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When abdominal pain is chronic and unremitting, with minimal or no relationship to eating or bowel function but often a relationship to posture (i.e., lying, sitting, standing), the abdominal wall should be suspected as the source of pain. Frequently, a localized, tender trigger point can be identified, although the pain may radiate over a diffuse area of the abdomen. If tenderness is unchanged or increased when abdominal muscles are tensed (positive Carnett's sign), the abdominal wall is the likely origin of pain. Most commonly, abdominal wall pain is related to cutaneous nerve root irritation or myofascial irritation. The pain can also result from structural conditions, such as localized endometriosis or rectus sheath hematoma, or from incisional or other abdominal wall hernias. If hernia or structural disease is excluded, injection of a local anesthetic with or without a corticosteroid into the pain trigger point can be diagnostic and therapeutic. (Am Fam Physician 2001;64:431-8.)
The abdominal wall as a source of pain has received little attention, and only a few reviews on the topic have been published in the past decade.',2 However, physicians who consider abdominal wall pain in their patients often find it. In fact, overlooking the abdominal wall as a source of pain can result in a prolonged, expensive, frustrating and dangerous evaluation.
Evaluation
In patients with acute or chronic abdominal pain, a number of clinical findings point to disease inside the abdomen (TabLe 1). When such findings are absent, consideration should be given to the abdominal wall as the source of pain.
In chronic abdominal pain, the abdominal wall often can be implicated based on the findings of the history and physical examination. This is especially true if the pain is not progressive and if no evidence of visceral disease is present.
Certain features may point to a pain source in the abdominal wall (Table 2). Unlike pain that originates in the digestive tract, pain from the abdominal wall is not made better or worse with food and is not altered by bowel movements. Furthermore, abdominal wall pain is often chronic, nagging and nonprogressive. An algorithm for the diagnosis and management of abdominal wall pain is provided in Figure 1.2
Tenderness originating from inside the abdominal cavity usually decreases when a supine...