โChronicโ is defined as pain lasting more than several weeks, though often for months or years, Chronic Abdominal Pain is almost always “functional,” meaning that whatever the reason, nothing bad ever happens, & people are able to live with it. The main causes:
- Irritable Bowel Syndrome (IBS)
- Dyspepsia (Digestion Difficulty; different from brief “indigestion”)
- Abdominal Wall Muscle Strain
- Anxiety or Depression (especially in children and teens) [technical term is “Somatization Disorder”, i.e. physical symptoms as a manifestation of psychological illness]
Our job is to try as hard as possible to show that itโs something else, more serious. Then, if we canโt convince ourselves, we can feel secure in our diagnosis. And we donโt order expensive or invasive (possibly dangerous) tests, or refer to specialists, unless truly necessary.
First we seek Red Flags that suggest there may be a serious condition responsible:
- Fevers or night sweats
- Blood in stool / black, tarry stools (“melena”)
- Regular nausea or vomiting
- Weight Loss
- Foot swelling (that we see for ourselves), which hides weight loss
- Age >50 y.o. when symptoms began
- Heavy alcohol history
A few comments about the Red Flags:
- Fever should be proven as >100.6ยฐ F (38.0ยฐ C), not just “feeling hot”
- โNight Sweatsโ are drenching, defined as โsoak the sheets or pajamas so much that sweat drips out when you wring themโ (more or less)
- Vomiting episodes are more significant than nausea, but persistent nausea is also concerning. However, persistent nausea with no weight loss at follow-up is less worrisome.
- โBlood in Stoolโ is more impressive if itโs noted in the toilet, not just on toilet paper.
- โMelenaโ means truly black stools, not just dark. It also means the person isn’t taking Pepto-Bismolยฎ or Iron, which turn stools black (iron might be mixed in with various multivitamin preparations)
- โWeight Lossโ can be suspected if clothing has become looser, especially if notches on the belt have changed for the tighter. Checking weights every 2-3 weeks gives ultimate proof, one way or another
- If thereโs significant swelling in the ankles, the extra fluid is adding to the measured weight. So thereโs loss of healthy weight, which is usually ominous
- Patients who say they have โno appetiteโ but donโt lose weight are certainly eating enough
We take a careful history to define the time-frame of symptoms. The longer theyโve been present, the more relaxed we are, because if something bad were going on, it’d have shown itself. However, the longer the symptoms, the more worried the patient often is.
Past episodes are especially important. Three months of pain this year, and 6 months of the same symptoms last year, rules out cancer, because cancer doesnโt come and go. Iโve had many patients smile, reassured by that simple explanation alone.
Of course, we ask about diarrhea & constipation. Are stools loose or frankly watery? For constipation, are stools hard? Most important, however, is being as exact as possible —
- Diarrhea: How many times per day, days in a row, diarrhea-free days in a row.
- Constipation: How many days in a row without bowel movements, days-in-a-row of normal stools.
All this helps us paint a picture for ourselves of exactly what the patient is experiencing.
We perform a decent physical exam looking for mouth sores, large thyroid, swollen lymph nodes, heart & lung abnormalities, and foot swelling. And of course, we perform a thorough abdominal exam, and maybe a rectal exam (especially for older patients). Pelvic and prostate exams are useful for Chronic Pelvic Pain and chronic Lower Urinary Tract Symptoms, which are not the topic at hand.
What we should never perform during exam (though so many clinicians do, & texts recommend), is a stool test for blood. That’s meant for patients over 50 to obtain at home, to screen for colon cancer. If we do it on younger patients, or during a rectal exam, we’ll wind up with a lot of false-positives, which make us order colonoscopies on people who don’t need them.
The only time I ever do a stool test for blood, in the office after a rectal exam, is if the patient mentions โblack stoolsโ & I want to see if thereโs melena (caused by significant active bleeding from stomach or bowel). True melena makes the specimen test blue in a second; if negative then, I quickly toss the card.
IF THERE ARE ANY RED FLAGS
We order basic lab tests:
- Complete Blood Count (CBC).ย Abnormalities like anemia, especially if it’s persistent, lead us to significant work-ups.
- Erythrocyte Sedimentation Rate (ESR, “Sed Rate”) and C-Reactive Protein (CRP).ย If significantly elevated, we’d wonder about Inflammatory Bowel Disease (“IBD” = Crohn’s or Ulcerative Colitis, not Irritable Bowel), or Cancer.
- Comprehensive Metabolic Panel (CMP), showing abnormalities of kidneys, liver, sugar, sodium, potassium, and proteins; these might lead a work-up in a certain direction.
- Tests for Iron (see Anemia).ย If low, we suspect blood loss from a serious stomach or bowel disease, or Celiac Disease.
- Tissue-Transglutaminase (tTG), IgA Antibody (not IgM or IgG).ย Very sensitive & specific for Celiac Disease (rarely false-negatives or false-positives)
- Lipase (blood test), for Chronic Pancreatitis.
- If constipation or diarrhea are prominent, a Thyroid Stimulating Hormone (TSH) for Hypo- or Hyperthyroidism.
We have the patient return in 3 weeks for lab results, and weigh them again. Then we begin our work-up:
Refer to Gastroenterologist for Endoscopy / Colonoscopy if:
- Signs of iron deficiency (anemia, low ferritin, low iron saturation), unless a young woman has heavy periods
- tTG elevated (= Celiac Disease). Since it requires a difficult lifetime dietary change, itโs nice to have a biopsy-proven diagnosis, as recommended by the American College of Gastroenterology. However, biopsies can be false-negative; the serum tTG may be a better diagnostic test in this regard.
- Elevated Sed Rate or CRP (especially if diarrhea is a symptom) — looking for Inflammatory Bowel Disease.
- Weight Loss (may be a variety of serious conditions)
- Age >50 (theyโd need some sort of colon cancer screening anyway; as long as they have some sort of abdominal symptoms, may as well do a colonoscopy)
Order an Abdominal CT Scan with Contrast (if kidney blood tests are normal) if:
- Significantly abnormal WBC count
- Elevated Sed Rate / CRP
- Elevated Lipase
- Weight Loss
- However, we might let a Gastroenterologist decide if a CT Scan is necessary
IF THERE ARE NO RED FLAGS
We postpone the lab tests and institute a โTherapeutic Trialโ based on our best guess Diagnosis that emerged from the history [assuming physical exam was normal]. Options include:
** If Bloating is a prominent symptom, treat for Dyspepsia with an antacid medication —
- A Proton-Pump Inhibitor (PPI);โฆ..PLUS
- Liquid Antacids used as needed;โฆ..PLUS
- Instructions to avoid eating 2-3 hours before bedtime.
Starting with a high dose of the PPI is important, because weโre aiming for a Diagnosis [hence the title of our Website]. If we give a low starting dose & it doesnโt help, we wouldnโt know if it had been wrong Diagnosis or wrong Dose. If high-dose helps, we can lower it on follow-up.
NOTE: It can be hard to distinguish Dyspepsia from Ulcer (an actual sore in the stomach) from Gastritis (like a scrape in the stomach). The last 2 conditions (same link) can sometimes cause serious complications. Patients usually seek care early on, when symptoms are acute, but some people wait a few months (not much more).
- Ulcer & Gastritis cause daily pain. If pain isn’t every day, it’s Dyspepsia.
- Ulcer & Gastritis hurt in the Epigastric area, which is usually tender to palpation on physical exam
- The same medicine for Dyspepsia works for Ulcers & Gastritis, though if we seriously consider the latter two, we’d order a test for the bacteria H. pylori.
If the PPI makes the person all better, after 2 months we might change to another type of antacid, for a couple of reasons. We get nervous about long-term PPI use. Maybe it causes osteoporosis (never well-proved, & probably doesn’t). More importantly, it’s easier to get gastrointestinal infections if acid is reduced too much for a long time. However, some people only get help from PPI’s. Also, PPI’s can hide the pain of gastric cancer, whereas other antacids don’t. It would be virtually impossible for cancer to be causing long-standing abdominal pain, but it we’re talking 3-6 months, and pain got better on a PPI, but returned on a different medication, we might refer for endoscopy.
** If Constipation is a prominent symptom, likely Irritable Bowel Syndrome (IBS) —
- Psyllium Fiber (e.g. Metamucilยฎ) in powder form, 3-times a day (mixed in 8 oz water, with another 8 oz water as a chaser);โฆ..PLUS
- Stool Softener (like Colaceยฎ) 3-times a day;โฆ..PLUS
- Increase dietary fiber, fluids, & exercise
** If Diarrhea is a prominent symptom, likely Irritable Bowel Syndrome (IBS) —
- Psyllium Fiber as above;โฆ.PLUS
- Kaolin-Pectin preparation;โฆ..PLUS
- Loperamide (Imodiumยฎ), used as needed
** If pain clearly gets worse when patient flexes their abdominal muscles (the “abs”), and we didn’t find a hernia on physical examination, it’s likely chronic Muscle Strain —
- Pain medications like NSAIDs or acetaminophen (Tylenolยฎ)
** If there are No Prominent Associated Symptoms —
- I tentatively diagnose and treat for Dyspepsia as above. Thatโs because PPIs work more rapidly & better for dyspepsia than anything works for Irritable Bowel Syndrome.
If all this seems like overkill, itโs because our focus at first is always diagnostic. We have the patient back in 3-4 weeks. We weigh them, & see how theyโre doing.
Once 3 Weeks Have Gone By (& no Weight Loss)
If the patient feels lots better, problem solved. We can reduce the intensity of medication.
If NONE BETTER, we’d discontinue whatever medicines given.
- Try a different Therapeutic Trial above, if it seems logical
- Order some lab tests above
- Begin asking about โstress,โ lest symptoms be a manifestation of Anxiety or Depression. If this seems possible, address it seriously as a problem by getting a thorough history, and beginning treatment with medication and/or therapy (clink for sobering anecdote on Somatization Disorder)
- See them back in 3 weeks and weigh them again
In another 3 weeks, if we prove weight loss, weโve got a Red Flag & can proceed as above.
If no still weight loss, no Red Flags, no laboratory abnormalities, and no improvement — well, thatโs Irritable Bowel Syndrome with abdominal pain [& not constipation or diarrhea]. It’s defined by the Rome III Diagnostic Criteria for Irritable Bowel Syndrome (mainly intended. for research purposes):
“Recurrent abdominal pain / discomfort for at least 3 days per month, over the last 3 months, associated with 2 or more of the following *:
- Improvement with defecation
- Onset associated with change in frequency of stool
- Onset associated with change in form (appearance) of stool
* Criteria must have been fulfilled for the last 3 months, but Symptom Onset required at least 6 months prior to diagnosis”
Diagnosis isnโt hard. But Treatment is often unfulfilling.
Refer to a Gastroenterologist????? In the private sector (patients with insurance), this gets done a lot, mainly for patient reassurance. The specialist will often do a procedure or two, because that’s what specialists do, but that increases medical costs. It isn’t necessary, and in the understaffed public sector, primary care clinicians appropriately manage Irritable Bowel & Chronic Abdominal Pain completely on our own.
See also Chronic Abdominal Pain for the clinicianโs condensed thought-process when face-to-face with a patient.