What are the next steps in the clinic for a patient presenting with abdominal pain (stomach ache)?

From the Guidelines

When a patient presents with a stomach ache in the clinic, the next steps should include a thorough history and physical examination to determine the cause, as the most recent and highest quality study 1 emphasizes the importance of a comprehensive approach in managing functional dyspepsia.

Initial Assessment

The initial assessment should start by asking about the pain characteristics (location, duration, severity, and aggravating/relieving factors), associated symptoms like nausea, vomiting, diarrhea, or fever, and recent dietary changes or medication use.

• Perform a focused abdominal examination including inspection, auscultation, percussion, and palpation.
• Basic laboratory tests may be warranted, including complete blood count, comprehensive metabolic panel, urinalysis, and possibly stool studies if infection is suspected.

Symptomatic Treatment

For mild cases, recommend symptomatic treatment with:

• Antacids (such as calcium carbonate 500-1000mg as needed)
• H2 blockers (ranitidine 150mg twice daily)
• Proton pump inhibitors (omeprazole 20mg daily) for acid-related discomfort.
• For cramping pain, antispasmodics like dicyclomine 10-20mg three times daily may help. Advise dietary modifications including smaller, more frequent meals, avoiding trigger foods, and adequate hydration.

Further Investigation

If red flag symptoms are present (severe pain, blood in stool, weight loss, persistent vomiting), or if symptoms don't improve within 1-2 weeks of conservative management, further investigation with imaging studies or referral to a gastroenterologist is necessary, as suggested by 1 and 1.

• Imaging studies such as ultrasonography or computed tomography (CT) may be indicated to rule out underlying causes of abdominal pain.
• Referral to a gastroenterologist may be necessary for further evaluation and management of functional dyspepsia or other underlying conditions.

Management of Functional Dyspepsia

According to the British Society of Gastroenterology guidelines 1, all patients with functional dyspepsia should be offered a stool test or breath test to look for a stomach infection called H. pylori.

• If the test is positive, they should receive a short course of antibiotic treatment for the infection to see if their symptoms improve.
• Patients who test negative, or patients who test positive, but whose symptoms continue after antibiotics, should be offered other medications to treat their symptoms.

From the FDA Drug Label

Concomitant antacids should be given as needed for pain relief to patients with active duodenal ulcer; active, benign gastric ulcer; hypersecretory states; GERD; and erosive esophagitis.

The next steps in the clinic for a patient presenting with abdominal pain (stomach ache) may include giving antacids as needed for pain relief.

• The patient's condition should be further evaluated to determine the underlying cause of the abdominal pain.
• Ranitidine may be considered if the patient is diagnosed with a condition such as duodenal ulcer, gastric ulcer, GERD, or erosive esophagitis 2.

From the Research

Next Steps in the Clinic for a Patient Presenting with Abdominal Pain

The next steps in the clinic for a patient presenting with abdominal pain involve a thorough evaluation to determine the underlying cause of the pain.

• History-taking: The patient's medical history is taken to identify any potential causes of the abdominal pain 3.
• Initial evaluation: A physical examination is performed to assess the patient's condition and identify any signs of illness 3.
• Laboratory studies: Common laboratory studies such as complete blood count, blood chemistry tests, and urinalysis may be ordered to help diagnose the cause of the abdominal pain 3.
• Diagnostic studies: Imaging studies such as X-rays, computed tomography (CT) scans, or ultrasound may be ordered to visualize the abdominal organs and help diagnose the cause of the pain 3.
• Differential diagnosis: A systematic approach is used to generate a differential diagnosis, considering multiple potential causes of the abdominal pain, including acute cholecystitis, pancreatitis, appendicitis, ectopic pregnancy, diverticulitis, gastritis, and gastroenteritis 3, 4.

Treatment Options

Treatment options for abdominal pain depend on the underlying cause of the pain.

• For acid-related diseases, treatment options may include H2-receptor antagonists or proton-pump inhibitors (PPIs) 5, 6.
• For gastroesophageal reflux disease (GERD), combination therapy with PPIs and histamine(2) receptor antagonists may be considered 7.
• For other causes of abdominal pain, treatment options may include antibiotics, surgery, or other medications, depending on the specific diagnosis 3, 4.

Importance of a Systematic Approach

A systematic approach to evaluating patients with abdominal pain is crucial to ensure accurate diagnosis and effective treatment.

• Clinicians should develop a framework for evaluating the complaint of acute abdominal pain to recognize patients who require expedited evaluation 4.
• A thorough evaluation, including history-taking, physical examination, laboratory studies, and diagnostic studies, is necessary to determine the underlying cause of the abdominal pain 3, 4.