Evaluation of Abdominal Pain by D.M. Eaves, MD, MSS, ACPE

PART 1

There are many illnesses/diseases that cause abdominal pain. In this series of articles, I will discuss the presentations, course of the diseases, investigative studies, and treatments of these various conditions.

Evaluation of abdominal pain encompasses a multitude of conditions with similar symptoms, and can frustrate even the best clinician. The common gastrointestinal diseases described here can be managed effectively in the primary care setting.  However, in many primary care practices, patients are unable to see their primary care physician on a same day/urgent visit. This has lead to increased visits to urgent care clinics and emergency departments for clinical evaluation.

The most common visits to Emergency Departments (EDs) are for chest and abdominal pain. From 1999 through 2008, the number of non-injury emergency department (ED) visits, in which abdominal pain was the primary reason for the visit and visits for chest pain increased by 31.8% and has continued to rise[i].

Chest and abdominal pain are the most common reasons for those 15 years and older to visit the emergency department (ED). Because EDs provide both emergency and non-emergency care, visits for these symptoms may vary in their acuity and wait times.  Advanced medical imaging is often ordered to assist in both diagnosing and ruling out serious illness associated with these symptoms.

With this in mind, let’s start our foray into abdominal pain with the esophagus.

Gastroesophageal reflux (GERD)

Acid reflux also known as gastroesophageal reflux occurs in as many as one in three persons. The incidence among pregnant women is 25 percent. It can present with pulmonary symptoms e.g. cough, or masquerade as atypical chest pain. There are several studies that can be done to determine reflux:

a)      An upper gastrointestinal series (UGI)

b)      Upper GI endoscopy

c)      CT scan with contrast

These studies are done to confirm the diagnosis of reflux as well as to exclude the diagnosis gastric/peptic ulcer disease, to rule out esophageal and/or gastric cancer, and/or to determine if there is a stricture in the distal esophagus. With chronic reflux, a condition known as Barrett’s Esophagus can develop. This condition occurs in the distal esophagus secondary to stomach acid entering this area and changing the lining of the esophagus. Barrett’s esophagus is a pre-cancerous condition that requires advanced medical management and treatment.

Hiatal Hernia

In 50 percent of patients over age 50, asymptomatic sliding hiatal hernia is found. A hiatal hernia results when the upper section of the stomach enters the chest cavity secondary to a widening in the diaphragmatic opening. When this occurs, the pressure difference between the chest cavity and the abdominal cavity is dramatically altered. No surgical treatment is needed, unless the hernia is solely of the para-esophageal  type or is a combination of a sliding and para-esophageal hiatal hernia. Para-esophageal hernias require surgical correction even in asymptomatic patients.

Symptomatic sliding hiatal hernia (esophageal hiatal hernia) occurs in less than 5 percent of the patient population. Medical management of a symptomatic hiatal hernia consists of elevation of the head of the bed to approximately 45 degrees, early evening meals, avoidance of fat, chocolate, tobacco, alcohol, and harmful medications, and the use of antacids.

If symptoms persist despite medical management, an acid perfusion test can be used to determine the sensitivity of the distal esophagus to acid reflux.  A positive test result has a sensitivity and specificity of 80 percent.  A pH probe is placed in the distal esophagus 5 cm above the lower esophageal sphincter. A pH of less than 4 in conjunction with reflux symptoms is diagnostic of gastroesophageal reflux.  If gastroesophageal reflux is confirmed, treatment can be accomplished with several classes of medications:

H2 Receptor Antagonist/Blockers (Histamine H2 receptors):

This classification of medication blocks the action of the chemical Histamine on stomach cells to decrease acid production. This class of medications includes Cimetidine [Tagamet], Ranitidine [Zantac]), and cholinergic agent Bethanechol (Duvoid, Urecholine). Sodium Alginate (Alginic Acid), a product obtained from brown algae, can be instituted to ameliorate symptoms.

H2 blockers ease reflux symptoms and decrease the need for antacids; Bethanechol increases the resting pressure of the lower esophageal sphincter (LES). Metoclopramide (Reglan), a dopamine antagonist, also increases this pressure, but this drug provides less symptomatic relief of reflux than the H2 blockers or Bethanechol.

H2 receptor antagonist/blockers are effective in treating the following conditions:

1. Peptic Ulcer Disease (PUD)

2. Gastroesophageal Reflux Disease (GERD)

3. Dyspepsia

4. Prevention of stress ulcers

Proton Pump Inhibitors (PPIs):

PPIs are a group of medications that produce a long lasting reduction of gastric acid production. This class of medications is the most effective inhibitors of gastric acid production, and has largely replaced H2 receptor antagonist. Included in this category of medications are the following:

1. Omeprazole (OTC names Gasec, Prilosec, Omepral UlcerGard)

2. Lansoprazole (Prevacid, Zoton, Monolitum, Levant)

3. Dexlansoprazole (Kapidex, Dexilant)

4. Esomeprazole (Nexium, Esotrex, Esso)

5. Pantoprazole (Protonix, Somac, Pantozol, Pantomed)

6. Rabeprazole (Aciphex, Pariet, Erraz, Razo, Rabecid)

PPIs have been used to treat a variety of medical conditions to include the conditions listed under H2 receptor antagonist in addition to the following:

1. Barrett’s Esophagus

2. Eosinophilic Esophagitis

3. Laryngopharyngeal Reflux

4. Zollinger-Ellison Syndrome

5. Gastrinomas

Some of these conditions we will explore in later articles.

Endoscopy can be beneficial in determining subsequent treatment if a history of esophagitis is elicited.

Drug therapy fails in I0% of patients necessitating performance of some type of antireflux procedure. Mortality associated with the various procedures ranges from 0.1% to 1.6%.

The information provided is for general interest only and should not be misconstrued as a diagnosis, prognosis or treatment recommendation. This information does not in any way constitute the practice of medicine, or any other health care profession. Readers are directed to consult their health care provider regarding their specific health situation. Marque Medical is not liable for any action taken by a reader based upon this information.

References

1 Eaves-(Hill) DM  Evaluation of the acute abdomen:  Postgraduate Medicine VOL 81/No 4 March 1987 129-135

2. Demeester TR, Wang, CI, Wernly, JA Technique, indications, and clinical use of 24 hour  esophageal  pH monitoring: J Thoracic Cardiovascular Surg 1 1980: 79(5)656-70

3. Johnson LF, DeMeester. Evaluation of the head of the bed, Bethanechol and antacid form tablets on gastroesophageal reflux  Dig Dis Sci 1981:26(8)-673-80

4. Richter JE, Castell DO, Gastroesophahael reflux pathogenesis, diagnosis and therapy. Ann Internal Med 1982:97(1):93-103

Footnotes