Gastroenterology – Chronic Abdominal Pain: By Brock Vair M.D.
Chronic abdominal pain can be defined as pain that persists unchanged for several weeks or longer. This pain can be described as constant or intermittent. Most cases of chronic abdominal pain are functional, with no demonstrable organic abnormality. Common examples of this include functional bowel disease or irritable bowel syndrome. However, sometimes, chronic abdominal pain can be due to organic causes.
These can be inflammatory, vascular, or mechanical. Inflammatory causes include those related to acid-pepsin diseases, such as gastritis, ulcers or reflux; biliary causes such as chronic cholecystitis, sphincter of Oddi dysfunction, pancreatitis; or intestinal inflammatory causes such as Crohn’s or diverticular disease. Vascular causes include mesenteric ischemia Mechanical causes can be due to a partial bowel obstruction or celiac disease. A thorough evaluation of a patient presenting with chronic abdominal pain includes a complete history and physical exam.
Red flags that point to an organic cause include: Onset of symptoms after age 50 Progression in severity of pain Chronic abdominal pain associated with fever or weight loss Family history of inflammatory GI conditions or GI malignancies Organomegaly, palpable abdominal or rectal mass, lymphadenopathy, or bruit on examination Any accompanying laboratory abnormalities when investigations are conducted Imaging investigations, such as abdominal ultrasound, CT, and MRI, can be ordered depending on findings from history and exam. Further investigation through endoscopy is warranted if abnormalities are present on non-invasive imaging. But remember to choose investigations wisely, avoid expensive and sometimes invasive investigations unless indicated by red flags or abnormal physical / lab findings. Treatment of chronic abdominal pain depends on the cause, and therapy should be specific to the diagnosis. Finally, it is important to be aware that many causes of chronic abdominal pain may progress to significant complications. For example, malignancy may occur with reflux from Barrett’s esophagus. The clinician should also realize that patients with longstanding abdominal discomfort can develop new pathology independent of the underlying cause for their chronic pain. New symptoms that arise in a background of chronic pain should be promptly and appropriately investigated.
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