The approach to chronic abdominal pain Dana Moffatt, MD

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Quit your belly achin!The approach to chronic
abdominal pain

• Dana Moffatt, MD, FRCPC
• University of Manitoba
• Section of Gastroenterology

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Outline

• 1. Defining chronic abdominal pain.
• 2. How common is chronic abdominal pain?
• 3. Differentiating organic and functional causes
  of chronic abdominal pain. What diagnostic work
  up is needed?
• 4. Therapy for chronic abdominal pain
• a) organic abdominal pain
• b) functional abdominal pain, with a focus on IBS
• 5. Communicating with functional pain patients

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Definitions

• Organic Abdominal pain
• Pain caused by structural disturbance, anatomical
  alteration, inflammation, infection, or cancerous
  growth of any organ in the abdominal cavity. (eg.
  chronic pancreatitis, celiac disease,
  inflammatory bowel disease, peptic ulcer disease,
  etc.)
• Functional Abdominal pain
• Pain caused by derangement of intestinal
  motility, entero-neurologic system, or other
  etiology with NO structural abnormality (eg. IBS,
  dyspepsia, colonic inertia, etc)

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Definitions
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FUNCTIONAL ABDOMINAL PAIN
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Epidemiology of chronic Abd Pain

• How common is chronic abdominal pain?
• 15 of children and adolescents will see an MD
  with the complain of chronic/recurrent abdominal
  pain!
• 75 of adolescents/young adults meet the
  diagnostic criteria for irritable bowel syndrome
  (if asked to fill out a questionnaire)
• Female to male ratio 61
• 34 of adults will see a health practitioner for
  chronic or intermittent abdominal pain in their
  lifetime!!!!

Drossman 1993 Dig Dis Science Talley 1991
Gastroenterology
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Health resources

• gt200,000 people in manitoba will see a
  physician/NP in there lifetime for chronic
  abdominal pain complaints!
• The average person with chronic abdominal pain
  sees 5 different MD/NPs, has 3-5 CT/MRI/US, 3
  endoscopies, 2.7 un-needed surgery!
• Estimate of costs/patient (excluding ER visits,
  and time off work) 7,500/patient!
• Including ER visits, admissions and time of work
  21,000/patient!
• US costs gt20 billion/year !!!!
• This is a major cost for a publicly funded
  system!! Any way to decrease these costs is
  important and valuable!

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Pathophsyiology of functional abdominal pain

• KEY POINT Functional abdominal pain is REAL
  pain!
• Functional MRI studies show real pain activity in
  the brain in patients with functional abd pain.
• What is happening?
• Upregulation of visceral nervous systems normal
  activity (increased contractions related to
  distention or peristalsis)
• Downregulation of spinal cord filtering of
  signals from the gut
• Classic hypersensitivity to GI stimulation
  documented with rectal or duodenal balloon,
  insertion and inflation compared to normal
• Alteration of microbiota? Injury of enteric
  nerves (gi infection), or priming related central
  nervous system (eg. sexual abuse)?

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Pain response to rectal balloon distention in IBS
vs. Healthy controls
IBS
Controls
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Differentiating types of chronic abd pain

• History and physical examination will give you
  the answer 99 of the time.
• Redflags on history that point to organic
  abdominal pain
• Different type, quality or location of pain from
  usual.
• Localized to very focal point in the abdomen (use
  caution with this).
• New onset of pain in individual over 50 years
  old.
• Presence of significant weight loss since pain
  onset.
• Presence of blood in stool or vomit since onset
  of pain
• Strong family history of intestinal malignancy
  (gt1 person)
• Presence of dysphagia, profound vomiting, early
  satiety, or narrow caliber stools (persistant NOT
  on a single occasion)

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Differentiating types of chronic abd pain

• Redflags on PHYSICAL that point to organic
  abdominal pain
• Documented fever, tachycardia, hyper/hypotension
• Clinical evidence of malnutrition (protein/muscle
  wasting)
• Absence of bowel sounds on auscultation
• Abdominal tenderness WITH peritoneal signs (i.e.
  rebound tenderness, positive psoas sign etc)
• Abdominal exam with focal mass
• Abnormal rectal exam with blood or a mass lesion

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Historical components of functional abdominal
pain

• Pain present continuously or intermittently for
  gt1 year with no red flags (often present since
  teenage years or youth)
• IBS TYPE
• Pain appears with associated constipation or
  diarrhea
• Often temporary improvement in pain right after
  defecation
• If altered bowel symptoms sense of incomplete
  evacuation, tenesmus, mucous in the stool, or
  stabbing pains in the rectum
• Pain worsens at times of social, psychological or
  physical stress
• Patients may be unrealistic, tearful or visibly
  anxious, often demand immediate action for a
  chronic problem present for years.... (this may
  in fact be diagnostic for IBS!)

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Historical components of functional abdominal
pain

• Dyspepsia or Reflux or Upper GI type funcional
  abdominal pain
• Symptoms consistent with GERD/heartburn, but DO
  NOT get better with antacids
• May be intermittent nausea and vomiting after
  eating
• Sense of fullness or foreign body in back of
  throat (Globus)
• Constant or increased burping (never a
  pathological finding!)

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Physical findings in function abd pain

• 1. Diffuse pain in all areas of the abdomen
• 2. No clear physical distress i.e. normal vital
  signs
• 3. More emotional distress or visible anxiety...
• 4. Normal rectal examination
• 5. Pain in epigastrium along the lower rib
  margins (chostochondritis pain commonly presents
  as abdominal pain)

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Differentiating types of chronic abd pain

• KEY POINTS TO REMEMBER
• 1. A change in bowel habits is common with
  abdominal pain of ALL types and is not a red
  flag
• 2. Without red flags, change in quantity, size,
  color, smell or contents of stool are almost
  NEVER concerning
• 3. Pain on abdominal examination is expected in
  chronic abdominal pain patients.... it may be
  mild - severe, or diffuse - focal.
• Use distraction techniques to examine (i.e.
  pressing while auscultating the abdomen) to see
  if the pain is consistent and reproducible.

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The Key to the whole talk!

• Relative frequency of functional and organic
  CHRONIC pain

Functional gt85!
Organic lt15
Both
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Work up for chronic abdominal pain

• History and Physical (!!)
• Basic work up
• Electrolytes, creatinine, urea, liver enzymes,
  bilirubin, complete blood count, urinalysis,
  stool C/S, stool c.difficile, stool WBC (if
  diarrhea present)
• C-reactive protein or ESR, albumin, ferritin to
  look for inflammation, or occult iron deficiency
  (occurs with all types of GI inflammation)
• Serology Celiac disease tissue
  transglutaminase (TTG), endomysial antibody
  (EMA), Peptic ulcer H.pylori serology
• Abdominal Xray, /- US abdomen or possibly CT
  scan of the abd.

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Work up for chronic abdominal pain

• If preliminary labs are normal -gt STOP
• The likelihood of finding significant organic
  pathology with normal physical exam, no red
  flags, normal lab work and normal imaging i lt 1
  
• The patient has functional abdominal pain
• Presence of anemia, low iron, low albumin, or
  abnormal stool tests -gt consider colonoscopy
• Presence of abnormal TTG or EMA, or H.pylori
  serology -gt upper endoscopy to rule out celiac
  disease or peptic ulcer disease

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Most common etiologies of functional abdominal
pain

• 1. IBS gt50 of pain
• 2. Functional dyspepsia gt20
• 3. Muscle wall pain 5-10
• 4. nonspecific functional pain syndromes.... the
  rest

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Diagnosing IBS

• IBS is NOT a diagnosis of exclusion (i.e. Every
  test does not need to be done). It is based on
  the ROME III consensus
• Recurrent abdominal pain or discomfort at least 3
  days/month for gt3 months with 2 or 3 of
• 1) Improvement of pain after defecation
• 2) Onset associated with a change in stool
  frequency
• 3) Onset associated with a change in
  form/appearance of stool
• Must impact on life negatively enough to seek
  medical care
• Supportive mucous in stool, incomplete
  evacuation, stress/anxiety/fear associated with
  onset or prior to symptoms

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Functional dyspepsia

• ROME III criteria At least three months with any
  of
• epigastric or stomach fullness
• bloating
• epigastric pain
• Reflux type symptoms with no evidence of reflux
  (and no response to therapy)
• Plus normal screen investigations (including
  upper endoscopy or barium)

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diagnosing abdominal wall pain

• Focal area of pain, or radicular patch of pain,
• Carnetts sign increased pain with flexing of
  abdominal wall
• Hover sign patients tense when your hand hovers
  over the spot (anticipation of pain)
• Often mis-diagnosed as visceral pain in the ER/ED
  -gt leads to uneeded testing
• Therapy NSAIDS, physiotherapy, and if no
  response, referall to physiatry for trigger point
  injections -gt 90 will get better!

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History and physical
Red flag present
No red flag present
1. Screening bloodwork 2. Directed
intervention/referral likely will need
endoscopy /- CT scan/MRI etc
Screening bloodwork CBC, electrolytes, stool
tests iron stores etc.
abnormal tests
abnormal tests
normal tests
1.Confirm functional diagnosis 2. Confront
anxiety and fear 3. Build therapeutic alliance
Treat organic condition
Tests normal
Further testing with endoscopy/imaging
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Therapy in functional abdominal pain
1. Confirm functional diagnosis 2. Confront
anxiety and fear 3. Build therapeutic alliance...
a) Identify co-morbid conditions i.e. GERD,
depression, anxiety, endometriosis b) Get the
terminology straight. c) Set the agenda
straight... treating symptoms, not a disease. d)
Set the goals of therapy, and manage expectations
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Medical therapy in functional Abd Pain

• FIBER (Psyillium)
• Definite benefits in IBS patients (both diarrhea
  and constipation predominant), with 60 of
  patients having significant improvement
• Added benefit in constipation predominant
  patients
• Limited by bloating and gas! Many patients will
  not persist with this.
• No worrisome side effects at all....

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Medical therapy in functional Abd Pain

• PROBIOTICS
• Very limited data in chronic functional abdominal
  pain despite the yogurt commercials
• Only 3 commercially available product in Canada
  with ANY hard data a) Lactobaccillus Plantarum
  -gt TU ZEN, and b) VSL 3 (cocktail of 8 strains
  of commensal organism), c) Ecoli Nissle 1917
  -gtMutaflor
• Slight decrease in diarrhea, pain and flatulence
• Studies only go out 3-6 months, so no way to know
  about long term effects

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Medical therapy in functional Abd Pain

• ANTISPASMODICS (dicetel, bentylol, hyosciamine)
• Barely better than placebo in all studies.
• No data on long term use
• Side effects include constipation, dry mouth,
  possible long term risk of depression/psychiatric
  disturbance
• Limited to a few patients with severe crampy
  pain, and dirarhea predominant IBS

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Medical therapy in functional Abd Pain

• NSAIDS
• limited benefit in visceral and neuropathic pain
• Occasionally can unmask MSK pain, or dysmenorrhea
  and help co-existent symptoms (headache,
  arthritis etc)
• Be careful not to cause an organic problem (i.e.
  peptic ulcer disease or gastritis)
• Use lowest effective dose, or add proton pump
  inhibitor

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Medical therapy in functional Abd Pain

• TRICYCLIC ANTIDEPRESSANTS
• Nortryptiline, amytriptilyne, doxepin,
  desipramine
• Definite benefit (50-60 of patients respond,
  30-40 get remission in the short term) in IBS
• Takes 4-6 weeks to work... encourage compliance!
• Side effects constipation, dry mouth, sedating,
  overdose can occur and be fatal (usually in
  setting of suicide attempt)
• Generally prescribe 1/4 of the effective dose eg.
  25mg of amitryptiline, 10mg nortryptiline at
  bedtime

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Medical therapy in functional Abd Pain

• SNRIs and SSRIS
• effexor, buprprion, paxil, fluoxetine etc.
• Small (20) but consistent benefits in all
  chronic abdominal pain patients, when compared to
  placebo
• More profound effects in those with co-existent
  depression or anxiety... often worth starting for
  this reason alone!
• Class related side effects Gi upset, sleep
  disturbance, an-orgasmia, low sex drive etc.

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Medical therapy in functional Abd Pain

• GABA RECEPTOR ANTAGONISTS
• Gabapentin (neurontin), pregabilin (lyrica)
• Similar to TCAs, decrease nerve input from gut to
  CNS
• Modest decrease in abdominal pain without much GI
  toxicity... really as a last stop before going
  onto narcotics
• Side effects fatigue, somnolence, dizziness,
  allergy

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Medical therapy in functional Abd Pain

• NARCOTICS
• Only in the most refractory of patients, as a
  method to keep them out of hospital and in the
  community
• Again use lowest effective dose, and avoid
  continuous dosing (addiction/dependency)
• Need stable social situation, good relationship
  with provider, with no prior addiction history
• Watch out for narcotic bowel syndrome (worsening
  constipation and pain, requiring higher doses of
  meds)

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Medical therapy

• Diarrhea
• use immodium up to 10 tablets per day... no long
  term concerns.
• Add fibre to soak up truly watery diarrhea and
  bulk the stool.
• Addition of codeine or lomotil can help as well.
• Constipation no concern with using laxatives
  long term.
• fibre -gtcolace -gt lactulose -gt PEG3350
  (lax-a-day) softeners
• Caffeine -gtSenna -gt dulcolax stimulants (make
  your colon contract)

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Medical therapy

• Diet literally no scientifically valid data on
  diet intervention in ibs... many highly flawed
  studies
• value of placebo effect? value of control over
  illness? harm of nutritional deficiencies and
  hopelessness when placebo fails?
• Exercise
• recent rct showed 4days/wk of aerobic physical
  activity eliminated flares of ibs, and on
  average pts had a 25 reduction in symptoms when
  compare to controls
• no harm and many many other health benefits! I
  recommend to everyone.

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Pain management in organic pain

• Aimed at the underlying condition (i.e. optimally
  control crohns disease, remove diseased organs,
  bypass diseased portions of bowel surgically)
• In chronic pancreatitis (organ cannot always
  safely be removed) and other diseases that have
  no medical treatement
• Chronic pain management is similar to all other
  diseases
• Maximize non-opiod therapies first (tylenol,
  NSAIDS, and coanelgesics such as gabapentin,
  TCAs, anti-seizure meds)
• Use long acting, lowest effective dose narcotics
  if necessary

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Communicating with functional pain patients

• Acknowledge
• Dont over-react
• Reassure
• Educate
• Set realistic goals

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Acknowledge

• MD Im glad to give you good news. Your blood
  test and ultrasound are normal. You do not have
  any serious organic problems!
• Patient You dont get it. I am barely
  surviving! Are you saying this is all in my
  head?!
• MD Clearly your gut does not work properly. You
  have a functional GI problem. It is not normal
  to have the symptoms you suffer with. I promise
  you over time you will not suffer as much as you
  are right now. We will work together

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Dont over-react

• BAD MD Im not sure what is wrong but something
  is! We are going to do some tests, probably a CT
  scan of the abdomen, and likely a colonoscopy
• Patient thinking he/she has no idea what they
  are doing
• GOOD MD I have an understanding of your
  symptoms now. Your bowel isnt working properly.
  Its a condition called IBS. I propose we do a
  few tests to rule out a few illnesses that can
  masquerade as IBS specifically...

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Reassure

• Bad MD Youre going to be fine. This is NOT
  cancer!
• Patient Im not fine, I am in pain. You think
  this is in my head! How do you know this isnt
  cancer?
• Good MD You have IBS, which is a troubling and
  painful condition that can have severe flares,
  like the one you are experiencing right now. It
  is not cancer because...
• Good MD We have investigated things thoroughly.
  I will still be involved in your care, and we can
  re-evaluate things if they change in the future

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Educate

• Gastro-colic reflex
• Visceral hypersensitivity
• Abnormal inhibitory pain pathways
• Post-infectious neuro-enteric dysfunction (post
  infectious IBS)
• Role of phsyical and sexual abuse in priming the
  CNS pain center
• Role of stress affecting the organ systems

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Educate

• Avoid incorrect constructs
• - your scope/ct/barium showed diverticulosis,
  which is likely causing your pain
• -your bowel was very spastic when we scoped you
  so you are going to suffer with cramps
• - you have hiatus hernia which can cause pain
• BE specific
• You have IBS, it is a well recognized medical
  condition, and it often happens in young healthy
  people like yourself....

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set Realistic Goals

• Bad MD lets try an antispasmodic... this will
  probably go away as you get older.... well see
  how you do and if things dont change we will do
  more tests
• Good MD
• The natural history of IBS ...
• Lets try targeting specific symptoms such as
  diarrhea...
• Do you have any specific fears or worries? is
  there a specific condition you are afraid we have
  not ruled out?

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Functional pain

• Make no mistake, these can be the most
  challenging patients in any clinical practice
• The main therapy we offer, is our interaction
• Data suggests more frequent, short, patient
  interactions is as effective as any other
  intervention in these patients
• Seeing them regularly does decrease ER visits,
  re-referals, treatment seeking, and may decrease
  adverse events
• Be Patient! Be Caring! Remember that functional
  GI pain is still PAIN and the disease course does
  fluctuate.