From the Guidelines
Evidence-based options for functional abdominal pain include a multimodal approach combining lifestyle modifications, psychological interventions, and medications, with the most recent and highest quality study suggesting that low-dose tricyclic antidepressants such as amitriptyline (10-50mg at bedtime) should be the first choice for abdominal pain, initiated at low doses and titrated according to symptomatic response 1.
Key Interventions
- First-line treatments include education about the condition and reassurance that it is not life-threatening.
- Dietary modifications such as reducing intake of gas-producing foods, FODMAPs, and caffeine can help reduce symptoms, with a low FODMAP diet being an effective treatment for global gastrointestinal symptoms, abdominal pain, bloating or distension, stool output, and quality of life 1.
- Regular physical activity and stress management techniques like deep breathing, meditation, and yoga are beneficial.
- Psychological interventions with strong evidence include cognitive behavioral therapy (CBT), gut-directed hypnotherapy, and mindfulness-based stress reduction, typically delivered over 6-12 weekly sessions.
Medication Management
- Antispasmodics like hyoscyamine (0.125-0.25mg as needed) or dicyclomine (10-20mg three to four times daily) can help with acute pain.
- Low-dose tricyclic antidepressants such as amitriptyline (10-50mg at bedtime) or selective serotonin reuptake inhibitors like citalopram (10-20mg daily) can reduce pain perception and improve gut motility.
- Peppermint oil capsules (0.2-0.4ml three times daily) may help with pain and bloating.
Approach to Management
- A combination approach typically yields better results than single interventions alone.
- Adopting an evidence-based approach to functional abdominal pain treatment and communicating this accurately to patients is vital to avoid harm from unregulated and unproven approaches.
- Central neuromodulation with neuromodulators such as tricyclic antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs) can act on pathways between the gut and the brain to improve symptoms, with TCAs being the first choice for abdominal pain 1.
From the Research
Evidence-Based Options for Functional Abdominal Pain
The following options are based on available research studies:
- Antidepressants: Tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) have been shown to be effective in relieving functional abdominal pain 2, 3.
- Antispasmodics: These medications can help relieve abdominal pain and discomfort 2, 4.
- Dietary changes: Increasing dietary fiber and using bulking agents can help improve constipation symptoms, while laxatives can help improve diarrhea symptoms 2, 5.
- Probiotics: Some probiotics may have a potential benefit in improving global IBS symptoms, including abdominal pain 2.
- Psychologic therapy: Certain types of psychologic therapy may be effective in improving global symptoms in some patients with functional abdominal pain 2, 5.
- Nonabsorbable antibiotics: A short-term course of nonabsorbable antibiotics may improve global IBS symptoms, particularly in patients with diarrhea-predominant IBS 2.
Considerations for Treatment
When considering treatment options, the following factors should be taken into account:
- Patient's symptoms: The treatment plan should be tailored to the patient's specific symptoms, such as constipation, diarrhea, or abdominal pain 2, 5.
- Psychiatric factors: Patients with psychiatric factors, such as depression or anxiety, may benefit from treatment with antidepressants or psychologic therapy 3, 5.
- Adverse effects: The potential adverse effects of each treatment option should be considered, including the risk of suicidality in children and young adults taking SSRIs 3, 6.
- Individualized treatment: Some patients may require individualized treatment, such as pelvic floor retraining for rectal evacuation disorders or sequestrants for bile acid diarrhea 5.