How should her abdominal pain be managed?

Management of Abdominal Pain

The management of her abdominal pain should be determined first by distinguishing whether inflammation is present or if the pain is chronic and centrally mediated, then implementing a stepwise approach starting with dietary modifications and antispasmodics, escalating to low-dose tricyclic antidepressants (10mg amitriptyline titrated to 30-50mg daily), and incorporating brain-gut behavioral therapies early for moderate-to-severe or persistent symptoms. 1, 2

Initial Diagnostic Framework

First, determine if active inflammation is driving the pain:

• If inflammation is present (in IBD context), acute pain typically resolves rapidly with appropriate anti-inflammatory medical therapy 1
• Once inflammation resolves, persistent pain likely reflects central pain mechanisms including allodynia (innocuous stimuli perceived as painful) or hyperalgesia (exaggerated response to noxious stimuli) 1
• The peripheral factors that initiated pain are different from the central factors that maintain and amplify it—addressing the maintaining factors is most critical 1

Assess for risk factors that predict chronic pain development:

• History of any chronic pain condition 1
• Early-life adversity, trauma, discrimination experiences, or poverty 1
• Poor coping styles like catastrophizing, pre-existing anxiety or depression 1
• Pain-reinforcing social factors: disability status, substance misuse history, worker's compensation 1

Stepwise Treatment Algorithm

First-Line Interventions

Dietary modifications should be implemented immediately:

• Temporarily eliminate lactose-containing products, alcohol, and high-osmolar supplements 2
• Eat frequent small meals of easily digestible foods (bananas, rice, applesauce, toast) 2
• Start soluble fiber (ispaghula) at low dose (3-4g/day), gradually increasing to avoid bloating 2
• Avoid insoluble fiber like wheat bran, which may worsen symptoms 2

Pharmacologic first-line treatment for pain:

• Antispasmodics (hyoscine butylbromide or dicyclomine) for pain, particularly when meal-related 1, 2
• Loperamide (4mg initially, then 2mg after each unformed stool) if diarrhea is present 2
• Acid-suppressive drugs (proton pump inhibitors, H2 antagonists) depending on symptom location 1

Second-Line Interventions for Persistent Pain

Low-dose tricyclic antidepressants are the cornerstone of chronic pain management:

• Start amitriptyline 10mg once daily at bedtime, titrate slowly to 30-50mg daily 1, 2
• Alternatively, use desipramine if anticholinergic side effects are problematic 1
• These have neuromodulatory and analgesic properties independent of psychotropic effects 1
• Therapeutic benefit occurs sooner and at lower doses than when treating depression 1
• Efficacy appears within 1-3 weeks 1

Serotonin-norepinephrine reuptake inhibitors (SNRIs) as alternatives:

• Consider if TCAs are not tolerated 1
• Also effective for chronic pain with lower side effect profile 1
• Efficacy within 2-4 weeks 1

SSRIs have limited role:

• Less evidence for direct pain reduction 1, 2
• Reserve for patients with significant comorbid anxiety or depression 1

Consider low FODMAP diet as second-line dietary therapy:

• Must be supervised by trained dietitian 2
• Only if first-line dietary measures fail 2

Brain-Gut Behavioral Therapies

These should be introduced early for moderate-to-severe pain, not as a last resort:

• Multidisciplinary care with a psychologist experienced in chronic abdominal pain is the most effective approach 1
• Cognitive behavioral therapy (CBT) for patients with insight into how thoughts, feelings, and behaviors relate to pain 1
• Gut-directed hypnotherapy for patients with visceral hypersensitivity or somatic symptoms (contraindicated in severe PTSD) 1, 2
• Relaxation training and breathing techniques can be taught by gastroenterologists 1, 2
• Mindfulness-based stress reduction teaches nonjudgmental observation of pain 1

These therapies reduce pain, anxiety, and improve coping regardless of whether they change GI physiology 1

Critical Communication Points

Explain the neurobiology to establish therapeutic alliance:

• Pain is real and multifactorial—set this expectation early so transition to chronic pain management doesn't seem abrupt 1
• Central mechanisms (spinal cord, brainstem, cortical sensitization) maintain pain even after peripheral triggers resolve 1
• Pain catastrophizing is not psychological weakness but reflects well-characterized brain mechanisms 1
• Use empathic, scientific, and firm communication 1

Listen for specific pain descriptors that guide treatment:

• "Unbearable" or "ripping and tearing" suggests high emotional reactivity and pain catastrophizing—prioritize cognitive-emotion targeted therapies 1
• "Burning" or "sharp" suggests altered sensory input—may respond better to neuromodulators 1
• "I cannot have this pain; there must be something wrong" indicates need to build pain acceptance 1

What to Avoid

Never use opioids for chronic abdominal pain:

• Risk of addiction and paradoxical amplification of pain sensitivity 2
• Should not be used specifically to treat abdominal pain 1

Avoid repetitive testing once functional pain is established:

• After organic pathology is confidently excluded, repetitive testing is not recommended 3
• Focus shifts to management rather than cure 1

Do not delay psychological interventions:

• Mental health professionals should be framed as part of the treatment team, not a referral for "failed" patients 1
• Greater benefit when symptoms relate to stressors, have associated anxiety/depression, or are of shorter duration with waxing/waning pattern 1