Br. J. Surg. Vol. 66 (1979) 348-349
Chronic abdominal pain : a surgical or psychiatric sy m ptom? C. R. J. W O O D H O U S E A N D S. B O C K N E R * SUMMARY
A prospecrim inaestigation of chronic, non-specific abdominal pain in 20 patients is reported. The cause was found to be psychiatric in 8 (40 per cent), while a surgical cause was .found in only 3 (15 per cent). Four had irritable colon (20 per cent) and no diagnosis was made in 5 (25 per cent). It is suggested that such pcriii is more often n psychiatric than a surgical symptom and therefore a psychiatric consultation should be a r,outine purr of the inaestigdon.
CHRONIC abdominal pain is one of the commoner presenting symptoms in surgical outpatient clinics. In many cases the pain is non-specific, the history does not suggest disease in any particular organ and physical signs are few or absent. Extensive investigation fails to show a surgical cause and the patients often remain undiagnosed. We have used a combined surgical and psychiatric approach to try t o establish a diagnosis in a group of such patients.
Patients and methods We investigated all patients over 18 years of age presenting with a history of abdominal pain for more than 2 years and whose symptoms did not indicate a specific disease. A full history was taken with particular reference to the duration of the pain, periodicity, precipitating factors and associated symptoms. They were specifically asked about recurrent pains in childhood and at other times. If they had had abdominal or pelvic surgery the indications for it were established. All had a ‘ward test’ of urine (Haemocombistix, Ames Ltd), urine culture and a full blood count. Other investigations were carried out according to the clinical indications (investigations are shown in Tnb1e 1). If there was no somatic diagnosis, a full psychiatric assessment was made.
Results Twenty-eight patients were seen between April and December 1977. Eight failed t o complete the course of investigation and were lost t o follow-up. Twenty patients are available for analysis. A definite diagnosis was made in 15 patients: 3 had a ‘surgical’ disease, 8 a psychiatric disease and 4 had an irritable colon. In the remaining 5 patients n o diagnosis was made. The results are summarized in Table 71. Surgical causes There were 3 patients in this group (15 per cent). All were over 60 years old. Their symptoms were not typical of their disease, but were relieved by conventional treatment for the identified lesion. The first patient was a woman of 76 years with a long history of pain in the epigastrium and both iliac fossas. She was eventually found to have diverticulosis coli with an irregular stricture of the upper sigmoid. At operation the stricture was found t o be due to inflammatory changes in the bowel wall. Reilly’s myotomy was performed and she remains free of symptoms 14 months later. The second patient was correctly diagnosed as having gallstones only when seen during a n attack of acute cholecystitis. The third woman had longstanding
collapse of 3 thoracic vertebrae causing root pain, which was only diagnosed, after prolonged investigation, when the crucial past history was elicited. Psychiatric causes A psychiatric diagnosis was made in 8 cases (40 per cent). Five had chronic anxiety states, 2 had obsessional states and I had endogenous depression. There were 6 women and 2 men in this group, with an average age of 32 years (range 25-44). Pain had been present for between 2 and 17 years but 3 patients could give no definite duration. None remembered having pain before puberty. All were vague about Table I : INVESTIGATIONS UNDERTAKEN IN 20 PATIENTS WITH CHRONIC, NON-SPECIFIC ABDOMINAL PAIN Investigation No. of cases Barium enema and sigmoidoscopy Barium meal Intravenous urogram Oral cholecystogram Liver function tests Thyroid function tests Spinal X-rays Intravenous cholangiogram Serum amylase Lactose tolerance test
16 15 13 8 3 2 2 1 1
1
Table 11: DIAGNOSIS OF 20 PATIENTS WITH CHRONIC, NON-SPECIFIC ABDOMINAL PAIN Diagnosis No. of cases Surgical causes Inflammatory stricture of colon Gallstones Collapsed thoracic vertebrae Psychiatric causes Chronic anxiety states Obsessional states Endogenous depression Irritable colon Undiagnosed
3 1 I 1
8 5 2 1 4 5
Table 111: SYMPTOMS ASSOCIATED WITH ABDOMINAL PAIN IN 8 PSYCHIATRIC CASES Svmotom No. of cases Bowel disturbance Worsening of pain with stress Anorexia Abdominal swelling Vomiting Weight loss (only during pain) Nausea Dyspareunia Micturition disturbance
* Only occasionally in
3* 3 2
2 2 1 1
1 1
1 case.
* The North Middlesex Hospital, London. Correspondence to: C. R. J. Woodhouse, St Peter’s Hospitals, The Shaftesbury Hospital, Shaftesbury Avenue, London WC2.
Chronic abdominal pain their symptoms, admitting, for example, to intermittent pain, yet only 2 having an accurate idea of its periodicity. Associated symptoms were scarce, as Table III shows. Physical signs were unhelpful. The patients all looked well and none was obese. Four had tenderness in the right iliac fossa, 2 with a poorly defined mass (these 2 were submitted to elective appendicectomy, 1 was unchanged after the operation and 1 was worse). Further consultation eventually established the correct diagnosis. Conventional treatment was given using psychotherapy and drugs as required; 5 out of the 8 have improved and have had no recurrence of their pain. The follow-up of these patients now ranges between 8 and 15 months and none has developed an organic disease.
Irritable colon In 4 Datients (20 Der cent) a diagnosis of irritable colon was *made. All’ had lower abdominal pain with alteration of bowel habit; 3 had constipation and 1 had variable constipation and diarrhoea. In spite of at least 3 years of history, all remained in good general health without weight loss. Only 1 patient associated his pain with stress and none had distinct psychiatric disease. Two patients had tender descending colons and 1 had minimal reddening of the rectal mucosa, which was found to be normal on histology of multiple biopsies. All 4 had normal barium enema examinations and extensive investigation failed to show another cause for the symptoms. The patients were treated with bulk laxative (ispaghula husk) with complete relief of symptoms and they all remain well after 11-15 months’ follow-up. Undiagnosedgroup In 2 men, aged 53 and 54 years respectively, the symptoms were considered sufficiently severe to warrant laparotomy: no pathology was found, but 1 had a normal appendix removed. Both remain free of abdominal pain after 8 and 14 months of follow-up. Three other patients remain undiagnosed and continue to have pain.
Discussion Chronic non-specific abdominal pain is a notoriously difficult symptom to diagnose. In one retrospective review of patients whose pain ‘failed to conform to specific patterns’ only 10 of 76 were diagnosed. The younger the patient and the greater the duration of symptoms, the more unlikely diagnosis became (Sarfeh, 1976). Gynaecological practice reveals similar experience when only 14 out of 49 patients with pain of ‘chronic non-specific type’ were found to have a n abnormality on laparoscopy (Ferguson, 1974). Even in acute episodes of abdominal pain diagnosis has been shown t o be possible in less than half of 1000 cases (Brewer et al., 1976). Abdominal pain has been known as a symptom of emotional disorders since ancient Greek times; hence the term ‘hypochondriasis’, meaning ‘below the costal cartilages’, coined by Hippocrates. In the language of symptoms, the unhappy patient is literally ‘bellyaching’ about his problems. Anxiety states, obsessional ’
29
349
states and endogenous depressions are the commonest psychiatric causes for abdominal pain (Gomez and Dally, 1977). Recently the role of psychiatric factors in the aetiology of chronic abdominal pain has been neglected, though such factors are well established in children (Apley and Naish, 1958; Dodge, 1976). Although it has been suggested that little bellyachers grow up into big bellyachers (Editorial, 1975), such histories were not given by our patients. In 8 of our 20 patients (40 per cent) psychiatric causes for chronic abdominal pain were found and over half of them have made a good response to treatment. A further 4 had irritable colon, and it has been shown that in this condition disturbed colonic motility can be mediated by emotional upsets (Chaudhary and Truelove, 1961). The histories of our patients were as long as 17 years, and yet their general health remained good. Nevertheless, there is a clear possibility that they may yet develop an organic disease, and a change of symptoms or relapse while under psychiatric treatment would be an indication for further investigation. Only rarely did we find that this type of pain had a ‘surgical’ cause and only when the patient was over 60 years old. We now accept that where a patient is under 40 years old, has few symptoms other than pain and no physical signs, it is sufficient to test the urine, do a full blood count and one radiological investigation. Within this framework the patient is shown that his complaint is being taken seriously and a psychiatric consultation is accepted. In this series no organic diagnosis would have been missed with this programme. We regard the psychiatric assessment as part of the routine work-up and positive psychiatric features do not preclude further investigation. Our experience with this difficult group of patients is that diagnosis is possible in 75 per cent of cases. Chronic, non-specific abdominal pain is more often a psychiatric than a surgical symptom and a combined approach by both specialties is helpful.
Acknowledgement We are most grateful to Mr J. M. Beaugie for permission to report on his patients.
References and NAISH N. (1958) Recurrent abdominal pains: a field survey of 1000 school children. Arch. Dis. Child. 33, 165-170. BREWER R. J., GOLDEN C. T., HITCH D . C. et al. (1976) An analysis of 1000 consecutive cases of abdominal pain in a university hospital emergency room. Am. J. Surg. 131, 219-223. CHAUDHARY N. A. and TRUELOVE S. C. (1961) Human Colonic moility. Gastroenterology 40, 27-36. DODGE J. A. (1976) Recurrent abdominal pain in children. Br. Med. J . 1, 385-387. EDITORIAL (1975) Do little bellyachers become big bellyachers? Br. Med. J. 2, 459. FERGUSON I. L. c. (1974) Laparoscopy for the diagnosis of nonspecific lower abdominal pain. Br. J. Clin. Pract. 28, 163-1 65. COMEZ J. and DALLY P. (1977) Psychologically mediated abdominal pain in surgical and medical outpatient clinics. BY. Med. J . 1 , 1451-1453. SARFEH I. J. (1976) Abdominal pain of unknown aetiology. Am. J. Surg. 132, 22-25. APLEY J.
Paper accepted 31 October 1978.
Chronic abdominal pain : a surgical or psychiatric sy m ptom? C. R. J. W O O D H O U S E A N D S. B O C K N E R * SUMMARY
A prospecrim inaestigation of chronic, non-specific abdominal pain in 20 patients is reported. The cause was found to be psychiatric in 8 (40 per cent), while a surgical cause was .found in only 3 (15 per cent). Four had irritable colon (20 per cent) and no diagnosis was made in 5 (25 per cent). It is suggested that such pcriii is more often n psychiatric than a surgical symptom and therefore a psychiatric consultation should be a r,outine purr of the inaestigdon.
CHRONIC abdominal pain is one of the commoner presenting symptoms in surgical outpatient clinics. In many cases the pain is non-specific, the history does not suggest disease in any particular organ and physical signs are few or absent. Extensive investigation fails to show a surgical cause and the patients often remain undiagnosed. We have used a combined surgical and psychiatric approach to try t o establish a diagnosis in a group of such patients.
Patients and methods We investigated all patients over 18 years of age presenting with a history of abdominal pain for more than 2 years and whose symptoms did not indicate a specific disease. A full history was taken with particular reference to the duration of the pain, periodicity, precipitating factors and associated symptoms. They were specifically asked about recurrent pains in childhood and at other times. If they had had abdominal or pelvic surgery the indications for it were established. All had a ‘ward test’ of urine (Haemocombistix, Ames Ltd), urine culture and a full blood count. Other investigations were carried out according to the clinical indications (investigations are shown in Tnb1e 1). If there was no somatic diagnosis, a full psychiatric assessment was made.
Results Twenty-eight patients were seen between April and December 1977. Eight failed t o complete the course of investigation and were lost t o follow-up. Twenty patients are available for analysis. A definite diagnosis was made in 15 patients: 3 had a ‘surgical’ disease, 8 a psychiatric disease and 4 had an irritable colon. In the remaining 5 patients n o diagnosis was made. The results are summarized in Table 71. Surgical causes There were 3 patients in this group (15 per cent). All were over 60 years old. Their symptoms were not typical of their disease, but were relieved by conventional treatment for the identified lesion. The first patient was a woman of 76 years with a long history of pain in the epigastrium and both iliac fossas. She was eventually found to have diverticulosis coli with an irregular stricture of the upper sigmoid. At operation the stricture was found t o be due to inflammatory changes in the bowel wall. Reilly’s myotomy was performed and she remains free of symptoms 14 months later. The second patient was correctly diagnosed as having gallstones only when seen during a n attack of acute cholecystitis. The third woman had longstanding
collapse of 3 thoracic vertebrae causing root pain, which was only diagnosed, after prolonged investigation, when the crucial past history was elicited. Psychiatric causes A psychiatric diagnosis was made in 8 cases (40 per cent). Five had chronic anxiety states, 2 had obsessional states and I had endogenous depression. There were 6 women and 2 men in this group, with an average age of 32 years (range 25-44). Pain had been present for between 2 and 17 years but 3 patients could give no definite duration. None remembered having pain before puberty. All were vague about Table I : INVESTIGATIONS UNDERTAKEN IN 20 PATIENTS WITH CHRONIC, NON-SPECIFIC ABDOMINAL PAIN Investigation No. of cases Barium enema and sigmoidoscopy Barium meal Intravenous urogram Oral cholecystogram Liver function tests Thyroid function tests Spinal X-rays Intravenous cholangiogram Serum amylase Lactose tolerance test
16 15 13 8 3 2 2 1 1
1
Table 11: DIAGNOSIS OF 20 PATIENTS WITH CHRONIC, NON-SPECIFIC ABDOMINAL PAIN Diagnosis No. of cases Surgical causes Inflammatory stricture of colon Gallstones Collapsed thoracic vertebrae Psychiatric causes Chronic anxiety states Obsessional states Endogenous depression Irritable colon Undiagnosed
3 1 I 1
8 5 2 1 4 5
Table 111: SYMPTOMS ASSOCIATED WITH ABDOMINAL PAIN IN 8 PSYCHIATRIC CASES Svmotom No. of cases Bowel disturbance Worsening of pain with stress Anorexia Abdominal swelling Vomiting Weight loss (only during pain) Nausea Dyspareunia Micturition disturbance
* Only occasionally in
3* 3 2
2 2 1 1
1 1
1 case.
* The North Middlesex Hospital, London. Correspondence to: C. R. J. Woodhouse, St Peter’s Hospitals, The Shaftesbury Hospital, Shaftesbury Avenue, London WC2.
Chronic abdominal pain their symptoms, admitting, for example, to intermittent pain, yet only 2 having an accurate idea of its periodicity. Associated symptoms were scarce, as Table III shows. Physical signs were unhelpful. The patients all looked well and none was obese. Four had tenderness in the right iliac fossa, 2 with a poorly defined mass (these 2 were submitted to elective appendicectomy, 1 was unchanged after the operation and 1 was worse). Further consultation eventually established the correct diagnosis. Conventional treatment was given using psychotherapy and drugs as required; 5 out of the 8 have improved and have had no recurrence of their pain. The follow-up of these patients now ranges between 8 and 15 months and none has developed an organic disease.
Irritable colon In 4 Datients (20 Der cent) a diagnosis of irritable colon was *made. All’ had lower abdominal pain with alteration of bowel habit; 3 had constipation and 1 had variable constipation and diarrhoea. In spite of at least 3 years of history, all remained in good general health without weight loss. Only 1 patient associated his pain with stress and none had distinct psychiatric disease. Two patients had tender descending colons and 1 had minimal reddening of the rectal mucosa, which was found to be normal on histology of multiple biopsies. All 4 had normal barium enema examinations and extensive investigation failed to show another cause for the symptoms. The patients were treated with bulk laxative (ispaghula husk) with complete relief of symptoms and they all remain well after 11-15 months’ follow-up. Undiagnosedgroup In 2 men, aged 53 and 54 years respectively, the symptoms were considered sufficiently severe to warrant laparotomy: no pathology was found, but 1 had a normal appendix removed. Both remain free of abdominal pain after 8 and 14 months of follow-up. Three other patients remain undiagnosed and continue to have pain.
Discussion Chronic non-specific abdominal pain is a notoriously difficult symptom to diagnose. In one retrospective review of patients whose pain ‘failed to conform to specific patterns’ only 10 of 76 were diagnosed. The younger the patient and the greater the duration of symptoms, the more unlikely diagnosis became (Sarfeh, 1976). Gynaecological practice reveals similar experience when only 14 out of 49 patients with pain of ‘chronic non-specific type’ were found to have a n abnormality on laparoscopy (Ferguson, 1974). Even in acute episodes of abdominal pain diagnosis has been shown t o be possible in less than half of 1000 cases (Brewer et al., 1976). Abdominal pain has been known as a symptom of emotional disorders since ancient Greek times; hence the term ‘hypochondriasis’, meaning ‘below the costal cartilages’, coined by Hippocrates. In the language of symptoms, the unhappy patient is literally ‘bellyaching’ about his problems. Anxiety states, obsessional ’
29
349
states and endogenous depressions are the commonest psychiatric causes for abdominal pain (Gomez and Dally, 1977). Recently the role of psychiatric factors in the aetiology of chronic abdominal pain has been neglected, though such factors are well established in children (Apley and Naish, 1958; Dodge, 1976). Although it has been suggested that little bellyachers grow up into big bellyachers (Editorial, 1975), such histories were not given by our patients. In 8 of our 20 patients (40 per cent) psychiatric causes for chronic abdominal pain were found and over half of them have made a good response to treatment. A further 4 had irritable colon, and it has been shown that in this condition disturbed colonic motility can be mediated by emotional upsets (Chaudhary and Truelove, 1961). The histories of our patients were as long as 17 years, and yet their general health remained good. Nevertheless, there is a clear possibility that they may yet develop an organic disease, and a change of symptoms or relapse while under psychiatric treatment would be an indication for further investigation. Only rarely did we find that this type of pain had a ‘surgical’ cause and only when the patient was over 60 years old. We now accept that where a patient is under 40 years old, has few symptoms other than pain and no physical signs, it is sufficient to test the urine, do a full blood count and one radiological investigation. Within this framework the patient is shown that his complaint is being taken seriously and a psychiatric consultation is accepted. In this series no organic diagnosis would have been missed with this programme. We regard the psychiatric assessment as part of the routine work-up and positive psychiatric features do not preclude further investigation. Our experience with this difficult group of patients is that diagnosis is possible in 75 per cent of cases. Chronic, non-specific abdominal pain is more often a psychiatric than a surgical symptom and a combined approach by both specialties is helpful.
Acknowledgement We are most grateful to Mr J. M. Beaugie for permission to report on his patients.
References and NAISH N. (1958) Recurrent abdominal pains: a field survey of 1000 school children. Arch. Dis. Child. 33, 165-170. BREWER R. J., GOLDEN C. T., HITCH D . C. et al. (1976) An analysis of 1000 consecutive cases of abdominal pain in a university hospital emergency room. Am. J. Surg. 131, 219-223. CHAUDHARY N. A. and TRUELOVE S. C. (1961) Human Colonic moility. Gastroenterology 40, 27-36. DODGE J. A. (1976) Recurrent abdominal pain in children. Br. Med. J . 1, 385-387. EDITORIAL (1975) Do little bellyachers become big bellyachers? Br. Med. J. 2, 459. FERGUSON I. L. c. (1974) Laparoscopy for the diagnosis of nonspecific lower abdominal pain. Br. J. Clin. Pract. 28, 163-1 65. COMEZ J. and DALLY P. (1977) Psychologically mediated abdominal pain in surgical and medical outpatient clinics. BY. Med. J . 1 , 1451-1453. SARFEH I. J. (1976) Abdominal pain of unknown aetiology. Am. J. Surg. 132, 22-25. APLEY J.
Paper accepted 31 October 1978.
