Pathophysiology

The diagnosis of cancer should be considered when evaluating presumably "chronic" disorders. This topic is the subject of an entire chapter in this text, so only brief mention will be given here, but cancer-related pain is illustrative of all other visceral pains.

Neoplasms can arise in all visceral structures and dull constant pain is often an early symptom. Some neoplasms occur more commonly in the presence of recurrent inflammatory processes such as chronic pancreatitis and ulcerative colitis, so establishment of a "benign" diagnosis does not preclude development of a malignant process [1]. Pain can be induced by stimulation of abdominal viscera in three ways: chemical stimulation that occurs secondary to local inflammatory or tissue-damaging processes; chemical stimulation that occurs secondary to ischemia; or high-intensity mechanical stimulation that is secondary to compres-sive/obstructive processes (which may be modified by inflammation or ischemia). Cancer can obviously be the etiology of all three of these types of stimuli. It can infiltrate a primary viscus or extend into a neighboring organ. It can cause bowel obstruction with secondary distension. There can be liver metastases that produce capsular or diaphragmatic irritation, portal vascular distension, ascites, and obstruction of the biliary tree. There can be ischemia and necrosis of viscera due to mesenteric vessel involvement. Extension of the disease process into retroperitoneal, parietal peritoneal, abdominal wall or bony structures can produce non-visceral pain that is equal to or greater than that due to the visceral process. In addition, neuropathic pain can result from lumbosacral plexus invasion or spinal cord compression. Sequelae of antineoplastic treatments can outlive the primary process in the form of postoperative pain syndromes, stent-related complications, and chemotherapy- or radiation therapy-induced neuropathies. Cancer serves as an "all-of-the-above" answer for possible pain mechanisms and so requires due consideration.

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