Management of Abdominal Pain

Diagnostic Evaluation

• The American College of Radiology recommends ultrasound as the first-line imaging for right upper quadrant abdominal pain 3
• The American College of Radiology recommends CT with IV contrast for right and left lower quadrant abdominal pain 4
• The World Journal of Emergency Surgery suggests CT with IV contrast for diffuse abdominal pain 4, 5

Management Based on Etiology

• The World Journal of Emergency Surgery states that source control is the cornerstone of management for intra-abdominal infections 1, 5, 3
• The World Journal of Emergency Surgery recommends antimicrobial therapy be initiated promptly, especially in septic patients 5, 3
• The World Journal of Emergency Surgery suggests 4 days of antibiotics post-source control is sufficient for uncomplicated infections in immunocompetent patients 1, 3
• The World Journal of Emergency Surgery recommends extending antibiotic therapy up to 7 days based on clinical response for immunocompromised or critically ill patients 1, 3
• The World Journal of Emergency Surgery recommends broad-spectrum antibiotics with activity against gram-negative, gram-positive, and anaerobic organisms in septic shock 1, 3
• The World Journal of Emergency Surgery recommends early laparoscopic cholecystectomy (within 7-10 days of symptom onset) for acute cholecystitis 3
• The World Journal of Emergency Surgery suggests percutaneous drainage may be considered for patients unfit for surgery 3
• The World Journal of Emergency Surgery recommends antibiotic therapy for 4-7 days depending on severity and immune status for acute cholecystitis 1, 3
• The World Journal of Emergency Surgery recommends laparoscopic appendectomy with 2-4 days of post-operative antibiotics for appendicitis 3
• The World Journal of Emergency Surgery suggests conservative management with antibiotics may be considered in selected cases for appendicitis 3
• The World Journal of Emergency Surgery recommends percutaneous drainage as a bridge to intervention for periappendicular abscess 3
• The World Journal of Emergency Surgery recommends conservative management without antibiotics in immunocompetent patients for uncomplicated diverticulitis 1
• The World Journal of Emergency Surgery suggests small abscesses can be treated with antibiotics alone, while larger abscesses require percutaneous drainage for complicated diverticulitis 1
• The Journal of the American College of Radiology recommends prompt diagnosis and intervention for mesenteric ischemia 6
• The Journal of the American College of Radiology suggests systemic anticoagulation with angiography and revascularization for embolic causes of mesenteric ischemia 6
• The Journal of the American College of Radiology recommends angioplasty and stent placement for atherosclerotic disease causing mesenteric ischemia 6

Chronic Abdominal Pain Management

• The American Gastroenterological Association recommends antispasmodics for pain exacerbated by meals for irritable bowel syndrome 7, 8
• The American Gastroenterological Association suggests tricyclic antidepressants for frequent or severe pain for irritable bowel syndrome 7, 8
• The American Gastroenterological Association recommends fiber supplementation (25g/day) for constipation-predominant irritable bowel syndrome 7
• The American Gastroenterological Association suggests loperamide (2-4mg, up to four times daily) for diarrhea-predominant irritable bowel syndrome 7
• The American Gastroenterological Association recommends cognitive-behavioral therapy for severe symptoms of irritable bowel syndrome 7, 8
• The American Gastroenterological Association suggests dynamic psychotherapy for severe symptoms of irritable bowel syndrome 7
• The American Gastroenterological Association recommends hypnotherapy for severe symptoms of irritable bowel syndrome 7, 8
• The American Gastroenterological Association suggests stress management/relaxation techniques for severe symptoms of irritable bowel syndrome 7, 8
• The American Gastroenterological Association recommends considering combination gut-brain neuromodulators (augmentation therapy) with vigilance for serotonin syndrome for severe or refractory pain 8
• The American Gastroenterological Association suggests multidisciplinary pain management for centrally-mediated pain 8
• The American Gastroenterological Association recommends avoiding opioids due to the risk of narcotic bowel syndrome 8

Analgesic Strategies

• The American College of Emergency Physicians recommends early administration of analgesia for mild to moderate pain 2
• The American College of Emergency Physicians suggests NSAIDs or acetaminophen for mild to moderate pain 2
• The American Gastroenterological Association recommends avoiding long-term opioid use for chronic abdominal pain 8

Special Considerations

• The World Journal of Emergency Surgery recommends further diagnostic investigation for patients with ongoing signs of infection beyond 7 days of appropriate treatment 1, 3
• The American College of Surgeons suggests considering palliative care when surgical intervention would be futile 2