GA5-103
Chronic abdominal pain in a pediatric patient after resolution of acute pancreatitis: a case report
Rappold T, Suleman M
Johns Hopkins University School of Medicine, Baltimore, MD, United states
Introduction: Pediatric patients with acute pancreatitis (AP) may develop chronic pain after resolution of clinical, laboratory, and radiographic signs of disease. These children may be diagnosed with functional abdominal pain which is associated with poor social development, lower quality of life scores, and higher rates of school absence (1). Here, we describe a patient who developed chronic abdominal pain after clinically resolved AP that responded well to local anesthetic and steroid injections. We attempt to suggest a possible mechanism for pain relief.
Methods: Two months after clinical resolution of AP, a 13-year-old boy with persistent, focal, periumbilical abdominal pain underwent thorough workup under the direction of a pediatric gastroenterologist without conclusive identification of pain etiology. He was diagnosed with functional abdominal pain and referred to a pediatric chronic pain specialist. The patient underwent bilateral transverse abdominis plane (TAP) blocks with local anesthetics and trigger point treatments. He returned one month later for repeat blocks with local anesthetics and dexamethasone.
Results: The patient experienced temporary relief with local anesthetic injections and long-lasting relief and functional improvement with steroid injections.
Discussion: This patient’s presentation of pain after AP—localized and periumbilical, Carnet’s sign positive, poor PO intake that required home nasogastric tube feeds—was typical of somatic pain that greatly affected his functional status. A multifactorial mechanism of relief includes treatment of abdominal wall nerve irritation secondary to persistent emesis and nausea and increased abdominal pressure. Also, he may have developed central sensitization presenting as somatic pain that was treated by our interventions. And third, anesthesia of anterior rami of nerves T10-L1 likely contributed to his relief. The main limitation of our report is that it is a single case based on clinical observation.
Conclusions: Chronic abdominal pain that is somatic rather than visceral in nature can complicate resolved AP; the use of TAP blocks and trigger point injections to relieve this pain has not been described. This patient's clinical course suggests that evaluation by a pediatric pain specialist prior to comprehensive workups for abdominal pain may be a faster, more cost-efficient care model. The use of regional analgesia techniques may apply to a broader set of resolved, visceral abdominal pathologies with persistent pain in pediatric patients.
Lessons Learned:
1. Think broadly beyond visceral pain. Disease processes that typically cause visceral pain may also have overlooked and untreated somatic components.
2. Patients with chronic abdominal pain should be evaluated by a pediatric pain specialist concurrently with or prior to evaluation by a pediatric gastroenterologist.
References:
1. Youssef NN, Atienza K, Langseder AL, Strauss RS. Chronic abdominal pain and depressive symptoms: analysis of the national longitudinal study of adolescent health. Clin Gastroenterol Hepatol. 2008;6(3):329-32.
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