Clinical approach to visceral pain in irritable bowel syndrome – pathophysiology, symptoms, and treatment
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Department of Internal Medicine, Medical University, Lublin, Poland
Department of Experimental and Clinical Pharmacology, Medical University, Lublin, Poland
Department of Paediatric Haematology and Oncology and Transplantology, Medical University, Lublin, Poland
Department of Neurology, District Hospital, Lubartów, Poland
Student Research Association, Medical University of Lublin, Poland
Department of Expert Medical Assistance with Emergency Medicine Unit, Medical University, Lublin, Poland
Department of Nephrology, Medical University, Lublin, Poland
Department of Clinical Endoscopy, Institute of Rural Health, Lublin, Poland
Andrzej Prystupa   

Department of Internal Medicine, Medical University, Lublin, Poland
Ann Agric Environ Med. 2013;20(Special Issue 1):8–13
Visceral pain has been defined as a pain resulting from activation of pain receptors localized in mucous membrane, serous membrane, and smooth muscles of hollow organs. The great majority of these organs are innervated by parasympathetic and sympathetic outflows. Afferent nerve fibres are involved in conduction of both acute and persistent pain and hyperalgesia. Visceral pain differs significantly from other types of pain in the way it originates and in clinical presentation. It can be misleading as a symptom, producing several problems in the diagnostic process. Sometimes, severe visceral pain is observed in the course of non-lifethreatening functional gastrointestinal disorders, while slight abdominal discomfort may be a first symptom of malignant tumours. For many years, the treatment of visceral pain has been considered as not satisfactory enough and covered a wide variety of pharmacological substances. For example, the complex therapy of pain and other manifestations associated with irritable bowel syndrome include psychotherapy/behavioural therapy, bulk-forming agents, probiotics, laxatives, antidiarrheals, antibacterial agents, antispasmodics, and antidepressants. The current knowledge about the pathogenesis of visceral pain gives a rationale for the development of new, more efficacious drugs with a positive benefit/risk ratio. Unfortunately, experience gained so far with the use of some agents affecting serotoninergic transmission in the gastrointestinal tract have shown a serious danger associated with their administration for patients with irritable bowel syndrome.
Sengupta JN. Visceral Pain: The Neurophysiological Mechanism. Handb Exp Pharmacol. 2009; 194: 31–74.
Sikandar S, Dickenson AH. Visceral Pain – the Ins and Outs, the Ups and Downs. Curr Opin Support Palliat Care. 2012; 6: 17–26.
Gebhart GF. Pathobiology of Visceral Pain: Molecular Mechanisms and Therapeutic Implications IV. Visceral afferent contributions to the pathobiology of visceral pain. Am J Physiol Gastrointest Liver Physiol. 2000; 278: 834–838.
Lynn PA, Blackshaw LA. In vitro recordings of afferent fibres with receptive fields in the serosa, muscle and mucosa of rat colon. J Physiol. 1999; 518:271–282.
Ozaki N, Gebhart GF. Characterization of mechanosensitive splanchnic nerve afferent fibers innervating the rat stomach. Am J Physiol. 2001; 281:1449–1459.
Mukerji G, Waters J, Chessell IP, Bountra C, Agarwal SK, Anand P. Pain during ice water test distinguishes clinical bladder hypersensitivity from overactivity disorders. BMC Urol. 2006; 6:31–42.
Camilleri M. Genetics of human gastrointestinal sensation. Neurogastroenterol Motil. 2013; 25: 458–466.
Brierley SM. Molecular basis of mechanosensitivity. Auton Neurosci 2010; 153: 58–68.
Sipe WE, Brierley SM, Martin CM, Phillis BD, Cruz FB, Grady EF, Liedtke W, Cohen DM, Vanner S, Blackshaw LA, Burnett NW. Transient receptor potential vanilloid 4 mediates protease activated receptor 2-induced sensitization of colonic afferent nerves and visceral hyperalgesia. Am J Physiol Gastrointest Liver Physiol, 2008; 294: 1288–1298.
Flasar MH, Cross R, Goldberg E. Acute Abdominal Pain. Prim Care Clin Office Pract. 2006; 33: 659–684.
Giamberardino MA. Visceral pain. International association for the study of pain; Clinical Updates 2005; 13(6): 1–6.
Locke III GR, Talley NJ, Fett SL, Zinsmeister AR, Melton III LJ. Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota. Gastroenterology. 1997; 112(5): 1448–1456.
Giamberardino MA. Referred pain from internal organs. In: Cervero F, Jensen T (eds.). Handbook of Clinical Neurology. Elsevier 2007.p.343–361.
Strigo IA, Bushnell MC, Boivin M, Duncan GH. Psychophysical analysis of visceral and cutaneous pain in human subjects. Pain 2002; 97(3): 235–246.
Giamberardino MA, Cervero F. The neural basis of referred visceral pain. In: Pasricha PJ (eds.). Chronic Adominal and Visceral Pain. Informa Healthcare. 2007.p.177–192.
Cartwright SL, Knudson MP. Evaluation of Acute Abdominal Pain in Adults. Am Fam Physician. 2008; 77(7): 971–978.
Miranda HF, Puig MM, Prieto JC, Pinardi G. Synergism between paracetamol and nonsteroidal anti-inflammatory drugs in experimental acute pain. Pain 2006; 121(1–2). p. 22–28.
Kulkarni SK, Patil CS, Jain NK, Singh A. Modulatory effect of diclofenac on antispasmodic effect of pitofenone in cholinergic spasm. Indian Journal of Experimental Biology. 2004; 42(6): 567–569.
Sengupta JN, Medda BK, Shaker R. Effect of GABAB receptor agonist on distension-sensitive pelvic nerve afferent fibers innervating rat colon. American Journal of Physiology Gastrointestinal and Liver Physiology. 2002; 283(6): 1343–1351.
Holdgate A, Pollock T. Nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for acute renal colic. Cochrane Database Syst Rev. 2004; 18(2): CD004137.
Flemming K. The use of morphine to treat cancer-related pain: asynthesis of quantitative and qualitative research. J Pain Symptom Manage. 2010; 39: 139–154.
Leon-Casasola OA. Neurolytic Blocks of the Sympathetic Axis for the Treatment of Visceral Pain in Cancer. Current Review of Pain. 1999; 3: 173–177.
Rykowski JJ, Hilgier M: Continuous celiac plexus block in acute pancreatitis. Reg Anesth. 1995; 20: 528–532.
Ischia S, Ischia A, Polati E, Finco G. Three posterior percutaneous celiac plexus block techniques: a prospective randomized study in 61 patients with pancreatic cancer pain. Anesthesiology 1992; 76: 534–540.
Plancarte R, Amescua C, Patt RB, Aldrete JA. Superior hypogastric plexus block for pelvic cancer pain. Anesthesiology 1990; 73: 236–239.
Plancarte R, Amescua C, Patt RB. Presacral blockade of the ganglion of Walther (ganglion impar). Anesthesiology 1990; 73: 751.
Dekel R, Drossman DA, Sperber AD. The use of psychotropic drugs in irritable nowel syndrome. Expert Opin Investig Drugs. 2013; 22(3): 329–339.
Elsenbruch S. Abdominal pain in Irritable Bowel Syndrome: a review of putative psychological, neural and neuro-immune mechanisms. Brain Behav Immun. 2011; 25(3): 386–394.
Nehring P, Mrozikiewicz-Rakowska B, Krasnodębski P, Karnafel W. Irritable nowel syndrome – a new approach to aetiopathogenesis. Prz Gastroenterol. 2011; 6 (1): 17–22.
Johnston JM, Shiff SJ, Quigley EM. A review of the clinical efficacy of linaclotide in irritable bowel syndrome with constipation. Curr Med Res Opin. 2013; 29(2): 149–160.
Bednarczuk A, Pawlik M, Rydzewska G. Irritable bowel syndrome – new aspects of diagnosis and treatment. Przew Lek. 2005; 10: 34–40.
Bartnik W. Irritable nowel syndrome. In: Gajewski P (eds.). Interna Szczeklika, Kraków 2013. p.943–945.
Guideline on the evaluation of medicinal products for the treatment of irritable bowel syndrome. Draft. 2013.06.27. CPMP/EWP/785/97 Rev. 1.
Pimentel M, Lembo A, Chey WD, Zakko S, Ringel Y, Yu J, Mareya SM, Shaw AL, Bortey E, Forbes WP; TARGET Study Group. Rifaximin therapy for patients with irritable nowel syndrome without constipation. N Engl J Med. 2011; 364(1): 22–32.
Ruepert L, Quartero AO, de Wit NJ, van der Heijden GJ, Rubin G, Muris JW. Bulking agents, antispasmodics and antidepressants for the treatment of irritable bowel syndrome. Cochrane Database Syst Rev. 2011; (8): CD003460.
Mozaffari S, Nikfar S, Abdollahi M. Metabolic and toxicological considerations for the latest drugs used to treat irritable bowel syndrome. Expert Opin Drug Metab Toxicol. 2013; 9(4): 403–421.
Novick J, Miner P, Krause R, Glebas K, Bliesath H, Ligozio G, Rüegg P, Lefkowitz M. A randomized, double-blind, placebo-controlled trial of tegaserod in female patients suffering from irritable bowel syndrome with constipation. Aliment Pharmacol Ther. 2002; 16(11): 1877–1888.
Evans BW, Clark WK, Moore DJ, Whorwell PJ. Tegaserod for the treatment of irritable bowel syndrome and chronic constipation. Cochrane Database Syst Rev. 2007; (4): CD003960.
Schiller LR, Johnson DA. Balancing drug risk and benefit: toward refining the process of FDA decisions affecting patient care. Am J Gastroenterol. 2008; 103(4): 815–819.
Brenner GM, Stevens CW. Drugs for Gastrointestinal Tract Disorders. In: Brenner GM, Stevens CW. Pharmacology, Fourth Edition, Philadelphia 2013.p.295–306.
Dai C, Zheng CQ, Jiang M, Ma XY, Jiang LJ. Probiotics and irritable nowel syndrome. World J Gastroenterol. 2013; 19(36): 5973–5980.
Moayyedi P, Ford AC, Talley NJ, Cremonini F, Foxx-Orenstein AE, Brandt LJ, Quigley EM. The efficacy of probiotics in the treatment of irritable nowel syndrome: a systematic review. Gut. 2010; 59(3): 325–332.
Corazziari E. Role of opioid ligands in the irritable bowel syndrome. Can J Gastroenterol. 1999; 13: 71–75.
Darvish-Damavandi M, Nikfar S, Abdollahi M. A systematic review of efficacy and tolerability of mebeverine in irritable bowel syndrome. World J Gastroenterol. 2010; 16(5): 547–553.
Grigoleit HG, Grigoleit P. Peppermint oil in irritable bowel syndrome. Phytomedicine. 2005; 12(8): 601–606.
Ford AC, Talley NJ, Schoenfeld PS, Quigley EM, Moayyedi P. Efficacy of antidepressants and psychological therapies in irritable bowel syndrome: systematic review and meta-analysis. Gut. 2009; 58(3): 367–378.
Chial HJ, Camilleri M, Ferber I, Delgado-Aros S, Burton D, McKinzie S, Zinsmeister AR. Effects of venlafaxine, buspirone, and placebo on colonic sensorimotor functions in healthy humans. Clin Gastroenterol Hepatol. 2003; 1(3): 211–218.
Wagstaff AJ, Frampton JE, Croom KF. Tegaserod: a review of its use in the management of irritable bowel syndrome with constipation in women. Drugs. 2003; 63(11): 1101–1120.
Brandt LJ. The FDA’s decision-making process: isn’t it time to temper the principle of protective paternalism? Am J Gastroenterol. 2008; 103(5): 1226–1227.
Camilleri M. Pharmacology and clinical experience with alosetron. Expert Opin Investig Drugs. 2000; 9(1): 147–159.
Lucak S. Irritable bowel syndrome and ischemic colitis: evidence supporting the increased use of alosetron. Therap Adv Gastroenterol. 2012; 5(4): 215–218.
Tong K, Nicandro JP, Shringarpure R, Chuang E, Chang L. A 9-year evaluation of temporal trends in alosetron postmarketing safety under the risk management program. Therap Adv Gastroenterol. 2013; 6(5): 344–357.