What is the recommended treatment for abdominal pain?

Treatment for Abdominal Pain

Start with antispasmodics or peppermint oil as first-line pharmacological treatment for abdominal pain, followed by tricyclic antidepressants (TCAs) at low doses (10 mg amitriptyline) as second-line therapy if pain persists. 1

First-Line Pharmacological Approaches

Antispasmodics

• Antispasmodics are the primary pharmacological treatment for abdominal pain, showing significant improvement in both global symptoms (RR 0.67) and abdominal pain (RR 0.74) compared to placebo. 1
• Common options include hyoscine butylbromide or dicyclomine, taken before meals if pain is meal-related. 2, 3
• Common side effects include dry mouth, dizziness, and blurred vision, but serious adverse events are rare. 1
• Titrate the dose carefully to minimize side effects like abdominal pain, bloating, nausea, and constipation. 1

Peppermint Oil

• Peppermint oil ranks third in network meta-analyses for abdominal pain relief, performing similarly to antispasmodics and TCAs. 1
• This is a safe and effective option with minimal side effects. 1

Second-Line Pharmacological Treatment

Tricyclic Antidepressants (TCAs)

• TCAs are the most effective second-line treatment for abdominal pain, ranking first in network meta-analyses and showing significant benefit over placebo in meta-analyses. 1
• Start amitriptyline at 10 mg once daily at bedtime and titrate slowly to a maximum of 30-50 mg once daily based on symptom response and tolerability. 1, 2, 3
• TCAs work through central neuromodulation, altering pain perception and central processing, and may also reduce visceral hypersensitivity peripherally. 1
• Provide careful explanation to patients about the rationale for using an antidepressant for pain, emphasizing the gut-brain neuromodulator mechanism rather than psychiatric indication. 1
• TCAs can cause constipation by prolonging gut transit time, which may be beneficial in diarrhea-predominant conditions. 1

Selective Serotonin Reuptake Inhibitors (SSRIs)

• SSRIs are less effective than TCAs for abdominal pain specifically and should be considered only if TCAs fail or are not tolerated. 1
• SSRIs may show possible improvement in symptom relief (RR 0.74) but evidence is low quality with significant inconsistency. 1
• If a mood disorder is suspected, start an SSRI at therapeutic doses (not low doses) as it may address both gastrointestinal and psychological symptoms simultaneously. 1

Adjunctive Non-Pharmacological Interventions

Dietary Modifications

• Recommend regular exercise to all patients with abdominal pain. 1
• Start with first-line dietary advice: small frequent meals (5-6 per day), avoiding high-fat foods, caffeine, and alcohol. 1, 2, 3
• Begin soluble fiber (ispaghula) at 3-4 g/day and build up gradually to avoid bloating; this is effective for global symptoms and abdominal pain. 1, 3
• Avoid insoluble fiber (wheat bran) as it may exacerbate symptoms. 1, 3
• Consider a low FODMAP diet as second-line dietary therapy under supervision of a trained dietitian, with systematic reintroduction according to tolerance. 1, 3

Probiotics

• Probiotics as a group may be effective for global symptoms and abdominal pain, though no specific species or strain can be recommended. 1
• Advise a 12-week trial and discontinue if no improvement occurs. 1

Critical Warnings

Avoid Opioids

• Never use conventional opioid analgesia for chronic abdominal pain due to risk of addiction and paradoxical amplification of pain sensitivity through central sensitization. 1, 3

When to Escalate Care

• Immediate surgical consultation is required for signs of perforation, complete gastric outlet obstruction, or uncontrolled bleeding. 2
• Refer to gastroenterology if symptoms persist after 8-12 weeks of appropriate therapy, if alarm features develop (weight loss, nocturnal diarrhea, rectal bleeding, age >50 with new-onset symptoms, family history of GI malignancy), or for recurrent symptoms despite appropriate treatment. 2

Context-Specific Considerations

If Pain Improves with Food (Peptic Ulcer Disease Pattern)

• Start a proton pump inhibitor (PPI) immediately while pursuing H. pylori testing via test-and-treat strategy for patients under 55 without alarm symptoms. 2
• Omeprazole 20 mg once daily heals 75% of duodenal ulcers at 4 weeks. 2, 4
• Use triple therapy if H. pylori is detected: omeprazole 20 mg twice daily + clarithromycin 500 mg twice daily + amoxicillin 1 g twice daily for 10-14 days. 2

If Pain is Aggravated by Eating

• Prioritize antispasmodics taken before meals (hyoscine butylbromide or dicyclomine) as first-line treatment. 3
• Implement dietary modifications with small frequent meals and easily digestible foods. 3
• Consider low FODMAP diet as second-line therapy under dietitian supervision. 3