Introduction Centrally mediated disorders are characterised by chronic continuous or near continuous abdominal pain (CCAP)1. Due to lack of cohort-specific evidence, their management remains challenging. We examined impacts of opiate use, surgery and anti-neuropathic (antiNP) analgesia on clinical outcome in a cohort of CCAP patients.
Method Consecutive tertiary referrals with CCAP to a neurogastroenterology clinic between 2009–2016 were included. Other primary functional gut disorders and anterior cutaneous nerve entrapment were excluded. Medical, surgical and drug histories; interventions and outcomes were collected retrospectively. Clinical outcomes were compared (categorical: Chi Square/Fisher; continuous: one way ANOVA) by neuropathic pain (NP)2 diagnosis and opiate use.
Results 104 patients (mean age 40 years, 86% female) were included. 92/104 (88%) had been diagnosed clinically with NP and 12/104 (12%) with narcotic bowel syndrome (NBS).
Opiate use was associated with poor symptom response in most patients (50/73, 68% NP and 11/12, 92% NBS). Short-acting oral morphine (p=0.02) and use of ≥4 opiates (p=0.01) were associated with NBS. Weaker opiates were inversely associated with NBS (p=0.03). Current (p=0.01) and previous opiate use (p=0.004) were associated with constipation.
44/104 (42%) patients had ≥1 diagnostic or therapeutic surgical procedure for their pain. Surgery did not resolve symptoms in any patient and 13/44 (35%) patients, reported pain worsened after surgery. Opiate use (p=0.03) and NBS (p=0.03) were associated with increased number of surgeries performed for pain.
96/104 (92%) received antiNP drugs with clinical outcomes in 51/96 (response 34/51, 67%; non-response 10/51, 19%; intolerant 7/51, 14%). Sub-analyses (n=7 excluded as unknown prescribing sequence) showed combination therapy (>1 antiNP (86% response, n=14), or antiNP + linaclotide (100% response, n=11) was superior to antiNP monotherapy (47% response, n=19), p=0.002. Duloxetine was the single most effective antiNP (p=0.05). Opiate use and NBS were associated with more tertiary appointments and service use (p=0.02).
Conclusion This is the largest cohort-specific study of centrally mediated abdominal pain management to date. Opiate use, exploratory and therapeutic surgical procedures for CCAP are associated with worse clinical outcomes. Combinations of antiNP agents and linaclotide appear efficacious but optimum regimes need further exploration.
. Keefer, et al. Gastro2016.
. Searle, et al. Br J Anaes2012.
Disclosure of Interest None Declared
- abdominal pain
- neuropathic pain
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