What are the guidelines for managing abdominal pain?

Guidelines for Abdominal Pain Management

Initial Assessment and Diagnosis

The optimal management of abdominal pain requires a multidisciplinary approach involving appropriate diagnostic tools and treatment strategies based on the underlying cause, with early identification of urgent conditions being critical to reduce morbidity and mortality.

• Abdominal pain should be categorized as acute (duration ≤5 days) or chronic to guide appropriate management strategies 1
• Diagnostic imaging selection should follow evidence-based protocols:
  • Ultrasonography is recommended as first-line imaging for right upper quadrant pain 2
  • CT scan is recommended for right and left lower quadrant pain 2
  • Plain radiography has no place in the initial evaluation of acute abdominal pain due to lack of added value 1
• Laboratory tests alone (CRP, WBC) are insufficient to differentiate urgent from non-urgent causes but should be used to support clinical assessment 1

Management of Acute Abdominal Pain

Trauma-Related Abdominal Pain

• For hemodynamically unstable trauma patients, immediate resuscitation with damage control principles is necessary, including large-caliber vascular access, blood product transfusion, and prevention of hypothermia 3
• FAST (Focused Assessment with Sonography for Trauma) should be used for rapid detection of free intraperitoneal fluid in trauma patients 3
• Immediate laparotomy is indicated for patients with persistent hemodynamic instability, peritonitis, evisceration, uncontrolled gastrointestinal bleeding, or pneumoperitoneum 3

Non-Traumatic Abdominal Pain

• Analgesics should be administered early to patients with acute abdominal pain as this reduces discomfort without impairing diagnostic accuracy 4
• For suspected inflammatory bowel disease with acute abdominal pain:
  • Intravenous corticosteroids are the initial medical treatment for severe active ulcerative colitis in hemodynamically stable patients 5
  • Response to intravenous steroids should be assessed by the third day 5
  • In non-responders who remain hemodynamically stable, rescue therapy with infliximab in combination with a thiopurine, or ciclosporin should be considered 5

Management of Abscesses in Abdominal Pain

• For abscesses >3 cm related to Crohn's disease:
  • Percutaneous drainage with early empiric antibiotics is recommended as first-line treatment 5
  • Antimicrobial therapy should be adjusted based on culture results and patient's clinical response 5
• For smaller abscesses (<3 cm):
  • Early empiric antimicrobial therapy with close monitoring is recommended 5
• Surgery should be considered when:
  • Percutaneous drainage fails 5
  • Patient shows signs of septic shock 5
  • Enteric fistulae are present with persistent clinical evidence of sepsis 5

Pharmacological Management

• NSAIDs such as ibuprofen should be used with caution:
  • Use the lowest effective dose for the shortest duration (maximum 3200 mg/day) 6
  • Monitor for gastrointestinal adverse effects, which occur in approximately 1% of patients treated for 3-6 months 6
  • Use with extreme caution in patients with history of ulcer disease, gastrointestinal bleeding, hypertension, or heart failure 6
  • Monitor renal function, especially in elderly patients or those with pre-existing renal impairment 6

Chronic Abdominal Pain Management

• For irritable bowel syndrome with abdominal pain:

  • Low-dose tricyclic antidepressants and serotonin noradrenergic reuptake inhibitors can be prescribed by gastroenterologists 5
  • Cognitive behavioral therapy should be considered for patients with insight into how thoughts, feelings, and behaviors relate to their pain 5
  • Hypnotherapy may benefit patients with visceral hypersensitivity, provided by certified clinical providers 5

• For severe or refractory abdominal pain:

  • Combination therapy with neuropathic analgesics (e.g., duloxetine plus gabapentin) may be more efficacious than monotherapy 5
  • Monitor for serotonin syndrome when combining SSRIs and SNRIs 5

Special Considerations

• All patients with inflammatory bowel disease presenting with acute abdominal pain should receive:

  • Adequate intravenous fluids 5
  • Low-molecular-weight heparin for thromboprophylaxis 5
  • Correction of electrolyte abnormalities and anemia 5

• Antibiotics should not be routinely administered in IBD patients unless:

  • Superinfection is suspected 5
  • Intra-abdominal abscess is present 5

• Nutritional support is mandatory in severely undernourished patients with abdominal pain related to IBD 5

Common Pitfalls and Caveats

• Avoid repeated diagnostic testing once a diagnosis of functional pain is established 7
• Be vigilant for serotonin syndrome when combining multiple neuromodulators (symptoms include fever, hyperreflexia, tremor, sweating, and diarrhea) 5
• NSAIDs can cause serious gastrointestinal adverse events including bleeding and perforation, which can occur at any time during treatment 6
• Preoperative treatments with immunomodulators, anti-TNF-α agents, and steroids increase the risk of intra-abdominal sepsis in patients requiring emergency surgery 5