What is the treatment for abdominal pain?

Treatment of Abdominal Pain

The most effective first-line treatment for abdominal pain depends on the underlying cause, with antispasmodics being the recommended initial therapy for most cases of abdominal pain, particularly in irritable bowel syndrome (IBS). 1

First-Line Treatments

Non-Pharmacological Approaches

• Regular exercise should be advised to all patients with abdominal pain, particularly those with IBS 1
• First-line dietary advice should be offered, including soluble fiber supplementation starting at low doses (3-4 g/day) and gradually increasing 1
• Soluble fiber (ispaghula) is effective for global symptoms and abdominal pain, while insoluble fiber (wheat bran) should be avoided as it may worsen symptoms 1

Pharmacological Options

• Antispasmodics are recommended as first-line treatment for abdominal pain, particularly when symptoms are exacerbated by meals 1

  • Certain antispasmodics may effectively treat global symptoms and abdominal pain in IBS 1
  • Those with anticholinergic action appear slightly more effective, though dry mouth, visual disturbance, and dizziness are common side effects 1
  • Peppermint oil may be an effective alternative for global symptoms and abdominal pain, though gastro-esophageal reflux is a common side effect 1

• For diarrhea-predominant symptoms:

  • Loperamide (2-4 mg, up to four times daily) is effective for diarrhea at doses of 4-12 mg daily 1
  • Careful dose titration may avoid side effects such as abdominal pain, bloating, nausea, and constipation 1

• For constipation-predominant symptoms:

  • Polyethylene glycol may be effective, though abdominal pain is a common side effect 1
  • Increased dietary fiber (25 g/day) is recommended for simple constipation 1

Second-Line Treatments

Neuromodulators

• Tricyclic antidepressants (TCAs) are strongly recommended as second-line treatment for global symptoms and abdominal pain 1

  • Should be started at low doses (e.g., 10 mg amitriptyline once daily) and titrated slowly to 30-50 mg once daily 1
  • TCAs have shown significant benefit for abdominal pain compared to placebo 1
  • They are best avoided if constipation is a major feature 1
  • TCAs can cause constipation by prolonging whole-gut transit time, which may be helpful in diarrhea-predominant IBS 1

• Selective serotonin reuptake inhibitors (SSRIs) may be effective as second-line treatment for global symptoms 1

  • Consider SSRIs if symptoms don't respond to TCAs 1
  • If a mood disorder is suspected, an SSRI at therapeutic dose might be better than low-dose TCAs 1

Specialized Treatments for IBS-Diarrhea

• Eluxadoline (a mixed opioid receptor drug) is efficacious for IBS with diarrhea but contraindicated in patients with sphincter of Oddi problems, cholecystectomy, alcohol dependence, pancreatitis, or severe liver impairment 1
• 5-HT3 receptor antagonists (ondansetron, alosetron, ramosetron) are efficacious for IBS with diarrhea, though constipation is the most common side effect 1
• Rifaximin (non-absorbable antibiotic) is efficacious for IBS with diarrhea, though its effect on abdominal pain is limited 1

Special Considerations

Psychological Approaches

• Psychological treatments should be initiated when symptoms are severe enough to impair quality of life 1
• Cognitive-behavioral therapy, dynamic psychotherapy, hypnotherapy, and stress management/relaxation can be effective for reducing abdominal pain and diarrhea 1
• These approaches are particularly beneficial for patients who relate symptom exacerbations to stressors or have associated anxiety or depression 1

Common Pitfalls to Avoid

• Conventional analgesia, including opiates, is not a successful strategy for treating intestinal pain and should be avoided 1, 2
• Food elimination diets based on IgG antibodies are not recommended for IBS 1
• Gluten-free diets are not recommended unless celiac disease is confirmed 1
• Drugs may be counterproductive in patients with major psychological problems as they may reinforce abnormal illness behavior 1

Treatment Algorithm

1. Initial assessment: Determine predominant symptom pattern (pain, diarrhea, constipation, or mixed)
2. First-line: Antispasmodics ± peppermint oil for pain, loperamide for diarrhea, soluble fiber for constipation
3. If inadequate response: Add neuromodulators (TCAs first, then SSRIs if needed)
4. For refractory symptoms: Consider specialized treatments based on predominant symptoms
5. For psychological comorbidity: Add psychological interventions

Remember that abdominal pain can sometimes originate from the abdominal wall rather than internal organs, particularly when pain is chronic, unremitting, and related to posture 3. In such cases, different treatment approaches may be needed.