Chronic abdominal pain is a common clinical problem that originates from abdominal wall are frequently misdiagnosed and treated as suffering from visceral pain.

CARNETT’S TEST
Carnett’s test is a simple clinical test in which abdominal tenderness is evaluated while the patient tenses the abdominal muscles.
It is useful for differentiating abdominal wall pain from intra-abdominal pain.
When pain arises from an intra abdominal source, the tensed muscles in the abdominal wall guard the underlying bowel, thus reducing the discomfort (negative test). However, when the pain arises from the abdominal wall, the muscle contraction will accentuate the pain (positive test).

CLINICAL FEATURES
Chronic abdominal pain may initially be sharp, followed by a dull persistent ache. It may range from mild to excruciating, continuous to intermittent, with complete remissions lasting for months or years. Radiation may be widespread, sometimes extending posteriorly over the dermatome.

An important diagnostic clue is that pain may be so sharply localized that the patient indicates that a fingertip can entirely cover the area. This almost always indicates that the pain originates in the abdominal wall; visceral pain cannot be so precisel localized.

ROLE OF INJECTION OF LOCAL ANAESTHETIC IN DIAGNOSIS
Substantial pain relief after an accurately placed anterior cutaneous nerve block or trigger point anesthetic injection is considered confirmatory.

MANAGEMENT
INJECTION OF LOCAL ANAESTHETIC AND STEROID Local nerve blocks or myofascial trigger point anesthetic/ corticosteroid injections may be needed for pain that intrudes on the patient’ s quality of life. In a large majority of these patients the pain alleviation by the injections frequently lasts for prolonged periods, sometimes permanently. Anesthetics are thought to “ break” a chronic pain cycle, but the reasons for long term relief are unclear. Frequently corticosteroids are used in conjunction with the local anesthetic because they seem to enhance the anesthetic effect, perhaps by “ membrane stabilization.” They also have been found to reduce ectopic discharges from experimental neuromas.

ULTRASOUND GUIDED ABDOMINAL CUTANEOUS NERVE BLOCK
Ultrasound can reliably be used for infiltration of the abdominal cutaneous nerves. This will improve the safety as well as diagnostic utility of the procedure.

PULSED RADIOFREQUENCY LESIONING OF ABDOMINAL CUTANEOUS NERVE
Pulsed radiofrequency treatment can be applied to the abdominal cutaneous nerves for patients who get a positive response to local anaesthetic blocks. Pulsed radiofrequency can provide sustained pain relief in patients with chronic abdominal wall pain or abdominal cutaneous nerve entrapment syndrome (ACNES).