Case of the month #12: Visceral Pain

Published: 01/02/2022


Empathetic listening and indeed simply going through the patient’s history in detail and explaining the rationale behind previous scans, blood tests and histology report from colon biopsies helped to start to build a rapport with the patient who had come initially to the pain clinic feeling that she had been “discarded” by the gastroenterologists and fobbed off with a diagnosis of irritable bowel syndrome (IBS)

Discussing IBS and how in some patients this condition can be more than just a nuisance helped to start the process of helping the patient start to understand and accept.  

Diverticular disease was also discussed including the difference between diverticular disease and diverticulitis.  Importance of dietary measures to manage this condition was discussed and the patient directed towards the NICE guideline’s patient information on this aspect of management. 

The impact of diabetes on the autonomic nervous system and the gut was explained.  The potential side-effects of high dose Metformin and its likelihood of compounding some of the symptoms was also discussed and it was agreed that a request would be made for a review by the primary care diabetes team to discuss alternative oral hypoglycaemic medication. 

The impact of pain and altered body image and the perceived lack of support was discussed and it was agreed that seeing a Clinical Psychologist with a view to discussing ways of managing this and also exploring potential therapy that can help with managing pain from IBS.  Hypnotherapy has been found to be effective and is indeed recommended by NICE. 

The patient was also advised to avoid any codeine-based products and to consider a trial of TENS to manage her abdominal pain.  Due to her being on warfarin, it was not advisable to consider peppermint oil as but in vitro evidence suggests that peppermint oil (which contains menthol) inhibits CYP2C9, the most important enzyme in the metabolism of warfarin.
The patient was happy to engage with the clinical psychologist and dietary measures and exploring alternative hypoglycaemic therapy.