What is the appropriate management for a patient with abdominal pain, considering their past medical history and demographic factors?

Management of Abdominal Pain

Initial Diagnostic Approach

The management of abdominal pain requires immediate determination of whether life-threatening pathology exists, followed by anatomic localization to guide imaging selection and definitive diagnosis.

Rule Out Life-Threatening Causes First

• Pain out of proportion to physical examination findings is the hallmark of mesenteric ischemia and demands immediate CT angiography, particularly in elderly patients with cardiovascular disease, as this condition carries 30-90% mortality 1
• Aortic dissection or ruptured abdominal aortic aneurysm presents with severe abdominal and back pain with abrupt onset and requires emergent CT angiography 1
• Perforated viscus manifests with abdominal rigidity and peritoneal signs requiring immediate surgical evaluation 1
• When peritoneal signs are present, code as acute abdomen (R10.0) as this indicates potential surgical pathology requiring immediate evaluation 2

Anatomic Localization Guides Imaging Selection

• For right upper quadrant pain, ultrasonography is the preferred initial imaging to evaluate for acute cholecystitis, which represents 9-11% of acute abdominal pain cases 1, 3
• For right lower quadrant pain, CT abdomen and pelvis with IV contrast is recommended to evaluate for appendicitis, which accounts for approximately one-third of emergency department presentations and is most common in patients aged 10-30 years 1, 3
• For nonlocalized acute abdominal pain with fever or concerning features, CT abdomen and pelvis with IV contrast is the preferred initial imaging 1
• Plain radiographs have limited value as findings appear late when infarction has occurred 1

Critical Laboratory and Clinical Considerations

• Beta human chorionic gonadotropin testing is mandatory before imaging in all women of reproductive age 1
• Laboratory values may be normal despite serious infection, especially in elderly and immunocompromised patients 1
• In immunocompromised or neutropenic patients, code both the abdominal pain and underlying immunocompromised state 2

Management of Acute Pain During Active Inflammation

For patients with inflammatory bowel disease experiencing acute abdominal pain during disease flares, optimize medical therapy targeting the underlying inflammation, as acute pain during episodes of inflammation generally disappears rapidly with appropriate treatment 4

• 50-70% of IBD patients experience pain during active disease 1
• Nocturnal symptoms in IBD may indicate active inflammation requiring therapy optimization 1

Management of Chronic Abdominal Pain

When Chronic Pain Develops

Chronic abdominal pain in IBD or functional disorders requires early multidisciplinary intervention combining brain-gut behavioral therapies and neuromodulators, as central mechanisms of pain modulation play the primary role in pain persistence 4

Risk Factors for Transition to Chronic Pain

• History of any type of chronic pain, prior early-life adversity or trauma including discrimination experiences and poverty, poor coping styles such as catastrophizing, pre-existing anxiety and depression, or prior negative experiences with pain predict transition to chronic pain 4, 5
• Pain-reinforcing factors in the social environment including lack of positive social support, substance misuse, disability status, or worker's compensation hasten conversion to chronic pain conditions 4, 5

Pharmacologic Management

Start low-dose tricyclic antidepressants (amitriptyline 10 mg once daily at bedtime, titrating slowly to 30-50 mg daily) as baseline therapy, as TCAs serve as gut-brain neuromodulators with analgesic properties independent of mood effects 5

• TCAs modulate pain processing in the brain and spinal cord through descending serotonergic and noradrenergic pathways, with analgesic efficacy taking 1-3 weeks 4, 5
• TCAs are superior to SSRIs for abdominal pain based on meta-analysis data 5
• Serotonin noradrenergic reuptake inhibitors can also be prescribed and managed by gastroenterologists 4

Critical Medication Avoidance

Never prescribe opioids for chronic functional abdominal pain, as opioids cause narcotic bowel syndrome (occurring in approximately 6% of chronic users), dependence, gut dysmotility, serious infection risk, and increased mortality 5

Brain-Gut Behavioral Therapies

Refer patients to a psychologist experienced in chronic pain management for cognitive behavioral therapy or gut-directed hypnotherapy early in the course of treatment 4, 5

• CBT is most effective for patients who have insight into how thoughts, feelings, and behaviors relate to their pain 4, 5
• Patients with more visceral hypersensitivity or somatic symptoms do well with hypnotherapy, provided they do not have severe post-traumatic stress disorder and it is delivered by a certified clinical provider 4
• Relaxation and stress management interventions reduce pain in inactive Crohn's disease (symptom frequency reduction index=-26.7 for psychologist-led and -11.3 for self-directed stress management at 6-month follow-up) 6

Self-Management Strategies

• Initiate breathing techniques and relaxation training immediately, which can be taught by the gastroenterologist, as these address heightened autonomic arousal related to pain and stress 5
• Regular exercise improves physical function and quality of life by offsetting the negative consequences of pain-related inactivity 5

Dietary Interventions

• Consider referral to a specialized gastroenterology dietitian if dietary triggers are suspected, as a low FODMAP diet supervised by a trained dietitian may help moderate-to-severe gastrointestinal symptoms 5
• A Mediterranean diet should be considered for patients with psychological-predominant symptoms 5

Management of Irritable Bowel Syndrome

A working diagnosis of IBS can be safely made in general practice based on typical symptoms (abdominal pain relieved by defecation, associated with altered stool frequency or consistency), normal physical examination, and absence of sinister features (weight loss, rectal bleeding, nocturnal symptoms, or anemia) 4

Supportive Features

• The diagnosis is more likely if the patient is female, aged <45 with a history >2 years, and has attended frequently in the past with non-gastrointestinal symptoms 4
• Lethargy, poor sleep, fibromyalgia, backache, urinary frequency, and dyspareunia are more frequent in IBS and supportive of the diagnosis 4

When to Refer

• If symptoms are atypical, the history short, or the patient over 45, perform further investigations, often via hospital referral 4
• Those referred to hospital will usually require sigmoidoscopy if there are colonic symptoms, with biopsy of any abnormality and all patients with diarrhea to detect unsuspected microscopic colitis 4

Special Considerations for Elderly Patients

Elderly patients with acute abdominal pain require heightened vigilance as physical examination can be misleadingly benign even with catastrophic conditions, and initial diagnosis is correct only one-half of the time in older patients with appendicitis 7

• Changes in the biliary system due to aging make older patients vulnerable to acute cholecystitis, the most common indication for surgery in this population 7
• Diverticulitis is a common cause of abdominal pain in older patients and may be treated on an outpatient basis with oral antibiotics in appropriately selected patients 7
• Small and large bowel obstructions, usually caused by adhesive disease or malignancy, are more common in the aged and often require surgery 7

Communication and Assessment Strategies

Listen for specific pain descriptors that provide insights into modifiable psychological factors: describing pain as "unbearable" or "ripping and tearing" indicates high activation of emotional reactivity networks and points to pain catastrophizing, while "burning" or "sharp" points more to altered sensory input 4

• Patients who make comments like "I cannot have this pain; there must be something wrong" require efforts to build acceptance of chronic pain and shift focus from "cure" toward management 4
• Emphasize to patients that catastrophizing is not a psychological weakness but the consequence of well-characterized brain mechanisms, such as biased engagement of the brain's salience system 4
• Screen explicitly for intimate partner violence using direct questions about physical harm, emotional abuse, and feeling unsafe at home, as early-life adversity and trauma are established risk factors for chronic pain 5

Common Pitfalls to Avoid

• Avoid repetitive testing once functional diagnosis is established, as this increases costs without benefit and reinforces illness behavior 5
• Avoid language suggesting the patient "shouldn't be in so much pain" or continuing to order tests to find the "cause," as this engages in pain catastrophizing 5
• Validate that both gastrointestinal and psychological symptoms are real and taken seriously to build trust and improve outcomes 5

Over-the-Counter Pain Management

For acute, self-limited abdominal pain without concerning features, acetaminophen may be used as a pain reliever at a dose of 2 caplets every 8 hours (maximum 6 caplets in 24 hours), but patients should stop use and consult a physician if pain gets worse or lasts more than 10 days, as these could be signs of a serious condition 8