Learn about causes of chronic abdominal pain and available therapies for Centrally Mediated Abdominal Pain.

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.
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