gastrointestinal disorders
Chronic Abdominal Pain and Recurrent Abdominal Pain
Evaluation
History of present illnessshould elicit pain location, quality, duration, timing and frequency of recurrence, and factors that worsen or relieve pain (particularly eating or moving bowels). A specific inquiry as to whether milk and milk products cause abdominal cramps, bloating, or distention is needed because lactose intolerance is common, especially among Black people, Hispanics, Asians (particularly East Asian countries), and American Indians with increasing frequency with aging. Review of systemsseeks concomitant GI symptoms such as gastroesophageal reflux, anorexia, bloating or “gas,” nausea, vomiting, jaundice, melena, hematuria, hematemesis, weight loss, and mucus or blood in the stool. Bowel symptoms, such as diarrhea, constipation, and changes in stool consistency, color, or elimination pattern, are particularly important. Diet history is important. For example, ingestion of large amounts of cola beverages, fruit juices (which may contain significant quantities of fructose andsorbitol), or gas-producing foods (eg, beans, onions, cabbage, cauliflower) can account for otherwise puzzling abdominal pain. Past medical historyshould include nature and timing of any abdominal surgery and the results of previous tests that have been done and treatments that have been tried. A drug history should include details concerning prescription and illicit drug use as well as alcohol. Family history of RAP, fevers, or both should be ascertained, as well as known diagnoses of sickle cell trait or disease, familial Mediterranean fever, and porphyria. Review of vital signs should particularly note presence of fever or tachycardia. General examination should seek presence of jaundice, skin rash, and peripheral edema. Abdominal examination should note areas of tenderness, presence of peritoneal findings (eg, guarding, rigidity, rebound), and any masses or organomegaly. Rectal examination and (in women) pelvic examination to locate tenderness and masses and stool examination for occult blood are essential. The following findings are of particular concern: Fever Anorexia, weight loss Pain that awakens patient Blood in stool or urine Jaundice Edema Abdominal mass or organomegaly Clinical examination alone infrequently provides a firm diagnosis. Determining whether CAP is physiologic or functional can be difficult. Although the presence of red flag findings indicates a high likelihood of a physiologic cause, their absence does not rule it out. Other hints are that physiologic causes usually cause pain that is well localized, especially to areas other than the periumbilical region. Pain that wakes the patient is usually physiologic. Some findings suggestive of specific disorders are listed in table Physiologic Causes of Chronic Abdominal Pain . Functional CAP may result in pain similar to that of physiologic origin. However, there are no associated red flag findings, and psychosocial features are often prominent. A history of physical or sexual abuse or an unresolved loss (eg, divorce, miscarriage, death of a family member) may be a clue. The History for diagnosis of irritable bowel syndrome are the presence of abdominal pain for at least 1 day/week in the last 3 months along with at least 2 of the following: Pain is related to defecation. Pain is associated with a change in frequency of defecation. Pain is associated with a change in consistency of stool ( Evaluation reference ). 1.Drossman DA: Functional gastrointestinal disorders: History, pathophysiology, clinical features, and Rome IV.Gastroenterology150:1262–1279, 2016. doi: 10.1053/j.gastro.2016.02.032 nitrogen, glucose, and lipase) should be done. Abnormalities in these tests, the presence of red flag findings, or specific clinical findings mandate further testing, even if previous assessments have been negative. Specific tests depend on the findings ( see Table: Physiologic Causes of Chronic Abdominal Pain ) but typically include ultrasonography for ovarian cancer in women > 50 years, CT of the abdomen and pelvis with contrast, upper GI endoscopy (particularly in patients > 60 years old) or colonoscopy, and perhaps small-bowel imaging or stool testing. The benefits of testing patients with no red flag findings are unclear. Patients>50 or with risk factors for colon cancer (eg, family history) should probably have a colonoscopy; patients≤50 can be observed or have CT of the abdomen and pelvis with contrast if an imaging study is desired. Magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and laparoscopy are rarely helpful in the absence of specific indications. Between the initial evaluation and the follow-up visit, the patient (or family, if the patient is a child) should record any pain, including its nature, intensity, duration, and precipitating factors. Diet, defecation pattern, and any remedies tried (and the results obtained) should also be recorded. This record may reveal inappropriate behavior patterns and exaggerated responses to pain or otherwise suggest a diagnosis. 