Author: Dr Paul Rolfe
A 47-year-old accountant was referred for pain management by his gastroenterologist following normal investigations for upper abdominal pain. He initially presented with an insidious onset of neuropathic pain in his abdomen over a four period. This later progressed to involve his chest, back and lower abdomen. He described the pain as sharp and prickly. This prevented him from sleeping on his front. He was intolerant of tight clothes and his duvet at night. The distribution of was pain is symmetrical. He had lost 2 stone in weight but otherwise had no other symptoms. Bowel and bladder function was normal.
A gastroscopy, colonoscopy and CT scan of his abdomen was entirely reassuring. His full blood count, liver function, bone profile, urea, electrolytes, vitamin D, thyroid function and inflammatory markers were all normal. He had taken insulin since his type 1 diabetes had been diagnosed when he was 10. He described recent difficulty controlling his blood sugar, which was sometimes over 10mmol/L. He also took metformin but no other medications. He had no allergies.
His GP had suggested a trial of amitriptyline 10mg in the evening but unfortunately, he could not concentrate at work and discontinued it. Paracetamol, ibuprofen and codeine were ineffective.
On examination he walked with a normal gait. He was of average build. There were no skin lesions on the abdomen or thorax. There was a symmetrical band of allodynia extending from T4 to 10 bilaterally. The abdomen was soft with no organomegaly. Neurological examination of the upper limbs was normal. His cranial nerves were intact. Tone, power and sensory examination was normal in the lower limbs. Knee reflexes were normal. Ankle reflexes were absent. There were no nerve root tension signs.
Before continuing, consider the following questions:
- Is there any other information you would like to know?
- What are the potential differential diagnoses?
- Are there further investigations that would be helpful?
- Would this patient benefit from evaluation by another speciality?