What is the treatment for acute on chronic abdominal pain with a history of low-grade ileus (partial bowel obstruction) and constipation, as seen on previous abdominal X-ray?

From the Guidelines

For acute on chronic abdominal pain with a history of low-grade ileus and constipation, I recommend starting with a bowel regimen including a stimulant laxative such as bisacodyl 10mg daily or senna 8.6mg twice daily, combined with an osmotic agent like polyethylene glycol 17g once or twice daily, as this approach is supported by recent guidelines and studies 1. This approach is based on the principle of addressing the underlying constipation while monitoring for complications of ileus. The combination of laxatives works by both drawing water into the bowel and stimulating peristalsis, which can help to relieve constipation and promote bowel motility. Some key points to consider in the management of acute on chronic abdominal pain with a history of low-grade ileus and constipation include:

• Ensuring adequate hydration with oral or IV fluids as needed
• Avoiding opioids which can worsen constipation and ileus
• Encouraging ambulation as tolerated to promote bowel motility
• Considering a clear liquid diet initially, progressing to low-residue foods as symptoms improve
• Monitoring for complications of ileus, such as worsening abdominal pain, vomiting, or abdominal distension, and obtaining a repeat abdominal X-ray if necessary It's also important to note that the management of irritable bowel syndrome (IBS), which may be a contributing factor to the patient's symptoms, involves a multimodal approach that includes dietary changes, lifestyle modifications, and pharmacologic therapy, as recommended by recent guidelines 1. However, in the context of acute on chronic abdominal pain with a history of low-grade ileus and constipation, the primary focus should be on addressing the underlying constipation and monitoring for complications of ileus, rather than solely managing IBS symptoms. Overall, a stepwise approach that prioritizes the patient's safety and comfort, while also addressing the underlying causes of their symptoms, is essential in the management of acute on chronic abdominal pain with a history of low-grade ileus and constipation.

From the Research

Acute on Chronic Abdominal Pain

The patient presents with acute on chronic abdominal pain, a history of low-grade ileus, and constipation, as seen on previous abdominal X-rays. The treatment approach for such a condition involves a comprehensive evaluation to determine the underlying cause of the pain.

Diagnostic Approach

• A detailed history and physical examination are essential in evaluating patients with chronic abdominal pain, as emphasized by 2 and 3.
• The primary care provider should differentiate between organic and functional disorders, referring to a specialist if necessary, as stated in 2.
• Diagnostic investigations should be limited and adapted according to clinical features, alarm symptoms, and symptom severity, as recommended in 2.

Considerations for Acute Abdominal Pain

• Acute abdominal pain can have various causes, including gastroenteritis, nonspecific abdominal pain, cholelithiasis, urolithiasis, diverticulitis, and appendicitis, as discussed in 4 and 5.
• Pain location, history, and examination findings help guide the workup, ensuring hemodynamic stability, as outlined in 4.
• Imaging studies, such as computed tomography or ultrasonography, may be necessary to confirm certain diagnoses, as mentioned in 4.

Management and Treatment

• The treatment plan should be based on the underlying cause of the pain, as determined by the diagnostic evaluation, as implied by 2 and 3.
• Functional disorders, such as irritable bowel syndrome, should be considered after excluding organic pathology, and repetitive testing is not recommended, as stated in 2.
• Patients with functional pain may benefit from psychological support, such as cognitive therapy, and available pharmacological therapeutic options, as suggested in 2.