Functional Abdominal Pain Syndrome: Constant or Frequently Recurring Abdominal Pain
Functional Abdominal Pain Syndrome: Constant or Frequently Recurring Abdominal Pain
复制标题
功能性腹痛综合征：持续或频繁复发的腹痛
DOI：
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发表时间：
2010
影响因子：
9.8
通讯作者：
D. Drossman
中科院分区：
文献类型：
--
作者：
A. Sperber;D. Drossman
The American Journal of GASTROENTEROLOGY VOLUME 105 | APRIL 2010 www.amjgastro.com CHRONIC ABDOMINAL PAIN Abdominal pain is a symptom that can be either acute or chronic and has many etiologies. Physical diagnosis textbooks provide extensive tables on the diff erential diagnosis of acute and chronic abdominal pain, but to make a diagnosis merely by trying to fi t the patient ’ s symptoms into a list is not enough. It is the skill of active listening and the integration of historical data into a conceptual framework that guides the diagnostic strategy; physical examination and confi rmatory studies then follow ( 1 ). Th is is particularly true for chronic abdominal pain. In fact, clinicians approach the diagnosis and treatment of acute and chronic pain diff erently. Making a diff erential diagnosis of acute abdominal pain seems more understandable, because acute pain is usually generated from a single peripheral source. Th ere are characteristic features regarding the symptom description, location, its time course, and the aggravating and relieving factors. Th us, clinicians are in agreement when considering the diagnosis of a peptic ulcer when the patient describes the recent onset of intermittent burning epigastric pain that is relieved by meals and antacids and associated with black stools. In contrast, it is more diffi cult to apply an acute pain model to patients with chronic abdominal pain. Herein, the symptoms may not behave in the expected manner, being ever present, poorly localized, associated with negative diagnostic tests, and not readily responsive to gut-acting treatments. Not only is the clinician perplexed about diagnostic and therapeutic options but also the very legitimacy of the condition may come into question. What is required is a broader biopsychosocial construct to approach the chronic gastrointestinal pain ( 2 ). Th ere are diff erent types of chronic abdominal pain. Many have a peripheral contribution, e.g., pain that is due to chronic pancreatitis or infl ammatory bowel disease. Herein, the nature and severity of the symptoms are attributed to the underlying pathological damage. However, as the pain becomes more chronic, treatments targeted to the peripheral organ become less than optimal, particularly when there is little or no evidence for structural damage. When abdominal pain becomes a constant presence, defi es a gut-associated structural etiology, and is disruptive to life, it is categorized as a functional gastrointestinal disorder. Functional abdominal pain syndrome (FAPS) is a debilitating functional gastrointestinal disorder characterized by continuous and persistent or frequently recurrent abdominal pain that is associated with the loss of daily functioning ( 3 ). Th ere is no evidence of structural (biochemical) abnormalities to explain the symptom and it is not factitious. FAPS is less prevalent than irritable bowel syndrome with which it may be confused. Owing to its debilitating nature, the burden of disease in terms of absenteeism from work and utilization of health-care services is substantial ( 4 ). Although FAPS was once classifi ed as one of the functional bowel disorders, in the Rome III classifi cation of the functional gastrointestinal disorders, it was placed in its own separate category ( 3 ). Th e pain is not related to abnormal motility or even enhanced visceral signaling ( 5 ), and clinically it is not associated with change in bowel habit, or eating, nor is it relieved by defecation. Th e greater contribution to the pain experience relates to abnormal cingulate functioning that may be linked to psychosocial disturbances ( 6 – 8 ). As there is a dearth of literature on FAPS, this contention is based on data obtained from patients with severe painful irritable bowel syndrome and psychosocial disturbances, which could be considered as a surrogate condition that represents FAPS. From a pathophysiological perspective, pain can have contributions from anywhere in the neuraxis. When injuring a fi nger, the pain clearly arises from peripheral neural injury with increased aff erent nociceptive input to the brain. Th is is also true for acute visceral infl ammation or injury, such as acute cholecystitis or bowel obstruction. However, when a gastrointestinal disorder becomes chronic, as noted previously with infl ammatory bowel disease or chronic pancreatitis, the pain experience is increasingly infl uenced by central nervous system function. In functional gastrointestinal disorders, the symptoms become even more associated with central dysregulation amplifying the pain, in addition to the bowel dysfunction. Finally, in FAPS, there may be little or no gastrointestinal disturbance and the major disturbance is an “ abnormal perception of normal gut function, ” rather than an abnormal gut function. Indeed, the main mechanism for altered pain regulation with FAPS relates to the failure to inhibit and possibly even the amplifi cation of normal regulatory aff erent input through altered central “ gate control ” mechanisms (originating in the prefrontal and cingulate cortex and other limbic structures) ( 7 ). Th is Functional Abdominal Pain Syndrome: Constant or Frequently Recurring Abdominal Pain
The American Journal of GASTROENTEROLOGY VOLUME 105 | APRIL 2010 www.amjgastro.com CHRONIC ABDOMINAL PAIN Abdominal pain is a symptom that can be either acute or chronic and has many etiologies. Physical diagnosis textbooks provide extensive tables on the diff erential diagnosis of acute and chronic abdominal pain, but to make a diagnosis merely by trying to fi t the patient ’ s symptoms into a list is not enough. It is the skill of active listening and the integration of historical data into a conceptual framework that guides the diagnostic strategy; physical examination and confi rmatory studies then follow ( 1 ). Th is is particularly true for chronic abdominal pain. In fact, clinicians approach the diagnosis and treatment of acute and chronic pain diff erently. Making a diff erential diagnosis of acute abdominal pain seems more understandable, because acute pain is usually generated from a single peripheral source. Th ere are characteristic features regarding the symptom description, location, its time course, and the aggravating and relieving factors. Th us, clinicians are in agreement when considering the diagnosis of a peptic ulcer when the patient describes the recent onset of intermittent burning epigastric pain that is relieved by meals and antacids and associated with black stools. In contrast, it is more diffi cult to apply an acute pain model to patients with chronic abdominal pain. Herein, the symptoms may not behave in the expected manner, being ever present, poorly localized, associated with negative diagnostic tests, and not readily responsive to gut-acting treatments. Not only is the clinician perplexed about diagnostic and therapeutic options but also the very legitimacy of the condition may come into question. What is required is a broader biopsychosocial construct to approach the chronic gastrointestinal pain ( 2 ). Th ere are diff erent types of chronic abdominal pain. Many have a peripheral contribution, e.g., pain that is due to chronic pancreatitis or infl ammatory bowel disease. Herein, the nature and severity of the symptoms are attributed to the underlying pathological damage. However, as the pain becomes more chronic, treatments targeted to the peripheral organ become less than optimal, particularly when there is little or no evidence for structural damage. When abdominal pain becomes a constant presence, defi es a gut-associated structural etiology, and is disruptive to life, it is categorized as a functional gastrointestinal disorder. Functional abdominal pain syndrome (FAPS) is a debilitating functional gastrointestinal disorder characterized by continuous and persistent or frequently recurrent abdominal pain that is associated with the loss of daily functioning ( 3 ). Th ere is no evidence of structural (biochemical) abnormalities to explain the symptom and it is not factitious. FAPS is less prevalent than irritable bowel syndrome with which it may be confused. Owing to its debilitating nature, the burden of disease in terms of absenteeism from work and utilization of health-care services is substantial ( 4 ). Although FAPS was once classifi ed as one of the functional bowel disorders, in the Rome III classifi cation of the functional gastrointestinal disorders, it was placed in its own separate category ( 3 ). Th e pain is not related to abnormal motility or even enhanced visceral signaling ( 5 ), and clinically it is not associated with change in bowel habit, or eating, nor is it relieved by defecation. Th e greater contribution to the pain experience relates to abnormal cingulate functioning that may be linked to psychosocial disturbances ( 6 – 8 ). As there is a dearth of literature on FAPS, this contention is based on data obtained from patients with severe painful irritable bowel syndrome and psychosocial disturbances, which could be considered as a surrogate condition that represents FAPS. From a pathophysiological perspective, pain can have contributions from anywhere in the neuraxis. When injuring a fi nger, the pain clearly arises from peripheral neural injury with increased aff erent nociceptive input to the brain. Th is is also true for acute visceral infl ammation or injury, such as acute cholecystitis or bowel obstruction. However, when a gastrointestinal disorder becomes chronic, as noted previously with infl ammatory bowel disease or chronic pancreatitis, the pain experience is increasingly infl uenced by central nervous system function. In functional gastrointestinal disorders, the symptoms become even more associated with central dysregulation amplifying the pain, in addition to the bowel dysfunction. Finally, in FAPS, there may be little or no gastrointestinal disturbance and the major disturbance is an “ abnormal perception of normal gut function, ” rather than an abnormal gut function. Indeed, the main mechanism for altered pain regulation with FAPS relates to the failure to inhibit and possibly even the amplifi cation of normal regulatory aff erent input through altered central “ gate control ” mechanisms (originating in the prefrontal and cingulate cortex and other limbic structures) ( 7 ). Th is Functional Abdominal Pain Syndrome: Constant or Frequently Recurring Abdominal Pain