What is the treatment for exertional abdominal pain in a patient with normal scans?

Treatment for Exercise-Related Abdominal Pain with Normal Scans

For patients with exercise-related abdominal pain and normal imaging studies, the recommended treatment is modification of exercise habits, including proper warm-up, improved posture, core strengthening exercises, and timing meals at least 2 hours before exercise. 1

Understanding Exercise-Related Abdominal Pain

Exercise-related transient abdominal pain (ETAP), commonly known as a "stitch," is a well-documented condition affecting approximately 70% of runners. This pain is typically:

• Localized in the lateral aspects of the mid-abdomen along the costal border
• Sharp or stabbing when severe, cramping or pulling when less intense
• Exacerbated by eating before exercise, especially hypertonic beverages
• More common in younger individuals but can affect anyone regardless of fitness level 1

Diagnostic Considerations

When evaluating exercise-related abdominal pain with normal scans:

1. Recognize the limits of imaging: The American College of Radiology notes that CT scans have limited diagnostic yield for chronic abdominal symptoms without acute presentation 2

2. Consider functional causes: When scans are normal, functional disorders are likely the primary cause, particularly when symptoms have a specific relationship to physical activity 2

3. Rule out rare but serious causes: While uncommon, conditions like chronic mesenteric ischemia can present with exertional abdominal pain and may require specific vascular imaging 3

Treatment Approach

First-Line Interventions:

• Timing of meals: Avoid large volumes of food and beverages for at least 2 hours prior to exercise 1
• Hydration modification: Avoid hypertonic beverages before exercise 1
• Posture improvement: Focus on thoracic posture during exercise 1
• Core strengthening: Improve abdominal muscle support 1
• External support: Consider wearing a supportive broad belt during exercise 1

Additional Management Strategies:

• Gradual exercise progression: Start with lower intensity workouts and gradually increase duration and intensity
• Breathing techniques: Practice diaphragmatic breathing during exercise
• Pain relief techniques: During an episode, bending forward, applying pressure to the painful area, or deep breathing may provide relief

When to Consider Further Evaluation

If symptoms persist despite these interventions, consider:

1. Upper endoscopy (EGD): Recommended as first-line evaluation for chronic upper GI symptoms with meal relationships 2

2. Abdominal ultrasound: Good for evaluating gallbladder and hepatobiliary disease that might be exacerbated by exercise 2

3. Video capsule endoscopy: For suspected small bowel pathology if conventional studies are negative 2

4. Vascular studies: If symptoms suggest exercise-induced mesenteric ischemia (rare but important to consider) 3

Common Pitfalls to Avoid

• Premature advanced imaging: Avoid unnecessary radiation exposure from repeated CT scans 2
• Ignoring chronicity: Recognize that exercise-related pain often has a functional or mechanical basis 2
• Overlooking abdominal wall pain: Pain originating in the abdominal wall muscles can be misdiagnosed as intra-abdominal pathology 4

Exercise-related abdominal pain with normal imaging is typically benign and responds well to conservative management focusing on exercise modification, proper nutrition timing, and core strengthening. Persistent symptoms warrant a targeted diagnostic approach rather than repeated imaging studies.