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Diarrhea, Bloating, Abdominal Pain May Appear Together But Should Be Evaluated Individually

October 23, 2017
Taking a stepwise approach in the assessment of patients with this common triad of gastrointestinal symptoms will improve the efficiency of diagnosing the likely root cause, and determining the most appropriate treatment, assuring the most satisfactory outcome.

With Amy S. Oxentenko, MD, FACP, FACG, AGAF, Lawrence Schiller, MD, MACG and Walter Park, MD

Chronic diarrhea, bloating, and abdominal pain are likely to make the top three list of complaints heard daily by primary care physicians, gastroenterologists and pain specialists who see patients with gastrointestinal disorders.

While this commonly occurring constellation of symptoms is often presented together, focusing on one at a time may achieve a better resolution,1 according to Amy S. Oxentenko, MD, FACG, professor of medicine and associate chair of the Department of Medicine at the Mayo Clinic in Rochester, Minnesota.

She addressed the necessary assessment process for each of the three symptoms during a presentation at the World Congress on Gastroenterology at ACG 2017, which was the American College of Gastroenterology annual meeting, held in Orlando, Florida.

For patients who present with abdominal pain, bloating, and diarrhea, should be evaluated separately for each symptom.

"I have found that approaching them separately allows clinicians to focus on that one symptom more clearly,” she told Practical Pain Management, which may improve outcomes for many patients since too many physicians have approached these symptoms as a trio, treating them collectively.

Dr. Oxentenko suggested that by addressing the symptoms one at a time, in a stepwise fashion, the process would allow for a more effective use of time and cost for both the clinician and the patient.1 In addition, the stepwise approach will also work just as well for patients who may not present with the triad of GI-related complaints.1 For example, a patient may come in with only abdominal pain, or just diarrhea. For each patient, the clinician will need to have a different algorithm to address the symptom(s) presented, said Dr. Oxentenko. 

Here are highlights from Dr. Oxentenko presentation, offering a recommended approach to evaluate each of these problematic gastrointestinal symptoms.

Stepwise Approach to Evaluate Bloating

Nearly 30% of adults report bloating, Dr. Oxentenko said. The suggested step-wise approach to assess for this complaint is as follows:2

  • Clarify the predominant symptom. Is it belching, actual bloating, or distension? With distension, there is an objective enlargement around the waist, she said.
  • Identify the timing of onset—within 30 minutes of eating or several hours later? If the symptoms present within a short time following an eating episode (ie, snack, meal, dessert), the likelihood of a gastric etiology is greatest whereas a longer time suggests a small bowel or dietary origin.
  •  Do a thorough dietary evaluation. Ask about meal volume, frequency, speed of eating, intake of carbonated and caffeinated beverages. Ask, too about lactose, gluten (versus wheat), fructose and other commonly gassy founds such legumes, and cruciferous vegetables (ie, cabbage, Brussels sprouts, asparagus, cauliflower) and use of artificial sweeteners.
  • Ask about other associated gastrointestinal symptoms—abdominal pain, change in stool form or frequency, constipation, diarrhea or weight loss.
  • Review all medications and supplements. Ask about opioids, psyllium, iron, metformin, magnesium, hidden sources of fiber (eg, high intake of apples or oats), sorbitol, multivitamins, over the counter antidiarrheal medications, lactulose/osmotics.
  • Consider comorbidities such as small intestinal bacterial overgrowth risk factors, roux-en-y gastric bypass surgery, radiation, prior abdominal surgery, use of a continuous positive airway pressure (CPAP) ventilator for sleep apnea (swallowed air), Nissen fundoplication (gas-bloating).

The Complaint of Bloating Is Not So Simple

Dr. Oxentenko indicated that the next step ought to depend on the type of bloating present, as this complaint may originate from different causes or arise for a variety of reasons.1,2

  • For bloating of gastric origin—Management should begin with a thorough dietary assessment, empirical treatments, upper endoscopy (EDG) and gastric scintigraphy can be tried.
  • If small bowel bloating is the issue—Consider bowel obstruction, inflammatory bowel disease, small intestine bacterial overgrowth (SIBO). To confirm suspected cause, clinicians may suggest avoidance of dairy (for possible lactose intolerance), breath test for SIBO, or enterography imaging.
  • Constipated bloaters—These patients could have IBS with constipation, slow transit constipation, or other issues. A trial of thyroid and calcium supplementation might be suggested, and a colonoscopy considered as well as anorectal manometry, and a transit study.
  • For belching—Testing is rarely needed. Instead, the best management approach is a dietary referral to evaluate eating behaviors (speed of eating and other mechanisms affecting rate of food intake), and a referral for cognitive behavioral therapy and anxiety assessment.

Sorting Out Acute from Chronic Diarrhea

In conducting a work-up for the patient with diarrhea, Dr. Oxentenko suggested the following:1

  • Is it really diarrhea? Current recommendations indicate that a pattern of more than three unformed bowel movements a day, with more than 25% loose or mushy stool and a Bristol stool scale of 6 or 7 is indicative that possible treatment is needed.
  • Is it chronic? Acute is considered a pattern that lasts two to four weeks, while chronic is confirmed if it has been persistent for more than four weeks.
  • Can you categorize the type of diarrhea? Small bowel diarrhea usually has large volume, with vitamin and mineral deficiencies; colon has smaller volume and can be bloody. Diarrhea with an osmotic gap below 50 is secretory (caused by infections, bile acids, colitis, other); above 100, it is osmotic (due to excessive intake of artificial sweeteners, or fat/sugar malabsorption, other).
  • Are there historical clues to the diagnosis? For instance, a family history or itchy rash may point to celiac, younger patients with fever and bloody stools might have IBD. If the pain is recurrent, (at least one day a week for three months) and is related to defecation and change in frequency of stools (or form and consistency), with symptoms for at least six months, suspect IBS.
  • Is it diet or medication-induced? More than 700 drugs may be implicated in onset of diarrhea with 7% of medication side effects resulting in diarrhea.

When conducting a patient examination, Dr. Oxentenko cautioned pain practitioners to be aware of ''alarm'' features. These include family history of IBS, bowel cancer, new-onset and older age, or patients who are immunosuppressed.

Among the tests to consider:

  • Baseline labs with CBC, TTG, TSH, electrolytes, C-RP
  • Endoscopy imaging
  • Quantitative stool tests

Abdominal Pain

For more than 90% of patients presenting with abdominal pain, there is a single site of pain with upper abdominal pain arising most commonly (75% of cases) and right side of abdominal pain presenting more often as the chief complaint in 50% of cases.1

The assessment may include:1

  • Evaluation for features suggesting a structural anomaly. Assess for clues of IBD, celiac, ulcer, and other issues. Alarm bells: over age 50, weight loss, night pain, family history.
  • Questions about changes in bowel form or frequency, response to defecation.
  • Does the pain arise in the upper or lower region of the abdomen? Upper abdominal pain could point to ulcer, chronic pancreatitis, other. If abdominal pain is located in the lower region, consider inflammatory bowel syndrome, celiac, intestinal inflammation, ovarian issues, or a possible hernia. Pain that gets worse with eating could signal a peptic ulcer, bowel obstruction, biliary colic, or functional dyspepsia.
  • Evaluate for abdominal wall pain. In these cases, obesity often coexists, as might inflammatory bowel syndrome or dyspepsia. Women outnumber men 4:1.

The Carnett sign yields a diagnostic accuracy of 97% pointing to abdominal wall as the pain origin rather than being visceral abdominal pain. Pain that worsens despite escalating narcotics could point to narcotic bowel syndrome.

Among the assessment options are CBC, C-RP, upper or lower GI endoscopy, imaging if indicated. After dietary modification, laxatives, prescription meds (TCAs and linaclotide) and behavioral and psychological therapies, as well as a multidisciplinary pain management program, can be suggested.

Perspectives from Pain Experts

The stepwise approach suggested by Dr. Oxentenko is not necessarily new, but it reinforces valuable information—and good advice to ''keep things logical and consistent," especially for pain practitioners, said Walter Park, MD, a gastroenterologist at Stanford Health Care and assistant professor of medicine at Stanford University School of Medicine.

The guidance is valuable, he said.

"If you have a patient with vague symptoms who is very worried, a clinician might throw the kitchen sink at them in terms of testing," he said, "Nowadays we have so many potential tests to offer the patients."  One point it seems Dr. Oxentenko is making, he told Practical Pain Management, is that ''many of these symptoms that are vague are due to very benign causes; some may be anxiety induced."

The rational, stepwise approach may help quell that anxiety, he said, while helping the pain practitioner avoid unnecessary testing.

The information is especially useful for PCPs, said Lawrence Schiller, MD, MACG, a gastroenterologist and program director of the gastroenterology fellowship at Baylor University Medical Center in Dallas, Texas. His advice echoed that of Dr. Oxentenko's.

"Do the simple things first," Dr. Schiller suggested, “Get a thorough history. Do a good physical exam, make sure you review the meds they are on. Don't settle for a diagnosis of IBS with diarrhea before giving it sufficient consideration, taking into account the whole picture of the patient."

Drs. Oxentenko, Schiller, and Park reported no financial conflicts of interest.

 

Last updated on: October 23, 2017
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