What is the appropriate workup for chronic abdominal (abd) pain?

From the Guidelines

The workup for chronic abdominal pain should begin with a thorough history and physical examination to identify potential causes, followed by initial laboratory tests and imaging studies as needed, with a focus on a multidisciplinary approach to manage symptoms and underlying causes, as recommended by the most recent study 1. The initial laboratory tests should include complete blood count, comprehensive metabolic panel, inflammatory markers (ESR, CRP), urinalysis, and stool studies for occult blood, ova, parasites, and calprotectin. Imaging studies typically start with abdominal ultrasound, followed by CT scan or MRI if needed, as suggested by the American College of Radiology Appropriateness Criteria 1. Endoscopic procedures like upper endoscopy and colonoscopy may be necessary to visualize the GI tract directly. For suspected functional disorders like irritable bowel syndrome, Rome IV criteria can guide diagnosis, and treatment may include a low FODMAP diet, cognitive behavioral therapy, and neuromodulators such as tricyclic antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs), as recommended by the most recent study 1. Additional specialized tests may include hydrogen breath testing for small intestinal bacterial overgrowth or lactose intolerance, gastric emptying studies for gastroparesis, and HIDA scan for gallbladder dysfunction. If pain persists despite negative findings, consider functional abdominal pain syndrome or central sensitization, and a multidisciplinary approach involving gastroenterology, pain management, and sometimes psychology or psychiatry often yields the best results, as suggested by the study on irritable bowel syndrome and mental health comorbidity 1. Treatment should target the underlying cause when identified, while symptom management may include antispasmodics like dicyclomine (10-20mg three times daily), neuromodulators such as amitriptyline (10-25mg nightly) or gabapentin (300mg three times daily), and non-pharmacological approaches like cognitive behavioral therapy and dietary modifications, as recommended by the study on irritable bowel syndrome and mental health comorbidity 1. Key considerations in the management of chronic abdominal pain include:

• A thorough history and physical examination to identify potential causes
• Initial laboratory tests and imaging studies as needed
• A multidisciplinary approach to manage symptoms and underlying causes
• Treatment of underlying causes, such as inflammatory bowel disease, as recommended by the AGA clinical practice update 1
• Symptom management with antispasmodics, neuromodulators, and non-pharmacological approaches
• Consideration of functional abdominal pain syndrome or central sensitization if pain persists despite negative findings.

From the Research

Chronic Abdominal Pain Workup

• The workup for chronic abdominal pain can be challenging due to a broad differential diagnosis and sometimes extensive and negative workup 2.
• A systematic approach for evaluating patients and initiating a management plan are recommended in the primary care setting, starting with a detailed history and physical examination 2, 3.
• Diagnostic investigations should be limited and adapted according to the clinical features, the alarm symptoms, and the symptom severity 2.
• The primary role of the general practitioner is to differentiate an organic disease from a functional one, to refer to a specialist, or to provide treatment for the underlying cause of pain 2.
• Functional disorders, such as irritable bowel syndrome, should be considered after the organic pathology has been confidently excluded 2, 4.

Diagnostic Tools and Approaches

• A detailed history from the patient, along with review-specific details of their history and physical examination, can provide clues about the etiology of the abdominal pain 3.
• Laboratory tests, such as those ordered in the emergency department, can help narrow the differential diagnosis based on the patient's history and examination 5.
• The gastroenterologist approach to chronic abdominal pain involves considering various causes, including gastroesophageal reflux disease, epigastric pain syndrome, duodenal ulcers, gastric ulcer, irritable bowel syndrome, and chronic pancreatitis 4.
• A practical approach to management includes identifying predominant bloaters and abdominal wall pain, excluding organic disease, and considering chronic functional abdominal pain and pharmacotherapies 6.

Key Considerations

• The costs associated with a diagnostic workup can be an expensive burden to healthcare, and repetitive testing is not recommended once a diagnosis of functional pain is established 2.
• Patients with chronic abdominal pain may require referral to a specialist, such as a gastroenterologist, or to receive psychological support, such as cognitive therapy, associated with available pharmacological therapeutic options 2, 3.