Case of the month #12: Visceral Pain

Published: 01/02/2022


A full medical history revealed that the patient was on life long Warfarin having had two unprovoked episodes of deep vein thrombosis in the past. She was therefore wary of trying any medications for fear of upsetting her warfarin control, but through her GP had tried Paracetamol, Nortriptyline and Gabapentin. None had helped and she had sensibly discontinued them.  

She described having occasional episodes of low lumbar back pain, which sounded very much mechanical in nature. These were short lasting generally easing after a few days. As mentioned above, she was slim and generally tried to keep active.  

She admitted that her mood was starting to suffer as a result of the constant pain as well as the altered body shape. She also suffered from anxiety in particular in relation to concern that she may one day end up with a pulmonary embolus.

On examination, she had a markedly distended abdomen with no specific area of allodynia. Percussion did not suggest any presence of ascites and she was tender only on deep palpation of the left iliac fossa with no masses palpable. She could sit up and come off the examining couch without assistance.

Measurement tools used on the first day included:
1.    A verbal rating scale – she rated her back ground abdominal pain as 5 out of 10 with the sharp stabbing pains as 10 out of 10
2.    Hospital Anxiety Depression scale score her in the high range for both anxiety and depression.
3.    Pain Catastrophising Scale, she scored moderately high.