What are the treatment options for stomach pains?

Treatment Options for Stomach Pains

First-line treatments for stomach pains should include dietary modifications, antispasmodics, and peppermint oil, with selection based on symptom pattern and severity. 1

First-Line Treatment Options

Dietary and Lifestyle Approaches

• Regular exercise should be recommended to all patients with stomach pain as it helps reduce symptoms and improves overall well-being 1, 2
• First-line dietary advice should be offered, with individualized recommendations based on symptom triggers 1
• Soluble fiber (e.g., ispaghula) can be effective for abdominal pain but should be started at a low dose (3-4 g/day) and gradually increased to avoid bloating 1
• Low FODMAP diet can be considered as second-line dietary therapy for abdominal pain but should be supervised by a trained dietitian 1

Medication Options

• Antispasmodics (anticholinergics) are effective for global symptoms and abdominal pain, particularly when symptoms are exacerbated by meals 1
• Peppermint oil is effective for global symptoms and abdominal pain, though gastro-esophageal reflux is a common side effect 1
• For diarrhea-predominant stomach pain, loperamide may be effective, but careful dose titration is needed to avoid side effects like constipation 1
• For constipation-predominant stomach pain, polyethylene glycol can be effective, though abdominal pain is a potential side effect 1

Second-Line Treatment Options

Neuromodulators

• Tricyclic antidepressants (TCAs) are effective second-line treatments for abdominal pain and should be started at a low dose (e.g., 10 mg amitriptyline once daily) and titrated slowly to 30-50 mg daily 1
• TCAs are particularly beneficial when pain is frequent or severe 1
• Selective serotonin reuptake inhibitors (SSRIs) may be effective for global symptoms when TCAs are not tolerated 1
• For severe cases, combination therapy with neuromodulators (e.g., duloxetine plus gabapentin) may be more effective than monotherapy 1, 2

For Specific Subtypes

• For diarrhea-predominant stomach pain, 5-HT3 receptor antagonists like ondansetron (titrated from 4 mg once daily to maximum 8 mg three times daily) are highly efficacious 1
• For constipation-predominant stomach pain, osmotic laxatives should be used with dose titration according to symptoms 1

Psychological Interventions

• Cognitive behavioral therapy has demonstrated excellent results for functional abdominal pain and should be considered early in treatment 1, 2
• Gut-directed hypnotherapy is effective for reducing abdominal pain and global symptoms 1, 2
• Mindfulness-based stress reduction techniques can help manage pain perception 1, 2

Management of Severe or Refractory Pain

• Review the diagnosis and consider further targeted investigation for severe or refractory symptoms 1
• Adopt an integrated multidisciplinary approach for management 1
• Avoid opioids for chronic abdominal pain due to risk of dependence, hyperalgesia, and worsening of gastrointestinal symptoms 1, 2

Common Pitfalls to Avoid

• Prescribing opioids, which can worsen symptoms and lead to narcotic bowel syndrome 1, 2
• Implementing overly restrictive diets without dietitian guidance 2
• Focusing solely on pharmacological approaches without addressing psychological factors 1, 2
• Performing unnecessary surgical interventions that may lead to iatrogenic complications 2

Treatment Algorithm

1. Begin with dietary modifications and antispasmodics or peppermint oil for mild symptoms 1
2. If inadequate response after 4-6 weeks, add low-dose TCA (for non-constipated patients) or SSRI 1
3. For persistent symptoms, consider psychological interventions like CBT or gut-directed hypnotherapy 1, 2
4. For severe or refractory cases, implement a multidisciplinary approach with pain specialists 1

The evidence strongly supports a stepped approach to treatment, starting with the least invasive options and progressing to more complex interventions as needed, while avoiding treatments with potential for harm such as opioids 1, 2.