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Left: viscerosomatic hyperalgesia: each segment in the spinal cord receives afferent fibres from visceral as well as somatic structures. viscero-somatic hyperalgesia or referred pain originates because of this convergence of spinal afferents. The brain therefore interprets the pain as originating from a somatic structure with the same segmental innervation, for example, referred pain in the right shoulder because of pain originating from the gall bladder. Referred pain can be enhanced by spinal hyperexcitability caused by, for example, local inflammation, hence causing a larger referred pain area. Right: viscero-visceral hyperalgesia: the convergence of visceral afferent nerves in the spinal dorsal horn from different organs results in an increased nociceptive input to this particular segment of the spinal cord. Here shown with convergence of afferent nerves from the heart and gall bladder at the spinal level of Th5. This generates a stronger pain stimulus, a mechanism known as viscero-visceral hyperalgesia.
Source publication
Pain is common in gastroenterology. This review aims at giving an overview of pain mechanisms, clinical features, and treatment options in oesophageal disorders. The oesophagus has sensory receptors specific for different stimuli. Painful stimuli are encoded by nociceptors and communicated via afferent nerves to the central nervous system. The pain...
Citations
... Following hiatus hernia repair, somatic pain generated from Aδ and C fibres is found in crural nerve fibres (vagal afferent nociceptive nerve fibres), which can be significantly stimulated from the hiatal dissection, suture cruroplasty, the peritoneum and the abdominal wall (Kollarik et al., 2010) . Visceral pain fibres, Aδ and C fibres via the autonomic nervous system are found in the lower oesophageal sphincter, the phrenooesophageal ligament, associated viscera, peritoneum and the mediastinum (Lottrup et al., 2011) (Kollarik et al., 2010). As such there are multiple centres that can trigger pain and as such be targeted for multimodal analgesia. ...
Hiatus hernia repair is a commonly performed gastrointestinal surgeries performed worldwide for the treatment of gastro-oesophageal reflux. In the last two decades, there has been a widespread shift from open to laparoscopic repair and this has been proven to significantly reduce postoperative pain, an earlier discharge and a faster return to work. Importantly, there is an obvious gap in the literature regarding postoperative pain experiences and whether any analgesia adjuncts are utilised and to what effect they have on reducing pain and reducing the need for traditional analgesia such as opioids. One novel adjunct uncommonly utilised clinically but not thus far researched is diaphragmatic crural regional infiltration with long-acting local anaesthesia, aiming to dampen pain signals generated from the abdominal and thoracic dissection performed during hiatus hernia repair. This is a low risk, low effort technique performed intraoperatively by the surgeon under direct vision at the end of surgery targeting the vagal afferent nociceptive nerve fibres found in the crural fibres, a viable target for blockade by local anaesthesia. A cohort comparison study was performed at a single centre assessing the effects of crural infiltration with long-acting local anaesthesia performed routinely by one higher volume upper gastrointestinal surgeon, whose cohort is the intervention group. The primary end points assessed were postoperative pain outcomes and opioid requirements and the intervention cohort’s results were compared against that of another high volume upper gastrointestinal surgeon at the same hospital who does not perform crural infiltration. Consecutive cases were analysed from 2019-2021, comparing the two cohort groups’ primary endpoints. Crural infiltration was found to be opioid-sparing, with patients requiring 2mg less morphine each day compared to the non-interventional group. In addition, the interventional cohort experienced reduced peak pain scores compared to the non-interventional group. Increasing age was protective against postoperative pain whilst patients who had purely para-oesophageal hernias experienced more pain than other hernia types. There appear to be potential positive effects of crural anaesthesia infiltration following hiatus hernia repair, though not statistically significant in this study. As such more research into its effects as it can be an important adjunct in reducing postoperative pain.
... The activity in the GI organs does not usually reach the higher brain centers, except for information due to the filling of the esophagus, stomach, and rectum. When the organs are potentially in danger, for example, due to diseases, symptoms such as discomfort and pain are sensed [45]. Furthermore, mechanisms involved in the occurrence of heartburn include esophageal hypersensitivity, peripheral or central sensitization, microscopic alteration of the esophageal mucosa, and dilated intercellular spaces. ...
... In animal models of somatic nerve mononeuropathy or neuritis, hyperalgesia is characteristically produced and is long-lasting [48][49][50][51][52]. Ligand and voltage-gated channels in sensory neurons may be altered subsequent to a nerve injury and thus contributes to the occurrence of pain. Candidate channels include voltage-gated sodium and calcium channels, acid-sensing and temperature-sensing ion channels, and ion channels gated by endogenous ligands such as serotonin or ATP [40][41][42][43][44][45]. ...
Functional gastrointestinal disorders (FGIDs) are a highly prevalent group of heterogeneous disorders, and their diagnostic criteria are symptom-based, with the absence of anatomical and biochemical abnormalities of the gastrointestinal tract. Chronic visceral symptoms are common both in patients with an identifiable organic disease but also in FGID patients. Patients suffering from upper gastrointestinal functional disorders typically present with various symptoms such as early satiety, postprandial fullness, bloating, nausea, vomiting, and epigastric pain. Considering their increasing prevalence, difficulties in diagnosis, and low quality of life, FGIDs have become an emerging problem in gastroenterology. We aimed to provide an updated summary of pathways involved in visceral sensitization. We examined the recent literature searching for evidence of the most important studies about the mechanisms underlying gastrointestinal symptom generation and sensitization.
... OIBD symptoms are potentially difficult to localize and distinguish from each other due to the complex organization of the visceral sensory system; visceral afferents show diffuse termination over many segments of the spinal cord [50][51][52]. It is therefore plausible that colonic distension due to OIC may also be felt in the upper abdomen. ...
Objective:
To formulate timely evidence-based guidelines for the management of opioid-induced bowel dysfunction.
Setting:
Constipation is a major untoward effect of opioids. Increasing prescription of opioids has correlated to increased incidence of opioid-induced constipation. However, the inhibitory effects of opioids are not confined to the colon, but also affect higher segments of the gastrointestinal tract, leading to the coining of the term "opioid-induced bowel dysfunction."
Methods:
A literature search was conducted using Medline, EMBASE, and EMBASE Classic, and the Cochrane Central Register of Controlled Trials. Predefined search terms and inclusion/exclusion criteria were used to identify and categorize relevant papers. A series of statements were formulated and justified by a comment, then labeled with the degree of agreement and their level of evidence as judged by the Strength of Recommendation Taxonomy (SORT) system.
Results:
From a list of 10,832 potentially relevant studies, 33 citations were identified for review. Screening the reference lists of the pertinent papers identified additional publications. Current definitions, prevalence, and mechanism of opioid-induced bowel dysfunction were reviewed, and a treatment algorithm and statements regarding patient management were developed to provide guidance on clinical best practice in the management of patients with opioid-induced constipation and opioid-induced bowel dysfunction.
Conclusions:
In recent years, more insight has been gained in the pathophysiology of this "entity"; new treatment approaches have been developed, but guidelines on clinical best practice are still lacking. Current knowledge is insufficient regarding management of the opioid side effects on the upper gastrointestinal tract, but recommendations can be derived from what we know at present.
... Visceral pain is difficult to characterize in contrast to somatic pain, mainly due to diffuse termination of afferents and poor corticotropic organization. 28 This makes treatment often challenging for physicians and alternative treatments very relevant. To obtain detailed information about the visceral pain response, experimental pain models can be used to induce visceral pain in a controlled manner, while psychophysical and neurophysiological measures are carried out. ...
Background and objectives
Contradictory results have been found about the effect of different exercise modalities on pain. The aim of this study was to investigate the early effects of aerobic and isometric exercise on different types of experimental pain, including visceral pain, compared to an active control condition.
Methods
Fifteen healthy subjects (6 women, mean [standard deviation] age 25 [6.5] years) completed 3 interventions consisting of 20 minutes of aerobic cycling, 12 minutes of isometric knee extension and a deep breathing procedure as active control. At baseline and after each intervention, psychophysical tests were performed, including electrical stimulation of the esophagus, pressure pain thresholds and the cold pressor test as a measure for conditioned pain modulation. Participants completed the Medical Outcome Study Short-Form 36 and State-Trait Anxiety Inventory prior to the experiments. Data were analyzed using two-way repeated measures analysis of variance.
Results
No significant differences were found for the psychophysical tests after the interventions, compared to baseline pain tests and the control condition.
Conclusion
No hypoalgesic effect of aerobic and isometric exercise was found. The evidence for exercise-induced hypoalgesia appears to be not as consistent as initially thought, and caution is recommended when interpreting the effects of exercise on pain.
... If this is not a one-page article please supply the first and last pages for this article in reference [15]. ...
... These neurons terminate in the dorsal horn of the spinal cord, from which synapses are made to neurons which ascend to the brainstem. 15 In comparison with somatic sensation, the relative number of visceral afferents is considerably smaller and frequently converge on the spinal dorsal horn over several levels, thus visceral nociception is poorly localized in comparison with somatic. Furthermore, this can lead to a phenomenon referred to as "viscero-somatic convergence," such that esophageal pain can be referred to anatomically distinct somatic structures, albeit ones that synapse with dorsal horn at the same spinal level. ...
The Rome IV diagnostic criteria delineates 5 functional esophageal disorders which include functional chest pain, functional heartburn, reflux hypersensitivity, globus, and functional dysphagia. These are a heterogenous group of disorders which, despite having characteristic symptom profiles attributable to esophageal pathology, fail to demonstrate any structural, motility or inflammatory abnormalities on standard clinical testing. These disorders are associated with a marked reduction in patient quality of life, not least considerable healthcare resources. Furthermore, the pathophysiology of these disorders is incompletely understood. In this narrative review we provide the reader with an introductory primer to the structure and function of esophageal perception, including nociception that forms the basis of the putative mechanisms that may give rise to symptoms in functional esophageal disorders. We also discuss the provocative techniques and outcome measures by which esophageal hypersensitivity can be established.
... The recognition that a variety of spastic oesophageal motility disorders were a result of reflux related acid exposure led to the concept of oesophageal hypersensitivity [7,8] . Symptomatic improvement of oesophageal pain has been seen with the use of Proton pump inhibitors and they have been recommended as a safe first line management option [8,9] . ...
... The recognition that a variety of spastic oesophageal motility disorders were a result of reflux related acid exposure led to the concept of oesophageal hypersensitivity [7,8] . Symptomatic improvement of oesophageal pain has been seen with the use of Proton pump inhibitors and they have been recommended as a safe first line management option [8,9] . ...
Introduction: Oesophageal motility disorders (OMDs) are a recognized cause of pain in 25-33% of patients with non-cardiac chest pain. The understanding of these disorders based on standard multichannel oesophageal manometry has improved with high resolution oesophageal manometry (HROM). This could facilitate selection of treatment modality including identifying those suitable for surgical myotomy while preserving oesophageal function.
Material and methods: This discussion is based on a 65 year old lady with a 17 year history of oesophageal pain due to Nutcracker oesophagus. Persistence of symptoms despite medical management using proton pump inhibitors, calcium channel blockers, nitrates, endoscopic pneumatic dilatation & Botulinum toxin injection prompted re-referral to our specialist unit and analysis of residual oesophageal function using HROM. This revealed a segment of nutcracker oesophagus in the mid oesophagus with significant supine reflux.
Result: Surgical treatment with trans-hiatal open focused oesophageal myotomy with preservation of lower oesophageal sphincter and floppy Nissen fundoplication led to satisfactory and complete resolution of symptoms.
Discussion: HROM provides a clearer classification of the functional abnormalities and their co-relation to symptoms. This allows application of the best available treatment modality including surgery to achieve symptomatic relief with preservation of residual oesophageal function.
Conclusion: Limited evidence is currently available on the comparative benefits of available treatment modalities for OMDs. HROM provides greater insight into OMDs and the benefits of available treatment modalities allowing selection of optimal treatment modality and preserving oesophageal function while achieving relief of the patients distressing symptoms.
Gastroesophageal Reflux Disease (GERD) is a common chronic gastrointestinal disorder affecting both men and women. Nonerosive reflux disease generally affects more women, whereas GERD complications such as Barrett's esophagus (BE) or esophageal cancer affect more men. The aim of this study was to evaluate sex- and gender-specific symptoms and health-related quality of life (HRQoL) among men and women with GERD. Patients with clinical signs of reflux and completion of 24-hour pH-Impedance testing at the University Hospital Cologne were included into the study. Evaluation of symptoms and HRQoL included the following validated questionnaires: GERD-Health-Related Quality of Life (GERD HRQL), Gastrointestinal Quality of Life Index (GIQLI), and Hospital Anxiety and Depression Scale (HADS). In all, 509 women and 355 men with GERD were included. Men had a significantly higher DeMeester score (60.2 ± 62.6 vs. 43 ± 49.3, P < 0.001) and a higher incidence of BE (18.6 vs. 11.2%, P = 0.006). Women demonstrated significantly higher levels of anxiety (30.9 vs. 14.5%, P = 0.001), more severely impacting symptoms (45.3 ± 11.3 vs. 49.9 ± 12.3, P < 0.001), as well as physical (14.2 ± 5.7 vs. 16.7 ± 5.6, P < 0.001) and social dysfunction (13.3 ± 4.8 vs. 14.8 ± 4.3, P = 0.002). Women further reported a lower HRQoL (85.3 ± 22.7 vs. 92.9 ± 20.8, P < 0.001). Men and women differ on biological, psychological, and sociocultural levels.
Visceral pain, particularly chronic pain, is a significant problem for the physical, psychological, social, and economic aspects. Although it has often been studied by applying the mechanisms of somatic pain, it presents many differences, both in clinical and in physio-pathological aspects. Despite these differences the current management of visceral pain generally follows the guidelines derived from the somatic pain literature. However, the knowledge of the key mechanisms underlying chronic visceral plays a fundamental role in the general management of the patient and in the choice of treatment. In this chapter the anatomical data and the functional aspects that make visceral pain unique will be briefly discussed. Particularly, clinical presentation, mechanisms of peripheral and central sensitization, and the role of dorsal columns and of descending pathways that modulate spinal nociceptive transmission will be presented.
Gastroesophageal reflux disease (GERD) is a disorder due to the retrograde flow of refluxate into the esophagus. Although GERD is a common clinical diagnosis, its pathogenesis is quite complex. As a result of its multifactorial development, many patients continue to experience adverse symptoms due to GERD despite prolonged acid suppression with proton pump inhibitor therapy. The pathogenesis of GERD involves an interplay of chemical, mechanical, psychologic, and neurologic mechanisms, which contribute to symptom presentation, diagnosis, and treatment. As such, GERD should be approached as a disorder beyond acid. This review will investigate the major factors that contribute to the development of GERD, including factors related to the refluxate, esophageal defenses, and factors that promote pathologic reflux into the esophagus. In reviewing GERD pathogenesis, this paper will highlight therapeutic advances, with mention of future opportunities of study when approaching GERD.
