From the Guidelines
Management for chronic abdominal pain should prioritize a collaborative, empathic, and culturally sensitive patient-provider relationship, focusing on non-pharmacologic therapies and avoiding opioids due to their risks of dependence and paradoxical hyperalgesia. This approach is supported by the most recent and highest quality study, which emphasizes the importance of a multifaceted management plan that includes patient education, stress management, and lifestyle modifications 1.
Key Components of Management
- Non-pharmacologic therapies: These should be considered routinely as part of comprehensive pain management, ideally introduced early in care. This includes cognitive behavioral therapy, stress management techniques, dietary modifications, regular physical activity, and heat therapy 1.
- Pharmacologic management: When necessary, pharmacologic options should be chosen based on the underlying cause of pain and the presence of neuropathic pain components. Tricyclic antidepressants like amitriptyline or SNRIs like duloxetine may be considered for neuropathic pain, while antispasmodics like dicyclomine can help with cramping pain 1.
- Avoidance of opioids: Opioids should not be prescribed for chronic gastrointestinal pain due to the high risk of dependence and potential for paradoxical hyperalgesia, as highlighted in recent clinical practice updates 1.
Lifestyle and Behavioral Modifications
- Dietary changes: Eliminating trigger foods and considering diets like the low FODMAP diet can help manage symptoms in conditions such as irritable bowel syndrome (IBS) 1.
- Regular physical activity: Exercise can help improve physical function and quality of life, and is recommended as part of the management plan for chronic abdominal pain 1.
- Stress management: Techniques such as mindfulness-based stress reduction, gut-directed hypnotherapy, and cognitive behavioral therapy can be beneficial in managing stress and improving symptoms 1.
Monitoring and Adjustment
- Regular follow-up: Essential to monitor treatment efficacy, adjust the management plan as needed, and ensure that the patient's quality of life is improving 1.
- Patient education: Setting realistic expectations and educating patients about their condition and management options is crucial for achieving significant improvement in function and quality of life 1.
From the Research
Management Strategies for Chronic Abdominal Pain
- The primary role of the general practitioner is to differentiate an organic disease from a functional one, to refer to a specialist, or to provide treatment for the underlying cause of pain 2.
- A systematic approach for evaluating patients and initiating a management plan are recommended in the primary care setting, starting with a detailed history and physical examination 2.
- Diagnostic investigations should be limited and adapted according to the clinical features, the alarm symptoms, and the symptom severity 2.
Pharmacological and Interventional Options
- Centrally targeted pharmacotherapy, such as antidepressants, can be an effective treatment option for chronic abdominal pain, especially in functional gastrointestinal disorders 3.
- Interventional treatment modalities, including sympathetic nerve blocks, neurolytic injections, neuromodulation, and intrathecal drug delivery, can be considered for chronic abdominal and pelvic visceral pain 4.
- First and second line pharmacotherapies can be considered for chronic functional abdominal pain, and seeking specialist care in a pain clinic, psychiatry, or behavioural therapy may be necessary 5.
Approach to Diagnosis and Treatment
- Identifying predominant bloaters and abdominal wall pain, and excluding organic disease, including consideration of laparoscopy for diagnosis, are important steps in managing chronic abdominal pain 5.
- Considering chronic functional abdominal pain and referring patients to receive psychological support, such as cognitive therapy, associated with available pharmacological therapeutic options, can be beneficial 2.
- Gastroenterologists should consider various gastrointestinal diseases, such as gastroesophageal reflux disease, epigastric pain syndrome, duodenal ulcers, gastric ulcer, irritable bowel syndrome, and Crohn's disease, when evaluating chronic abdominal pain 6.