Abdominal pain is one of the most common gastrointestinal symptoms, affecting 22-25% of the general population at any given time.1  Pinpointing the source of the pain can be challenging because there are so many different conditions which can cause abdominal pain.  Diagnosis also becomes difficult when symptoms are vague or intermittent. The top 10 causes of chronic abdominal pain are listed below.

What should case managers do? 

Refer clients to the GP in the first instance for a proper diagnosis, but if symptoms persist, also refer clients to a dietitian.

ALL abdominal pain needs to be assessed by a GP (or if severe, a consultant at A&E) to rule out acute and life-threatening conditions, such as appendicitis, pancreatitis, bowel obstruction/perforation, faecal impaction, bowel cancer, haemorrhage, aneurysm or ectopic pregnancy (amongst other conditions).  Severe abdominal pain that comes on suddenly and is accompanied by symptoms such as a rapid heart rate, fever or blood in vomit, stool, or urine requires immediate medical attention at A&E.2

Once a GP/consultant has ruled out life-threatening causes, an accurate diagnosis may require clients to attend several appointments and/or have further investigations.  Diagnosis and treatment may be delayed if a) clients have trouble booking or attending frequent GP appointments, b) if clients end up seeing a different clinician each time and/or c) if clients have difficulty articulating their symptoms.  The consequence of a delayed diagnosis is that clients can suffer with abdominal pain for YEARS, and end up with nutrient deficiencies, other secondary health issues and a reduced quality of life.  If someone is concurrently dealing with a brain injury, spinal cord injury or complex orthopaedic injury, the abdominal pain can also interrupt or derail the rest of their rehabilitation. This is because it’s incredibly difficult to engage in physiotherapy or psychology when you have excruciating abdominal pain.  Abdominal pain can also result in challenging behaviour in those who are unable to communicate what they are experiencing.

How dietitians can help

• Dietitians often have more time to assess a client’s symptoms, food intake, medication, and other potential triggers. They can then clearly summarise this information for GPs or gastroenterologists to support an accurate diagnosis.
• Dietitians can highlight any “red flag” symptoms to the GP, such as unexplained weight loss or blood in the stool.
• Dietitians can ask GPs to refer clients to NHS gastroenterology.  Dietitians can also refer clients directly to private gastroenterology when required (and sometimes even accompany clients to their appointments).
• Dietitians can give first-line dietary advice to try and manage any symptoms which are triggered by food.
• Dietitians can ask the GP to conduct relevant blood/stool tests and/or flag up any medications which may be making symptoms worse.
• Dietitians can make sure a client’s diet is nutritionally adequate, even if certain foods need to be eliminated to manage symptoms.

Top 10 causes of chronic abdominal pain

1. Constipation/wind/side effect of laxatives (3)

Hardened stool and/or trapped gas can cause abdominal distention, pressure build-up and/or contractions of the intestinal wall, which can all cause abdominal pain. Sometimes the laxatives prescribed to manage the constipation end up making the abdominal pain worse (with bisacodyl, sodium picosulfate and lactulose being the worst offenders for this).

Dietitians can advise clients on how to manage constipation by altering the type and amount of fibre that is eaten, increasing fluid intake and/or liaising with the GP around medication/laxatives/fibre supplements.

For more information on this topic, go to our previous blog post on Constipation & laxative use after catastrophic injury.

2. Gallstones (4, 5, 6, 7)

Gallstones can cause sudden and severe colicky abdominal pain.  The pain tends to be in the centre of the abdomen or under the ribs on the right-hand side, and can last 1-5 hours. The pain tends to be constant and isn’t relieved by going to the toilet, passing wind or being sick. The pain can also wake someone up if they are asleep.

Surgery is the most common way to treat gallstones.  Dietetic input has historically helped clients reduce their fat intake (pre-surgery) in order to manage gallstone pain, although the benefit of doing this is currently under review.

3. Food allergies/intolerances (8)

If abdominal pain is accompanied by other symptoms such as diarrhoea, vomiting or a skin reaction such as hives, the client may have a food allergy or intolerance. The most common food allergies are to milk, wheat, eggs, peanuts, tree nuts, fish, shellfish and corn.  The most common food intolerances are to lactose (the natural sugar in cow’s milk), and certain fermentable carbohydrates such as those found in onions, garlic and legumes.  Clients will need to keep very detailed food, fluid and symptom charts in order to pinpoint the problem.

Once diagnosed, dietitians can help clients identify trigger foods, educate clients on which substitutions to make and help ensure a client’s diet is nutritionally balanced despite any restrictions.  Dietitians can also help clients trial an elimination diets if food allergies and intolerances have been ruled out, but a food sensitivity is still suspected.

4. Irritable Bowel Syndrome (9, 10, 11)

If a client has abdominal pain or discomfort in addition to altered bowel habits, irritable bowel syndrome should be considered.

Dietitians can help ensure clients get the required diagnostic blood tests and then offer first-line and second-line dietary advice to help relieve symptoms (e.g. adjusting fibre intake or implementing a low FODMAP diet).  Dietetic oversight is required for any short-term implementation of a low FODMAP diet, because this diet is so restrictive.  This helps to ensure a client’s food intake remains nutritionally adequate and ensures the client only uses the low FODMAP diet on a short-term basis for diagnostic purposes.

For more information on this topic, please see our previous blog post on Irritable Bowel Syndrome…no need to suffer.

5. Diverticular disease (12)

Intermittent abdominal pain and tenderness in the left lower quadrant, combined with constipation, diarrhoea or rectal bleeding, could be diverticular disease.

Dietitians can support clients with decreasing their fibre intake to manage an acute episode and then increasing fibre intake to prevent future flare-ups.  They can also advise clients on ways to increase their fluid intake and liaise with the GP as required around the need for fibre supplements or laxatives.

6. Coeliac disease (13)

Recurrent abdominal pain combined with unexplained weight loss, anaemia, constipation, diarrhoea and/or vomiting, could be coeliac disease.  Some clients with coeliac disease have no symptoms at all, so a coeliac screen blood test is generally done any time there are any gut-related symptoms.  This blood test must ALWAYS be done BEFORE cutting gluten out of the diet, otherwise the test will be inaccurate.

People with coeliac disease must follow a gluten-free diet for life.  Dietitians can help educate clients on which foods contain gluten, which grains to use instead, which supplements are required and how to follow a nutritionally balanced diet in spite of these dietary restrictions.  Dietitians can also ensure that annual blood tests are completed to ensure clients are complying with the diet and to screen for other secondary health complications.

7. Inflammatory bowel disease (Crohn’s or Ulcerative Colitis) (14, 15)

Inflammatory bowel disease involves inflammation of the gut mucosa which generally results in abdominal pain, diarrhoea lasting longer than 4 weeks and blood or mucus in the stool.

Dietitians can request blood tests to check for nutrient deficiencies and then advise on dietary changes and/or nutritional supplements to help manage symptoms and maintain someone’s nutritional status.

8. Ulcer in the stomach or small intestine (16, 17)

A burning or gnawing pain in the centre of the abdomen could relate to a peptic ulcer.

Treatment for an ulcer involves checking the client for Heliobacter pylori bacteria and/or treating with a proton pump inhibitor.  Dietitians can support clients in getting the appropriate treatment and educating them on ways to change their diet to prevent ulcers from reoccurring.

9. Pancreatitis (18, 19)

Chronic or recurrent upper abdominal pain could be pancreatitis, particularly if there is nausea, vomiting, fever or pain that radiates to someone’s back.

Pancreatitis can interfere with the absorption of nutrients.  Dietitians can request blood tests to check for nutrient deficiencies, ensure a client’s diet is nutritionally adequate, liaise with the GP about dietary enzymes (if required) and advise clients on ways to maintain their weight.

10. Bile malabsorption (20)

Abdominal pain combined with bloating, excessive wind and diarrhoea that is pale, greasy, hard to flush or an unusual colour, could be bile malabsorption.  Bile malabsorption is quite common after gallbladder removal or in people with gut issues like Crohn’s disease, coeliac disease, or chronic pancreatitis

Bile malabsorption is generally treated with medication alongside a strict low-fat diet.  Dietitians can advise on a low-fat diet and also ensure that clients have annual blood tests to check for fat-soluble vitamin deficiencies.

Chronic abdominal pain and gut-related problems can be incredibly complex and difficult to diagnose and treat successfully.  This is because there are so many different explanations for why someone can experience abdominal pain.

For more information or to refer a case management client with abdominal pain for a comprehensive dietetic assessment and report, contact Specialist Nutrition Rehab at 0121 384 7087 or info@specialistnutritionrehab.co.uk.

For more articles like this delivered direct to your email inbox, please sign up for our free monthly newsletter below.