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Persistent Abdominal Pain: Not Always IBS

Persistent abdominal pain may be caused by a whole range of different conditions, say French experts who call for more physician awareness to achieve early diagnosis and treatment so as to improve patient outcomes.

Benoit Coffin, MD, PhD, and Henri Duboc, MD, PhD, from Hôpital Louis Mourier, Colombes, France, conducted a literature review to identify rare and less well-known causes of persistent abdominal pain, identifying almost 50 across several categories.

“Some causes of persistent abdominal pain can be effectively treated using established approaches after a definitive diagnosis has been reached,” they write.

“Other causes are more complex and may benefit from a multidisciplinary approach involving gastroenterologists, pain specialists, allergists, immunologists, rheumatologists, psychologists, physiotherapists, dieticians, and primary care clinicians,” they write.

The research was published online in Alimentary Pharmacology and Therapeutics.

Frequent and  Frustrating Symptoms

Although there is “no commonly accepted definition” for persistent abdominal pain, the authors say it may be defined as “continuous or intermittent abdominal discomfort that persists for at least 6 months and fails to respond to conventional therapeutic approaches.”

They highlight that it is “frequently encountered” by physicians and has a prevalence of 22.9 per 1000 person-years, regardless of age group, ethnicity, or geographical region, with many patients experiencing pain for more than five years.

The cause of persistent abdominal pain can be organic with a clear cause or functional, making diagnosis and management “challenging and frustrating for patients and physicians.”

“Clinicians not only need to recognize somatic abnormalities, but they must also perceive the patient’s cognitions and emotions related to the pain,” they add, suggesting that clinicians take time to “listen to the patient and perceive psychological factors.”

Coffin and Duboc highlight that the most common conditions associated with persistent abdominal pain are irritable bowel syndrome and functional dyspepsia, as well as inflammatory bowel disease, chronic pancreatitis, and gallstones.

To examine the diagnosis and management of its less well-known causes, the authors conducted a literature review, beginning with the diagnosis of persistent abdominal pain.

Diagnostic Workup

“Given its chronicity, many patients will have already undergone extensive and redundant medical testing,” they write, emphasizing that clinicians should be on the lookout for any change in the description of persistent abdominal pain or new symptoms.

“Other ‘red flag’ symptoms include fever, vomiting, diarrhea, acute change in bowel habit, obstipation, syncope, tachycardia, hypotension, concomitant chest or back pain, unintentional weight loss, night sweats, and acute gastrointestinal bleeding,” the authors say.

They stress the need to determine whether the origin of the pain is organic or functional, as well as the importance of identifying a “triggering event, such as an adverse life event, infection, initiating a new medication, or surgical procedure.” They also recommend discussing the patient’s diet.

There are currently no specific algorithms for diagnostic workup of persistent abdominal pain, the authors say. Patients will have undergone repeated laboratory tests, “upper and lower endoscopic examinations, abdominal ultrasounds, and computed tomography scans of the abdominal/pelvic area.”

Consequently, “in the absence of alarm features, any additional tests should be ordered in a conservative and cost-effective manner,” they advise.

They suggest that, at a tertiary center, patients should be assessed in three steps:

  • In-depth questioning of the symptoms and medical history

  • Summary of all previous investigations and treatments and their effectiveness

  • Determination of the complementary explorations to be performed

The authors go on to list 49 rare or less well-known potential causes of persistent abdominal pain, some linked to digestive disorders, such as eosinophilic gastroenteritis, mesenteric panniculitis, and chronic mesenteric ischemia, as well as endometriosis, chronic abdominal wall pain, and referred osteoarticular pain.

Systemic causes of persistent abdominal pain may include adrenal insufficiency and mast cell activation syndrome, while acute hepatic porphyrias and Ehlers–Danlos syndrome may be genetic causes.

There are also centrally mediated disorders that lead to persistent abdominal pain, the authors note, including postural orthostatic tachycardia syndrome and narcotic bowel syndrome due to opioid therapy, among others.

Writing support for the manuscript was funded by Alnylam Switzerland GmbH. Coffin has served as a speaker for Kyowa Kyrin and Mayoly Spindler and as an advisory board member for Sanofi and Alnylam. Duboc  reports no relevant financial relationships. 

Alimentary Pharmacology & Therapeutics. Published online June 2, 2022. Full text

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