Chronic Abdominal Pain

Likely Diagnoses

Red Flags (need work-up)

  • Fevers or night sweats
  • Blood in stool / melena
  • Regular nausea or vomiting
  • Weight Loss
  • Pedal edema (objective), which masks weight loss
  • Age >50 y.o. at onset of symptoms
  • Heavy alcohol history
IF NO RED FLAGS ON H&P:
  • Treat empirically for most likely diagnosis
  • Follow weights
  • If no response, reassure & adjust therapy
  • Order Labs [see below] (work up abnormals)
  • Explore Stressors and possible Mood Disorder as indicated
  • Refer to GI as last resort

RED FLAGS IDENTIFIED ON H & P

Lab Tests to Order
  • CBC.
  • Sed Rate.  If elevated, think Inflammatory Bowel Disease (IBD, not IBS) or cancer.
  • Chemistry panel, including electrolytes, calcium, total protein, plus renal & liver function.
  • Ferriten.  If low, suspect blood loss from a lesion or Celiac Disease.
  • Tissue-Transglutaminase (TTG), IgA Antibody  —-  Celiac Disease.
  • Lipase, for chronic pancreatitis.
  • If constipation is prominent, a TSH for Hypothyroidism.
Who Needs Endoscopy / Colonoscopy
  • Anemia
  • Low Ferriten (= iron deficiency)
  • History of Melena / Hematochezia (frank blood in stool)
  • TTG elevated (= Celiac Disease; Bx is standard recommendation, though TTG more sensitive & very specific).
  • Elevated Sed Rate (especially if diarrhea is a symptom)  —  looking for IBD.
  • Weight Loss
  • Age >50 (need colon cancer screening anyway)

 Who Needs Abdominal CT

  • Significantly abnormal WBC count
  • Elevated Sed Rate
  • Elevated Lipase
  • Weight Loss documented (or let GI order it)

See posting Chronic Abdominal Pain.