What is the appropriate workup for abdominal pain associated with eating?

From the Guidelines

The workup for abdominal pain associated with eating should begin with a thorough history and physical examination to identify potential causes, followed by a step-up approach with laboratory tests and imaging studies as needed, according to the British Society of Gastroenterology guidelines on the management of functional dyspepsia 1. The diagnostic approach should be tailored to the specific pattern of pain, associated symptoms, and risk factors to efficiently identify the underlying cause.

• Initial laboratory tests may include complete blood count, comprehensive metabolic panel, lipase, and amylase.
• Imaging studies are essential, starting with an abdominal ultrasound to evaluate the gallbladder, liver, and pancreas.
• For persistent symptoms, upper endoscopy can identify mucosal abnormalities, ulcers, or H. pylori infection.
• A stool test or breath test to look for a stomach infection called H. pylori should be offered to all patients with functional dyspepsia, and if the test is positive, they should receive a short course of antibiotic treatment 1.
• Patients should be advised to keep a food diary to identify trigger foods and temporarily avoid fatty meals, alcohol, caffeine, and spicy foods which commonly exacerbate symptoms.
• The management of functional dyspepsia may include regular exercise, lifestyle changes, and medications such as acid suppression with proton pump inhibitors or antispasmodics, as well as psychological or behavioural therapies 1.
• A low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet may be recommended as a second-line dietary therapy for patients with irritable bowel syndrome, under the supervision of a trained dietitian 1.
• Probiotics may be an effective treatment for global symptoms and abdominal pain in irritable bowel syndrome, but it is not possible to recommend a specific species or strain 1.
• Certain antispasmodics may be an effective treatment for global symptoms and abdominal pain in irritable bowel syndrome, but dry mouth, visual disturbance, and dizziness are common side effects 1.
• Loperamide may be an effective treatment for diarrhea in irritable bowel syndrome, but abdominal pain, bloating, nausea, and constipation are common, and may limit tolerability 1.
• A gluten-free diet is not recommended in irritable bowel syndrome, unless there is a confirmed diagnosis of celiac disease 1.
• Soluble fiber, such as ispaghula, is an effective treatment for global symptoms and abdominal pain in irritable bowel syndrome, but insoluble fiber should be avoided as it may exacerbate symptoms 1.
• Food elimination diets based on IgG antibodies are not recommended in patients with irritable bowel syndrome 1.
• A diet low in FODMAPs may be an effective treatment for global symptoms and abdominal pain in irritable bowel syndrome, but its implementation should be supervised by a trained dietitian and FODMAPs should be reintroduced according to tolerance 1.

From the Research

Diagnostic Approach

The diagnostic approach for abdominal pain associated with eating involves a thorough evaluation of the patient's symptoms, medical history, and physical examination. According to 2, the diagnosis of irritable bowel syndrome (IBS) can be made on the basis of clinical history with limited and judicious use of investigations, unless alarm symptoms such as weight loss or rectal bleeding are present.

Differential Diagnosis

The differential diagnosis for abdominal pain associated with eating includes:

• Musculoskeletal causes, such as hip and/or low back pain, which can be addressed through physical therapy evaluation and treatment 3
• Nonmusculoskeletal causes, such as irritable bowel syndrome, inflammatory bowel disease, and coeliac disease 2
• Rare anomalies, such as mobile caecum, endometriosis, and pinworm infections, which can present as acute appendicitis 4
• Pyocolpos, a rare complication of hydrocolpos, which can cause recurrent abdominal pain and requires a thorough physical examination, including that of the external genitalia 5

Diagnostic Evaluation

The diagnostic evaluation for abdominal pain associated with eating may include:

• Laboratory tests, such as complete blood count and blood chemistry tests
• Imaging studies, such as computerised tomography of the abdomen and pelvis
• Exploratory laparoscopy, in some cases
• A thorough physical examination, including that of the external genitalia, to rule out rare causes such as pyocolpos 5

Treatment Approach

The treatment approach for abdominal pain associated with eating depends on the underlying cause. According to 2, the mainstays of treatment for IBS include patient education, dietary changes, soluble fibre, and antispasmodic drugs. Other treatments, such as central neuromodulators, intestinal secretagogues, and psychological therapies, may be reserved for patients with severe symptoms. In cases where the cause is surgical, such as acute appendicitis, cholecystitis, or ileus, interventional or surgical treatment may be necessary 6.