What are the treatment options for abdominal discomfort?

Treatment Options for Abdominal Discomfort

For abdominal discomfort, a stepped approach starting with antispasmodics for mild symptoms and progressing to tricyclic antidepressants for moderate to severe symptoms is most effective for reducing pain and improving quality of life. 1

First-Line Treatments

Dietary and Lifestyle Modifications

• Regular exercise should be recommended to all patients with abdominal discomfort 1
• First-line dietary advice should include avoiding trigger foods and monitoring symptoms 1
• Soluble fiber (such as ispaghula) is effective for global symptoms and abdominal pain, starting at low doses (3-4g/day) and gradually increasing to avoid bloating 1
• Insoluble fiber (e.g., wheat bran) should be avoided as it may worsen symptoms 1
• Low FODMAP diet can be considered as second-line dietary therapy but should be supervised by a trained dietitian with gradual reintroduction of FODMAPs according to tolerance 1

Pharmacological Options

• Antispasmodics are effective for treating abdominal pain, with anticholinergic agents showing slightly better efficacy 1
  • Common side effects include dry mouth, visual disturbance, and dizziness 1
• Peppermint oil is effective for abdominal pain relief and ranked highly in network meta-analyses 1
• Probiotics may help with global symptoms and abdominal pain, though no specific strain can be recommended; a 12-week trial is reasonable 1
• For diarrhea-predominant symptoms:
  • Loperamide (4-12mg daily) is effective for reducing stool frequency and urgency 1
  • Codeine (15-30mg, 1-3 times daily) is an alternative but may cause sedation 1

Second-Line Treatments

Neuromodulators

• Tricyclic antidepressants (TCAs) are the most effective second-line treatment for abdominal pain 1
  • Start at low dose (10mg amitriptyline once daily) and titrate slowly to 30-50mg once daily 1
  • TCAs should be avoided if constipation is a major symptom 1
  • These medications work through central and peripheral mechanisms to reduce pain perception 1
• Selective serotonin reuptake inhibitors (SSRIs) may be effective for global symptoms but have less analgesic effect than TCAs 1

For Specific Bowel Pattern Subtypes

• For diarrhea-predominant symptoms:

  • 5-HT3 receptor antagonists (ramosetron, alosetron, ondansetron) are highly effective 1
  • Ondansetron can be titrated from 4mg once daily to a maximum of 8mg three times daily 1
  • Eluxadoline (mixed opioid receptor drug) is effective but contraindicated in patients with prior sphincter of Oddi problems, cholecystectomy, alcohol dependence, pancreatitis, or severe liver impairment 1
  • Rifaximin (non-absorbable antibiotic) is effective though its effect on abdominal pain is limited 1
  • Cholestyramine may help patients with bile acid malabsorption (approximately 10% of diarrhea-predominant cases) 1

• For constipation-predominant symptoms:

  • Secretagogues like linaclotide are effective for abdominal pain and constipation 1

For Severe or Refractory Symptoms

• For severe or refractory abdominal pain, intramuscular hyoscine may be effective 1
• Combination therapy with neuromodulators (e.g., duloxetine plus gabapentin) may be more effective than monotherapy for severe chronic continuous abdominal pain 1
  • Caution is needed regarding serotonin syndrome when combining serotonergic medications 1
• Psychological interventions should be considered, including:
  • Cognitive behavioral therapy (CBT) 1
  • Gut-directed hypnotherapy 1
  • Mindfulness-based stress reduction 1

Important Considerations and Caveats

• Opioids should be avoided for chronic abdominal discomfort due to risk of dependence and potential to worsen symptoms long-term 1
• Drugs may be counterproductive in patients with major psychological problems as they may reinforce abnormal illness behavior 1
• Underlying psychiatric conditions like depression and anxiety should be identified and treated appropriately 1
• Treatment response should be monitored, and diagnosis reconsidered if symptoms persist or worsen 1
• For patients with symptoms suggestive of bile acid malabsorption (especially after cholecystectomy), appropriate testing and treatment with bile acid sequestrants should be considered 1