ABSTRACT
You see a 46-year-old woman in the Emergency Department for the third time in the past month because of severe right upper quadrant pain. For two months, she has needed hydrocodone with acetaminophen every four to six hours to ‘‘take the edge off’’ the pain that interfered with sleep and her work as a high school teacher. Nonsteroidal anti-inflammatory drugs (NSAIDs) had been unhelpful. A selective serotonin reuptake inhibitor was started two weeks ago. Beginning two years ago, the pain varied from dull to sharp and from moderate to ‘‘excruciating . . . 11/10.’’ Initially, it was intermittent but has been constant for the last six months. She has not identified accentuating or alleviating factors. Except for a 15-lb weight gain over the past three years, she had been without complaints. Five months ago a laparoscopic cholecystectomy was performed. An acalculous gall bladder with ‘‘minimal mucosal inflammatory reaction’’ was removed. Earlier ultrasonic examination had suggested a ‘‘slightly thickened gall bladder wall’’ and ‘‘possible sludge.’’ Upper gastrointestinal series, hepatobiliary scan, esophagogastroduodenoscopy and, endoscopic retrograde cholangiopancreatography were normal. No cholesterol crystals were found in the duodonal aspirate after cholecystokinin stimulation. Abdominal computerized tomography showed mild hepatic steatosis and absence of the gall bladder. Numerous laboratory tests were normal. The obviously uncomfortable patient is sitting with her left hand pressed to her right upper quadrant. Her vital signs are normal. On examination you find tenderness localized to a 2-cm area in the right upper quadrant at the lateral border of the rectus abdominis, 5 cm from the nearest laparoscopy scar. With the examining finger fixed on the tender point, the pain becomes unbearable as she tenses the recti abdominis by lifting her head off the pillow-a positive Carnett sign. After two years, chronic abdominal wall pain (CAWP) has been diagnosed!
