What is the best treatment for acute upper gastrointestinal (GI) pain?

Treatment of Acute Upper GI Pain

For acute upper gastrointestinal pain, immediately assess hemodynamic stability and obtain CT abdomen/pelvis with IV contrast as the primary diagnostic tool, then treat acid-related pain with proton pump inhibitors (PPIs) as first-line therapy, reserving opioids only for severe pain unresponsive to non-opioid analgesics. 1, 2, 3

Immediate Stabilization and Assessment

• Check vital signs first for fever, tachycardia, tachypnea, hypotension, and altered mental status, which indicate potential organ failure requiring immediate resuscitation 1
• Establish IV access and initiate fluid resuscitation if signs of sepsis or shock are present 1
• Administer low-molecular-weight heparin for VTE prophylaxis in all patients with acute abdominal pain 1

Diagnostic Imaging Strategy

• Obtain CT abdomen/pelvis with IV contrast as the primary imaging modality after ensuring hemodynamic stability, as this changes diagnosis in 51-54% of cases and alters management in 25-42% of patients 1
• Use single-phase IV contrast-enhanced CT; pre-contrast and delayed phases are unnecessary 1
• Do NOT delay CT for oral contrast, as it delays diagnosis without improving accuracy 1
• Plain radiographs have limited utility and should generally be avoided 1

Key History Elements to Discriminate Causes

• Age >60 years plus atherosclerotic risk factors should prompt consideration of mesenteric ischemia 1
• Recent surgery or prior abdominal operations raises concern for adhesive small bowel obstruction 1
• Vomiting before pain onset makes appendicitis less likely 1

Laboratory Testing

• Order lactate if concerned for bowel ischemia or sepsis 1
• C-reactive protein can be elevated in inflammatory conditions 1

Pharmacologic Treatment Algorithm

For Acid-Related Upper GI Pain (Peptic Ulcer, GERD, Erosive Esophagitis)

• Start with PPIs as first-line therapy for acid reflux and peptic ulcer disease 4, 2
• H2-receptor antagonists (ranitidine) are an alternative for short-term treatment of active duodenal ulcer, active benign gastric ulcer, GERD, and erosive esophagitis 2
• Symptomatic relief commonly occurs within 24 hours after starting therapy 2
• Add prokinetics for up to 6 weeks if acid reflux persists despite PPI therapy 4
• Oral sucralfate suspension may be useful for recurrent bile reflux 4
• Concomitant antacids should be given as needed for pain relief 2

For Moderate to Severe Pain

• Provide early analgesia without compromising diagnostic accuracy 1
• Treat moderate to severe pain with intravenous nonopioid analgesic drugs (NSAIDs or acetaminophen) as first-line 3, 5
• For biliary colic specifically, add butylscopolamine to nonopioid analgesics 3
• Parenteral NSAIDs (indomethacin or diclofenac) are effective but underutilized for colic pain 3

For Severe Pain Requiring Opioids

• If nonopioid analgesics are inadequate, use highly potent opioids intravenously 3
• For biliary colic and acute pancreatitis, choose opioids that do not influence the sphincter of Oddi: buprenorphine, nalbuphine, or tramadol 3
• Avoid opioids in chronic or functional abdominal pain, as they cause narcotic bowel syndrome, dependence, gut dysmotility, and increased mortality 1, 6

Antibiotic Administration

• Do NOT routinely administer antibiotics for undifferentiated abdominal pain 1
• Antibiotics are indicated only when intra-abdominal abscess is identified, clinical signs of sepsis are present, or specific infection is confirmed 1
• If superinfection or abscesses are present, use antimicrobials against Gram-negative/aerobic bacilli, Gram-positive streptococci, and obligate anaerobic bacilli 4

When to Involve Surgery

• Surgical consultation is needed for signs of peritonitis, hemodynamic instability despite resuscitation, free air on imaging, complete bowel obstruction, mesenteric ischemia, or ruptured abdominal aortic aneurysm 1
• Signs of complete intestinal obstruction and severe abdominal pain require emergency surgical assessment 4

Critical Pitfalls to Avoid

• Do not obtain repeat CT scans without clear clinical indication, as diagnostic yield drops from 22% on initial CT to 5.9% on fourth or subsequent CTs 1
• Elderly patients may have normal labs despite serious infection, so maintain high suspicion and rely on imaging 1
• With new onset or unexplained pain, tumor recurrence should be considered in cancer patients 4
• Postprandial pain after upper GI surgery is commonly due to eating too much at one sitting 4

Multidisciplinary Approach for Complex Cases

• A multidisciplinary approach is required to manage patients with chronic pain after abdominal surgery or radiotherapy, including input from gastroenterology, surgery, pain management, and nutrition teams 4
• For patients with persistent pain despite treatment, consider behavioral and psychological approaches (cognitive behavioral therapy), particularly in those requiring multidisciplinary pain management without opioids 6