What are the treatment options for abdominal cramps?

Treatment of Abdominal Cramps

For abdominal cramping pain, first-line treatment should be antispasmodics (such as hyoscine or dicyclomine) or peppermint oil, with tricyclic antidepressants (starting at 10 mg amitriptyline) as effective second-line therapy when initial treatments fail. 1

First-Line Pharmacological Approach

Antispasmodics

• Antispasmodics are the primary treatment for abdominal cramping pain, working by relaxing intestinal smooth muscle 1, 2
• Anticholinergic agents (dicyclomine, hyoscine) show slightly better efficacy than direct smooth muscle relaxants (mebeverine, alverine citrate), though dry mouth, visual disturbance, and dizziness are common side effects 1
• Hyoscine butylbromide has high affinity for muscarinic receptors in the GI tract, with minimal systemic absorption (<1% bioavailability), making it well-tolerated with few anticholinergic side effects 3
• Peppermint oil is equally effective as antispasmodics for abdominal pain relief and represents a safe alternative 1

Important Caveat

• Conventional analgesics including NSAIDs (like ibuprofen 4) and opioids are not successful strategies for functional abdominal cramping pain and should be avoided 1
• Opioids can worsen symptoms and create dependency without addressing the underlying cramping mechanism 1

Second-Line Treatment: Neuromodulators

Tricyclic Antidepressants (TCAs)

• TCAs are the most effective second-line drugs for abdominal pain, demonstrating significant benefit in multiple randomized controlled trials 1
• Start with low-dose amitriptyline 10 mg once daily at bedtime, titrating slowly to maximum 30-50 mg daily based on response 1
• TCAs work through multiple mechanisms: altering pain perception centrally, reducing visceral hypersensitivity, and modifying gut motility 1
• Avoid TCAs if constipation is a major feature, as constipation is the most common side effect 1
• Careful explanation of rationale is required, as patients may be concerned about taking an "antidepressant" for abdominal pain 1

SSRIs as Alternative

• Selective serotonin reuptake inhibitors (SSRIs) are effective second-line alternatives if TCAs fail or are not tolerated 1
• SSRIs should be the initial choice when mood disorder is suspected, as therapeutic doses are needed to treat both psychological and GI symptoms simultaneously 1
• SSRIs have fewer constipating effects than TCAs and may accelerate gut transit 1

Adjunctive Dietary Approaches

Soluble Fiber

• Soluble fiber (ispaghula) is effective for abdominal pain, but must be started at low dose (3-4 g/day) and increased gradually to avoid bloating 1
• Avoid insoluble fiber (wheat bran) as it may exacerbate cramping symptoms 1

Low FODMAP Diet

• Consider as second-line dietary therapy under supervision of trained dietitian 1
• Effective for global symptoms and abdominal pain, but requires proper reintroduction phase according to tolerance 1

Probiotics

• May be effective for abdominal pain when taken for up to 12 weeks 1
• No specific species or strain can be recommended; discontinue if no improvement after 12 weeks 1

Symptom-Specific Treatments

For Diarrhea-Predominant Cramping

• Loperamide 4-12 mg daily effectively reduces urgency and frequency 1
• Titrate dose carefully as abdominal pain, bloating, and constipation can limit tolerability 1
• 5-HT3 receptor antagonists (ondansetron 4-8 mg) are highly efficacious second-line options in secondary care 1

For Constipation-Predominant Cramping

• Osmotic laxatives (polyethylene glycol) or stimulant laxatives (senna) as first-line 1
• Secretagogues (linaclotide, plecanatide) as second-line therapy 1

Critical Pitfalls to Avoid

• Do not repeatedly investigate once functional pain is established; this reinforces illness behavior and increases healthcare costs 5
• Exclude organic pathology first through targeted history focusing on alarm features (weight loss, bleeding, nocturnal symptoms, age >50 with new symptoms) 5, 2
• Avoid prescribing drugs to patients with major psychological problems without addressing underlying issues, as this may reinforce abnormal illness behavior 1
• Never use opioids for functional abdominal cramping—they are ineffective and carry significant risk of dependency 1

When to Refer

• Refer for psychological therapies (cognitive behavioral therapy, gut-directed hypnotherapy) early if symptoms persist despite first-line treatments, as these build lifelong management skills 1
• Psychiatric referral is appropriate when depression or anxiety overshadows GI symptoms 1
• Gastroenterology referral for consideration of advanced therapies (rifaximin, eluxadoline) in refractory cases 1