Approach To Abdominal Pain Dr. Nahla A Azzam MRCP,FACP Assistant Professor &Consultant...

Approach To Abdominal Pain

Dr. Nahla A Azzam MRCP,FACP

Assistant Professor &Consultant Gastroenterology

• 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

Introduction

• Abdominal pain is an unpleasant experience commonly associated with tissue injury. The sensation of pain represents an interplay of pathophysiologic and psychosocial factors.

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.

.

• 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.

• 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

• 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.

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

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

• Onset

• Character

• Location

• Severity

• Duration

Abdominal Pain

History

• Eating

• Drinking

• Drugs

• Body position

• Defecation

Abdominal Pain

History Aggravating and alleviating factors

• Anorexia• Weight loss• Nausea/vomiting• Bloating• Constipation• Diarrhea• Hemorrhage• Jaundice• Dysurea• Menstruation

Abdominal Pain

HistoryAssociated symptoms

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

Physical Exam

Abdominal Pain

General appearance

Ambulant

Healthy or sick

In pain or discomfort

Stigmata of CLD

Vital signs

Physical Exam- Abdomen

Abdominal Pain

InspectionDistention, scars, bruises, hernia

PalpationTenderness GuardingReboundMasses

AuscultationAbd sounds: present, hyper, or absent

• CBC

• Liver profile

• Amylase

• Glucose

• Urine dipsticks

• Pregnancy test

Laboratory Testing

Abdominal Pain

Plain films

Ultrasonography

Computed Tomography

Imaging

Abdominal Pain

Endoscopy

EGD

Colonoscopy

ERCP/EUS

Abdominal Pain

Approach

Abdominal pain

Acute Chronic

Surgical nonsurgical

Abdominal Pain

RUQ-PAIN

• Cholecystitis• Cholangitis• Hepatitis• RLL pneumonia• Subdiaphragmatic

abscess

Abdominal Pain

LUQ- PAIN

• Splenic infarct• Splenic abscess• Gastritis/PUD

Abdominal Pain

RLQ-PAIN

• Appendicitis• Inguinal hernia• Nephrolithiasis• IBD• Salpingitis• Ectopic pregnancy• Ovarian pathology

Abdominal Pain

LLQ-PAIN

• Diverticulitis• Inguinal hernia• Nephrolithiasis• IBD• Salpingitis• Ectopic pregnancy• Ovarian pathology

Abdominal Pain

Epigastric-Pain

• PUD• Gastritis• GERD• Pancreatitis• Cardiac (MI, pericarditis, etc)

Abdominal Pain

Periumbelical-Pain

• Pancreatitis• Obstruction• Early appendicitis• Small bowel pathology• Gastroenteritis

Abdominal Pain

Pelvic-Pain

• UTI• Prostatitis• Bladder outlet obstruction• PID• Uterine pathology

Abdominal Pain

Diffuse Pain

• Gastroenteritis• Ischemia• Obstruction• DKA• IBS• Others

– FMF– AIP– Vitamin D deficiency– Adrenal insufficiency

Abdominal Pain

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

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

• 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

• 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.

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Introduction

• 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?

• Rome III Diagnostic criteria.

• Manning’s Criteria.

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Diagnostic Criteria

• 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.

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Rome III Diagnostic Criteria.

• 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.

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Rome IlI Diagnostic Criteria.

– General:• Feeling of incomplete evacuation.• Passing mucus per rectum.• Abdominal fullness, bloating or

swelling.

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Rome IlI Diagnostic Criteria.

• Diarrhoea predominant.

• Constipation predominant.

• Pain predominant.

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Subtypes

• 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

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Associated Symptoms

IBS Pathophysiology

Heredity; nature vs nurture Dysmotility, “spasm”

Visceral HypersensitivityAltered CNS perception of visceral eventsPsychopathologyInfection/InflammationAltered Gut Flora

ImmuneActivation

Mast CellActivation

Luminal Flora

A New Paradigm

ImmuneActivation

Mast CellActivation

Luminal FloraSTRESS

INFECTION

ALTERED MICROBIOTA

ImmuneActivation

Mast CellActivation

Luminal Flora

Systemic Immune Compartment in IBSSerum Cytokines

Dinan, et al. Gastroenterology. 2006.

* IL-6

IBS Controls

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IL-6

(p

g/m

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* sIL-6r

IBS Controls0

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-6r

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

•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

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ControlsVolunteers

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Lessons from PI-IBS

Disturbed Flora

Susceptible Host

Inflammatory Response

Myo-Neural DysfunctionSYMPTOMS

• 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.

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.

• Placebo effect of up to 70% in all IBS treatments.

• Treatment should depend on symptom sub-type.

• Often considerable overlap between sub-groups.

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Treatment Approaches.

• Antispasmodics will help 66%.

• Mebeverine is probably first choice.

• Hyoscine 10mg qid can be added.

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Pain Predominant.

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

• 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

• Poor evidence for efficacy.

• Better evidence for tricyclics and SSRIs.

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Antidepressants

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]

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

• 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

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

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.

• 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%

• 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

• 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

RECENT THERAPYAntibiotics

PROBIOTICS

“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)

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!

Probiotics

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

% 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

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

• 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?

• 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

Self-help• IBS network,

• IBS support group

• Awareness

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THANK YOU

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