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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Abdominal pain

• 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

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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
Abdominal Pain

• 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.

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Acute abdominal pain
Abdominal Pain

• Surgical
• Appendicitis
• Cholecystitis
• Bowel obstruction
• Acute mesenteric ischemia
• Perforation
• Trauma
• Peritonitis

• Medical
• Cholangitis
• Pancreatitis
• Choledocholithiasis
• Diverticulitis
• PUD
• Gastroenteritis
• Nonabdominal causes

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Abdominal Pain
History

• Onset
• Character
• Location
• Severity
• Duration

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Abdominal Pain
History Aggravating and alleviating factors

• Eating
• Drinking
• Drugs
• Body position
• Defecation

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Abdominal Pain
HistoryAssociated symptoms

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

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History
Abdominal Pain

• 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

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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

• Inspection
• Distention, scars, bruises, hernia
• Palpation
• Tenderness
• Guarding
• Rebound
• Masses
• Auscultation
• Abd sounds present, hyper, or absent

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Laboratory Testing
Abdominal Pain

• CBC
• Liver profile
• Amylase
• Glucose
• Urine dipsticks
• Pregnancy test

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Imaging
Abdominal Pain

• Plain films
• Ultrasonography
• Computed Tomography

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Endoscopy
Abdominal Pain

• EGD
• Colonoscopy
• ERCP/EUS

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Approach
Abdominal Pain

• Abdominal pain
• Acute Chronic
• Surgical nonsurgical

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RUQ-PAIN
Abdominal Pain

• Cholecystitis
• Cholangitis
• Hepatitis
• RLL pneumonia
• Subdiaphragmatic abscess

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LUQ- PAIN
Abdominal Pain

• Splenic infarct
• Splenic abscess
• Gastritis/PUD

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RLQ-PAIN
Abdominal Pain

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

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LLQ-PAIN
Abdominal Pain

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

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Epigastric-Pain
Abdominal Pain

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

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Periumbelical-Pain
Abdominal Pain

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

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Pelvic-Pain
Abdominal Pain

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

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Diffuse Pain
Abdominal Pain

• Gastroenteritis
• Ischemia
• Obstruction
• DKA
• IBS
• Others
• FMF
• AIP
• Vitamin D deficiency
• Adrenal insufficiency

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Chronic abd pain approach
Abdominal Pain

• History

Intermittent
continuous
biliary
metastasis
intest. obstruction
Intest. tumor
pancreatic disorder
Intst. angina
endometriosis
pelvic inflammation
porphoryea
Addison dis
IBS
functional disorder
Alarm symptoms
Fever CS CT
Cholestasis US/CT ERCP
IDA Hematochezia Endoscopy
Weight loss Endoscopy CT
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Take Home Points
Abdominal Pain

• 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

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What Is IBS

• 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.

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Introduction

• First described in 1771.
• 50 of patients present lt35 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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Who Gets IBS?

• 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.

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Diagnostic Criteria

• Rome III Diagnostic criteria.
• Mannings 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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Rome III Diagnostic Criteria.

• 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 IlI 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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Subtypes

• Diarrhoea predominant.
• Constipation predominant.
• Pain predominant.

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Associated Symptoms

• 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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IBS Pathophysiology

• Heredity nature vs nurture
• Dysmotility, spasm
• Visceral Hypersensitivity
• Altered CNS perception of visceral events
• Psychopathology
• Infection/Inflammation
• Altered Gut Flora

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Luminal Flora
Mast Cell Activation
Immune Activation
A New Paradigm
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STRESS INFECTION ALTERED MICROBIOTA
Luminal Flora
Mast Cell Activation
Immune Activation
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Luminal Flora
Mast Cell Activation
Immune Activation
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Systemic Immune Compartment in IBSSerum Cytokines
Dinan, et al. Gastroenterology. 2006.
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Mucosal Compartment

• Frank inflammation
• Immune Activation
• ? IELs
• ? CD3, CD25
• Chadwick et al, 2002
• Decreased IgA B Cells
• Forshammar et al, 2008
• Altered expression of genes involved in mucosal
  immunity
• Aerssens et al, 2008

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Post-Infectious IBS

• 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

Dunlop, et al. 2003.
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Lessons from PI-IBS
Inflammatory Response
Disturbed Flora
Susceptible Host
Myo-Neural Dysfunction
SYMPTOMS
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Differential Diagnosis

• Inflammatory bowel disease.
• Cancer.
• Diverticulosis.
• Endometriosis.
• Celiac disease

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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 gt 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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Patients Concerns.

• 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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Treatment Approaches.

• 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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Pain Predominant.

• Antispasmodics will help 66.
• Mebeverine is probably first choice.
• Hyoscine 10mg qid can be added.

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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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Antidepressants

• Poor evidence for efficacy.
• Better evidence for tricyclics and SSRIs.

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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 pain
• 30-50 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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Diarrhea predominant

• 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

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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 THERAPYAntibioticsPROBIOTICS
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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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Hitting the Target!
Endpoints Target 1 Rif 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 plt0.03
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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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Global Assessment of Symptom Relief
P0.0118
Answering Yes at Week 4
B. infantis 1x106
B. infantis 1X1010
B. infantis 1X108
Placebo
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• Prospective, multicenter, double-blind,
  placebo-controlled, crossover trial assessing the
  efficacy and safety of the probiotic, VSL3
• Patients treated with VSL3 had a significant
  improvement in the primary endpoint, which was
  the global relief of IBS symptoms (p lt 0.05).
  Secondary endpoints of abdominal pain (p 0.05)
  and bloating (p lt 0.001) were also improved.
• Guandalini et al. 2008

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What about diet?

• 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.

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Alternative Medicine

• 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.

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Self-help

• IBS network,
• IBS support group
• Awareness

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THANK YOU