What is the initial treatment for stomach pain?

Initial Treatment for Stomach Pain

Start with antispasmodics (such as mebeverine or hyoscine butylbromide) or peppermint oil as first-line pharmacological treatment for stomach pain, combined with dietary modifications including small frequent meals and temporary elimination of lactose, alcohol, and high-osmolar supplements. 1, 2

Immediate First-Line Approach

Lifestyle and Dietary Modifications

• Advise regular exercise at the initial visit, as this is recommended for all patients with abdominal pain 1
• Implement eating frequent small meals consisting of easily digestible foods such as bananas, rice, applesauce, and toast 2
• Temporarily eliminate lactose-containing products, alcohol, and high-osmolar supplements as first-line dietary advice 2
• Start soluble fiber (ispaghula) at 3-4 g/day, gradually increasing to avoid bloating, which is effective for global symptoms and abdominal pain 1, 2

First-Line Pharmacological Treatment

• Antispasmodics are the initial drug choice for stomach pain, with mebeverine having direct inhibitory effects on intestinal smooth muscle and causing fewer systemic side effects 1, 2
• Peppermint oil is equally effective as a first-line option for abdominal pain 1
• For pain aggravated by eating specifically, use antispasmodics such as hyoscine butylbromide or dicyclomine to relieve intestinal spasms 2

Important caveat: The evidence quality for antispasmodics is rated as very low, though they remain guideline-recommended first-line agents 1. Despite weak evidence, they are safe and widely recommended across multiple guidelines.

Second-Line Treatment (If Pain Persists After 3-6 Weeks)

Tricyclic Antidepressants (TCAs)

• Start amitriptyline 10 mg once daily at bedtime if pain persists after first-line therapy 1, 2
• Titrate slowly to a maximum of 30-50 mg once daily based on symptomatic response 1, 2
• TCAs have moderate evidence quality, which is stronger than antispasmodics, and work through neuromodulatory and analgesic properties independent of psychotropic effects 3, 1
• TCAs should be the first choice for abdominal pain among neuromodulators, as meta-analyses demonstrate significant benefit compared with placebo 3
• TCAs can cause constipation by prolonging gut transit time, which may be serendipitously helpful in diarrhea-predominant conditions 3

Alternative Neuromodulators

• SSRIs (such as fluoxetine, paroxetine, or sertraline) can be considered if TCAs are not tolerated or if comorbid anxiety/depression is present 3, 1, 2
• If a mood disorder is suspected, use an SSRI at therapeutic dose rather than low-dose TCAs, as low doses are unlikely to adequately treat mood disorders 3
• SSRIs have less evidence for direct pain reduction compared to TCAs but offer lower side effect profiles and better safety 3, 2

Second-Line Dietary Therapy

• A low FODMAP diet can be used under dietitian supervision to reduce abdominal pain and bloating, though evidence quality is very low 1, 2

Critical Pitfalls to Avoid

What NOT to Use

• Avoid conventional analgesia, including opiates, as they are not successful for treating abdominal pain and carry risks of addiction and paradoxical amplification of pain sensitivity 3, 2
• Avoid insoluble fiber (such as wheat bran), as it may exacerbate symptoms 2
• Avoid anxiolytics due to weak treatment effects, potential for physical dependence, and drug interactions 3

Adjunctive Therapies to Consider Early

Psychological Interventions

• Cognitive-behavioral therapy and gut-directed hypnotherapy are effective for reducing abdominal pain and should be considered early, not just after multiple drug failures 1, 2
• Psychological treatments are particularly beneficial when symptoms are severe enough to impair quality of life, or when patients relate symptom exacerbations to stressors 3

Probiotics

• Probiotics may be effective for global symptoms and abdominal pain, though no specific strain can be recommended; trial for 12 weeks 1

Treatment Algorithm Summary

1. Week 0: Start antispasmodics or peppermint oil + dietary modifications + exercise
2. Week 3-6: If inadequate response, add TCA (amitriptyline 10 mg at bedtime)
3. Week 6-12: Titrate TCA to 30-50 mg; consider SSRI if TCA not tolerated
4. Throughout: Consider psychological interventions early, especially for severe symptoms
5. Refractory cases: Multidisciplinary approach with integrated pharmacological treatment and psychological support 2

The key principle is that antispasmodics remain first-line despite weak evidence because they are safe, guideline-recommended, and provide a rational starting point before escalating to neuromodulators with stronger evidence but more side effects.