What are the causes of chronic abdominal pain in a patient with Gilbert's syndrome (a benign genetic liver disorder)?

From the Guidelines

Chronic abdominal pain in patients with Gilbert syndrome is typically not caused by the syndrome itself, but rather by unrelated conditions such as irritable bowel syndrome (IBS), inflammatory bowel disease, gastroesophageal reflux disease (GERD), peptic ulcer disease, gallbladder disease, chronic pancreatitis, or abdominal wall pain syndromes. The most common causes of chronic abdominal pain in these patients are likely due to disorders of gut-brain interaction, including IBS, functional dyspepsia, and centrally mediated abdominal pain syndrome (CAPS) 1. Patients with Gilbert syndrome may experience mild right upper quadrant discomfort during fasting, illness, or stress when bilirubin levels rise, but this is usually transient.

Causes of Chronic Abdominal Pain

• Irritable bowel syndrome (IBS)
• Inflammatory bowel disease
• Gastroesophageal reflux disease (GERD)
• Peptic ulcer disease
• Gallbladder disease
• Chronic pancreatitis
• Abdominal wall pain syndromes
• Disorders of gut-brain interaction, including functional dyspepsia and centrally mediated abdominal pain syndrome (CAPS) 1

Management

Management should focus on identifying and treating the underlying cause of the abdominal pain through appropriate diagnostic workup, including laboratory tests, imaging studies, and possibly endoscopic evaluation. It's essential to optimize medical therapies that modulate pain and differentiate between visceral and centrally mediated factors 1. Lifestyle modifications such as regular meals, adequate hydration, and stress management may help reduce episodes of hyperbilirubinemia in Gilbert syndrome patients, potentially alleviating any mild discomfort associated with the condition.

Treatment Approach

• Identify and treat the underlying cause of abdominal pain
• Optimize medical therapies that modulate pain
• Differentiate between visceral and centrally mediated factors
• Consider lifestyle modifications to reduce episodes of hyperbilirubinemia
• Avoid opioids for chronic gastrointestinal pain due to the risk of opioid use disorders and overdose-related deaths 1

From the Research

Causes of Chronic Abdominal Pain in Gilbert Syndrome

The causes of chronic abdominal pain in patients with Gilbert syndrome can be multifaceted. Some studies suggest that:

• Functional disorders, such as irritable bowel syndrome, should be considered after organic pathology has been excluded 2
• A detailed history and physical examination are essential in evaluating patients with chronic abdominal pain 2, 3
• The pathophysiology of chronic abdominal discomfort syndrome (CADS) is noted to be neurogenic, possibly stemming from visceral sympathetic nerves or abdominal wall afferent nerves 4

Specific Considerations for Gilbert Syndrome

In patients with Gilbert syndrome, the following factors may contribute to chronic abdominal pain:

• Recurrent jaundice, which can be associated with abdominal pain, dyspepsia, or loss of appetite 5
• Risk factors for hyperbilirubinemia, such as general anesthesia, pregnancy, fasting, and low-calorie weight loss plans 5
• Nutritional deficiencies, such as low 25-Hydroxyvitamin D3 levels, which can impact health-related quality of life 5

Diagnostic Approach

A systematic approach to evaluating patients with chronic abdominal pain is recommended, including:

• A detailed history and physical examination 2, 3
• Limited and targeted diagnostic investigations, adapted to the clinical features and symptom severity 2
• Consideration of functional disorders, such as CADS, and referral to a pain physician or specialist as needed 2, 4