Visceral Vague Pain vs.

Parietal Somatic Localized Pain

Stimulation of hollow abdominal viscera is mediated by splanchnic afferent fibers within muscle
wall, visceral peritoneum and mesentery that are sensitive to distention and contraction. Visceral
afferent nerves are loosely organized, innervate several organs, and enter spinal cord at several
levels. Most viscera contain only few pain receptors, so a localized damage (eg. by cutting the
intestine with a knife) is almost not painful. Thus, visceral pain is vague or dull in character and
diffuse; patients attempting to localize the pain often move their entire hand over the upper,
middle, or lower abdomen. Most visceral pain is steady, but cramping, intermittent pain or
colic results from peristaltic contractions caused by partial or complete obstruction of the small
intestine, ureter, or uterine tubes. The gastrointestinal viscera (liver, biliary system, pancreas, and
GI tract) arise during embryology from midline structures that have bilateral innervations (both
left and right abdominal organs are innervated by the sensory strip fibres of both left and right
hemispheres). Thus, GI visceral pain is typically localized to the abdominal midline.
In contrast to visceral innervation, the parietal peritoneum is innervated unilaterally by a dense
network of nerve fibers that follow a spinal T6 to L1 somatic distribution. Pain fibers of the
parietal peritoneum are stimulated by stretch or distention of the abdominal cavity or
retroperitoneum; direct irritation from infection, pus, or secretions (e.g., caused by a ruptured
viscus); or inflammation caused by contact between the parietal peritoneum and an adjacent
inflamed organ (e.g., appendicitis). Parietal pain is sharp, well characterized, and localized by
the patient to a precise location on the abdomen, often by pointing with one finger.
Some viscera are pain insensitive eg. the liver tissue, lung alveoli and the visceral layers of the
peritoneum, pleura and pericardium (but the parietal layers of these membranes are very
painful).

Visceral Pain
Parietal Pain (somatic)
Vague, dull & diffuse
Severe, sharp, localized
Localized to abdominal midline, patient move Localized to precise location on abdomen,
entire hand over upper/middle/lower abdomen point with one finger
Innervated bilaterally - midline
Innervated unilaterally precise local
Abdominal viscera, visceral peritoneum, Parietal peritoneum
mesentery
Stimulated by:

Stretch/distension of hollow viscous

Visceral ischemia

Afferent nerve fibres follow sympathetic

Stimulated by:

Stretch/distension of abd cavity

Direct irritation from infection / pus /

secretion
Contact with adjacent inflamed organ
Nerve fibres follow a spinal T6 to L1 somatic

(mainly) / parasympathetic fibres course distribution

through plexus, nerve to spinal cord
Few pain receptors
Eg. Biliary colic (dull epigastric pain)

Many pain receptors?

Eg. Acute cholecystitis (Sharp RUQ pain &

Stretching / spasm of gallbladder stimulate Murphys sign)

pain afferent visceral neurons

Inflammed gallbladder comes into contact with

parietal peritoneum, stimulate pain afferent
fibres of parietal peritoneum

Character of visceral pain

Abdominal (visceral pain) can be divided into two phases. Changes in the character of
pain from one phase to another indicate a progression of disease process within the abdomen.
1. The first phase of abdominal pain is called true visceral pain. It results from the
distension of a viscus usually secondary to spasm of smooth muscle. True visceral pain is
a diffuse, vague and dull ache, generally referred to the midline patients attempting to
localize pain often move their entire hand over the upper / middle / lower abdomen. It is
not sharp or localized. This pain is not associated with muscle rigidity or voluntary
guarding of abdominal muscles.
2. The second phase of abdominal pain is called referred visceral pain (to somatic
structures ie. skin). Pain arising from an intraperitoneal viscus is referred to the
dermatome supplied by the peripheral somatic nerve entering the spinal cord at the same
level as the viscerosensory nerve fibers. This pain is due to continued stimulation of
visceral pain fibers, and subsequent involvement of both the visceral and somatic sensory

nerve pathways. As a result of crossover stimulation (transmission of impulses) between

viscerosensory fibers and the sensory fibers of the somatic nerves (at the spinal cord), the
pain is referred to the superficial area of body surface (somatic) or dermatome supplied
by the peripheral somatic nerve arising from the same segment of the cord. This pain
occurs when the irritable focus within a viscus has increased, giving rise to stronger
stimuli, and usually indicates some type of pathology within the viscus. The pain,
because of its relationship to the somatic dermatome is fairly well localized to specific
areas of the abdominal wall. This pain is usually associated with muscle guarding but not
true rigidity.
Intense visceral impulses spread into skin pain neurons to register pain from skin (crossover stimulation)

Pain referred to skin from visceral stimulus

Intensely stimulated (continued stimulation) visceral pain fibers

Referred visceral pain patterns :

Visceral Pain
Stomach, duodenum
Liver, gallbladder,
ducts
Pancreas

Dermatomes
T5-T9
bowels, T5-T9
T5-T9

Referred visceral pain

Epigastric area
R midepigastrium
Epigastrium, directly through to
the back
Paraumbilical area (T10)
Paraumbilical area

Small intestines
T10
Appendix, large intestines T10-T11
(transverse)
Afferent
sensory
fibres
from:ovary, T10-T11
Kidney,
upper
ureter,
Low epigastrium, paraumbilical,
testicle
flank
Stomach,
liver,
gallbladder,
pancreas

celiac
plexus

greater
sphlanchnic nerves thoracic
Distal colon, upper rectum
T11, T12, L1
Suprapubic
sympathetic
chain spinal
cord (T5-T9)
Uterus, fallopian
tube, ovaries
T11-L1
Suprapubic (L1)
Bladder
S2-S4
Suprapubic, tip of penis (S3)
Kidney, upper ureter, testis, ovary celiac plexus lesser splanchnic nerves thoracic sympathetic
chain spinal cord (T10-T11)
Duodenum, small intestines, proximal large bowel up till transverse colon superior mesenteric plexus
celiac plexus lesser splanchnic nerves thoracic sympathetic chain spinal cord (T10-T11)
Rectum, distal ureter, bladder dome, uterus fundus, fallopian tubes superior & inferior hypogastric
plexus first lumbar sphlancnic nerve thoracic sympathetic chain T11, T12, L1
Bladder neck, prostate, distal rectum, uterine, cervix, upper vagina inferior hypogastric plexus
parasympathetic pelvic sphlancnic nerves S2, S3, S4

Visceral afferent nerves

1. Autonomic nerves: Generally, sympathetic nerves transmit pain from the viscera lying
between the thoracic and pelvic lines, while parasympathetic nerves transmit pain from
the viscera beyond these lines.
2. Somatic nerves: Pain from gall bladder is transmitted by the phrenic nerves (when
irritating the central part of the diaphragm). Also, pain from the parietal pleura,
peritoneum and pericardium is transmitted by somatic spinal nerves (so it is sharp, welllocalized and not referred).
Causes of visceral pain
Painful stimuli, which give rise to impulses that pass along these afferent sympathetic and
parasympathetic nerves, are triggered by three mechanisms:
1. Ischemia of viscus
2. Mechanical stimuli:
a. Overdistension / stretching of hollow viscera (eg. urinary bladder). Pain in this
case is due to increase in intraluminal pressure of the hollow viscus, causing
direct stimulation of the pain receptors and ischemia that occurs due to collapse of
the vessels that encircle viscus.
b. Spasm of certain viscera (eg. the small intestine, bile ducts and ureters) in which
pain occurs by the same mechanisms of overdistension