Referred Trophic Changes

Referred pain with hyperalgesia is frequently accompanied by changes in trophism of the deep layers of the body wall, namely an increased thickness of the subcutis and a decreased thickness of the muscle (tendency to muscle atrophy) (2,10). These changes are easily detectable clinically by pinch palpation. Instrumental quantification via ultrasounds has also been performed. In symptomatic urinary and biliary calculosis, as well as in symptomatic gallbladder shape abnormality, in fact, subcutis thickness was found to be significantly higher and muscle thickness significantly lower on the side ipsilateral to the affected organ than on the contralateral side (Fig. 2).

No changes were observed, in contrast, in patients with asymptomatic gallbladder, urinary stones, or asymptomatic gallbladder shape abnormality (9,19). Thus, similarly to the hyperalgesia, also the referred trophic changes from viscera appear only in the case of painful visceral conditions. It has recently been shown, however, that while the hyperalgesia tends to decrease with the progressive fading of the painful manifestations from the visceral focus (though remaining still significant), the trophic changes do not. Patients with symptomatic gallbladder calculosis presenting both hyperalgesia and trophic changes in the cystic point area in basal conditions were reevaluated after a period of six months, during which a subgroup of them had not complained of further colics while another subgroup had continued to present with colics. In the symptomatic subgroup, the hyperalgesia was accentuated while in the asymptomatic subgroup it was diminished; in contrast, trophic changes remained unaltered in both (19). Thus, while referred hyperalgesia appears strictly modulated by the algogenic input from the viscera, the referred trophic changes would rather seem an on-off phenomenon.

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