Pain radiating from T11 and T12 runs at an oblique angle and
follows the course of these nerves. Such pain can suggest urolithiasis;
however, patients with urolithiasis are usually seen writhing in pain,
where as patients with ACNES tend to lie quietly on the table with their
hand placed over the area of discomfort.

T11 involvement
on the right side may suggest appendicitis, and involvement
on either side may suggest ovarian involvement
or spigelian hernia; all these conditions should be identified
by proper physical examination.
Symptomatology of ACNES 4

Pain on the right side at the T8 or T9 level may suggest cholecystitis or

peptic ulcer;

•Chronic ACNES patients suffer considerable anxiety and worry that they
may have some horrible condition as yet undiscovered.

•As a result, they may be given a psychiatric diagnosis (eg, anxiety,

somatization, or depression) and therefore often take antidepressant drugs ,
tranquilizers, muscle relaxants, or pain relievers.

•Such a medical history should raise the question of ACNES.

N.B :Other things such as nausea, bloating, overeating, and
menstruation can make pain worse by causing congestion of
blood vessels and further nerve compression .

Oral contraceptives and pregnancy have also been reported to

increase abdominal wall pain, probably from hormone induced
tissue swelling
Physical Examination 1
• Superficial tenderness :
• Often extreme tenderness upon gentle stroking or pinching in that area of the skin.
• The patient may guard the area from light touch, sometimes by seizing the
examiner's hand. .
• The pain may extend backwards and up to the vertebral body if its origin is related
to nerve root in the spinal cord.
• The pain may be exacerbated by conditions that can cause nerve pressure or
traction, such as coughing , straining , tight clothing, obesity or post-operative
scarring.
• Relief may be obtained by sitting, lying or relatively frequently by hand-splinting the
affected area.
 Physical Examination 2
• Often Localised the pain & tenderness?
The patient usually responds by placing
several fingers over the area, where upon the examiner says,
“Show me with one finger.”
As patients place a fingertip on the exact spot,
pushing a little harder to find it, they usually say,
“Right here!” and flinch as the tender spot is
pressed.
 Physical Examination 3
Carnett's Sign
Carnett's test is the key in a physical examination for diagnosing abdominal wall pain.

A positive test is demonstrated by palpating the tender region in the supine

(lying down) relaxed patient and observing continuing or often increased
tenderness as the patient tenses the abdominal wall by elevating the head and
shoulders or raising their legs.
When pain arises from an intra abdominal source, the tensed muscles in the
abdominal wall guard the underlying bowel, thus reducing the discomfort
(negative test). However, when the pain arises from the abdominal wall, the
muscle contraction will accentuate the pain (positive test) This test has been
found to be sensitive and specific, in one study saving on average $900
per case on unnecessary investigations. (GreenBaum & Joseph ,1994)

N.B :Sometimes, intra abdominal disease with involvement of peritoneum (membrane

lining of the abdominal cavity) may give a false positive Carnett test.

It is also not very useful to apply this test to individuals with wide spread abdominal pain
rather than localized area of pain to avoid misdiagnosis.
DIAGNOSIS OF CAWP
ACNES questionnaire
A VALIDATED QUESTIONNAIRE WITH THE ANSWER KEY.
A 10-POINT CUTOFF VALUE RESULTS IN AN OPTIMAL 94% SENSITIVITY AND 92% SPECIFICITY .
 A highly suggested history can
be confirmed by :
Physical Examination
•Superficial tenderness.
•Localised tenderness
•Positive carnett`s Sign
Response to local anaesthetic
A significant (> 50%) pain relief
after an accurately placed nerve
block or trigger point anesthetic
injection is considered
confirmatory of CAWP
diagnosis.
Sharpstone et al (1994)
concluded that a successful
injection after a positive Carnett
sign (to diagnose CAWP) "must
be one of the most cost effective
procedures in gastroenterology"
A highly suggested history :

It is important to recognize that the presence of CAWP does not

always rule out an existing intra abdominal source of pain and
misdiagnoses have been reported.

For example, Thompson et al noted that 4 of 62 (6%) patients

diagnosed with CAWP were later found to have an intra-
abdominal cause of pain . Gray et al reported that 5 of 53 (9.4%)
patients with positive Carnett test actually had appendicitis .

Of interest, one study also demonstrated the presence of irritable

bowel syndrome and functional dyspepsia (indigestion) in 29%
and 11% of patients with CAWP, respectively ( Langdon , 2002).
MANAGEMENT
The management of CAWP depends on the severity of symptoms.

In cases of mild pain, minimizing activities that aggravate the pain may be
sufficient.
An abdominal binder may be useful if gentle hand pressure helps ease
the pain.
Local nerve blocks or trigger point injections using anesthetic/steroid
injections are the treatment of choice for patients with moderate to severe
abdominal wall pain.
Drugs for neuralgic pain ?????
 Conclusion
When patients present with persistent or recurrent abdominal pain it is all too easy to
consider a visceral source and overlook other origins for their symptoms.

Patients with chronic abdominal pain are often subjected to a variety of procedures in an
attempt to find a cause: simple investigations may give way to more complex
and invasive ones in the pursuit of ever more obscure diagnoses.

Then failure to find a visceral cause for the pain may prompt the physician to
apply a functional or psychosomatic label to the patient, with any treatment directed along
thoselines.
An awareness, however, that abdominal
pain may have a non-visceral origin' can forestall
a fruitless search for intra-abdominal pathology.

A careful history and examination, and being alert to the

possibility of the symptoms arising from outside the abdominal
cavity, should permit an accurate diagnosis to be made,
appropriate treatment given, and an ever downward
spiral of yet more negative investigations avoided.