THE RED SECTION 645
A Stick and a Burn: Our Approach to
Abdominal Wall Pain
Manish Singla, MD, FACG1,2 and Jeffrey T. Laczek, MD, FACG1,2
Am J Gastroenterol 2020;115:645–647. https://doi.org/10.14309/ajg.0000000000000533; published online February 18, 2020
SCOPE OF THE PROBLEM
Abdominal wall pain is a common condition in gastroenter-
ology clinics that frustrates both patients and providers. Up to
30% of patients with chronic abdominal pain have components
of abdominal wall pain (1). The prevalence of abdominal wall
pain may be higher in patients with persistent right upper
quadrant pain after cholecystectomy (2). Abdominal wall pain
has a 4:1 female preponderance and commonly affects patients
in their fifth to sixth decades of life (3). Predisposing con-
ditions include obesity, previous abdominal surgery, preg-
nancy, and sports-related injuries (4). The right upper
quadrant is the most common location of pain, but patients
may report pain in the epigastrium or in multiple locations.
Comorbid conditions include depression, irritable bowel
syndrome, gastroesophageal reflux disease, and chronic low
back pain (1).
CLINICAL SUSPICION
Given the frequency of abdominal pain as a presenting symptom
in our outpatient clinic, we have a high index of suspicion in
anyone who comes to our clinic with abdominal pain. Patients
may have coincident conditions such as irritable bowel syndrome,
elevated liver enzymes, and inflammatory bowel disease, all of
which can present with abdominal pain. The evaluation of ab-
dominal wall pain begins with the patient’s history: does motion
(getting out of bed, standing up from a seat, lifting a baby) ex-
acerbate the pain? Did something acute occur at the onset? Pain
can worsen with eating because the abdominal wall is a dynamic
structure. Some patients will point to a spot of focal pain with
their fingers on their abdomens. Patients generally present with
less than a year of symptoms, but some present with many years of
the same discomfort. Consistent with existing data (5), many of
these patients have already had computed tomography scans,
endoscopies, and extensive serum evaluations that could be
avoided with a thorough examination. We also find that patients
can have abdominal wall pain at the location of surgical scars,
regardless of proximity to the surgery.
The examination for abdominal wall pain is simple: evaluate
for a positive Carnett sign (Figure 1). In our practice, we ask
patients to use just 1 finger and point to the fingerbreadth’s area of
maximal tenderness in their abdomen. We firmly palpate there
while the patient has a relaxed abdomen and then ask the patient
to flex their abdomen during palpation. Often this can be done by
1
Gastroenterology Service, Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA; 2Department of Medicine,
Uniformed Services University, Bethesda, Maryland. Correspondence: Manish Singla, MD, FACG. E-mail: manishsingla@gmail.com.
Received November 27, 2019; accepted January 2, 2020
© 2020 by The American College of Gastroenterology
Copyright © 2020 by The American College of Gastroenterology. Unauthorized reproduction of this article is prohibited.
HOW I APPROACH IT
asking the patient to do a sit-up with their knees flexed, but in
patients who cannot do this, asking the patient to flex forward
their neck or lift their leg can achieve the same result. A positive
Carnett sign occurs when the point tenderness worsens with
abdominal flexion.
The differential diagnosis for patients with a positive Carnett
sign without a hernia includes nerve entrapment syndrome and
myofascial trigger point pain, both of which are consistent with
abdominal wall pain. Red flag symptoms such as anemia, elevated
inflammatory markers, or weight loss should be further in-
vestigated for other causes.
MANAGEMENT
A trigger point injection using a local anesthetic, such as lido-
caine, can be used as a confirmatory and therapeutic test for
abdominal wall pain. Greater than 50% relief of pain after in-
jection of a local anesthetic at the point of maximal tenderness
supports a diagnosis of abdominal wall pain (6). Given that a di-
agnostic lidocaine injection often led to recurrent pain, we rec-
ommend an injection combining lidocaine and triamcinolone as
the initial treatment for a patient with a positive Carnett sign.
Before injection, we counsel patients that the corticosteroid may
cause hypopigmentation or thinning of the subcutaneous tissue,
and during the procedure, they may experience the sensations of
“a stick and a burn.” There is a small risk of infection, given the
need for an injection. At Walter Reed, we use the 5-point tech-
nique described below.
Instructions for abdominal wall injection (5 point technique,
Figure 2)
1. Mix 4 mL of 1% lidocaine with 40 mg (1 mL) of triamcinolone
in a 5 mL syringe. Attach to a narrow-caliber (21 gauge or less)
5/80 or 10 needle.
2. Mark the site of the patient’s pain on the abdominal wall and
prep with chlorhexidine.
3. Insert the needle perpendicular to the patient’s abdomen at the
marked site with the goal to reach the rectus abdominis
muscle; this normally requires the full length of the needle. We
warn patients that they may feel a “stick” or a “sting” sensation.
4. Once the tip of the needle is at the point of maximal
tenderness, inject 1 mL of the mixture. Before injection, warn
patients that they may feel a “burning” sensation.
The American Journal of GASTROENTEROLOGY
 646
HOW I APPROACH IT THE RED SECTION

Figure 1. Proper placement of injection.

5. Withdraw the needle from the skin, redirect upward at a 45°

angle, and reinsert the needle to a maximal depth; inject an
additional 1 mL of mixture.
6. Repeat step 5 with the needle directed to the left, downward,
and right, each at a 45° angle, and then remove the needle while
applying pressure with sterile gauze.
7. Gently massage the injection site and apply a bandage if
needed for hemostasis.

We do not repeat a corticosteroid injection sooner than 3

months to reduce the risk of thinning the connective tissue in the
region of the injection. We use 5/8” needles in patients with lower
body mass indices and when performing injections in the upper
abdomen. In the lower abdomen (where patients have a thicker
layer of subcutaneous adipose tissue) or in patients with higher
body mass indices, we choose 1” needles. We do not use ultra-
sound guidance for injection; to our knowledge, no studies have
shown that ultrasound improved outcomes with trigger point
injection.
In patients with abdominal wall pain who fail to respond or
incompletely respond to a trigger point injection, we recom-
mend a daily nonsteroidal anti-inflammatory drug, such as
meloxicam 15 mg once daily. If this is ineffective or if the patient
does not want to take a daily oral medication, we recommend
application of lidocaine patches, topical diclofenac, or capsaicin
cream, although our success with these medications has been
limited.
Figure 2. Carnett’s sign. Palpate the area of maximum tenderness; if the
pain worsens with flexion of the abdominal wall, the exam is consistent with
REIMBURSEMENT abdominal wall pain.
Successful injection of local anesthetic after a positive Carnett
sign “must be one of the most cost-effective procedures in gas- injections under the 2019 International Classification of Dis-
troenterology” (6). Review your local payer policies before using eases, Tenth Revision, Clinical Modification Diagnosis Code
this coding guidance. We code abdominal wall trigger point M79.1 (Myalgia) using the current procedural terminology code

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Copyright © 2020 by The American College of Gastroenterology. Unauthorized reproduction of this article is prohibited.

20552 (injection(s); single or multiple trigger point(s), 1 or 2
muscles). You can also use code J1030 for the injectable tri-
amcinolone. These current procedural terminology codes cor-
respond to 0.66 relative value units according to the Medicare
National Fee Schedule, if your local payer uses a relative value
unit-based model.
Abdominal wall pain is common in patients presenting with
abdominal pain, and we should suspect it based on certain his-
torical features, such as localization and specific motions exacer-
bating the pain. Abdominal wall pain can be confirmed on physical
examination by searching for localized pain and a positive Carnett
sign. We use the 5 point technique, as previously mentioned, to
perform lidocaine and corticosteroid injections on patients di-
agnosed with abdominal wall pain. Proper coding can help re-
imburse providers for the treatment provided to patients with this
very common condition. With accurate diagnosis, patients can
avoid unneeded imaging and endoscopy. We hope that this guide
will help providers feel more comfortable with identifying this
condition and performing trigger point injections.
CONFLICTS OF INTEREST
Guarantor of the article: Manish Singla, MD, FACG.
© 2020 by The American College of Gastroenterology
Copyright © 2020 by The American College of Gastroenterology. Unauthorized reproduction of this article is prohibited.
THE RED SECTION 647
Specific author contributions: Both authors contributed equally to
the concept, manuscript writing, and editing.
Financial support: None to report.
HOW I APPROACH IT
Potential competing interests: None to report.
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The American Journal of GASTROENTEROLOGY