Abdominal pain is one of the most common gastrointestinal symptoms, with 22-25% of the general population suffering with it at any given point in time.1 Diagnosis can be tricky (especially if the abdominal pain is intermittent or symptoms are vague), because there are so many different conditions which can cause abdominal pain. 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, refer on 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).  Abdominal pain which is severe, comes on suddenly, and is accompanied by other symptoms such as fever, fast heart rate or the presence of blood in vomit, stool or urine, indicates that someone needs to go to A&E.2

Once a GP/consultant has ruled out life-threatening causes, clients may then need several more appointments (and possibly more investigations) to arrive at an accurate diagnosis to explain the abdominal pain. Diagnosis and treatment may be delayed, if clients have trouble booking or attending frequent GP appointments, if they end up seeing a different clinician each time and/or 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 generally have more time to piece together a client’s symptoms, food intake, triggering foods/situations and medication and can succinctly present this information to GP’s or gastroenterologists to help them make the correct diagnosis.
• Dietitians can highlight any “red flag” symptoms that clients may not have shared or that occur after the client has seen the GP.
• Dietitians can ask GP’s to refer a client to NHS gastroenterology or can refer clients directly to private gastroenterology when required (and sometimes even accompany clients to their appointment).
• 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 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 laxatives are prescribed to try and manage the constipation, but then these medications can sometimes contribute to even more abdominal pain (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.

Treatment of gallstones is usually surgical.  Dietetic input has historically helped clients reduce their fat intake in order to manage 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, it’s possible there is 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 records in order to help a dietitian liaise with the consultant to get the correct diagnosis.

Once diagnosed, dietitians can help clients determine which foods are triggering their symptoms, educate clients on which foods to avoid and which substitutions to use and how to make sure their diet is nutritionally balanced in spite of any restrictions.  Dietitians can also help clients with elimination diets if a food allergy and intolerance have been ruled out, but a food sensitivity is still suspected.

4. Irritable Bowel Syndrome (9, 10)

If a client has abdominal pain, bloating and a change in 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 supervision is required for any short-term implementation of a low FODMAP diet because this diet is so restrictive.  This helps ensure a client’s food intake remains nutritionally adequate.

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

5. Diverticular disease (11)

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 (12)

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) (13, 14)

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 (15, 16)

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 (17, 18)

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, liaise with the GP about dietary enzymes if required, advise clients on ways to maintain their weight and ensure their nutritional needs are being met.

10. Bile malabsorption (19)

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 someone has had their gallbladder removed or if someone has other gut-related problems such as Crohn’s disease, coeliac disease or chronic pancreatitis.

Bile malabsorption is generally treated with medication alongside a strict low-fat diet that dietitians can advise on.  Dietitians can also ensure that clients have annual blood tests to check fat-soluble vitamin levels to ensure deficiencies do not develop.

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.

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