What medications can be given to a patient presenting with abdominal pain?

Medications for Abdominal Pain: Initial Management

For patients presenting with undifferentiated abdominal pain, provide early analgesia with intravenous paracetamol (acetaminophen), dipyrone, or piritramide as first-line agents, but do NOT routinely administer antibiotics or acid-suppressive drugs like omeprazole unless specific pathology is identified. 1, 2

Immediate Stabilization (Before Medications)

• Establish IV access and initiate fluid resuscitation if signs of sepsis, shock, tachycardia, hypotension, or hemodynamic instability are present 3, 1
• Administer low-molecular-weight heparin for VTE prophylaxis in all patients with acute abdominal pain, as this population carries high thrombotic risk 3, 1
• Correct electrolyte abnormalities and anemia before proceeding with further management 3

Pain Management: What TO Give

Early analgesia improves patient comfort without compromising diagnostic accuracy and should be provided promptly. 1, 4, 2

First-Line Analgesics:

• Intravenous paracetamol (acetaminophen), dipyrone, or piritramide are the analgesics of choice for acute abdominal pain in the emergency setting 2
• Combinations of non-opioids and opioids should be administered for moderate, severe, or extreme pain, with repeated pain assessment to guide titration 2

Critical Caveat - Avoid Opioids in Specific Contexts:

• Do NOT use opioids for chronic or functional abdominal pain, as they cause narcotic bowel syndrome, dependence, gut dysmotility, and increased mortality 1
• Opioids should not be used specifically to treat abdominal pain in patients with suspected functional disorders 3

Acid-Suppressive Drugs (Omeprazole): When NOT to Give

Omeprazole 20mg IV should NOT be routinely administered for undifferentiated abdominal pain. 1

Appropriate Indications for Omeprazole (per FDA labeling):

Omeprazole is indicated only for specific diagnosed conditions, NOT for empiric use in acute abdominal pain 5:

• Active duodenal ulcer (20mg once daily for 4 weeks)
• Active benign gastric ulcer (40mg once daily for 4-8 weeks)
• Symptomatic GERD (20mg once daily for up to 4 weeks)
• Erosive esophagitis (20mg once daily for 4-8 weeks)
• Pathological hypersecretory conditions

When Acid Suppression May Be Considered:

• Proton pump inhibitors or H2 receptor antagonists can be considered for abdominal pain specifically localized to the upper abdomen with features suggesting acid-related pathology (dyspepsia, epigastric pain) 3
• This requires clinical suspicion of peptic disease, NOT empiric use for undifferentiated pain

Antibiotics: When NOT to Give

Do NOT routinely administer antibiotics for undifferentiated abdominal pain. 3, 1

Specific Indications for Antibiotics:

Antibiotics are indicated ONLY when 3, 1:

• Intra-abdominal abscess is identified on imaging (>3cm requires percutaneous drainage plus antibiotics; <3cm may respond to antibiotics alone)
• Clinical signs of sepsis are present (fever, leukocytosis, hemodynamic instability)
• Superinfection is confirmed or strongly suspected

Antibiotic Selection When Indicated:

• Cover Gram-negative aerobic/facultative bacilli, Gram-positive streptococci, and obligate anaerobic bacilli according to local epidemiology and resistance patterns 3
• Fluoroquinolones or third-generation cephalosporin PLUS metronidazole is the recommended combination for Crohn's disease-related abscesses 3
• Duration depends on clinical and biochemical response (CRP levels) 3

Antispasmodics for Functional Pain

If functional disorder (IBS) is suspected after excluding organic pathology 3, 6:

• Hyoscyamine, dicyclomine, or peppermint oil can be used as first-line antispasmodics
• Intramuscular hyoscine has reported efficacy for severe or refractory abdominal pain

Neuromodulators for Chronic Pain

For chronic abdominal pain after organic causes excluded 3, 6:

• Tricyclic antidepressants (TCAs) are the only class proven to improve abdominal pain in meta-analyses
• Selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), pregabalin, or gabapentin can be considered
• Combinations (e.g., duloxetine plus gabapentin) may be more efficacious than monotherapy for severe continuous pain, but monitor for serotonin syndrome 3

Common Pitfalls to Avoid

• Do not give omeprazole empirically for undifferentiated abdominal pain—it has no role without specific upper GI pathology identified 1, 5
• Do not give antibiotics prophylactically—they are harmful without documented infection and contribute to resistance 3, 1
• Do not withhold analgesia pending diagnosis—this outdated practice increases patient suffering without improving diagnostic accuracy 1, 4, 2
• Do not use opioids for functional pain—this creates dependency and worsens outcomes 1