Pain in the gut

Sometimes a careful history and minimal screening are more effective than extensive scans and tests.

When encountering a patient with severe, persistent abdominal pain, hospitalists may be inclined to order extensive scans and tests to pinpoint the cause. But a careful patient history, screening and minimal blood work may be all that's needed if a patient has a previously undiagnosed functional bowel disorder.

While these disorders normally are diagnosed in the outpatient setting, undiagnosed patients do show up at the hospital. The disorders—which include irritable bowel syndrome (IBS), chronic functional abdominal pain and nonulcerative dyspepsia—can present with symptoms ranging from chronic abdominal pain and nausea to constipation or severe diarrhea. The common denominator is that cases seen in the hospital are often the most challenging.

Photo by Thinkstock
Photo by Thinkstock.

“Basically, the hospitalist is getting the most severe and complex patients with functional bowel disorders,” said Albena Halpert, MD, assistant professor of medicine, section of gastroenterology, Boston University School of Medicine, and a gastroenterologist at Pentucket Medical Associates in Haverhill, Mass.

Hospitalists need to be alert for signs of an underlying functional disorder when conducting a workup, said Brennan Spiegel, MD, associate professor of medicine at Veterans Administration Greater Los Angeles Healthcare System and University of California, Los Angeles.

“The real issue is, does this patient have something like IBS or functional abdominal pain syndrome?” Dr. Spiegel said. “Because those patients are hospitalized often for their symptoms and often undergo unnecessary procedures—even operations sometime—when they really didn't need that.”

Pinpointing functional disorders

A thorough physical examination and patient history are key to recognizing a functional bowel disorder, with chronicity being a major indicator, experts said.

“If somebody has acute-onset abdominal pain and doesn't normally suffer from gastrointestinal (GI) symptoms, we never think about a functional GI disorder,” Dr. Spiegel said. “We think about an acute intraabdominal problem: appendicitis, cholecystitis, pancreatitis, bowel obstruction, etc.”

The Rome III criteria, which address onset and duration of pain and discomfort, as well as stool changes, are a reliable resource for diagnosing functional GI disorders. If a patient meets the criteria and doesn't present any red flags (such as blood in the stool, vomiting blood, weight loss, abnormal physical examination, or a family history of colon cancer or inflammatory bowel disease), the literature suggests she has an approximately 99% likelihood of a functional bowel disorder, said Douglas A. Drossman, MD, professor of medicine and psychiatry and co-director of the University of North Carolina at Chapel Hill's Center for Functional Gastrointestinal and Motility Disorders.

The Rome III criteria are online.

Functional disorders may be triggered or exacerbated by stimuli such as stress, food, and medication, which is why taking a complete history is important, experts said. For example, narcotics given for pain can cause a condition called narcotic bowel disorder, even in patients who don't have other bowel problems.

Functional disorders may be triggered by or exacerbated by stimuli such as food stress and medication Photo by Thinkstock
Functional disorders may be triggered by or exacerbated by stimuli such as food, stress and medication. Photo by Thinkstock.

“Narcotic bowel disorder can occur not only with people with functional GI disorders, but in people with structural diseases like Crohn's disease or even patients who are postoperative who are given high doses of narcotics,” Dr. Drossman said.

In narcotic bowel syndrome (NBS), “some people, probably for genetic reasons, are more likely to develop a paradoxical hyperalgesia. So instead of (the narcotics) helping the pain, after a period of time the pain gets worse,” he added.

The only way to determine whether a patient with abdominal pain has NBS is through his or her history. “Have they had this (pain) for a long time, or did this pain develop or get worse while on the narcotics? We recently learned that when taking these patients off the narcotics over several days in the hospital, the pain gets better and continues to improve as long as they stay off the narcotics,” Dr. Drossman said.

As part of the physical exam for diagnosing persistent abdominal pain in the hospital, it's prudent to order a complete blood count in order to rule out other illnesses, experts said. Electrolyte levels, liver function, C-reactive protein, and erythrocyte sedimentation rate should be studied for signs of anemia, infection or inflammation, they said. Some physicians test for celiac disease at this time, as well, if the patient has diarrhea.

Patients older than age 50 should have a colonoscopy, too, Dr. Drossman said.

If a patient matches the Rome III criteria and her blood tests and colonoscopy are clear, no further workup is needed, he added. “You don't have to do (computed tomography) or things like that,” he said, unless the patient's clinical profile changes later or red flags appear.

Managing the disorder

The goal of treatment for inpatients with functional bowel disorder “is to get them functional enough to be able to manage as an outpatient, in my mind,” Dr. Halpert said.

Constipation-prone patients with IBS can be treated with stool softeners and fiber products. If these don't work, another option is polyethylene glycol 3350, which is not absorbed into the body and doesn't attract water into the intestines via osmosis, thus promoting bowel movement, said John W. Wiley, MD, an internal medicine professor and director of the Functional Bowel Disorders Program at the University of Michigan, Ann Arbor. Medicines such as lubiprostone (Amitiza) also can help, he said.

Patients with IBS who are prone to diarrhea may be given antidiarrheals like loperamide (Imodium A-D). Antianxiety drugs are also used, because they affect neurotransmitters that not only regulate mood but gut motility, secretion and pain, said Amy E. Foxx-Orenstein, DO, FACP, associate professor of medicine and director of the Constipation and Pelvic Floor Program at the Mayo Clinic in Scottsdale, Ariz.

“Increased motility can lead to faster transit: diarrhea potential. Reduced transit: constipation potential,” said Dr. Foxx-Orenstein.

Dr. Spiegel emphasized that understanding a patient's biopsychosocial history may help discern the best treatment. “Some of the longest consults I've done, in-house anyway, have been functional GI patients. (I) spent a good hour with a patient, really talking to them about their biopsychosocial history and really trying to understand the context within which their symptoms developed, trying to learn about whether there were psychological or physical or dietary influences, what stresses were happening in their life,” he said.

If a patient shows clear signs of underlying depression, hospitalists should consider involving a psychiatrist, who should know which medications are useful in treating both the psychological condition and the pain from a functional bowel disorder, Dr. Wiley said.

When suggesting a psychiatric referral, Dr. Foxx-Orenstein explains to patients that she wants to understand more about what is contributing to their pain because the brain and gut communicate constantly with each other. “I want them to be informed about what sorts of things can tip their symptoms,” she said. “The more they know about it, the more aware and prepared they are going to be.”

She also refers some patients to a biofeedback expert, who can teach breathing and relaxation techniques to help patients control symptoms. “So if they get a surge of discomfort, they don't have to reach for a pill,” she said. “They do their exercises.”

If patients have narcotic bowel disorder, it's essential to develop a withdrawal plan and find treatment alternatives, she added. This may take weeks or months of slow weaning or involvement in a chronic pain treatment program, Dr. Foxx-Orenstein said.

Specialists and PCP involvement

Well-trained hospitalists should be able to manage most routine presentations of functional bowel disorders on their own, Dr. Wiley said. “The time when they would want to refer to a GI doctor is if they're having trouble getting the symptom complex under control,” he said.

However, Dr. Spiegel recommended a consult with a gastroenterologist for all hospital patients admitted specifically for IBS symptoms, since the admission itself signals a severe case. “Just like nobody would admit an inflammatory or Crohn's disease patient without getting GI involved, a severe IBS patient should also require a GI (specialist),” he said.

Before a patient is discharged, ongoing care should be scheduled with his or her primary care physician, including a recommendation for follow-up with a gastroenterologist if symptoms don't improve. Hospitalists also should make sure patients understand they have a chronic condition with symptoms that may take time to resolve, experts said. This is particularly true if treatment involves an antidepressant.

Dr. Foxx-Orenstein said follow-up at three to six weeks is best, in order to ensure the patient's therapy is working. Hospitalists should also urge patients to call their primary care physicians if symptoms worsen, she noted.