Approach To Abdominal Pain
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Approach To Abdominal Pain
Dr. Nahla A Azzam MRCP,FACP
Assistant Professor &Consultant Gastroenterology
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• One of the most common causes for OP & ER visits
• Multiple abd and non-abd pathologies can cause abd pain, therefore an organized approach is essential
• Some pathologies require immediate attention
Abdominal pain
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Introduction
• Abdominal pain is an unpleasant experience commonly associated with tissue injury. The sensation of pain represents an interplay of pathophysiologic and psychosocial factors.
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ANATOMIC BASIS OF PAIN
• Sensory neuroreceptors in abdominal organs are located within the mucosa and muscularis of hollow viscera, on serosal structures such as the peritoneum, and within the mesentery.
.
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• two distinct types of afferent nerve fibers: myelinated A-delta fibers and unmyelinated C fibers.
• A-delta fibers are distributed principally to skin and muscle and mediate the sharp, sudden, well-localized pain that follows an acute injury.
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• C fibers are found in muscle, periosteum, mesentery, peritoneum, and viscera. Most nociception from abdominal viscera is conveyed by this type of fiber and tends to be dull, burning, poorly localized
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• The abdominal pain receptors are directly activated by substances released in response to:
• local mechanical injury
• Inflammation
• Tissue ischemia and necrosis
• Thermal or radiation injury.
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Definitions
• Acute abdominal pain with recent onset within hours-days
• Chronic abdominal pain is intermittent or continuous abdominal pain or discomfort for longer than 3 to 6 months.
Abdominal Pain
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Acute abdominal pain
Surgical– Appendicitis– Cholecystitis– Bowel obstruction– Acute mesenteric
ischemia– Perforation– Trauma– Peritonitis
Medical – Cholangitis– Pancreatitis– Choledocholithiasis– Diverticulitis– PUD– Gastroenteritis– Nonabdominal causes
Abdominal Pain
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• Onset
• Character
• Location
• Severity
• Duration
Abdominal Pain
History
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• Eating
• Drinking
• Drugs
• Body position
• Defecation
Abdominal Pain
History Aggravating and alleviating factors
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• Anorexia• Weight loss• Nausea/vomiting• Bloating• Constipation• Diarrhea• Hemorrhage• Jaundice• Dysurea• Menstruation
Abdominal Pain
HistoryAssociated symptoms
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PMH: Similar episodes in past Other relevant medical problems
Systemic illnesses such as scleroderma, lupus, nephrotic syndrome, porphyrias, and sickle cell disease often have abdominal pain as a manifestation of their illness.
PSH: Adhesions, hernias, tumors, trauma
Drugs: ASA, NSAIDS, antisecretory, antibiotics, etc
GYN: LMP, bleeding, discharge
Social: Nicotin, ethanol, drugs, stress
Family: IBD, cancer, ect
Abdominal Pain
History
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Physical Exam
Abdominal Pain
General appearance
Ambulant
Healthy or sick
In pain or discomfort
Stigmata of CLD
Vital signs
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Physical Exam- Abdomen
Abdominal Pain
InspectionDistention, scars, bruises, hernia
PalpationTenderness GuardingReboundMasses
AuscultationAbd sounds: present, hyper, or absent
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• CBC
• Liver profile
• Amylase
• Glucose
• Urine dipsticks
• Pregnancy test
Laboratory Testing
Abdominal Pain
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Plain films
Ultrasonography
Computed Tomography
Imaging
Abdominal Pain
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Endoscopy
EGD
Colonoscopy
ERCP/EUS
Abdominal Pain
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Approach
Abdominal pain
Acute Chronic
Surgical nonsurgical
Abdominal Pain
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RUQ-PAIN
• Cholecystitis• Cholangitis• Hepatitis• RLL pneumonia• Subdiaphragmatic
abscess
Abdominal Pain
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LUQ- PAIN
• Splenic infarct• Splenic abscess• Gastritis/PUD
Abdominal Pain
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RLQ-PAIN
• Appendicitis• Inguinal hernia• Nephrolithiasis• IBD• Salpingitis• Ectopic pregnancy• Ovarian pathology
Abdominal Pain
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LLQ-PAIN
• Diverticulitis• Inguinal hernia• Nephrolithiasis• IBD• Salpingitis• Ectopic pregnancy• Ovarian pathology
Abdominal Pain
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Epigastric-Pain
• PUD• Gastritis• GERD• Pancreatitis• Cardiac (MI, pericarditis, etc)
Abdominal Pain
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Periumbelical-Pain
• Pancreatitis• Obstruction• Early appendicitis• Small bowel pathology• Gastroenteritis
Abdominal Pain
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Pelvic-Pain
• UTI• Prostatitis• Bladder outlet obstruction• PID• Uterine pathology
Abdominal Pain
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Diffuse Pain
• Gastroenteritis• Ischemia• Obstruction• DKA• IBS• Others
– FMF– AIP– Vitamin D deficiency– Adrenal insufficiency
Abdominal Pain
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Chronic abd pain approach
History
Intermittentcontinuous
biliary
intest. obstruction
Intst. angina
endometriosisporphoryea
IBS
metastasis
Intest. tumor
pancreatic disorder
pelvic inflammationAddison dis
functional disorderAlarm symptoms
IDA Hematochezia
Endoscopy
Cholestasis
US/CT ERCP
Fever
C&S CT
Weight loss
Endoscopy CT
Abdominal Pain
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Take Home Points
• Good history and physical exam is important (History is the most important step of the diagnostic approach )
• Lab studies limitations.
• Imaging studies selection (appropriate for presentation and location).
• Alarm symptoms oriented investigations
• Early referral of sick patients
• Treatment initiation
Abdominal Pain
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• Irritable bowel syndrome (IBS) is an intestinal disorder that causes abdominal pain or discomfort, cramping or bloating, and diarrhea or constipation. Irritable bowel syndrome is a long-term but manageable condition.
What Is IBS
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• First described in 1771.• 50% of patients present <35 years old.• 70% of sufferers are symptom free after 5
years.• GPs will diagnose one new case per week.• GPs will see 4-5 patients a week with IBS.
32
Introduction
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• It is estimated that between 10% and 15% of the population of North America, or approximately 45 million people, have irritable bowel syndrome.
• only about 30% of them will consult a doctor about their symptoms.
• IBS tends to be more common in In women, IBS is 2 to 3 times more common than in men.
Who Gets IBS?
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• Rome III Diagnostic criteria.
• Manning’s Criteria.
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Diagnostic Criteria
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• The positive predictive value (PPV) of the Manning criteria for the diagnosis of IBS has ranged between 65 and 75%,
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• At least 12 weeks history, which need not be consecutive in the last 12 months of abdominal discomfort or pain that has 2 or more of the following:– Relieved by defecation.– Onset associated with change in stool frequency.– Onset associated with change in form of the
stool.
36
Rome III Diagnostic Criteria.
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• Supportive symptoms.– Constipation predominant: one or more of:
• BM less than 3 times a week.• Hard or lumpy stools.• Straining during a bowel movement.
– Diarrhoea predominant: one or more of:• More than 3 bowel movements per day.• Loose [mushy] or watery stools.• Urgency.
37
Rome IlI Diagnostic Criteria.
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– General:• Feeling of incomplete evacuation.• Passing mucus per rectum.• Abdominal fullness, bloating or
swelling.
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Rome IlI Diagnostic Criteria.
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• Diarrhoea predominant.
• Constipation predominant.
• Pain predominant.
39
Subtypes
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• In people with IBS in hospital OPD.– 25% have depression.– 25% have anxiety.
• Patients with IBS symptoms who do not consult doctors [population surveys] have identical psychological health to general population.
• In one study30 % of women IBS sufferers have fibromyalgia
40
Associated Symptoms
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IBS Pathophysiology
Heredity; nature vs nurture Dysmotility, “spasm”
Visceral HypersensitivityAltered CNS perception of visceral eventsPsychopathologyInfection/InflammationAltered Gut Flora
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ImmuneActivation
Mast CellActivation
Luminal Flora
A New Paradigm
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ImmuneActivation
Mast CellActivation
Luminal FloraSTRESS
INFECTION
ALTERED MICROBIOTA
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ImmuneActivation
Mast CellActivation
Luminal Flora
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Systemic Immune Compartment in IBSSerum Cytokines
Dinan, et al. Gastroenterology. 2006.
* IL-6
IBS Controls
6
5
4
3
2
1
0
IL-6
(p
g/m
l)
* sIL-6r
IBS Controls0
50000
100000
150000
sIL
-6r
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Mucosal Compartment
• Frank inflammation• Immune Activation
– ↑ IEL’s– ↑ CD3+, CD25+
Chadwick et al, 2002
• Decreased IgA+ B CellsForshammar et al,
2008
• Altered expression of genes involved in mucosal immunity
Aerssens et al, 2008
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•10-14% incidence following confirmed bacterial gastroenteritis
Dunlop, et al. 2003. Mearin, et al. 2005.
•Risk factors– Female– Severe illness– Pre-morbid psyche
•Depression
– Persistent inflammation•EC cells•T lymphocytes
Post-Infectious IBS
Dunlop, et al. 2003.
300
200
100
0PI-IBS Patient
ControlsVolunteers
Lam
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rop
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ocyte
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ControlsVolunteers
EC
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Lessons from PI-IBS
Disturbed Flora
Susceptible Host
Inflammatory Response
Myo-Neural DysfunctionSYMPTOMS
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• Inflammatory bowel disease.• Cancer.• Diverticulosis.• Endometriosis.• Celiac disease
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Differential Diagnosis
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Blood test for IBS
• Current best evidence does not support the routine use of blood tests to exclude organic gastrointestinal disease in patients who present with typical IBS symptoms without alarm symptoms.
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Reasons to Refer
Age > 45 years at onset.
Family history of bowel cancer.
Failure of primary care management.
Uncertainty of diagnosis.
Abnormality on examination or investigation.
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Urgent Referral
Constant abdominal pain.
Constant diarrhoea.
Constant distension.
Rectal bleeding.Weight loss or
malaise.
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Treatment
• Patients’ concerns.
• Explanation.
• Treatment approaches.
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• Usually very concerned about a serious cause for their symptoms.
• Take time to explore the patients agenda.
• Remember that investigations may heighten anxiety.
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Patients’ Concerns.
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• Placebo effect of up to 70% in all IBS treatments.
• Treatment should depend on symptom sub-type.
• Often considerable overlap between sub-groups.
56
Treatment Approaches.
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• Antispasmodics will help 66%.
• Mebeverine is probably first choice.
• Hyoscine 10mg qid can be added.
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Pain Predominant.
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Smooth Muscle Relaxants
• Some patients improve particularly those whose symptoms are induced by meals
• Most studies that have looked at these medications have been poorly designed, poorly controlled, and have not shown significant benefits above placebo
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• A data from meta-analysis of 22 studies involving 1778 patients and 12 different antispasmodic agents demonstrated modest improvements in global IBS symptoms and abdominal pain
• However, up to 68% of patients suffered side effects when given the high dose required to improve abdominal pain
Page and Dirnberger, 1981
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• Poor evidence for efficacy.
• Better evidence for tricyclics and SSRIs.
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Antidepressants
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Tricyclic Antidepressants TCAs likely modulate pain both centrally and
peripherally
The best data supporting the use of TCAs in the treatment of IBS is from a large placebo-controlled study evaluating desipramine .
This highlights the fact that if a patient can tolerate some of the side effects of a TCA, then he or she is more likely to note an improvement in chronic abdominal pain compared with a patient treated with placebo
[Drossman et al. 2003]
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Selective Serotonin Reuptake Inhibitors (SSRIs
• Six studies have been conducted to date, two each involving fluoxetine, paroxetine and citalopram
• Talley et al. 2008; Tack et al. 2006; Vahedi et al. 2005; Tabas et al. 2004; Kuiken et al. 2003; Masand et al. 2002].
• Most patients noted an improvement in overall wellbeing, although none of the studies showed any benefit with regards to bowel habits, and abdominal pain was generally not improved
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• Only one trial has provided a head-to-head comparison between a TCA (imipramine 50 mg) and an SSRI (citalopram 40 mg),
• Although neither drug demonstrated significant improvements in global IBS symptoms over placebo
• Talley et al. 2008
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Constipation
Lifestyle Modifications Bowel Training and Education Fibre Twelve randomized controlled trials have been
performed to date evaluating the efficacy of fiber in the treatment of IBS. Four of these studies noted an improvement in stool frequency (polycarbophil and ispaghula husk), while one noted an improvement in stool evacuation
Toskes et al. 1993; Jalihal and Kurian, 1990; Prior and Whorwell, 1987; Longstreth et al. 1981].
No improvement in abdominal pain30-50% of patients treated with a fiber product will
have a significant increase in gas
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Over-the-counter Medications
• PEG
• Lactulose
• Tegaserod stimulate gastrointestinal peristalsis, increase intestinal fluid secretion and reduce visceral sensation
• 5 HT agonist FDA approved for chronic constipation in women.
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• Lubiprostone stimulates type 2 chloride channels in epithelial cells of the gastrointestinal tract thereby causing an efflux of chloride into the intestinal lumen
• It was approved by the FDA for the treatment of adult men and women with chronic constipation in January 2006
• Nausia and diarrhea 6-8%
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• Increasing dietary fibre is sensible advice.
• Fibre varies, 55% of patients will get worse with bran.
• “Medical fibre” adds to placebo effect.
• Loperamide may help
Diarrhea predominant
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Diarrhea
• Loperamide inhibiting intestinal secretion and peristalsis, loperamide slows intestinal transit and allows for increased fluid reabsorption, thus improving symptoms of diarrhea
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• Alosetron is 5-HT3 receptor antagonist that slows colonic transit
• meta-analysis of eight randomized controlled trials involving 4842 patients determined that alosetron provided a significant reduction in the global symptoms of diarrhea, abdominal pain, and bloating in patients with IBS and diarrhea
• four-fold increased risk for ischemic colitis compared to placebo
[Ford et al. 2008
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RECENT THERAPYAntibiotics
PROBIOTICS
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“Target” Trials
• 1,260 patients with non-constipation irritable bowel syndrome (IBS) recruited in the US and Canada
• Rifaximin 550 mg, 3 times daily, for 2 weeks
• Primary endpoint:– The proportion of subjects who achieved
adequate relief of IBS symptoms for at least 2 weeks during the first 4 weeks (weeks 3-6) of the 10-week follow-up phase
• Also assessed relief of IBS bloating and symptom responses at 12 weeks (10 weeks after end of therapy)
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Endpoints
Target 1Rif vs
Placebo
Target 2 Rif vs
Placebo
Combined Rif vs
Placebo
Adequate relief of IBS symptoms
41% vs 31%
41% vs 32%
41% vs 32%
Adequate relief of IBS bloating
40% vs 29%
41% vs 32%
40% vs 30%
All p<0.03
Hitting the Target!
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Probiotics
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Mode of Action of Probiotics?
• Competition with, and exclusion, of pathogens
• Anti-bacterial:– Produce bacteriocins– Destroy toxins
• Enhance barrier function, motility• Enhance host immunity
– Immune modulation– Cytokine modulation– IgA production
• Metabolic functions
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% A
nsw
eri
ng
“Y
es” a
t W
eek 4
70
60
50
40
30
80
B. infantis 1x106
B. infantis 1X1010
B. infantis 1X108
Placebo
P=0.0118
Global Assessment of Symptom Relief
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Prospective, multicenter, double-blind, placebo-controlled, crossover trial assessing the efficacy and safety of the probiotic, VSL#3
Patients treated with VSL#3 had a significant improvement in the primary endpoint, which was the global relief of IBS symptoms (p < 0.05). Secondary endpoints of abdominal pain (p = 0.05) and bloating (p < 0.001) were also improved.
Guandalini et al. 2008
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• Avoid caffeine. • Limit your intake of fatty foods. Fats increase gut
sensations, which can make abdominal pain seem worse.
• If diarrhea is your main symptom, limit dairy products, fruit, or the artificial sweetener sorbitol.
• Increasing fiber in your diet may help relieve constipation.
• Avoiding foods such as beans, cabbage, or uncooked cauliflower or broccoli can help relieve bloating or gas.
What about diet?
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• Hypnosis. Hypnosis can help some people relax, which may relieve abdominal pain.
• Relaxation or meditation. Relaxation training and meditation may be helpful in reducing generalized muscle tension and abdominal pain.
• Biofeedback. Biofeedback training may help relieve pain from intestinal spasms. It also may help improve bowel movement control in people who have severe diarrhea.
Alternative Medicine
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Self-help• IBS network,
• IBS support group
• Awareness
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THANK YOU
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