What is the treatment for abdominal pain suspected to be ulcerative colitis?

Treatment of Abdominal Pain in Suspected Ulcerative Colitis

For abdominal pain suspected to be from ulcerative colitis, first-line treatment should be a combination of topical mesalazine 1g daily with oral mesalazine 2-4g daily, as this combination therapy is more effective than either treatment alone. 1

Initial Assessment and Treatment Approach

Disease Localization and Severity

• Proctitis (limited to rectum):

  • Mesalazine 1g suppositories once daily (preferred) 1
  • Alternative: Mesalazine foam or enemas 1

• Left-sided colitis:

  • Combination therapy: Topical mesalazine + oral mesalazine 2-4g daily 1
  • Topical formulation should match disease extent (suppositories for rectosigmoid, foam/liquid enemas for more proximal disease) 1

• Extensive colitis:

  • Oral mesalazine 2-4g daily plus topical therapy 1

For Moderate to Severe Disease

If mild-moderate therapy fails or if presenting with moderate-severe symptoms:

1. Oral prednisolone 40mg daily 1
2. Taper gradually over 8 weeks to avoid early relapse 1
3. Continue topical agents as adjunctive therapy 1

For Severe Disease Requiring Hospitalization

• Intravenous steroids: hydrocortisone 400mg/day or methylprednisolone 60mg/day 1, 2
• Subcutaneous heparin for thromboembolism prophylaxis 1, 2
• IV fluid and electrolyte replacement (potassium supplementation of at least 60 mmol/day) 1
• Consider concomitant IV metronidazole if infection cannot be ruled out 1

Pain Management Considerations

• Identify and treat the underlying cause of pain (inflammation, strictures, fissures) 1
• For non-specific pain relief, consider medications with less effect on gut motility 1
• Avoid opioids when possible due to risks of dependence, infection, narcotic bowel syndrome, and gut dysmotility 1
• Consider tricyclic antidepressants as adjuvant analgesics for chronic pain 1

Treatment for Refractory Disease

If failing conventional therapy with oral corticosteroids combined with oral and rectal 5-ASA:

1. Consider hospitalization for IV steroid therapy 1
2. For steroid-dependent disease, consider:
   • Thiopurines (azathioprine) 1
   • Anti-TNF therapy (infliximab) - preferably combined with thiopurines 1, 3
   • Vedolizumab 1
   • Methotrexate 1

Common Pitfalls to Avoid

• Delaying treatment: Don't wait for stool microbiology results before starting corticosteroids in acute presentations 2
• Overlooking proximal constipation: Consider abdominal X-ray to diagnose proximal constipation, which can affect drug delivery in distal colitis 1
• Neglecting maintenance therapy: Lifelong maintenance therapy is generally recommended to prevent relapse and reduce colorectal cancer risk 1, 2
• Failing to consider surgical options: Surgery should be considered for patients with refractory disease 1
• Missing extraintestinal manifestations: Up to 27% of UC patients have extraintestinal manifestations that may contribute to pain 4

Long-term Management

• After achieving remission, continue appropriate maintenance therapy 5
• Regular surveillance colonoscopies to monitor disease and screen for dysplasia/cancer 4
• Consider joint medical and surgical management for severe cases 2

By following this treatment algorithm and avoiding common pitfalls, abdominal pain from suspected ulcerative colitis can be effectively managed to improve quality of life, achieve steroid-free remission, and minimize long-term complications.