WA HoogerwerfMD and P Jay PasrichaMD

All of us have experienced acute pain, an unpleasant sensory and emotional experience that is associated with actual or potential tissue damage and which tells us that something is wrong with our body. This pain has a function because it allows for rapid identification of the site of origin of the underlying disease or injury and it allows for initiation of targeted therapy. On the contrary, chronic pain, one of the most common gastrointestinal (GI) conditions seen by primary care physicians and gastroenterologists, usually does not allow for rapid diagnosis of an underlying organic problem and is even less likely to lead to satisfactory therapy. Patients with chronic abdominal pain often have a track record of frequent emergency room visits and multiple physician examinations and of having been through a variety of diagnostic studies.

Pain is a subjective experience; there are no diagnostic tests that can determine the quality or intensity of an individual's pain. Regardless of whether there is an apparent so-called "organic" cause of the pain or not, the physician should bear in mind that pain often dominates the lives of patients in a negative fashion. Unfortunately, the patient with chronic abdominal pain is increasingly perceived as a clinical "liability" by the busy practitioner, with his or her symptoms either trivialized or perhaps worse, dismissed as representative of either "malingering", "psychosomatic", or "drug-seeking" behavior. These and various other, rather unscientific euphemisms of a similar nature are reflective of the physician's lack of understanding of the biological basis, as well as the psychosocial dimensions, of chronic pain and the consequent frustration of not being able to place the symptom in a conceptually familiar frame of reference (as compared with a symptom such as hematochezia). This has led to a set of physician behaviors, which are often rather irrational, towards these patients that include multiple diagnostic testing ("furor medicus"), referrals to various other specialists, and a pervasive fear of prescribing anything more than the mildest of analgesics. Ultimately, however, such behaviors do a disservice to both the medical community as well as the patients that it serves. The truth is that most patients with chronic abdominal pain are neither hypochondriacs nor drug addicts and their suffering is real and considerable. it therefore behooves the careful and compassionate gastroenterologist to remain engaged in the management of chronic abdominal pain; indeed the care of this condition can be both rewarding and relatively simple to perform, provided some basic principles are adhered to. It is the purpose of this chapter to review some of these principles and provide our own personal approach to these patients.

Peace in Pain

Peace in Pain

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