Chronic Abdominal Pain for the ED Provider
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Learn about causes of chronic abdominal pain and available therapies for Centrally Mediated Abdominal Pain.
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Chronic Abdominal Pain for the ED Provider
- 1. Chronic Abdominal Pain Department of Emergency Medicine Moving Beyond Frustration
- 2. No Disclosures Disclosure Statement Department of Emergency Medicine
- 3. Jane Department of Emergency Medicine Chronic abdominal pain 6 CT in the last 12 months EGD, Colonoscopy neg Does not usually keep visits “they tell me nothing is wrong with me”
- 4. Chronic Abdominal Pain Centrally Mediated Abdominal Pain Functional Abdominal Pain Narcotic Bowel Syndrome Abdominal Myofascial Pain Syndrome “Constipation” Diarrhea Irritable Bowel Syndrome Department of Emergency Medicine
- 5. Abdominal Pain Masquerade Department of Emergency Medicine
- 6. Abdominal Wall Pain abdominal myofascial pain syndrome Positive Carnett’s Sign (increased pain with abdominal wall contraction) Point Tenderness Relief with injection of local anesthetic Glissen Brown, J Clin Gastroenterol, 2016 Department of Emergency Medicine
- 7. Functional Abdominal Pain functional dyspepsia / irritable bowel syndrome Functional Dyspepsia = upper abdominal symptoms Irritable Bowel Syndrome = abdominal discomfort and change in stool Symptoms are temporally related to meals Symptoms are episodic Department of Emergency Medicine
- 8. Narcotic Bowel Syndrome opioid induced gastrointestinal hyperalgesia On chronic opioid therapy Pain not explained by other diagnoses Escalating abdominal pain despite meds Pain worsens with decreased opioids Pain improves when opioids are resumed Patients may have co-morbid GI illness Drossman D, Am J Gastroenterol Suppl, 2014 Department of Emergency Medicine
- 9. Centrally Mediated Abdominal Pain Department of Emergency Medicine
- 10. 1% Keefer L, Gastroenterology, 2016 Department of Emergency Medicine
- 11. 1% Must include all of the following: •Continuous or nearly continuous abdominal pain •No or only occasional relationship of pain with physiological events •Pain limits some aspect of daily functioning •The pain is not feigned •Pain is not explained by another structural or functional gastrointestinal disorder or other medical condition Department of Emergency Medicine Keefer L, Gastroenterology, 2016
- 12. Increased Inflammatory Cytokines Luminal Irritants Decreased inhibitory feedback Feed-forward Excitatory signals PAIN Department of Emergency Medicine
- 13. (life) Pain Experience+ = history of trauma social stressors lack of social support learned behaviors co-morbid mental health disorders symptoms are real patients may “catastrophize” coping PAIN Department of Emergency Medicine
- 14. CMAP Therapy Patients NEED to have a gastroenterologist Focused testing based on red flag symptoms Treat co-morbid mental health conditions Medical Therapy with TCAs, SSRIs and atypical antipsychotics Department of Emergency Medicine
- 15. Department of Emergency Medicine Jane
- 16. Step 1: Empathy Department of Emergency Medicine Jane
- 17. Red Flag symptoms: Age >50 Weight Loss Rectal Bleeding New change in GI symptoms Department of Emergency Medicine Step 2: Careful History
- 18. Department of Emergency Medicine Step 3: Set an Agenda
- 19. Department of Emergency Medicine Step 4: Try something new
- 20. metoclopramide haloperidol carafate ketamine iv lidocaine lorazepam Department of Emergency Medicine Step 4: Try something new
- 21. metoclopramide haloperidol carafate ketamine iv lidocaine lorazepam Ramirez R et al. AJEM 2017 Roldan et. Al. AEM 2017 Department of Emergency Medicine Step 4: Try something new
- 22. Department of Emergency Medicine Step 5: Appropriate follow up
- 23. Glissen Brown JR, Bernstein GR, Friedenberg FK, Ehrlich AC. Chronic Abdominal Wall Pain: An Under-Recognized Diagnosis Leading to Unnecessary Testing. J Clin Gastroenterol. 2016 Nov/Dec;50(10):828-835. PubMed PMID: 27548731. Keefer L, Drossman DA, Guthrie E, Simrén M, Tillisch K, Olden K, Whorwell PJ. Centrally Mediated Disorders of Gastrointestinal Pain. Gastroenterology. 2016 Feb 19. pii: S0016-5085(16)00225-0. doi: 10.1053/j.gastro.2016.02.034. [Epub ahead of print] PubMed PMID: 27144628. Bharucha AE, Chakraborty S, Sletten CD. Common Functional Gastroenterological Disorders Associated With Abdominal Pain. Mayo Clin Proc. 2016 Aug;91(8):1118-32. doi: 10.1016/j.mayocp.2016.06.003. Review. PubMed PMID: 27492916; PubMed Central PMCID: PMC4985027. Nakano M, Oka S, Tanaka S, Igawa A, Kunihara S, Ueno Y, Ito M, Chayama K. Indications for Small-bowel Capsule Endoscopy in Patients with Chronic Abdominal Pain. Intern Med. 2017;56(12):1453-1457. doi: 10.2169/internalmedicine.56.7458. Epub 2017 Jun 15. PubMed PMID: 28626168; PubMed Central PMCID: PMC5505898. Recommended Reading