Priority Topic: Abdominal Pain & Priority Topic: Chronic Disease

Abdominal Pain

Key Feature 2: In a patient with diagnosed abdominal pain (ex: gastroesophageal reflux disease, peptic ulcer disease, ulcerative colitis, Crohn’s disease), manage specific pathology appropriately (ex: with. medication, lifestyle modifications). 
Skill: Clinical Reasoning
Phase: Treatment

Key Feature 8: Given a patient with a diagnosis of inflammatory bowel disease (IBD) recognize an extra intestinal manifestation. 
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Chronic Disease

Key Feature 1: In a patient with a diagnosed chronic disease who presents with acute symptoms, diagnose:

1. Acute complications of the chronic disease (ex: diabetic ketoacidosis).
   
2. Acute exacerbations of the disease (ex: asthma exacerbation, acute arthritis).
   
3. A new, unrelated condition.

Skill: Clinical Reasoning
Phase: Diagnosis

​When I was on rotation on the Family Practice Teaching Service at St Paul's Hospital I was managing a 27 year old female inpatient admitted with abdominal pain NYD (not yet diagnosed). Her past medical history was significant for ulcerative colitis, intravenous drug use now on opioid agonist therapy, pelvic inflammatory disease, and a ruptured ovarian cyst. Prior to the onset of the pain that brought her into the emergency department, she had not been taking any medications for the ulcerative colitis (the disease had been in remission) and she was on opioid agonist therapy to help manage her opioid use disorder. When she presented to the ED with acute abdominal pain she did not have a clear etiology to blame, and she was certainly unwell, so she was admitted to our service so we could manage her pain and figure out what was going on to resolve the underlying issue. After a couple of days into her admission and many investigations later, the team surmised that her pain was likely secondary to a flare up of the ulcerative colitis compounded with the pain of acute opioid withdrawal - the opioid agonist therapy she was taking was in the form of ingested slow-release oral morphine, which was likely not getting absorbed in her gut given its disposition. She was started back up on her antiinflammatory medication, her pain was temporarily managed with hydromorphone, and soon she was feeling back to her baseline. 

The list of possible aetiologies for abdominal pain is - as I've highlighted in previous blog posts - extensive. I will outline here the general management of selected aetiologies of abdominal pain that I must be  familiar with as a family doctor.

My information was gathered from Bugs & Drugs and the following UpToDate articles:

• Medical management of gastroesophageal reflux disease in adults
• Antiulcer medications: Mechanism of action, pharmacology, and side effects
• Peptic ulcer disease: Management
• Treatment regimens for Helicobacter pylori
• Management of mild to moderate ulcerative colitis in adults
• Management of severe ulcerative colitis in adults
• Overview of the medical management of mild (low risk) Crohn disease in adults 
• Overview of the medical management of severe or refractory Crohn disease in adults

Overview of the management of gastroesophageal reflux disease (GERD)
For uncomplicated GERD without alarm features*

1. Lifestyle/dietary modifications
   1. Weight loss: if overweight or recent weight gain
   2. Positional interventions: Elevation of the head of the bed if symptoms occur at night or if there are laryngeal symptoms (ex: cough, hoarseness, throat clearing). In the same vein, not eating 2-3 hours before bedtime or laying down after eating would be advisable.
   3. Dietary modifications: To selectively eliminate individualised triggers. Common triggers include fatty foods, caffeine, chocolate, spicy food, carbonated beverages, and peppermint. Alcohol can also be a trigger. Patients need not eliminate anything that is not a trigger for them, but these are common culprits to counsel about that may be worth a trial of elimination. 
2. Acid-suppressing medication
   1. Antacid therapy: With only intermittent episodes of bothersome heartburn occurring less than once weekly, starting with an over-the-counter antacid medication is a good first-line strategy
   2. H2RA therapy: If there are recurrent episodes happening no more than about once weekly, then a low-dose histamine 2 receptor antagonist (H2RA), taken only as needed, would suffice. My go to H2RA is ranitidine, which can be prescribed or purchased over-the-counter. And if there is an extra occasional episode of heartburn, perhaps because of a dietary indiscretion, then supplementing with an additional dose of over-the-counter antacid therapy would be totally appropriate. If the pain is not alleviated with a low-dose of H2RA used as needed, then stepping up to taking it regularly two times daily for a minimum of 2 weeks is warranted.
   3. PPI therapy: If the symptoms of heartburn continue to occur despite this continuous treatment, then it is time to discontinue the H2RA and initiate a once-daily proton pump inhibitor (PPI), starting at a low dose, and increasing this if the pain is still not controlled. Alternatively, if the patient first presented complaining of heartburning happening at least twice weekly from the get-go, starting a once-daily PPI at a low-dose without first trying antacids or an H2RA is warranted. My go-to PPI for GERD is omeprazole. The increase in the dose of the PPI, if needed, should be gradual, occurring after a 2 to 4 week interval at the trialed dose. Then, once the discomfort is controlled, the treatment (be it the H2RA or the PPI) should be continued at the first effective dose for at least 8 weeks. 
   4. Gastroenterology referral: Patients who fail to respond to once-daily PPI therapy are considered to have refractory GERD and should be referred to a gastroenterologist for further evaluation. They should also be referred to a gastroenterologist if they exhibit any alarm features* as part of their presentation. 
   5. Trial of cessation: If symptoms resolve completely with acid-suppressing medication, after a minimum of 8 weeks on this therapy, a trial of cessation is in order (unless there is another complicating factor to their acid reflux such as known esophagitis or Barrett's esophagus). If, after stopping the acid-suppressing therapy, the symptoms of acid reflux recur within three months, then the patient may need to be on the medication indefinitely. If it's been more than 3 months since stopping when the symptoms recur, then simply repeated a course of the above approach would be warranted.

*If any of the following alarm features are present, a referral to a gastroenterologist is indicated:

1. New onset epigastric discomfort in patients ≥60 years
2. Dysphagia or odynophagia
3. Anorexia, persistent vomiting, or unexplained weight loss
4. Evidence of gastrointestinal bleeding (hematemesis, melena, hematochezia, or occult blood in stool) or iron deficiency anaemia
5. Gastrointestinal cancer in a first-degree relative

Overview of the management of peptic ulcer disease (PUD)
The patient will have already been seen by a gastroenterologist, as endoscopy would've been done to detect the presence of ulceration. Although this means the gastroenterologist almost certainly will have developed a treatment plan for the patient to follow, it is important for family doctors to understand what needs to be done so they can ensure patient compliance.

1. Stop NSAID use: The patient should abstain from taking any NSAIDs. Avoiding tobacco is also recommended.
2. H. pylori eradication: If the patient was diagnosed as being infected with H. pylori, current standard of therapy specific to this part of the world, unless there are patient-specific reasons for prescribing an alternative regimen, is concomitant quadruple therapy for 2 weeks. This consists of a PPI twice daily, along with 3 antibiotics once daily: amoxicillin 1 g twice daily, clarithromycin 500 mg twice daily, and metronidazole 500 mg twice daily.
3. PPI therapy: The patient will need to be on daily PPI therapy for a total of 12 weeks, regardless of whether or not it was used as part of an H. pylori eradication regimen 
4. Test for cure: After 12 weeks of treatment and resolution of symptoms, if the patient was treated for H. pylori, a test for cure is warranted. This can be in the form of a urea breath test, fecal antigen test, or upper endoscopy. PPI therapy must be stopped at least 2 weeks before testing as the acid suppression reduces H. pylori bacterial load and so makes the testing for H. pylori less sensitive. If eradication was successful, awesome! No more treatment is indicated. But if eradication was not successful, a second alternative antibiotic regimen should be tried, and patient compliance with the antibiotic regimen should be assessed. If the second eradication regimen fails, gastroenterology followup should definitely be arranged if not already being done so as to get samples of the organism to determine its microbial sensitivity. 
5. Possible indefinite acid suppression: There may be some individuals who will have risk factors that may warrant ongoing acid-suppressing treatment.  These may include having a peptic ulcer that cannot be attributed to H. pylori infection or NSAID use, having a "giant" ulcer (>2 cm), or having comorbidities that warrant continued PPI use, among others. 

Overview of the management of inflammatory bowel disease [IBD] (ulcerative colitis [UC] or Crohn's disease [CD])
As with patients diagnosed with PUD, patients diagnosed with IBD will be seen and likely will continue to be seen by a gastroenterologist. It is important for family doctors to understand the management of IBD because they will be actively involved in helping patients manage the disease as well as their overall health, which can be impacted in numerous ways by IBD.

1. Vaccinations: Patients who have IBD are more immunocompromised, and the antiinflammatory medication needed to treat the disease compounds this. It is important to ensure patients are up to date on their vaccinations, of which more are indicated after being diagnosed with IBD. I list this management item first simply because patients are at increased risk of contracting infection once they start antiinflammatory medications, so this should be one of the first interventions that is addressed.
2. Antiinflammatory therapy: First line medication therapy will depend on severity and location, and patients with inflammatory bowel disease will almost certainly have a gastroenterologist whom they follow up with to manage treatment. The mainstay of therapy will be antiinflammatory medications. Common first-line ones include 5-aminosalicylic acid, budesonide, or sulfasalazine, among others. Corticosteroids and big guns like cyclosporine may be needed for refractory and severe symptoms (these medications being more potent but also with more negative side effects). And there are also newer and often highly effective but expensive monoclonal antibody therapies that may be used.
3. Management of complications: Patients with severe enough disease may need to be referred to the emergency department for more urgent management, hospital admission, and possibly even surgery. They may have a secondary gastrointestinal infection warranting antibiotics, they may be hypovolemic from having significant bloody diarrhea, and they made need intravenous strength medications. 
4. Management of extraintestinal manifestations: UC and CD have extraintestinal manifestations involving a number of other body systems, most commonly affecting the skin*, the eyes, or even the lungs. They will need to have management of all of these comorbidities, along with the underlying disease process (as treated with antiinflammatory medications).
5. Monitoring overall health: Routine monitoring of global health status is indicated in these patients, and there is lots to think of. In children and adolescents who are diagnosed with inflammatory bowel disease in particular, monitoring growth and nutritional status are major priorities, as the bowel disease wrecks havoc in the gut that leads to decreased absorption of nutrients, compounded by bouts of sickness that can lead to inability to ingest as many nutrients, along with increased expenditure of nutrients secondary to the inflammation and greater cell turnover. Because of this excess degree of inflammation, risk of bowel cancer is elevated in patients with IBD, and in particular UC, so it is also important to ensure that patients are being screened for colorectal cancer in keeping with recommendations.
6. Patient-centred care: With my family doctor hat on here specifically, it is important to also monitor how patients are coping with management of their disease. There is such variability in how active or quiescent inflammatory bowel disease may be, and it tends to have a relapsing-remitting course, so it is important to inquire as to how patients are coping. If patients are better able to cope, they will likely also have better health outcomes, promoting a positive feedback loop. The negative corollary is also likely true.

*Interestingly, the patient I was managing who had ulcerative colitis had an outbreak of lesions on her arms and legs, which she said started only a few days before she went in to the ED with abdominal pain. The two common types of extraintestinal  skin manifestations associated with IBD are erythema nodosum and pyoderma gangrenosum. According to the UpToDate article, Dermatologic and ocular manifestations of inflammatory bowel disease, "Erythema nodosum typically appears as raised, tender, red or violet subcutaneous nodules on the extensor surfaces of extremities. As erythema nodosum usually parallels intestinal disease activity, treatment is directed at the underlying IBD. If skin nodules precede any bowel symptoms or occur during quiescent phases of IBD, therapy with other medications, including prednisone, may be required." I looked up pictures of erythema nodosum, and the lesions the patient had certainly fit the look, along with the fact that they were nodular and tender to palpation, and were located on the extensor surfaces of her arms and legs. How interesting that they erupted at the same time or possibly right before the concomitant flare-up in her bowel disease! 

In summary, this has been another long but not even very detailed post that provides an overview of  important elements in the management of common and occasionally serious causes of abdominal pain.