Assessment of Patients with Abdominal Pain

Assessment of Patients with Abdominal Pain

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Assessment of Patients with Abdominal Pain Peter Thomson, BSc(Pharm), PharmD Date of Revision: March 2013

Introduction

Abdominal pain is a nonspecific symptom arising from a variety of sites. Virtually everyone experiences abdominal symptoms on an intermittent basis. Although abdominal pain is one of the most common reasons for a physician visit, many sufferers self-medicate with nonprescription products. Fortunately, the vast majority of symptoms are benign in nature. Recurrent upper abdominal pain or discomfort occurs in approximately 25–40% of the western population and may involve a variety of symptoms including dyspepsia, nausea and heartburn.1

Pathophysiology

Sites that contribute to the majority of gastrointestinal (GI) tract complaints include the esophagus, stomach, liver, gallbladder, pancreas and intestines. Excluding an acute abdomen, some causes of abdominal pain are listed in Table 1. Table 1: Conditions Associated with Abdominal Pain

a

Frequency

Condition

Very Common

Functional (non-ulcer) dyspepsia

Irritable bowel syndrome

Menstrual cramps in females Common

Chronic constipation

Gastroenteritis

Gastroesophageal reflux disease Lactose intolerance

Peptic ulcer disease

Urinary tract infection Less Common

Abdominal hernia

Appendicitis

Cholelithiasis

Chronic pancreatitis Endometriosis

Inflammatory bowel disease (e.g., Crohn's disease, ulcerative colitis) Myofascial pain Uncommon

Cancer of the colon and other gastrointestinal areas

Food allergies

Ischemic heart disease

Pelvic inflammatory disease

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a

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Not a complete list.

Abdominal pain may be diffuse or localized. This may help in differentiating the potential cause of pain. Pain commonly arises from the epigastric, periumbilical or pelvic regions as well as from the right and left upper and lower quadrants. Most commonly, abdominal pain is due to unidentifiable organic causes (functional pain), but occasionally, pain may arise from a well-defined GI pathology. ROME III criteria formally classifies functional gastrointestinal disorders.2 Irritable bowel syndrome (IBS) and functional dyspepsia (FD) are common functional disorders of the GI tract. Although not a requirement, pain and abdominal discomfort due to IBS are more often localized below the umbilicus in combination with alteration in the frequency of bowel movements and/or consistency of the stool, whereas symptoms of dyspepsia usually arise from the epigastrium. IBS and FD are not likely to increase the risk of pathologic GI disorders yet they may significantly impair quality of life and increase utilization of health care resources. Together they can account for roughly half of all referrals to outpatient gastroenterology clinics.3 There are a number of evidence-based guidelines for the assessment and management of dyspepsia in adults.4,5,6 In general, the goal is to ensure those with serious GI pathology seek prompt investigation and treatment and to minimize overuse of diagnostic investigations unlikely to provide useful information.5,7,8

Patient Assessment Indications of Serious GI Pathology

Individuals presenting with common symptoms associated with serious GI pathology should seek timely medical attention. In a study of over 150 patients who developed gastric or esophageal cancer under the age of 55 years, over 97% had at least 1 the following serious signs and symptoms: dysphagia, weight loss (>3 kg over 6 months), persistent vomiting, bleeding, anemia, hematemesis or melena.9 Additional “red flags” include: age >50 years (especially if new onset dyspepsia or recent change in symptoms), jaundice, cancer history (strong family history) and multiple treatment failures. Fever and chills can represent an infectious source of abdominal pain requiring medical assessment (Figure 1).

Assessment of Patient Acuity

Obtain a detailed medical history from the person with abdominal pain in order to narrow down the possibilities to a few key potential diagnoses. Key assessment issues include location, duration, severity and triggers of pain, comorbid medical conditions and medication use. If no signs of serious GI pathology are apparent, undertake a systematic assessment of abdominal pain. Acute (<24 hours), well-localized, moderate or severe pain worsening over hours and tender to touch usually indicates a need for medical attention. Triggers of pain such as medications and foods may suggest specific disorders such as peptic ulcer disease (PUD), gastroesophageal reflux disease (GERD), lactase deficiency or celiac disease. Intolerance to foods can also give rise to abdominal pain. Spicy foods, citrus fruits and foods with a high fat content are examples. Postprandial pain is often associated with overindulgence. High fat intake and certain foods can produce indigestion and trigger symptoms of IBS. Review timing of pain with meals and current medications (including herbals and vitamins). Evaluate alcohol and recreational drug use (if appropriate). Certain disease states such as renal failure and heart failure may cause abdominal pain. Frequently pain is diffuse in nature in these conditions. Medications are commonly associated with epigastric abdominal pain (Table 2) and the presence of medicationinduced dyspepsia is not necessarily indicative of GI bleeding. Comorbid diseases can produce or mimic abdominal pain and may warrant physician assessment (e.g., ischemic heart disease, psychiatric disorders). Particular attention should be given to patients using immunosuppressive medications, such as systemic corticosteroids, in whom the symptoms of severe gastrointestinal disease may be attenuated. Extremes in age (very elderly, infants <1 month old) are often at risk for rapid decompensation and require closer evaluation and monitoring.10 Figure 1: Assessment of Patients with Chronic Abdominal Pain

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Abbreviations: AAA = abdominal aortic aneurysm; CRC = colorectal cancer; FD = functional dyspepsia; IBD = inflammatory bowel disease; IBS = irritable bowel syndrome; IHD = ischemic heart disease; LLQ = left lower quadrant; LUQ = left upper quadrant; MSK = musculoskeletal; PID = pelvic inflammatory disease; RLQ = right lower quadrant; RUQ = right upper quadrant

Table 2: Some Medications Commonly Associated with Abdominal Pain Amiodarone (especially loading dose)

Metformin

Antiepileptic drugs

Neuroleptics

Antibiotics

Antineoplastics Antiretrovirals

NSAIDs, celecoxib, ASA and other antiplatelets Opioids SSRIs

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Dabigatran

Ferrous gluconate, sulfate, fumarate

https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/... Sulfasalazine

Location of Abdominal Pain

Pain is often, but not always, localized to different areas of the abdomen. Localization often helps determine the most likely causes of the pain. It may also assist in assessing when to refer a patient for medical care. More common causes of epigastric pain include GERD, PUD, FD and pancreatitis (the latter also causes back pain). Right upper quadrant pain often involves the liver or gallbladder but can also include pancreatitis. Right upper quadrant pain usually requires medical assessment. Left upper quadrant pain may involve the spleen but can also include epigastric and musculoskeletal sources of abdominal pain. Peri-umbilical pain may be due to conditions involving the pelvic organs (e.g., pelvic inflammatory disease or ectopic pregnancy), gastroenteritis or inflammatory bowel disease (IBD) in addition to IBS. Causes of right lower quadrant pain include appendicitis, IBD, IBS and pelvic organs. Small bowel obstructions, IBD, IBS and diverticulitis can appear as both right or left lower quadrant pain.10

Caveats to Abdominal Pain Assessment

In many cases, the cause of abdominal pain varies with patient age as well as comorbid medical conditions. There is a considerable overlap in symptoms among many of the common disorders that cause abdominal pain. For example, over 80% of IBS patients will also exhibit symptoms of dyspepsia.11 Moderate to intense pain is not a characteristic feature of dyspepsia. In biliary tract disease and pancreatitis, the pain is usually acute and more intense in nature.11 Recurrent peri-umbilical abdominal pain occurs in various intensities in approximately 10% of school-aged children. Nausea and vomiting may also occur but weight loss is uncommon. In over 90% of cases there is no organic cause. Stress (e.g., school) may be a component. Drug therapy is generally not recommended.12

Suggested Readings

Silen W. Abdominal pain. In: Kasper DL et al., eds. Harrison's principles of internal medicine. 16th ed. New York: McGraw-Hill; 2005. p. 82-4.

References 1. Talley NJ, Silverstein MD, Agreus L et al. AGA technical review: evaluation of dyspepsia. American Gastroenterological Association. Gastroenterology 1998;114:582-95. 2. Drossman DA. The functional gastrointestinal disorders and the Rome III process. Gastroenterology 2006;130:1377-90. 3. Jones J, Boorman J, Cann P et al. British Society of Gastroenterology guidelines for the management of the irritable bowel syndrome. Gut 2000;47:ii1-19. 4. Talley NJ; American Gastroenterological Association. American Gastroenterological Association medical position statement: evaluation of dyspepsia. Gastroenterology 2005;192:1753-5. 5. Veldhuyzen van Zanten SJ, Flook N, Chiba N et al. An evidence-based approach to the management of uninvestigated dyspepsia in the era of Helicobacter pylori. Canadian Dyspepsia Working Group. CMAJ 2000;162:S3-23. 6. Mason JM, Delaney B, Moayyedi P et al. Managing dyspepsia without alarm signs in primary care: new national guidance for England and Wales. Aliment Pharmacol Ther 2005;21:1135-43. 7. Suzuki H, Nishizawa R, Hibi T. Therapeutic strategies for functional dyspepsia and the introduction of the Rome III classification. J Gastroenterol 2006;41:513-23.

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8. Veldhuyzen van Zanten SJ, Bradette M, Chiba N et al. Evidence-based recommendations for short- and long-term management of uninvestigated dyspepsia in primary care: an update of the Canadian Dyspepsia Working Group (CanDys) clinical management tool. Can J Gastroenterol 2005;19:285-303. 9. Gillen D, McColl KE. Does concern about missing malignancy justify endoscopy in uncomplicated dyspepsia in patients aged less than 55? Am J Gastroenterol 1999;94:75-9. 10. Glasgow RE, Mulvihill SJ. Abdominal pain, including the acute abdomen. In: Feldman M, Sleisenger MH, Scharschmidt BF, eds. Sleisenger & Fordtran's gastrointestinal and liver disease: pathophysiology, diagnosis, management. 6th ed. Philadelphia: Saunders; 1998. p. 80-9. 11. McQuaid K. Dyspepsia. In: Feldman M, Sleisenger MH, Scharschmidt BF, eds. Sleisenger & Fordtran's gastrointestinal and liver disease: pathophysiology, diagnosis, management. 6th ed. Philadelphia: Saunders; 1998. p. 105-16. 12. Hay WW. Recurrent abdominal pain. In: Hay WW, Hayward AR, Levin MJ et al., eds. Current pediatric diagnosis and treatment. 14th ed. Old Tappan: Appleton & Lange; 1999. p. 550-2. CPhA assumes no responsibility for or liability in connection with the use of this information. For clinical use only and not intended for for use by patients. Once printed there is no quarantee the information is up-to-date. [Printed on: 03-02-2016 11:57 PM] RxTx, Compendium of Therapeutics for Minor Ailments © Canadian Pharmacists Association, 2016. All rights reserved

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