What is the management for abdominal pain?

Management of Abdominal Pain

The management of abdominal pain should follow a structured approach based on the underlying cause, with initial focus on ruling out life-threatening conditions requiring immediate intervention. 1

Initial Assessment and Triage

• Hemodynamic stability assessment: First priority is rapid cardiopulmonary assessment to ensure hemodynamic stability 1
• Pain characteristics: Location, intensity, duration, radiation, aggravating/alleviating factors
• Associated symptoms: Fever, vomiting, diarrhea, constipation, urinary symptoms
• Red flags requiring immediate attention:
  • Hemodynamic instability (tachycardia, hypotension)
  • Peritoneal signs (rebound tenderness, guarding)
  • Large peritoneal effusion on imaging
  • Signs of sepsis or septic shock

Diagnostic Approach

Imaging

• Ultrasound: First-line imaging for most cases with moderate to severe pain with localizing findings 1
• CT with IV contrast: Preferred for trauma cases, suspected pancreatitis, or when ultrasound is inconclusive 1
• MRI: Consider in pregnant patients when ultrasound is inconclusive 1

Laboratory Tests

• White blood cell count with differential
• C-reactive protein
• Liver and pancreatic enzymes
• Urinalysis
• Pregnancy test in women of childbearing age

Management Algorithm Based on Cause

1. Inflammatory Causes

Appendicitis

• Treatment: Surgical appendectomy (laparoscopic preferred) 1
• Antibiotics: Until intervention and for 2-4 days post-intervention 1
• Alternative: Antibiotic therapy alone for uncomplicated cases in select patients

Diverticulitis

• Uncomplicated:
  • Conservative treatment without antibiotics for immunocompetent patients 1
  • Antibiotic therapy (≤7 days) for immunocompromised/elderly patients 1
• Complicated (abscess):
  • Small abscess: Antibiotics alone for 7 days 1
  • Large abscess: Percutaneous drainage plus antibiotics for 4 days 1

Cholecystitis

• Uncomplicated: Early laparoscopic cholecystectomy (within 7-10 days) 1
• Complicated: Laparoscopic cholecystectomy plus antibiotics for 4 days (immunocompetent) or up to 7 days (immunocompromised) 1
• High surgical risk: Consider cholecystostomy with antibiotics for 4 days 1

Cholangitis

• Treatment: Biliary drainage + antibiotics 1
• Duration: 4 days (immunocompetent) or up to 7 days (immunocompromised) 1

2. Traumatic Abdominal Pain

• Hemodynamically unstable with large peritoneal effusion: Immediate emergency surgery 1
• Hemodynamically stable without active bleeding: Non-operative management 1
• Ongoing intraperitoneal bleeding: Consider emergent angioembolization 1
• Laparoscopic approach: Consider in stable patients with suspected diaphragmatic or hollow viscus injury 1

3. Functional/Non-inflammatory Causes (e.g., IBS)

• First-line: Education, reassurance, and simple non-prescription treatments 2
• Pharmacological options:
  • Antispasmodics (e.g., hyoscine butylbromide) for meal-related pain 2, 3
  • Acetaminophen and NSAIDs for moderate pain 2
  • Gabapentin for neuropathic pain components (up to 2400 mg/day) 2
• For severe or refractory pain:
  • Consider tricyclic antidepressants or SNRIs 1, 2
  • Cognitive behavioral therapy or gut-directed hypnotherapy 1
  • Avoid opioids due to risk of dependence and narcotic bowel syndrome 1, 2

Special Considerations

Severe/Refractory Abdominal Pain

• For IBD-related pain: Address both inflammatory and non-inflammatory components 1
• For severe IBS-C: Consider linaclotide or elobixibat 1
• For severe IBS-D: Consider ondansetron 1
• For neuropathic components: Consider combination therapy (e.g., duloxetine plus gabapentin) with vigilance for serotonin syndrome 1

Monitoring and Follow-up

• Continuous monitoring with repeated physical examinations 1
• Patients with ongoing signs of infection beyond 7 days of treatment warrant further diagnostic investigation 1
• Consider secondary imaging if clinical improvement is not observed 1

Pitfalls to Avoid

• Delaying surgical intervention in patients with hemodynamic instability and large peritoneal effusion (mortality increases by 1% every 3 minutes) 1
• Overreliance on pharmacological treatments without addressing psychosocial factors 2
• Using opioids as first-line treatment for chronic abdominal pain 1, 2
• Dismissing pain reports when physical findings don't correlate with reported intensity 2

By following this structured approach, clinicians can effectively manage abdominal pain while prioritizing interventions that reduce morbidity and mortality.