Constant or Frequently Recurring Abdominal Pain

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patient with constant or frequently recurring abdominal pain for at least 6 months: not associated with known systemic disease with loss of daily function including work and socializing
referral to mental health care professional to exclude malingering
is pain associated with bowel movements, eating or menses?
alarm features identified on history or physical examination?
suspicion that pain is feigned?
consider IBS, EPS and other painful FGIDs, or mesenteric ischemia. Other possible diagnoses include painful gynecologic disorders, e.g. endometriosis
do appropriate diagnostic workup for alarm features
functional abdominal pain syndrome
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Case History - Constant or Frequently Recurring Abdominal Pain

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A 33 year old woman is referred to a gastroenterologist by her primary care physician(PCP) because of a long history of constant and severe abdominal pain refractory to all prior treatments; she has associated loss of daily functioning and is unable to work (Box 1, Fig 1). She has no known systemic disease that has explained the pain.

The gastroenterologist obtains the history that the patient first developed recurrent episodes of abdominal pain at the age of 6 years, and these episodes led to school absence. The frequency and severity of the episodes of pain increased after menarche. Over the last 10 years the pain has become more frequent and more severe, and for the last 5 years, has been present constantly, occurring on a daily basis. It is described as dull or cramping in character and is usually located in the mid to lower abdomen. Specifically, the pain is not related to or affected by bowel movements, eating or the menstrual cycle (Box 2). The patient communicates intense pain by wincing and holding her abdomen, and she requests that diagnostic studies be done to “find and fix” the problem (Box 1). Her records indicate that physical examinations in the past and diagnostic studies have been negative for other medical disorders (Box 3). The tests have included two colonoscopies, upper gastrointestinal endoscopy, computerized tomography (CT) scan of the abdomen, capsule endoscopy, pelvic ultrasound, and abdominal magnetic resonance imaging (MRI). An exploratory laparotomy 5 years earlier suggested endometriosis, leading to an unsuccessful trial of leuprolide acetate. She also underwent cholecystectomy 3 years earlier due to a low ejection fraction on DISIDA (isotope) scan. There are no alarm features (Box 4).

The patient states that she has had > 30 emergency room visits where she usually receives intravenous morphine and phenergan, and is discharged with a week’s supply of oral narcotics, hydrocodone or oxycodone. In the letter of referral, her PCP states that she often needs to refill these prescriptions to prevent the patient returning to the emergency room. She has had 5 hospitalizations for the abdominal pain when emergency room treatments were unsuccessful.

Further history reveals that at age 16 the patient left home before finishing high school, and after becoming pregnant, married at age 17. After 4 years she left her spouse when he became physically abusive. The patient and her daughter are currently living with her mother. For the last 2 years she has been unable to work (Box 1) and is currently receiving disability payments. The gastroenterologist notes that a psychiatry consultant diagnosed major depression with post-traumatic stress disorder resulting from a childhood history of family deprivation, and sexual and physical abuse. The pain is thought to be consistent with a Pain Disorder Associated with Psychological Factors (DSM-IV 307.80), and there is no evidence for malingering (Box 7). The psychiatrist recommended treatment with paroxetine 20 mg per day and follow up at a local mental health center. She was discharged with paroxetine and also oxycodone 10 mg three times per day.

Upon presentation on this occasion, the patient is lying on her side on the examination table with hips flexed. She complains of severe cramping abdominal pain in the mid and lower abdomen with nausea. The examination is again negative (Box 4) except for a positive Carnett’s test (see Box 5 in Figure 1 and Legend 5). She is asking to be hospitalized to determine the cause of the pain and to receive intravenous medication to relieve the pain. A diagnosis of FAPS is made (Box 8).

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