What can be taken for abdominal pain?

Management of Abdominal Pain

For abdominal pain, first-line treatments include antispasmodics, peppermint oil, and gut-brain neuromodulators, with treatment selection based on pain characteristics and underlying cause. 1

Diagnostic Considerations

Before selecting treatment, consider the potential causes of abdominal pain:

• Irritable Bowel Syndrome (IBS): Recurrent abdominal pain at least 1 day/week in the last 3 months associated with defecation changes 1
• Inflammatory Bowel Disease (IBD): May present with acute abdominal pain requiring multidisciplinary management 2
• Abdominal Wall Pain: Often posture-related with localized trigger points 3
• Acute Conditions: Including appendicitis, diverticulitis, or bowel obstruction 4, 5

First-Line Treatments

For Mild to Moderate Pain

1. Antispasmodics:

   • Effective for cramping abdominal pain, especially in IBS
   • Examples include hyoscine (shown efficacy for severe pain) 2

2. Peppermint Oil:

   • Acts as a natural antispasmodic
   • Recommended in step-wise approach for IBS 1

3. Dietary Modifications:

   • Low-FODMAP diet for IBS-related pain 1
   • Soluble fiber supplementation (ispaghula) starting at 3-4g/day 1
   • Avoid insoluble fiber (wheat bran) which may worsen symptoms 1

For Moderate to Severe Pain

1. Gut-Brain Neuromodulators:

   • Tricyclic antidepressants (e.g., amitriptyline): Start at 10mg at bedtime, titrate to 25-50mg 1
   • SSRIs: Particularly useful when pain is accompanied by anxiety 1
   • For severe cases, combination therapy (e.g., duloxetine plus gabapentin) may be more effective than monotherapy 2

2. H2 Receptor Antagonists:

   • Ranitidine 150mg twice daily for GERD-related abdominal pain 6

3. Antibiotics:

   • Not for routine use in abdominal pain 2
   • Only indicated if superinfection is suspected or intra-abdominal abscess is present 2
   • When needed, cover Gram-negative bacteria and anaerobes (fluoroquinolones or third-generation cephalosporin plus metronidazole) 2
   • Rifaximin 550mg three times daily for 14 days may help in IBS-D 1

Special Considerations

For IBD-Related Pain

• Multidisciplinary approach involving gastroenterologist and acute care surgeon 2
• IV corticosteroids for severe active ulcerative colitis if hemodynamically stable 2
• Infliximab may be considered for penetrating ileocecal Crohn's disease after resolution of abscesses 2

For Severe or Refractory Pain

• Cognitive-behavioral therapy, gut-directed hypnotherapy, or mindfulness-based stress reduction 1
• Regular physical activity to reduce symptoms 1
• Consider referral to gastroenterology when symptoms are severe or refractory to first-line treatments 1

Treatment Algorithm

1. Assess pain characteristics and red flags

   • Location, timing, relation to meals/defecation
   • Alarm symptoms: weight loss, rectal bleeding, nocturnal symptoms

2. For mild pain without red flags:

   • Start with antispasmodics or peppermint oil
   • Implement dietary modifications

3. For moderate pain or inadequate response to step 2:

   • Add gut-brain neuromodulators (TCAs or SSRIs)
   • Consider H2 blockers if GERD symptoms present

4. For severe pain or inadequate response to step 3:

   • Consider combination therapy with neuromodulators
   • Add psychological interventions
   • Refer to gastroenterology for further evaluation

Cautions and Pitfalls

• Avoid opioids for chronic abdominal pain due to risk of narcotic bowel syndrome 2
• Monitor for serotonin syndrome when using combination gut-brain neuromodulators (symptoms: fever, hyperreflexia, tremor, sweating, diarrhea) 2
• Avoid unnecessary antibiotics which can disrupt gut microbiota 2
• Be vigilant for centrally-mediated pain which may require referral to multidisciplinary chronic pain team 2