Management of Abdominal Pain
The optimal management of abdominal pain requires a structured diagnostic approach followed by targeted treatment based on the underlying cause, with early imaging studies when clinical assessment suggests serious pathology. 1
Diagnostic Approach
Initial Assessment
- Location of pain is a critical starting point for evaluation
- Right lower quadrant pain strongly suggests appendicitis
- Right upper quadrant pain may indicate gallbladder disease
- Diffuse pain may suggest bowel obstruction or peritonitis
Physical Examination Findings of Value
- Presence of positive psoas sign, fever, or migratory pain to right lower quadrant increases likelihood of appendicitis 2
- Abdominal distension and constipation strongly suggest bowel obstruction 1
- Peritoneal signs (rebound tenderness, guarding) indicate possible surgical emergency
Imaging Studies
- Ultrasound (US) recommended for right upper quadrant pain 3
- CT scan recommended for right and left lower quadrant pain 3
- MRI can be used in pregnant patients when US is inconclusive 2
- Diagnostic laparoscopy may be used when imaging is unhelpful, with definitive diagnosis rates between 86-100% 2
Treatment Approach
Infectious/Inflammatory Causes
- For intra-abdominal infections (appendicitis, diverticulitis, colitis):
Functional/Motility Issues
- For paralytic ileus:
- Neostigmine (2-2.5 mg IV over 3-5 minutes) with cardiac monitoring for persistent ileus 1
- Metoclopramide (10 mg IV every 6 hours) for partial obstruction/ileus 1
- Discontinue medications that impair motility (opioids, anticholinergics) 1
- Correct electrolyte abnormalities (potassium, magnesium, phosphate) 1
- Early mobilization to improve bowel function 1
Pain Management
- Avoid opioids when possible as they can worsen ileus and cause narcotic bowel syndrome 2, 1
- If opioids necessary, buprenorphine is preferred (patch 25 μg/h) for non-obstructive paralytic ileus 1
- Antispasmodics for cramping pain 1
- NSAIDs and paracetamol for opioid-sparing effect 1
- Tricyclic antidepressants (low-dose) for chronic abdominal pain 2
- Serotonin noradrenergic reuptake inhibitors for chronic pain with anxiety 2
Specific Symptom Management
- Loperamide (2-4mg up to four times daily) for diarrhea 1
- Magnesium Citrate (240 mL daily) for constipation (contraindicated in renal impairment) 1
Special Considerations
Inflammatory Bowel Disease
- Multidisciplinary approach involving gastroenterologist and acute care surgeon 2
- Intravenous corticosteroids for severe active ulcerative colitis in hemodynamically stable patients 2
- Response to IV steroids should be assessed by the third day 2
- For non-responders, consider rescue therapy with infliximab or ciclosporin 2
Chronic Abdominal Pain in Disorders of Gut-Brain Interaction
- Brain-gut psychotherapies show efficacy:
Common Pitfalls to Avoid
- Misdiagnosing persistent mechanical obstruction as ileus can lead to delayed treatment 1
- Overuse of opioids can significantly worsen ileus 1
- Delayed mobilization can worsen ileus 1
- Ignoring fluid and electrolyte status can worsen recovery 1
- Prolonged NPO status can worsen ileus; consider early enteral nutrition when possible 1
- Failing to recognize when abdominal pain is centrally mediated versus viscerally triggered 2
Red Flags Requiring Urgent Intervention
- Signs of peritonitis
- Worsening abdominal distension
- Fever with leukocytosis
- Persistent or worsening ileus despite 72 hours of conservative management 1
- Hypotension, hypoperfusion signs (oliguria, altered mental status, lactic acidosis) indicating organ failure 2
By following this structured approach to abdominal pain management, clinicians can effectively diagnose the underlying cause and implement appropriate treatment strategies to improve patient outcomes.