Letters 429

LETTERS TOTHE EDITOR

Painful rib syndrome

EDITOR,-The painful rib syndrome recentlydescribed by Scott and Scott is, in my opinion,a misnomer. Over the years I have seennumerous cases similar to the ones they report,and have found that the tender spots theyallude to are not in the ribs but in the muscles.They are, in fact, myofascial trigger points.Pain develops because of trauma inducedactivation ofnociceptors at these sites in what isnow called the myofascial pain syndrome.'These trigger points may be found in anymiuscle in the body. In the abdomen theycommonly occur in the rectus abdominis andexternal oblique muscles. They do not onlydevelop, however, at or near to their insertioninto the ribs, but also in their bellies and atlower attachment sites such as the iliac crest,inguinal ligament, and pubic bones.The pain emanating from trigger points in

this syndrome may be abolished by injecting alocal anaesthetic into them.2 Recently it hasbeen shown that pain is also relieved bystimulating A-delta nerve fibres at these siteswith dry needles; treatment that is physio-logically more rational besides being simpler,safer, and equally effective.3

Gastroenterologists must learn to recognise'trigger point pain' because it is common andcan be treated. The concept of the painful ribsyndrome restricts the diagnosis to pain in thelower thorax and upper abdomen, as well asimplying that there is no effective treatmentother than reassurance. Trigger point painmay occur anywhere in the abdomen withadditional sites in the perineum and back. Thepain can be recognised easily so unnecessaryinvestigations and operations are avoided. Itusually responds quickly to acupuncture;further courses can be given if relapse occurs.

N H DYERWorcester Royal Infirmary,

Ronkswood Branch,Worcester WR5 IHN

1 Simons D. Muscular pain syndromes. In: FrictonJR, Awad E, eds. Advances in pain research andtherapy. New York: Raven Press, 1990: 1-41.

2 Fricton JR. Management of myofascial painsyndromes. Ibid 325-46.

3 Baldry PE. Acupuncture, trigger points andmusculoskeletal pain. 2nd ed. Edinburgh:Churchill Livingstone, 1993.

EDITOR,- Scott and Scott review what they callthe painful rib syndrome (Gut 1993; 34:1006-8), consisting of three features: pain inthe lower chest or upper abdomen, a tenderspot on the costal margins, and reproduction ofthe pain on pressing the tender spot. In thediscussion, it is stated that the cause of thissyndrome is not known.

It is perhaps helpful to look at history. Theregion at or below the cartilaginous parts of theribs is also known as the hypochondrium fromGreek hypo=below and chondros=cartilage.It was Galen from Pergamon (living AD 129-199) who first described a syndrome at thislocation consisting of pain in the region belowthe ribs, bloating, and anxiety. He coined

the term hypochondriacum flatulentumquemorbum. 2

In Graeco-Roman times, hypochondria wasconsidered a part of melancholia - what wetoday call depression. Today, the meaning ofthe word hypochondria has changed. In theeighteenth century, hypochondria still had theantique denotation.2 As hypochondria was (oris?) particularly common in England, it hasbeen described as the English malady.3 I wouldlike to suggest that Scott and Scott will find theaetiology of their syndrome when they obtain amedical history looking for signs of depression.

G E FEURLEStadtkrankenhaus Neuwied,

56564 Neuwied,Germany

1 Claudii Galeni. Opera omnia. Kuhn G, ed. Lpz.1821-33.

2 Fischer-Homberger E. Hypochondnre. Bern:Huber, 1970.

3 Cheyne G. The English malady: or, a treatise ofnervous diseases of all kinds, as spleen, vapours,lowness of spirits, hypochondriacal, and hystericaldistempers, etc. London/Dublin: 1733.

Reply

EDITOR,-It is encouraging that others readilyrecognise the syndrome we described. It is alsointeresting that Dr Dyer sees this as part of awider syndrome and it behoves all clinicians tokeep this in mind when confronted withpatients who have pain that does not readily fitother well defined categories. At the least itmay prevent unnecessary investigations, and itmay even lead to effective treatment. Our studydid not look into the aetiology and Dr Dyer'sconcept of myofascial trigger points isplausible. Although reassurance and explana-tion is probably sufficient for most patients,some remain troubled and for them acupunc-ture is possibly appropriate. We agree withProfessor Feurle that depression possibly playsa part in this syndrome, but doubt that it is animportant part. Clinical depression was not aprominent feature among our patients at thetime of examination although 28% gave ahistory of either depression or anxiety.

E M SCOTTB B SCOTT

County Hospital,Lincoln LN2SQY

Colonoscopic surveillance in ulcerativecolitis

EDITOR,-We read with interest the article byLynch et al (Gut 1993; 34: 1075-80), and agreethat the problem of defining those patients atrisk of developing colorectal cancer poses greatlogistical problems. Yearly surveillancecolonoscopy did not detect most of the cancersin patients with colitis, but this was becausenearly all patients in whom cancer eventuallyoccurred fell outside their surveillance pro-gramme. Only three of nine patients whodeveloped colon cancer had their disease ini-tially assessed by colonoscopy, and a furthertwo patients had total colitis diagnosed bybarium enema. We would suggest that ideallyall patients with an initial diagnosis of colitisshould have the extent of their disease assessedcolonoscopically, thereby better defining thosepatients deemed to be at higher risk of develop-ing cancer.

It is obviously true that colonoscopy will notprevent cancer from developing in the colitic

colon' because of the imperfect link betweendysplasia and cancer, and because of the lowproportion of the surface area of the colonbiopsied during surveillance colonoscopy. Wewould therefore propose that surveillancecolonoscopy should not be the only follow upthat colitic patients receive. It is artificial toseparate colonoscopic surveillance from properclinical care of a patient with a condition thatrelapses and remits, and during which medicaltreatment may have to be changed. In thelargest prospective study of follow up ofpatients with colitis, 13 of 17 cancer patients inthe surveillance programme had a Dukes's A/Bcancer, suggesting that this group of patientswill have a better outlook than those patientspresenting symptomatically.2 The finding ofdysplasia in 22 patients treated by colectomywould possibly have prevented at least sevencancers.2 A recent study has also concludedthat an aggressive policy of colorectal cancerprevention had a much higher incidence ofearly tumours compared with a non-preventiongroup, which translated into a survival advan-tage at five years that was statistically signifi-cant.'We feel that Lynch et al have been too

pessimistic in their article on the value offollowup of colitis patients. Colonoscopy performedevery two years from the 10th year afterdiagnosis is clearly feasible, requiring 12colonoscopies per 100 000 population.' Allauthors agree that the risk of developingcolorectal cancer increases with duration andextent of disease.5 In addition, young age ofonset of colitis is also associated with increasedrisk,6 although other studies suggest that olderage of onset of colitis may be associated with ashorter interval to development of cancer.7 Wedo agree, however, that the strategy for followup of patients with colitis deemed to be at highrisk of developing colorectal cancer needsfurther thought and study. In the meantime,surveillance of high risk patients from the 10thyear after onset of colitis seems a sensibleapproach.

Z RAYTERR J LEICESTER

Department ofSurgery,St3James' Wing,

St George's Hospital,London SWI 7

1 Catnach SM, Rutter KRP, Bown RL. Colorectalcarcinoma in patients with ulcerative colitis andrecent colonscopy. Gut 1993; 34: 1148-9.

2 Lennard-Jones JE, Melville DM, Morson BC,Ritchie JK, Williams CB. Precancer and cancerin extensive ulcerative colitis: findings among401 patients over 22 years. Gut 1990; 31: 800-6.

3 Giardiello FM, Gurbuz AK, Bayless TM, YardleyJH. Colorectal cancer (CRC) in ulcerative colitis(UC): effect of a cancer prevention strategy onsurvival. Gastroenterology 1993; 104 (suppl):A705.

4 Jones HW, Grogono J, Hoare AM. Surveillance inulcerative colitis: burdens and benefit. Gut 1988;29: 325-31.

5 Sugita A, Sachar DB, Bodian C,Ribeiro MB,AufsesJr AH, Greenstein AJ. Colorectal cancer inulcerative colitis. Influence of anatomical extentand age at onset on colitis-cancer interval. Gut1991;32: 167-9.

6 Ekbom A, Halmick C, Zack M, Adami H-O.Ulcerative colitis and colorectal cancer. N EnglJ7Med 1990; 323: 1228-33.

7 Gyde SN, Prior P, Allan RN, Stevens A, JewellDP, Truelove SG, et al. A cohort study ofprimary referrals from three centres. Gut 1988;29: 206-17.

Reply

EDITOR,-Thank you for the opportunity ofreplying to Messrs Rayter and Leicester'sletter. We agree with much they say. In ourpaper we advocated longterm clinical follow