What is the best approach to treat stomach spasms in an adult patient with a functional gastrointestinal disorder, such as irritable bowel syndrome (IBS) or functional dyspepsia?

Treatment of Stomach Spasms in Functional Gastrointestinal Disorders

For stomach spasms in adults with functional GI disorders like IBS or functional dyspepsia, start with antispasmodics (dicyclomine or peppermint oil) as first-line pharmacological therapy, combined with lifestyle modifications including regular exercise and dietary adjustments. 1

Initial Management: Lifestyle and Dietary Modifications

All patients should begin with non-pharmacological interventions before escalating to medications:

• Prescribe regular physical activity to all patients, as exercise provides significant benefits for symptom management and can reduce spasms 1, 2

• Start soluble fiber supplementation (ispaghula/psyllium) at 3-4 g/day, gradually increasing to avoid bloating, particularly for constipation-predominant symptoms 1, 2

• Avoid insoluble fiber (wheat bran) as it consistently worsens symptoms including spasms and bloating 1, 2

• Consider a supervised low FODMAP diet for refractory symptoms, delivered in three phases: restriction, reintroduction, and personalization 2

First-Line Pharmacological Treatment for Spasms

Antispasmodics are the cornerstone of treating stomach spasms:

• Dicyclomine (anticholinergic antispasmodic) is recommended as first-line therapy for abdominal pain and spasms, particularly when symptoms are meal-related 1, 2

• Peppermint oil serves as an effective alternative antispasmodic with fewer side effects, though evidence is more limited 1, 2, 3

• Meta-analysis of 22 RCTs showed significant improvement in IBS-related global symptoms with antispasmodics, with modest improvement in abdominal pain and minimal risk of important adverse effects 1

Common side effects to counsel patients about: dry mouth, visual disturbances, and dizziness are common with anticholinergic antispasmodics 2

Second-Line Treatment: Neuromodulators for Refractory Spasms

When first-line therapies fail after 3 months, escalate to tricyclic antidepressants:

• Start amitriptyline 10 mg once daily at bedtime, titrating slowly (by 10 mg/week) according to response and tolerability to a maximum of 30-50 mg once daily 1, 2

• TCAs are the most effective pharmacological treatment for mixed symptoms and refractory pain, showing modest improvement in global relief and abdominal pain in multiple RCTs 1

• Continue for at least 6 months if the patient reports symptomatic response 1

• Use with caution in patients at risk for QT interval prolongation 1

SSRIs are NOT recommended: Pooled estimates from 5 RCTs showed no improvement in global relief symptoms or abdominal pain 1

Third-Line Treatment: Psychological Therapies

For symptoms persisting despite 12 months of pharmacological treatment:

• Refer for IBS-specific cognitive behavioral therapy or gut-directed hypnotherapy, which are effective for reducing abdominal pain and spasms 1, 2

• These brain-gut behavior therapies are specifically designed for IBS and differ from psychological therapies that target depression and anxiety alone 2

Treatment Algorithm Summary

1. Month 0-3: Exercise + dietary modifications + antispasmodics (dicyclomine or peppermint oil)
2. Month 3-6: If inadequate response, add tricyclic antidepressants (amitriptyline 10-50 mg daily)
3. Month 12+: If still refractory, refer for IBS-specific CBT or gut-directed hypnotherapy

Review efficacy after 3 months and discontinue ineffective medications 1, 2

Critical Pitfalls to Avoid

• Do NOT use anticholinergic antispasmodics in constipation-predominant patients, as they reduce intestinal motility and enhance water reabsorption, worsening constipation 1

• Do NOT prescribe SSRIs for spasms or pain, as evidence shows no benefit 1

• Do NOT continue ineffective therapies indefinitely—reassess at 3 months 1, 2

• Avoid insoluble fiber (wheat bran), which worsens spasms and bloating 1, 2

Special Considerations

For diarrhea-predominant symptoms with spasms:

• Loperamide 4-12 mg daily can be added to reduce stool frequency and urgency, though it has mixed results for abdominal pain 2, 4

For severe refractory diarrhea-predominant IBS with spasms:

• 5-HT3 receptor antagonists (ondansetron 4 mg once daily titrated to maximum 8 mg three times daily) are effective second-line options, though constipation is the most common side effect 2