What are the treatment options for an adult patient with no underlying medical conditions experiencing stomach cramps?

Treatment of Stomach Cramps in Adults Without Underlying Medical Conditions

For an otherwise healthy adult with stomach cramps, first-line treatment should be antispasmodic medications (such as dicyclomine, hyoscyamine, or peppermint oil) combined with dietary modifications including small frequent meals and avoidance of high-fat foods. 1

Initial Assessment and Red Flags

Before initiating treatment, exclude alarm features that require urgent investigation:

• Age >50 years with new-onset symptoms, unintentional weight loss, nocturnal diarrhea, rectal bleeding, family history of GI malignancy or inflammatory bowel disease 1
• Fever, peritonitis signs, blood loss, delirium, or abdominal cramps not relieved by loperamide (if diarrhea present) 2
• Severe dehydration, persistent vomiting with reduced urine output, or inability to eat 2

If any red flags are present, obtain complete blood count, comprehensive metabolic panel, inflammatory markers (CRP), and consider imaging with CT abdomen/pelvis with IV contrast before empiric treatment. 1, 3

First-Line Treatment Approach

Dietary Modifications

• Eat small, frequent meals rather than large meals 1
• Avoid high-fat foods, limit caffeine and alcohol, ensure adequate hydration 1
• Consider identifying specific food triggers: dairy products, wheat/gluten, high FODMAP foods 1

Pharmacologic Management

• Start with antispasmodics as first-line pharmacologic therapy: dicyclomine, hyoscyamine, or peppermint oil 1
• Over-the-counter symptomatic therapy is appropriate for mild patient-reported symptom severity 2

Critical caveat: Avoid NSAIDs (like naproxen or ibuprofen) for functional abdominal cramping, as they can cause stomach pain, ulcers, and bleeding in the stomach and intestines. 4

Second-Line Treatment for Refractory Symptoms

If symptoms persist after 8-12 weeks of first-line therapy:

Neuromodulator Therapy

• Initiate low-dose tricyclic antidepressants (TCAs) such as amitriptyline 10-25 mg at bedtime, titrating slowly based on response 1, 5
• Alternative: SNRIs such as duloxetine if TCAs are not tolerated or for more severe symptoms 2, 1, 5
• TCAs work through descending pain modulation pathways and can reduce visceral hypersensitivity 2

Dietary Escalation

• Consider supervised low FODMAP diet with a trained dietitian as second-line dietary therapy 1
• Add soluble fiber supplementation such as ispaghula 1

Psychological Interventions

For severe or refractory cramping pain:

• Initiate cognitive behavioral therapy (CBT) early, alongside medical therapy, to address catastrophizing and pain-related fear avoidance 1, 5
• Offer gut-directed hypnotherapy for patients with visceral hypersensitivity and somatic symptoms 1, 5
• Consider mindfulness-based stress reduction for psychological stress management 5

These psychological interventions have strong evidence for global symptom improvement and should not be delayed until after prolonged medication trials. 2, 5

Critical Pitfalls to Avoid

• Never prescribe opioids for functional gastrointestinal cramping pain, as they worsen outcomes and risk narcotic bowel syndrome 3, 5, 6
• Do not continue invasive testing once functional diagnosis is established with normal basic laboratory workup 5
• Avoid dismissing symptoms as "psychological" in a pejorative sense; explain that pain is real but involves central amplification mechanisms requiring brain-gut axis treatment 5
• Do not use NSAIDs chronically for abdominal cramping, as they directly cause stomach pain, ulcers, and GI bleeding 4

When to Refer to Gastroenterology

• Alarm features present after initial assessment 1
• Diagnostic uncertainty exists after initial workup 1
• Failure to respond to first-line therapies within 8-12 weeks 1
• Consideration needed for endoscopy if age >50 with new symptoms or family history of GI malignancy 1

Treatment Algorithm Summary

1. Mild symptoms: Dietary adjustments + over-the-counter antispasmodics 2, 1
2. Moderate symptoms: Prescription antispasmodics + dietary modifications + consider early CBT 1
3. Severe/refractory symptoms: Add low-dose TCAs or SNRIs + gut-directed hypnotherapy + multidisciplinary pain management without opioids 1, 5, 6

The foundation of all treatment is establishing a collaborative, empathic patient-provider relationship that acknowledges pain is real and multifactorial. 5