Anterior cutaneous nerve entrapment syndrome with pain present only during Carnett’s sign testing: a case report

BMC Research Notes, Oct 2017

Background The identification of anterior cutaneous nerve entrapment syndrome is often challenging, due to no widely accepted standard guidelines regarding laboratory and imaging tests for the diagnosis of ACNES. Case presentation A 77-year-old Japanese man presented with mild lower abdominal pain that had been present for the past 3 years. Physical examination revealed no abdominal pain during palpation, with normal laboratory and imaging testing; therefore, conservative therapy was initiated. However, the abdominal pain continued. Re-examination 16 days later revealed three tender points in accordance with intercostal nerves Th10, Th11, and Th12, with the pain occurring only during Carnett’s sign testing. A cutaneous injection of 1% lidocaine was administered, and the abdominal pain was resolved about 30 min later. Based on these results, anterior cutaneous nerve entrapment syndrome was diagnosed. Conclusions It is sometimes hard to diagnose anterior cutaneous nerve entrapment syndrome without testing for Carnett’s sign. If patients present with chronic abdominal pain, clinicians should test for Carnett’s sign even if no pain is elicited during regular abdominal palpation.

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Anterior cutaneous nerve entrapment syndrome with pain present only during Carnett’s sign testing: a case report

Tanizaki and Takemura BMC Res Notes Anterior cutaneous nerve entrapment syndrome with pain present only during Carnett's sign testing: a case report Ryutaro Tanizaki 0 2 Yousuke Takemura 0 1 0 Department of Community Medicine, Nabari, Mie University Graduate School of Medicine , Tsu, Mie , Japan 1 Department of Family Medicine, Mie University School of Medicine and Graduate School of Medicine , Tsu, Mie , Japan 2 General Medicine, Nabari City Hospital , Nabari, Mie , Japan Background: The identification of anterior cutaneous nerve entrapment syndrome is often challenging, due to no widely accepted standard guidelines regarding laboratory and imaging tests for the diagnosis of ACNES. Case presentation: A 77-year-old Japanese man presented with mild lower abdominal pain that had been present for the past 3 years. Physical examination revealed no abdominal pain during palpation, with normal laboratory and imaging testing; therefore, conservative therapy was initiated. However, the abdominal pain continued. Re-examination 16 days later revealed three tender points in accordance with intercostal nerves Th10, Th11, and Th12, with the pain occurring only during Carnett's sign testing. A cutaneous injection of 1% lidocaine was administered, and the abdominal pain was resolved about 30 min later. Based on these results, anterior cutaneous nerve entrapment syndrome was diagnosed. Conclusions: It is sometimes hard to diagnose anterior cutaneous nerve entrapment syndrome without testing for Carnett's sign. If patients present with chronic abdominal pain, clinicians should test for Carnett's sign even if no pain is elicited during regular abdominal palpation. ACNES; Carnett's sign; Lidocaine; Abdominal wall pain; Physical examination Background Anterior cutaneous nerve entrapment syndrome (ACNES) is a condition in which chronic or intermittent abdominal wall pain is caused by irritation of the cutaneous nerve roots passing through the abdominal fascia [ 1 ]. The incidence of ACNES is still unclear, and may account for 10–30% of patients with chronic abdominal pain in gastroenterological practice [ 2, 3 ] and 2% of patients presenting with acute abdominal pain in the emergency department [4]. When ACNES is suspected, cutaneous injection of an anesthetic agent into the painful area is used for both diagnosis and treatment [ 5 ]; if pain continues after anesthetic injection, surgery might be required [ 6, 7 ]. Carnett’s sign is a clinical examination finding that is useful for confirming whether pain originates from the abdominal viscera or from the abdominal wall. During testing for Carnett’s sign, the investigator identifies the point of maximal abdominal pain by deeply palpating with a finger; the patient is then asked to tense the abdominal muscles while the fingertip is released, followed again by deep palpation. If both stages of the test are painful, the source of the pain is the abdominal wall. In contrast, pain originating from the abdominal organs is associated with just a painful first stage [8]. Although Carnett’s sign is considered useful for diagnosing ACNES [ 9 ], identification of ACNES is often challenging due to poor recognition and a lack of widely accepted standard guidelines regarding laboratory and imaging tests for the diagnosis of ACNES. Furthermore, as the degree of pain can vary from mild to severe, if a patient presented with severe pain, ACNES might be misdiagnosed as visceral disease. Herein, we describe a case of ACNES in which the patient presented with no abdominal pain during regular palpation, but experienced abdominal pain when Carnett’s sign was examined. Case presentation A 77-year-old Japanese man presented with chronic mild lower abdominal pain for the past 3 years. The pain had occurred spontaneously and was exacerbated on an empty stomach and during feelings of stress, without any other accompanying symptoms. Despite the chronic abdominal pain, the patient was able to mountain climb as a hobby. The results of abdominal computed tomography and upper gastrointestinal endoscopy done at a local hospital were normal. Rebamipide and lansoprazole had been administered for abdominal pain by a local doctor, but the symptoms did not resolve. The patient had a past medical history of active pulmonary tuberculosis 2 years previously, and polypectomy of a colonic polyp 1  year previously. Physical examination revealed that the patient’s body temperature was 36.4  °C, blood pressure was 128/60  mmHg, pulse rate was 66  beats/min, respiratory rate was 15/min, and oxygen saturation was 95% (room air). There were no remarkable abnormalities of the head, eyes, ears, nose, mouth, chest, and extremities. There was no tenderness of the abdominal region during palpation, and swab testing, alcohol testing, and skin pinching all produced negative results. Carnett’s sign was not examined at that time. All laboratory investigations showed values within normal range. Thoracic magnetic resona (...truncated)


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Ryutaro Tanizaki, Yousuke Takemura. Anterior cutaneous nerve entrapment syndrome with pain present only during Carnett’s sign testing: a case report, BMC Research Notes, 2017, pp. 503, Volume 10, Issue 1, DOI: 10.1186/s13104-017-2816-1