20Osteopathic Family Physician (2019) 20 - 26Osteopathic Family Physician Volume 11, No. 1 January/February, 2019Review ARTICLEChronic Abdominal Pain: Tips for the Primary Care ProviderGina Charles, DO, MBS,1 Magdala Chery, DO, MBS,2 & Millicent King Channell DO, MA, FAAO212Serenity Aesthetics & Wellness, Philadelphia, PARowan University School of Osteopathic Medicine, Stratford, NJKEYWORDS:Chronic Abdominal PainChronic Abdominal Wall PainNarcotic Bowel SyndromeOsteopathic ManipulativeMedicineABSTRACT: Chronic abdominal pain (CAP) has become a common diagnosis in theprimary care setting. It is characterized by intermittent abdominal pain lasting for atleast six months. The list of causes in the differential diagnosis is extensive. The costsassociated with diagnostic workup is a expensive burden to healthcare. Managementof CAP is determined by the etiology. This manuscript reviews the causes of CAP,diagnostic workup, osteopathic considerations, special populations experiencingCAP, and management.INTRODUCTIONEPIDEMIOLOGYChronic abdominal pain (CAP) is defined as a continuousor intermittent abdominal discomfort lasting for at least sixmonths.1, 2, 3 CAP is common in the primary care setting and iscaused by a variety of abnormalities ranging from organic tofunctional. Managing CAP can be challenging, due to a broaddifferential diagnosis and sometimes extensive and negativeworkup.2 This condition is commonly associated with significanthealthcare costs, largely because it is so often misdiagnosedand many primary care practitioners are unfamiliar with howto approach diagnosis in a cost effective manner.4 Patientscomplaining of CAP may present with long standing symptoms oran exacerbation of an already existing problem. Evaluation of CAPrequires detailed history taking, awareness of alarm symptoms,thorough physical exam and its correlation to pattern recognitionfor a variety of diseases, psychosocial assessment consideration,and diagnostic investigation.5 This initial evaluation approachwill aid the primary care physician’s ability to narrow down thedifferential diagnoses and drive further diagnostic testing whenappropriate. Management of CAP includes, lifestyle modifications,discontinuation of offending agents, medical management,injections, osteopathic techniques, and referral to a specialist ifsurgery is required.The prevalence of CAP is uncertain. However current datapropose that the incidence of CAP is 22.9 per 1000 person-years.6Abdominal pain was reported in 25% of the adult populationduring cross-sectional surveys. There appears to be no substantialdifference in prevalence among different age groups, ethnicities,and geographic regions.6 Although there are studies that suggestthat women are more likely to report abdominal pain than men.The lack of statistical data to support precision in the reportedepidemiology of CAP could be accounted for in the variedinterpretation of symptoms.CORRESPONDENCE:Gina Charles, DO, MBS [email protected] 2019 by the American College of Osteopathic FamilyPhysicians. All rights reserved. Print ISSN: 1877-573XPSYCHOSOCIALHistorically, there has been well-documented correlation betweensomatic complaints and psychosocial conditions. It has beenestimated that nearly two thirds of patients with depressionpresent to primary care with somatic dysfunction.7 In regards toCAP there has been a well recognized association between CAPpresentation and a history of PTSD, abuse, somatization, anxiety,and depression.8, 9, 10 Timely consideration of psychosocial factorscan help primary care providers determine appropriate testingand management plans. Discussing family dynamics, screeningfor new life stressors, such as caring for a sick loved one, financialhardships, birth of new child, etc. may help with establishing acorrelation between the onset of CAP symptoms and moodchanges. Ultimately, this can substantially decrease healthcarecosts by minimizing unnecessary investigation and redirect careplans to managing underlying psychosocial condition with talktherapy intervention and/or medication if appropriate, which willlikely result in resolution of patients CAP. 2, 7

Charles, Chery, ChannellChronic Abdominal Pain: Tips for the Primary Care ProviderCLINICAL PRESENTATIONTABLE 1:Careful history taking is critical in guiding the initial evaluation.General information to gather during this initial history takinginclude symptom onset, duration, location, diffuse vs. nonspecific, quality and severity of pain, exacerbating factors, andalleviating factors. Associated signs and symptoms are paramountin narrowing the differential diagnosis. The localization of chronicabdominal pain is a common hurdle for patients to articulate tohealthcare providers. This ultimately makes it harder for primarycare physicians to sort through a multitude of possible differentialdiagnoses. Classification by organ system, as seen in Table 1,should be considered when patients present for CAP. Keeping thiscategorization in mind may assist in directing questions duringpatient encounters.Endometrial Cancer Risk FactorsPHYSICAL EXAMPatients presenting with CAP should have a thorough physicalexam including vital signs, abdominal exam, and osteopathicstructural exam. In patients with suspected psychogenic abdominalpain, it is important to perform the abdominal examinationwhile the patient is distracted. Systemic examination that mayprovide useful clues to diagnosis include: lack of moist mucousmembranes (dehydration), conjunctival pallor (anemia), ictericsclera (hepatobiliary disease), sunken eyes, prominent clavicles,and temporal wasting (significant weight loss).2 The location ofpain will help guide the primary care physician’s examination andthought process for further evaluation, see Figure 1, Page 22.Though many cases present with a benign physical examination,clinical findings that require urgent attention include: reboundabdominal tenderness, guarding or tenderness to palpation.Rectal exam should be considered in patients presenting withrectal bleeding or discharge. The presence of occult blood in stoolsmay provide clues to gastrointestinal cancer, bowel inflammation,or peptic ulcer disease.13 In women with pelvic or lower abdominalpain, a pelvic exam may help determine whether the pain arisesfrom the abdominal wall or is gynecologic in origin. If found duringexamination, costovertebral angle tenderness is suggestive ofrenal pathology. Diminished peripheral pulses and abdominaltenderness in the setting of vascular compromise is suggestiveof mesenteric ischemia.2, 14One specialized maneuver associated with abdominal painand possible cause is the carnett’s sign. The patient lies supine,tenses their abdominal wall and lifts their head off the table. Apositive sign (increased or unchanged tenderness) is suggestive ofabdominal wall/ somatic pain. A negative sign (decreased pain) issuggestive of intra-abdominal/ visceral pain.2, 15, 16 Several studieshave demonstrated that a combination of history, physical andpositive Carnett’s sign is a reliable predictor of chronic abdominalwall pain.16 A key feature of chronic abdominal wall pain is thatpatients are able to isolate the pain to a specific point/locationunlike, many other conditions that have a generalized abdominalpain presentation.The etiology of chronic abdominal pain may be visceral,psychological or mechanical. An osteopathic structural examshould be included. Additional Information contributing to thediagnose may be found through palpation of regions of theautonomic innervation in particular as outlined in Figure 1, Page 22.1721PULMONARYCystic ALGastroesophageal RefluxEsophageal CancerHernias (ventral, hiatal)Chronic GastritisGastric CancerGastroparesisFunctional DyspepsiaPeptic Ulcer DiseaseChronic CholecystitisChronic CholelithiasisCholangiocarcinomaChronic HepatitisHepatocellular CancerChronic PancreatitisPancreatic CancerCeliac DiseaseIrritable Bowel SyndromeLactase Deficiency/IntoleranceCrohn's DiseaseUlcerative ColitisColorectal CancerChronic Mesenteric IschemiaPost-Surgical AbdominalAdhesionsChronic Abdominal Wall PainNarcotic Bowel SyndromeAbdominal MigraineSubacute Intestinal ObstructionGYNECOLOGICOvarian CystOvarian CancerSequelae of Pelvic ICSickle Cell AnemiaPSYCHOLOGICALPsychiatric DisordersMISCELLANEOUS CAUSESFunctional AbdominalPain SyndromeReferred Pain from Extra-Abdominal OrganDrug/Medication InducedNEUROLOGICAbdominal cutaneous nerve entrapment syndromeCentrally Mediated AbdominalPain SyndromeHerpes ZosterChronic Narcotic UseThe above alarm symptoms from the history are cause for concern:Fever, unexplained weight loss, loss of appetite, pain that awakens thepatient during the night, hematemesis, hematochezia, hematuria, severevomiting, severe diarrhea, anemia, Jaundice, swelling of abdomen or legs,and difficulty swallowing.3, 11, 12 Tachycardia, Tachypnea, and hypotensionare considered urgent, and require immediate attention.2 The emergenceof new symptoms or any physiologic change in the description of painshould prompt the physician to consider an acute on chronic condition.2For example, immediate severe pain can be suggestive of an acute bileduct obstruction by a stone, perforation of a hollow organ (duodenalulcer), gastroparesis in a diabetic patient or a catastrophic ischemiccondition (acute mesenteric anemia).13 These conditions have seriousoutcomes and require immediate evaluation and intervention. 2DIAGNOSTIC WORKUPA thorough workup of labs and appropriate imaging will support orrefute the diagnosis. Begin by determining if there are any alarmsymptoms to warrant immediate inpatient evaluation. If alarmsymptoms are absent, proceed to the outpatient workup, refer toFigure 1. The following lab measurements are recommended forinitial work up of patients with CAP: urinalysis, complete metabolicpanel, complete blood count, thyroid function tests, lipase,amylase, and liver function tests. All women of reproductive ageshould undergo urine or serum pregnancy testing prior to anydiagnostic imaging.

22Osteopathic Family Physician Volume 11, No. 1 January/February, 2019FIGURE 1:Chronic Abdominal Pain Diagnostic Workup AlgorithmDiagnostic imaging in the setting of CAP is often overused andapproached erratically. One reliable starting tool for the primarycare physician is an abdominal ultrasound. Abdominal ultrasoundis a sensitive, non-invasive, cost effective test that can be used tohelp diagnose the cause of abdominal pain. For pain located in thelower abdomen and pelvic regions, a pelvic and/or transvaginalultrasound can also be useful in determining whether the pain isabdominal or gynecologic in nature.2, 18 While the abdominal CT isalso a useful tool in the diagnostic workup, it is extremely costly tothe healthcare system. In 2012-13, Mendelson et al. reported thatthere were over 330, 000 abdominal CT scan related Medicareservices at a cost of 146 million.3 Once initial testing has beenperformed, there are more specific tests to be considered basedon clinical findings. Upper GI causes should be evaluated via EGD,and lower GI causes evaluated via colonoscopy.Diagnostic imaging is not often indicated in the evaluation CAP.3Thus it is important to make enlightened cost effective decisionsabout ordering radiographic studies. Ultimately, it is the primarycare physician’s duty to determine which modalities are mostappropriate, to form a diagnosis, and subsequently develop a planfor management.MANAGEMENTThe etiology of a patient’s CAP can be from any organ system,making it extremely difficult to have a single specific treatmentalgorithm. In general for all patients, management should be,etiology specific and can include a combination of lifestylemodifications, medical therapies, OMT, surgical interventions, andalternative modalities.Lifestyle modificationsPrior to proceeding to specific investigations, a low cost strategyin the treatment of CAP is lifestyle and dietary modifications. Thiscan be particularly helpful for chronic abdominal pain thought tobe secondary to GERD, lactose Intolerance, Peptic Ulcer Disease,Gastroparesis, and chronic mesenteric ischemia. Simply limitingcertain foods that trigger pain symptoms, modifying diet to smallerfrequent meals, and/or changing to semi-solid or liquid form foodscan be prove to be effective.

Charles, Chery, ChannellChronic Abdominal Pain: Tips for the Primary Care Provider23TABLE PATHETIC Increased tone constrictspupil, significantly increasedsecretions of nasal, lacrimal,and submandibular glands. Facial (CN VII),glossopharyngeal (CN IX) —cranial dysfunction Vagus nerve CN X exits thejugular foramen (comprisedof occiput and temporalbones) Somatic Dysfunctions ofoccipito-atlantoid joint(OA), atlanto-axial joint(AA), C2 Compression ofoccipitomastoid sutures Increased tone vasoconstrictionand slight secretionsof nasal, lacrimal, andsubmandibular glands,increased blood flowto skeletal muscle Somatic Dysfunctionof T1–T5 Increased volume ofsecretions and relativebronchiole constriction Vagus nerve CN X exits thejugular foramen (comprisedof occiput and temporalbones Somatic Dysfunctions ofoccipito-atlantoid joint (OA),atlanto-axial joint (AA), C2 Compression ofoccipitomastoid (OM)sutures Increased tone Vasoconstrictionand slight secretionsof nasal, lacrimal, andsubmandibular glands,increased blood flowto skeletal muscle Decreased secretionsand bronchiole dilation Somatic Dysfunctionsof T1–T7 Increased tone increasedacid secretion and increasedperistalsis Vagus nerve CN X exits thejugular foramen (comprisedof occiput and temporalbones) Somatic Dysfunctions ofoccipito-atlantoid joint (OA) ,atlanto-axial joint (AA), C2 Compression ofoccipitomastoid sutures Pelvic splanchnics—S2–S4 Sacroiliac dysfun