What are the treatment options for a patient presenting with stomach pain?

Treatment Options for Stomach Pain

For patients presenting with stomach pain, CT scan with IV contrast is the first-line diagnostic imaging modality, followed by appropriate treatment based on the specific diagnosis identified. 1

Diagnostic Approach

Initial Assessment

• Determine pain location and characteristics:
  • Right lower quadrant pain suggests appendicitis
  • Right upper quadrant pain suggests biliary disease
  • Diffuse pain may indicate bowel obstruction, peritonitis, or functional disorders

Recommended Imaging

• CT abdomen and pelvis with IV contrast is the primary diagnostic tool for nonlocalized abdominal pain 1

  • Provides high diagnostic accuracy (can alter diagnosis in 54% of patients)
  • Single-phase IV contrast-enhanced examination is typically sufficient
  • Oral contrast may be optional depending on suspected pathology

• Ultrasonography is preferred for:

  • Right upper quadrant pain (suspected biliary disease)
  • Pregnant patients
  • Pediatric patients

Treatment Options Based on Diagnosis

Mechanical Bowel Obstruction

• Small bowel obstruction (accounts for 15% of hospital admissions for abdominal pain) 1
  • Caused by adhesions (55-75%), hernias, or neoplasms
  • Treatment:
    • IV fluid resuscitation
    • Nasogastric tube decompression
    • Surgical intervention if complete obstruction or signs of strangulation

Inflammatory Conditions

• Appendicitis

  • Treatment: Surgical appendectomy or antibiotics in select cases 1
  • Antibiotics should cover gram-negative and anaerobic bacteria 2

• Diverticulitis

  • Treatment:
    • Mild: Oral antibiotics, clear liquid diet
    • Moderate to severe: IV antibiotics, bowel rest
    • Abscesses >3cm require percutaneous drainage 2

Functional Disorders

• Irritable Bowel Syndrome

  • Treatment options:
    • Antispasmodics for abdominal pain (though evidence quality is very low) 1
    • Loperamide for diarrhea-predominant IBS (2-4mg up to four times daily) 1, 2
    • Peppermint oil for global symptoms and abdominal pain 1
    • Tricyclic antidepressants as second-line therapy for chronic pain 1, 2

• Gastroparesis

  • Treatment based on symptom severity:
    • Dietary modifications (small, frequent meals)
    • Anti-emetics for nausea/vomiting
    • Prokinetic agents for moderate symptoms 1

Acid-Related Disorders

• Gastroesophageal Reflux Disease (GERD)

  • Treatment: Proton pump inhibitors (e.g., omeprazole 20mg once daily for 4-8 weeks) 3
  • H2 receptor antagonists (e.g., ranitidine) as alternative 4

• Peptic Ulcer Disease

  • Treatment:
    • Omeprazole 20mg once daily for 4 weeks (duodenal ulcer) 3
    • Omeprazole 40mg once daily for 4-8 weeks (gastric ulcer) 3
    • Triple therapy for H. pylori eradication if present

Vascular Conditions

• Mesenteric Ischemia
  • Requires immediate intervention:
    • Systemic anticoagulation
    • Angiography with possible intervention 1
    • Surgical revascularization if needed

Pain Management Principles

• Avoid opioids when possible as they can worsen ileus and cause narcotic bowel syndrome 2

• For non-obstructive paralytic ileus, consider:

  • Buprenorphine (preferred option due to minimal effect on intestinal motility) 2
  • Antispasmodics
  • NSAIDs with opioid-sparing effect
  • Paracetamol

• For chronic abdominal pain:

  • Low-dose tricyclic antidepressants 2
  • Serotonin noradrenergic reuptake inhibitors for pain with anxiety 2

Special Considerations

• Malignancy: Consider in patients with weight loss, anemia, or family history of cancer

  • MRI has been shown to provide additional diagnostic information in 25% of patients with chronic abdominal pain 5

• Obstruction management:

  • For gastric outlet obstruction: Consider endoscopic placement of self-expanding metal stent as a minimally invasive option 1
  • For non-obstructive paralytic ileus: Early mobilization, correction of electrolyte abnormalities, and discontinuation of motility-impairing medications 2

By following this evidence-based approach to diagnosis and treatment, most causes of stomach pain can be effectively identified and managed, improving patient outcomes and quality of life.