Colic

Colic, paroxysmal pains originating from abdominal organs, having a spasmodic character and causing mostly very severe sensations of constriction and spasm. The pathogenesis of colicky pain is very complex. The old doctrine of Lennander and Mackenzie that only the parietal peritoneum possesses pain sensitivity in the abdominal cavity is now considered incorrect. The visceral peritoneum, the greater and lesser omentum, the connective tissue surrounding the pancreas and large bile ducts (Kappis), and blood vessels also possess pain sensitivity. Recent histological data have found sensitive nerve fibers in peritoneal adhesions as well. Finally, abdominal organs themselves possess independent pain sensitivity. But while pain in general can arise in the most diverse parts of the abdominal cavity, this cannot be said regarding colicky pain; the latter can arise only in the abdominal organs themselves and depending on the organ bears the name intestinal, appendicular, pancreatic, hepatic, renal. The primary irritation causing colicky pain should be considered abnormally strong and prolonged contraction, spasm of the musculature of one or another abdominal organ. Colic can also be caused by sudden swelling, distension of the organ (Ortner). This primary irritation is perceived by nerve elements located in these organs and constituting (Foerster) the first link of the "pain system," its receptor apparatus. From here this irritation is conducted along the sympathetic system, through the splanchnic nerves, solar plexus, corresponding sympathetic ganglia of the lateral columns, rami communicantes, posterior roots (perhaps also through anterior roots) (Dyi-Siv). Finally in the central gray masses (formatio reticularis, thalamus opticus, cortex cerebri), this irritation causes that neurodynamic change of their state, the psychological correlate of which is the feeling of pain (Ferster). These pain-conducting pathways make understandable that the impulse causing colic can originate not only from the organ where this colic occurs, not only reflexively from some other abdominal organ (sometimes paired, e.g., reno-renal reflex), but also from the central nervous system. Disease of one or another segment of the spinal cord (D_Yr-S_IV) of various nature (tabes, acute myelitis, hematomyelia, etc.) or processes irritating the posterior roots from the outside (spondylarthritis, spondylitis) can sometimes cause colicky pain simulating disease of one or another abdominal organ, for example: stomach, intestine, ureter, kidney, etc. For understanding the colicky symptom-complex, great importance is attached to the fact that within the spinal ganglia and posterior horns of the spinal cord in close contact are afferent sympathetic fibers going from abdominal organs and sensory fibers which come to the same place from the corresponding skin zones. Therefore colic is often accompanied by cutaneous hyperalgesia (Head's zone). For example, afferent sympathetic fibers going from the kidneys and ureters come to spinal segments D_x-Dxn, Li-L_ii, and to the same place come sensory nerves from the skin zones corresponding to these segments. Therefore in renal colic cutaneous hyperesthesia is observed in the lumbar region. Colic is often accompanied by typical radiation of pains. Since most sympathetic fibers from the testicles go to the same segments as from the kidneys, in renal colic radiation of pains to the testicles is observed, and sometimes also increased sensitivity of the latter. Colicky pain can spread not only along sympathetic nerves but also along the phrenic nerve, since a branch of the latter anastomoses with the solar plexus. Spread of pain along the phrenic nerve will occur especially when the process causing colic causes accompanying involvement of the subdiaphragmatic peritoneum. This happens in biliary colic, in which sometimes hyperalgesia in the area of the 3rd-4th, sometimes and 5th cervical dermatomes, supplied by those spinal segments into which the n. phrenicus enters, is noted. But if the process causing colic causes accompanying involvement of the parietal peritoneum, then pain can also spread along the intercostal nerves supplying the latter. Finally it is possible that pain originating from abdominal organs is also conducted along the n. vagus. Local causes causing colic can be various. Colic, for example originating from the intestines and in particular appendicular colic, is often caused by obstruction on the path of movement of contents. This obstruction can be both inside the intestines (fecal stone, tumor, scar, etc.) and from without (pressure by a tumor, pressure by an enlarged or displaced organ, peritoneal adhesion, etc.); and in both cases this obstruction can lead to strong and prolonged contraction of the intestine, and consequently colic. Besides obstruction on the path of movement of contents, any other cause which will lead to intensified and prolonged contraction of the intestine (for example lead poisoning, inflammation of the intestine itself, etc.) can cause colicky pain. Hepatic, renal, pancreatic colic can be caused by stones lying in the corresponding excretory ducts, as well as by other stenotic and inflammatory changes of the latter. Therefore in the same organs colic can also occur in the absence of stones, for example in pyelitis, acute cholecystitis, pancreatitis, etc. The course of colic is very diverse and depends mainly on the causes by which it is caused, on the organ in which it occurs, on the consequences of previous colic and individual sensitivity and peculiarities of the patient's organism. From this point of view it is necessary to note the age tendency to intestinal colic in small children. Depending on the factors just outlined colic can begin suddenly during complete health or represents an exacerbation of chronic constant pains. Colic can have the character of separate waves, of which each usually lasts not more than one minute (for example intestinal colic), or colic after sudden or gradual onset quickly reaches maximum strength, holds at this height without particular fluctuations for varying time, sometimes very briefly, and sometimes even more than a day, in order to stop suddenly or gradually (hepatic colic, renal). An attack of colic, having ceased, can very soon recur again, for example if pancreatic, biliary, etc. stones have not been expelled from the corresponding pathways as a result of the previous attack; but the attack can cease and for a long time, even for several years, sometimes even forever. Colic can be accompanied by localized pain, and this localization by no means always coincides with the normal location of the diseased organ; for example appendicular colic with a displaced appendix can be localized in the left iliac region, in the epigastric region, and in the right hypochondrium. Hepatic colic can be localized not necessarily in the right hypochondrium, but also in other places depending on displacement of the liver or gallbladder or adhesions of various organs with the latter. Colic, especially at the beginning, sometimes even all the time, can have a diffuse character, for example in intestinal obstruction, embolism or thrombosis of intestinal vessels, etc. Depending on the diseased organ, its relation to surrounding tissues and organs, the nature of the process, individual sensitivity of the patient, pain can be of the most diverse kinds, sometimes characteristic, sometimes atypical radiation. Finally colic can be accompanied by the most various general phenomena: elevation of temperature, chills, pallor, nausea, vomiting, anuria, strangury, even shock and collapse. Recognition of colic is sometimes possible already on the basis of the character of the attack, localization and radiation of pains. But even in the presence of localization and radiation of pains typical for the diseased organ, the diagnosis must be confirmed by comprehensive subjective and objective examination of the patient, all the more since establishing the diagnosis of one or another colic, for example hepatic or renal, by no means yet decides the question of the nature of the pathological process underlying it. For example one cannot on the basis of the character of colic establish whether the colic is caused by the presence of stones in an inflamed gallbladder, or acute cholecystitis, or pericholecystitis, or perhaps even periappendicitis giving an inflammatory exudate at the porta hepatis. Treatment of colic should be etiological. But the attack itself often needs symptomatic treatment, which in general amounts to rest, abstinence from food, local application of heat, sometimes injection of antispastic agents (atropine, papaverine), analgesic agents (morphine, pantopon), and sometimes also agents tonifying cardiac activity (camphor, caffeine).