What is the management plan for a patient with post-exertional abdominal pain, specifically after playing hockey?

Management of Post-Exertional Abdominal Pain in Hockey Players

This patient is experiencing exercise-induced gastrointestinal syndrome (EIGS), and management should focus on individualized assessment to identify underlying causes, followed by evidence-based nutritional and hydration strategies, with gut training as the cornerstone of prevention. 1

Initial Assessment and Diagnosis

The first priority is determining whether this represents functional exercise-associated gastrointestinal symptoms versus structural pathology requiring urgent intervention. 2

Key Diagnostic Considerations:

• Rule out serious pathology first: Assess for signs of hemodynamic instability, severe persistent pain, or inability to bear weight that would suggest vascular emergency, organ injury, or stress fracture 3, 4
• Timing and pattern matter: Pain occurring specifically during/after hockey suggests EIGS rather than structural injury like sports hernia, which typically causes persistent groin pain with activity 5, 6
• Exercise-induced GI syndrome is common: Abdominal pain during exercise affects a substantial proportion of athletes and represents splanchnic hypoperfusion, gastrointestinal ischemia, and neuroendocrine stress responses 1

Critical Red Flags Requiring Immediate Referral:

• Hemodynamic instability or signs of shock 4
• Severe persistent pain unrelieved by rest 2
• Focal bone tenderness suggesting stress fracture 3
• Signs of organ injury (rigid abdomen, guarding) 4

First-Line Management Strategies

The most effective evidence-based interventions include proper macronutrient intake, maintaining euhydration, FODMAP dietary manipulation, and gut training. 1

Nutritional Interventions During Exercise:

• Carbohydrate strategy: Use multiple transportable carbohydrates (glucose + fructose combinations) rather than single carbohydrate sources, which reduces GI symptoms compared to glucose alone 1
• Avoid high-fructose foods alone: Exclusively fructose-containing drinks increase symptoms, but fructose-glucose combinations are better tolerated 1
• Carbohydrate concentration: Ingest carbohydrates with sufficient water or choose lower concentration drinks to prevent high osmolality in the stomach 1
• Protein intake: Appropriate protein consumption before and during exercise provides beneficial outcomes 1

Hydration Management:

• Maintain euhydration: Dehydration exacerbates GI symptoms, so start exercise well-hydrated and maintain fluid balance 1
• Practice fluid tolerance: Athletes unaccustomed to fluid ingestion during exercise have a twofold risk of developing GI symptoms 1

Pre-Exercise Dietary Modifications:

• Avoid high-fiber foods: Eliminate high-fiber intake in the day(s) before competition 1
• FODMAP manipulation: Dietary restriction of fermentable oligo-, di-, and mono-saccharides and polyols has shown beneficial outcomes for GI symptom management 1
• Avoid NSAIDs: Ibuprofen and aspirin increase intestinal permeability three- to fivefold and aggravate exercise-induced small intestinal injury—strongly discourage use in athletes with GI symptoms 1

Gut Training Protocol

"Training the gut" through repeated practice of nutrition strategies during exercise is essential and reduces symptom risk by 50%. 1

Implementation Strategy:

• Progressive conditioning: Athletes not accustomed to fluid/food ingestion during exercise have double the risk of GI symptoms compared to those who regularly practice intake 1
• Repeated exposure improves tolerance: Studies demonstrate that 28 days of high carbohydrate intake during training improved exogenous carbohydrate oxidation and absorption, reducing GI distress 1
• Sensory adaptation occurs: Repeated sessions of drinking while exercising improved stomach comfort independent of changes in gastric emptying, suggesting desensitization to intragastric pressure 1

Practical Application:

• Practice race-day nutrition repeatedly: Experiment with the exact pre-game and during-game nutrition plan multiple times before competition 1
• Gradual volume increases: Start with smaller volumes and progressively increase fluid/food intake during training sessions 1
• Sport-specific training: Practice nutrition strategies during hockey-specific activities, not just general exercise 1

Second-Line Interventions for Persistent Symptoms

If symptoms persist despite first-line strategies, undertake individualized gastrointestinal assessment during exercise to identify specific causal factors. 1

Assessment Components:

• Exercise-specific evaluation: Test the athlete during actual hockey activity to reproduce symptoms and identify triggers 1
• Individual variability recognition: Large individual variation exists in EIGS markers, so standardized approaches often fail 1
• Multidisciplinary approach: Complex cases require collaboration between sports dietitians, physicians, and exercise scientists 1

Promising but Less-Established Strategies:

• Heat mitigation: May provide benefit but requires further investigation 1
• Prebiotic supplementation: Shows promise but needs more research 1
• Phenolic compounds: Preliminary evidence suggests potential benefit 1

Strategies to Avoid

Several interventions have demonstrated negative outcomes and should be avoided. 1

• Low-carbohydrate high-fat diets: Associated with worse GI outcomes 1
• Probiotic supplementation: Has not shown beneficial effects for exercise-associated GI symptoms 1
• Pharmaceutical interventions: Generally ineffective and potentially harmful 1
• NSAIDs (ibuprofen, aspirin): Aggravate exercise-induced intestinal injury and increase permeability—strongly contraindicated 1

Common Pitfalls

• Assuming all abdominal pain is benign: While EIGS is common, always exclude serious pathology like pancreatic injury, which can occur in contact sports like hockey 7
• Generic recommendations: Each athlete's GI response is unique; avoid one-size-fits-all approaches 1
• Inadequate practice time: Athletes need weeks of gut training, not just days, to adapt 1
• Ignoring groin/abdominal strain: Hockey players have high rates of groin/abdominal muscle strains (cumulative incidence 12-20 injuries/100 players/year), which present differently than EIGS 6

Monitoring and Follow-Up

• Track symptom patterns: Document when symptoms occur (timing in game, relationship to food/fluid intake) 2
• Progressive return: If symptoms resolve with interventions, gradually increase exercise intensity while maintaining nutrition strategies 5
• Referral thresholds: Persistent symptoms despite 4-6 weeks of appropriate management warrant gastroenterology consultation 2