Abdominal pain

My 35 year old patient with chronic alcoholism blames benign prostatic hypertrophy for his difficulty voiding. Could his bladder dysfunction be related to his alcoholism?

FA Manian MD, MPH, , , Leave a comment

Several case reports in the literature have stressed the association of bladder dysfunction (BD) with chronic alcohol abuse1,2.  Although some cases may be associated with concurrent thiamine deficiency (with its attendant neuropathy), other cases of BD do not appear to be. The mechanism of BD in this setting may be related to the toxic effect of alcohol on peripheral, autonomic and/or central nervous systems2,3.

Binge drinking may also be associated with urinary retention, with spontaneous atraumatic urinary bladder rupture having been reported on several occasions4. Lastly, alcohol withdrawal alone may precipitate urinary retention5.  

Unfortunately, many cases of abdominal pain due to urinary retention in the setting of alcohol abuse or withdrawal may be mistakenly attributed to ascites or other causes5.  High index of suspicion for BD is essential to minimize its complications.

In our patient, given the low prevalence of benign prostatic hypertrophy in men less than 40 years of age, urinary retention due to alcohol-related BD is more likely.

 

References

  1. Yuan R, Carcciolo VJ, Kulaga M. Chronic abdominal distension secondary to urinary retention in a patient with alcoholism. JAMA 2002;287;318-19.
  2. Sheremata WA, Sherwin I. Alcoholic myelopathy with spastic urinary bladder. Dis Nerv Syst 1972;33:136-139.
  3. Mellion M, Gilchrist JM, De La Monte S. Alcohol-related peripheral neuropathy: nutritional, toxic or both? Muscle Nerve 2011;43:309-16.
  4. Muneer M, Abdelrahman H, El-Menyar A, et al. Spontaneous atraumatic urinary bladder rupture secondary to alcohol intoxication: a case report and review of literature. Am J Case Rep 2015;16:778-81.
  5. Iga J-I, Taniguchi T, Ohmori T. Acute abdominal distension secondary to urinary retention in a patient after alcohol withdrawal. Alcohol Alcoholism 2005;40:86-87.
My 35 year old patient with chronic alcoholism blames benign prostatic hypertrophy for his difficulty voiding. Could his bladder dysfunction be related to his alcoholism?

“In my patient with abdominal pain, what physical exam finding can help differentiate abdominal wall from intra-abdominal sources of pain?”

FA Manian MD, MPH, , , , , , 1 Comment

Carnett’s sign (described by a surgeon, J.B. Carnett, in 1926) is a physical exam finding that helps differentiate abdominal wall or psychogenic pain from intra-abdominal sources of pain.

The test is considered positive when, upon locating the tender abdominal spot, the patient’s pain worsens on tensing of the abdominal wall muscles by lifting the head and shoulders from the bed or by raising both legs with straight knees. Conversely, if the pain decreases with this maneuver, an intra-abdominal source is more likely1,2. Sensitivity of ~80%, specificity of ~90%, positive likelihood ratio of 2.6 and negative likelihood ratio of 0.2 have been reported in various studies. 3,4,5

A positive Carnett’s sign should broaden the differential of abdominal pain to include: hernias, irritation of intercostal nerve roots, rectus sheath hematomas, myofascial pain, anterior cutaneous nerve entrapment or ACNES (see related pearl at www.Pearls4Peers.com 6) and psychogenic pain. In the appropriate clinical setting,  local corticosteroids or anesthetic injections, or the application of hot or cold packs may be therapeutic. 2,7

Liked this post? Download the app on your smart phone and sign up below to catch future pearls right into your inbox, all for free!

Subscribe to Blog via Email

Enter your email address to subscribe to this blog and receive notifications of new posts by email.

  References

  1. Carnett JB. Intercostal neuralgia as a cause of abdominal pain and tenderness. J Surg Gynecol Obstet 1926; 42:625-632.
  2. Bundrick JB, Litin SC. Clinical pearls in general internal medicine.  Mayo Clin Proceedings 2011;86: 70–74.  https://mayoclinic.pure.elsevier.com/en/publications/clinical-pearls-in-general-internal-medicine-2.
  3. Takada T, Ikusaka M, Ohira Y, et al. Diagnostic usefulness of Carnett’s test in psychogenic abdominal pain. Intern Med 2011;50:213-17. https://www.jstage.jst.go.jp/article/internalmedicine/50/3/50_3_213/_article
  4. Kamboj Ak, Hoverten P, Oxentenko AS. Chronic abdominal wall pain: a common yet overlooked etiology of chronic abdominal pain. Mayo Clin Proc 2019;94:139-44. https://www.mayoclinicproceedings.org/article/S0025-6196(18)30852-8/pdf
  5. Sweetser S. Abdominal wall pain: a common clinical problem. Mayo Clin Proc 2019;94:347-335.https://www.mayoclinicproceedings.org/article/S0025-6196(18)30671-2/fulltext  
  6. https://pearls4peers.com/2015/11/18/whats-acnes-anterior-cutaneous-nerve-entrapment-syndrome/
  7. Suleiman S , Johnston DE.  The abdominal wall: an overlooked source of pain. Am Fam Physician 2001; 64: 431-8. https://www.ncbi.nlm.nih.gov/pubmed/11515832

Contributed in part by Brad Lander MD, Mass General Hospital, Boston, MA.

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Massachusetts General Hospital, Harvard Catalyst, Harvard University, its affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

 

 

“In my patient with abdominal pain, what physical exam finding can help differentiate abdominal wall from intra-abdominal sources of pain?”

Are GI symptoms such as nausea, vomiting, and diarrhea common in patients with influenza?

FA Manian MD, MPH, , , , , , , Leave a comment

Typically, GI symptoms are more prominent in children with influenza than adults but during the H1N1 epidemic in 2009 (which has subsequently become endemic), up to 26% of hospitalized adults with H1N1 infection had abdominal pain or vomiting and up to 25% had diarrhea (1). 

In fact, H1N1 virus has been isolated from stool of adult hospitalized patients (2,3) and receptors of influenza virus have been identified in human GI epithelial cells, the correlation between GI symptoms and isolation of virus from stool is poorly defined (4).

Interestingly, the mechanism involved in influenza-mediated intestinal injury may have less to do with direct invasion of the intestinal mucosa by the virus and more to do with immune mediated changes  related to alterations in the intestinal microbiota induced by influenza virus infection itself (4,5)! 

Aside from direct or indirect effects of influenza virus on the GI tract, oseltamivir and non-steroidal anti-inflammatory use may also contribute to GI symptoms (4).

 

Liked this post? Download the app on your smart phone and sign up below to catch future pearls right into your inbox, all for free!

Subscribe to Blog via Email

Enter your email address to subscribe to this blog and receive notifications of new posts by email.

References

  1. Writing Committee of the WHO Consultation on Clinical Aspects of Pandemic (H1N1) 2009 influenza. Clinical aspects of pandemic 2009 influenza A (H1N1) virus infection. N Engl J Med 2010;362:1708-19. https://www.ncbi.nlm.nih.gov/pubmed/20445182
  2. Yoo SJ, Moon SJ, Kuak E-Y, et al. Frequent detection of pandemic (H1N1) 2009 virus in stools of hospitalized patients. J Clin Microbiol 2010; 48:2314-2315. https://www.ncbi.nlm.nih.gov/pubmed/20375236
  3. Minodier L, Charrel RN, Ceccaldi PE, et al. Prevalence of gastrointestinal symptoms in patients with influenza, clinical significance, and pathophysiology of human influenza viruses in faecal samples: what do we know? Virol J 2015;12:215. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4676820/
  4. Shu Y, Li CK, Gao R, et al. Avian influenza A(H5N1) viruses can directly infect and replicate in human gut tissues. J Infect Dis 2010;201:1173-7. https://www.ncbi.nlm.nih.gov/pubmed/20210629
  5. Wang J, Li F, Wei H, et al. Respiratory influenza virus infection induces intestinal immune injury via microbiota mediated Th17 cell-dependent inflammation. J Exp Med 2014;211:2397-2410. http://europepmc.org/article/PMC/4235643
Are GI symptoms such as nausea, vomiting, and diarrhea common in patients with influenza?

What’s ACNES (anterior cutaneous nerve entrapment syndrome)?

FA Manian MD, MPH, , , , , , , Leave a comment

 As the name implies, this is an abdominal pain syndrome thought to be due to the entrapment of cutaneous branches of an intercostal nerve at the level of the rectus abdominis muscle (1,2).   It may be acute or chronic.

Up to a third of patients with chronic abdominal pain may have ACNES with the source of pain attributed to the abdominal wall, not the viscera (1,3).  Unfortunately, a third of patients with ACNES experience pain for >1 year and about 10% for > 5 years before diagnosis of ACNES is made.

In about one-half of cases, ACNES begins spontaneously, with the remainder developing after abdominal surgery or pregnancy, or is associated with “sports”, “job” or “unusual activity” (4).   Females outnumber males by a 4:1 margin with an average age of 37  y (2).  Carnett’s sign on physical exam may be a clue (2,5) with a sensitivity of 78% and specificity of 88% for abdominal wall pain (6) .

Identification of abdominal wall trigger points and their infiltration with lidocaine may relieve the pain instantaneously and can serve as a diagnostic test.  Surgical neurectomy may be effective in those with only temporary or partial response to repeated lidocaine injections (1).

Liked this post? Download the app on your smart phone and sign up below to catch future pearls right into your inbox, all for free!

Subscribe to Blog via Email

Enter your email address to subscribe to this blog and receive notifications of new posts by email.

References

1. Boelens OBA, Scheltinga MR, Houterman S, et al. Randomized clinical trial of trigger point infiltration with lidocaine to diagnose anterior cutaneous nerve entrapment syndrome. Br J Surg 2013;100:217-221. https://www.ncbi.nlm.nih.gov/pubmed/23180371

2. van Assen T, Brouns JAGM, Scheltinga MR, et al. Incidence of abdominal pain due to anterior cutaneous nerve entrapment syndrome in an emergency department. Scand J Trauma Resusc Emerg Med 2015;23:19. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4327965  

3. van Assen T, de Jager-Kievit JW, Scheltinga MR, et al. Chronic abdominal wall pain misdiagnosed as functional abdominal pain. J Am Board Fam Med 2013;26:738-44. https://www.ncbi.nlm.nih.gov/pubmed/24204070

4. Boelens OB, Scheltinga MR, Houterman S, et al. Management of anterior cutaneous nerve entrapment syndrome in a cohort of 139 patients. Management of anterior cutaneous nerve entrapment syndrome in a cohort of 129 patients. Ann Surg 2011;254:1054-1058.  https://www.ncbi.nlm.nih.gov/pubmed/21881494

5. Pearls4Peers.  https://pearls4peers.com/2016/12/20/in-my-patient-with-abdominal-pain-what-physical-exam-finding-can-help-differentiate-abdominal-wall-from-intra-abdominal-sources-of-pain

6. Sweetser S. Abdominal wall pain: a common clinical problem. Mayo Clin Proc 2019;94:347-355. https://www.mayoclinicproceedings.org/article/S0025-6196(18)30671-2/fulltext

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis, Massachusetts General Hospital, Harvard Catalyst, Harvard University, their affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

 

What’s ACNES (anterior cutaneous nerve entrapment syndrome)?