From the Guidelines
A comprehensive workup for severe abdominal pain with exercise should begin with a detailed history and physical examination to identify potential causes, followed by imaging studies, starting with abdominal ultrasound, as recommended by the American College of Radiology 1. Initial evaluation should include vital signs, abdominal examination, and laboratory tests including complete blood count, comprehensive metabolic panel, lipase, and urinalysis. Some key points to consider in the workup include:
- Exercise-related abdominal pain may be caused by several conditions including exercise-induced ischemic colitis, splanchnic artery stenosis, abdominal wall hernias, or exercise-related transient abdominal pain (ETAP or "stitch") 1.
- For patients with suspected vascular causes, CT angiography or MR angiography may be necessary to evaluate mesenteric blood flow during exercise.
- A gastroenterology consultation is recommended, and in some cases, a vascular surgery evaluation may be appropriate.
- While awaiting diagnosis, patients should temporarily reduce exercise intensity and monitor which activities trigger symptoms.
- Pain management may include acetaminophen or NSAIDs like ibuprofen (400-600mg every 6-8 hours) with food, avoiding NSAIDs if GI bleeding is suspected, as suggested by recent studies 1. This systematic approach helps identify the underlying cause of exercise-induced abdominal pain, which is crucial for appropriate treatment and prevention of serious complications like bowel ischemia. Recent updates to the ACR Appropriateness Criteria for right lower quadrant pain also emphasize the importance of imaging in diagnosing appendicitis and other causes of abdominal pain, with a focus on reducing radiation exposure and improving diagnostic accuracy 1.
From the Research
Evaluation of Severe Abdominal Pain with Exercise
- Severe abdominal pain can be caused by various conditions, ranging from benign to surgical emergencies 2.
- The location of pain is a useful starting point for evaluation, with right lower quadrant pain suggesting appendicitis 2.
- A thorough evaluation, including patient history, physical examination, laboratory tests, and imaging studies, is necessary to determine the cause of abdominal pain 2, 3.
Role of Exercise in Abdominal Pain
- Exercise can be a contributing factor to abdominal pain, particularly if the pain is musculoskeletal in nature 4.
- A physical therapy evaluation can help determine if symptoms are musculoskeletal or nonmusculoskeletal in origin, and guide treatment accordingly 4.
Diagnostic Approach
- The diagnostic approach to abdominal pain involves a combination of laboratory tests, imaging studies, and physical examination findings 2, 3.
- Imaging studies, such as ultrasonography and computed tomography, are chosen based on the location of pain and index of suspicion for specific etiologies 2, 3.
- Point-of-care ultrasonography can aid in the prompt diagnosis of several etiologies of acute abdominal pain, including cholelithiasis, urolithiasis, and appendicitis 3.
Special Considerations
- Certain populations, such as women and the elderly, may require special consideration in the evaluation of abdominal pain 2.
- Women are at risk of genitourinary disease, which may cause abdominal pain, and the elderly may present with atypical symptoms of a disease 2.
- Screening for depression and/or anxiety may be performed during the evaluation of low-risk, recurrent abdominal pain 5.