Introduction
Chronic abdominal wall pain often poses diagnostic challenges, frequently leading to extensive and unnecessary investigations [1]. anterior cutaneous nerve entrapment syndrome (ACNES), a prevalent cause of chronic abdominal wall pain, warrants special attention in palliative care settings due to its significant impact on patients’ comfort and quality of life [2].
Case presentation
Recently, a 31-year-old male patient was diagnosed with ACNES in 2020. He presented with severe, localized abdominal pain persisting for several months, associated with a positive Carnett’s sign (pain aggravated by movement and with abdominal muscles’ tension). Despite an initial Numeric Rating Scale (NRS) pain score of 7, his reliance on as-needed (SOS) analgesics provided inconsistent relief, highlighting the inadequacy of current pain management strategies.
Upon a comprehensive evaluation, initiated was a structured pain management plan. Recognizing the importance of addressing all the aspects of pain management, a multifaceted approach was employed. This included administration of a transverse abdominis plane (TAP) block for targeted pain relief. Additionally, the oral analgesics regimen was optimized with NSAIDs and Gabapentin for their neuropathic pain management properties. Patient education emphasizing the consistent use of analgesics to prevent breakthrough pain, alongside detailed information about ACNES and its treatment, was integral to the intervention. Through this intervention, the patient’s pain significantly decreased from an NRS score of 7 to 2, demonstrating the efficacy of this approach. This outcome underscores the pivotal role of targeted pain management strategies and effective communication in palliative care.
Discussion
The present case highlights several important considerations. Characteristic features of ACNES, such as sharp, localized abdominal pain aggravated by movement and with abdominal muscles’ tension (positive Carnett’s sign) necessitate a structured diagnostic approach. Various interventions, including local anesthetic injections, TAP block, and oral analgesics, offer effective pain relief for ACNES (Table 1). Despite planned invasive interventions like the TAP block, maintaining consistent analgesic levels is essential for preventing breakthrough pain and ensuring patient comfort. The timing of interventions, including the TAP block, may vary depending on the patient’s pain severity and response to initial treatment. The differential diagnoses (Table 2) aid in distinguishing ACNES from other causes of abdominal pain in palliative care settings. While limited literature exists on ACNES within palliative care populations, further research in this area is warranted to enhance understanding and improve management strategies.
|
Therapeutic option |
Description |
Indications |
Advantages |
Disadvantages |
|
Local anesthetic injections |
Injection of local anesthetic at the site of nerve entrapment |
Diagnostic and therapeutic for ACNES |
Immediate pain relief |
The short duration of the effect |
|
TAP block |
Regional anesthesia technique targeting nerves in the abdominal wall |
Moderate to severe ACNES pain |
Longer duration of pain relief |
Requires expertise, potential complications |
|
Oral analgesics |
NSAIDs, acetaminophen for mild to moderate pain |
Mild to moderate pain |
Non-invasive, easy administration |
Limited efficacy in severe pain, side effects |
|
Opioid analgesics |
Step 2 opioids for moderate pain, Step 3 opioids for severe pain |
Moderate to severe pain |
Effective for severe pain |
Risk of tolerance, dependence, side effects |
|
Topical analgesics |
Lidocaine patches, capsaicin cream |
Localized pain |
Targeted relief, minimal systemic effects |
Limited efficacy, skin irritation |
|
Anticonvulsants |
Gabapentin, pregabalin for neuropathic pain |
Neuropathic pain |
Effective for neuropathic pain |
Sedation, dizziness, potential for misuse |
|
Antidepressants |
Tricyclic antidepressants (e.g., amitriptyline), SNRIs |
Neuropathic pain, comorbid depression |
Effective for chronic pain and depression |
Side effects, potential for drug interactions |
|
Physiotherapy |
Physical therapy, abdominal muscle exercises |
Adjunctive therapy for chronic pain |
Improves muscle strength, reduces pain |
Requires patient motivation and participation |
|
Psychological support |
Counseling, CBT |
Chronic pain with a psychological component |
Addresses emotional and psychological aspects |
Requires access to trained professionals |
|
Surgical intervention |
Neurectomy, nerve decompression |
Refractory ACNES not responding to other treatments |
Potentially curative for severe cases |
Invasive, potential surgical risks |
|
Acupuncture |
Traditional Chinese medicine technique |
Adjunctive therapy for pain management |
Minimal side effects, complementary approach |
Variable efficacy, requires multiple sessions |
|
Condition |
Key features |
Diagnostic tests |
|
ACNES |
Sharp, localized abdominal pain, positive Carnett’s sign, pain not associated with visceral symptoms |
Positive Carnett’s sign, diagnostic nerve block |
|
Cancer-related pain |
Persistent, progressive pain localized to a tumor site, possible palpable mass |
Imaging (CT, MRI), biopsy |
|
Opioid-induced constipation |
Abdominal distension, reduced bowel movements, discomfort, bloating |
Clinical diagnosis, abdominal X-ray |
|
Malignant bowel obstruction |
Colicky abdominal pain, vomiting, constipation, abdominal distension |
Abdominal X-ray, CT scan |
|
Peritoneal carcinomatosis |
Diffuse abdominal pain, ascites, history of abdominal malignancy |
Ultrasound, CT scan, paracentesis |
|
Chronic pancreatitis |
Persistent epigastric pain radiating to the back, weight loss, steatorrhea |
Serum amylase/lipase, abdominal CT or MRI |
|
Mesenteric ischemia |
Severe, sudden abdominal pain, risk factors like atrial fibrillation, heart failure |
CT angiography, mesenteric Doppler ultrasound |
|
Hepatomegaly/liver metastases |
Right upper quadrant pain, jaundice, weight loss, anorexia |
Liver function tests, abdominal ultrasound, CT |
|
Ascites |
Abdominal distension, shifting dullness, fluid wave, underlying liver disease or malignancy |
Ultrasound, paracentesis |
|
Peptic ulcer disease |
Epigastric pain, possible GI bleeding, nausea, melena |
Endoscopy, Helicobacter pylori, testing |
|
GERD |
Burning epigastric pain, and acid regurgitation, exacerbated by lying down |
Clinical diagnosis, endoscopy |
|
Infectious colitis |
Diarrhea, abdominal pain, fever, immunocompromised status |
Stool culture, colonoscopy |
|
Opioid withdrawal |
Abdominal cramping, agitation, sweating, nausea, diarrhea |
Clinical diagnosis, patient history |
This case serves as a reminder of the critical need for healthcare providers to consider conditions like ACNES in the differential diagnosis of chronic abdominal pain [10]. It also emphasizes the importance of educating patients about their conditions and the proper use of medications. By doing so, one can prevent the pitfalls of misdiagnosis and inadequate pain management, thereby enhancing patient outcomes and quality of life.
Managing ACNES in palliative care requires a holistic approach, integrating targeted interventions with patient education. By addressing the unique challenges of chronic abdominal wall pain, one can optimize outcomes and enhance the quality of life for patients in palliative care settings [11].
Article information and declaration
Data availability statement
The data that support the findings of this study are available from the corresponding author, Dr. Devina Juneja, upon reasonable request.
Acknowledgments
The author duly acknowledges the Department of Oncoanaesthesia and Palliative Medicine faculty, All India Institute of Medical Sciences, New Delhi.
Author contributions
Data collection, writing: original draft preparation — DJ; writing: review and editing — SV; supervision — SM, SB.
Conflict of interest
The author declares no conflict of interest.
Ethics statement
The authors certify that they have obtained all appropriate patient consent forms. In these forms, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity.
Funding
None.
Supplementary material
None.
