What are the recommended management strategies for patients with chronic abdominal pain who do not respond to standard treatments?

For patients with chronic abdominal pain who do not respond to standard treatments, several management strategies are recommended, focusing on re-evaluation, escalated pharmacological options, psychological interventions, and specialist referrals.

Firstly, it is crucial to reassess for any red flags that might suggest a serious underlying pathology, which would necessitate urgent referral or immediate assessment based on clinical judgement ¹,²,⁴. If symptoms are persistent or refractory, consider the possibility of an alternative diagnosis and manage it appropriately ²,³.

For Irritable Bowel Syndrome (IBS) specifically, if tricyclic antidepressants (TCAs) are ineffective, contraindicated, or not tolerated, selective serotonin reuptake inhibitors (SSRIs) such as citalopram or fluoxetine may be considered, with careful explanation of the rationale and potential adverse effects ²,⁴. TCAs are considered effective second-line drugs for global symptoms and abdominal pain in IBS, typically started at a low dose (e.g., 10 mg amitriptyline once a day) and slowly titrated ²,⁴.

Non-pharmacological and psychological interventions are key. For chronic primary pain, a supervised group exercise programme should be offered, taking into account the person’s specific needs, preferences, and abilities ¹. Acceptance and Commitment Therapy (ACT) or Cognitive Behavioural Therapy (CBT), delivered by appropriately trained healthcare professionals, can also be considered for chronic primary pain ¹. For IBS, psychological interventions (including CBT, hypnotherapy, and/or psychological therapy) should be considered if pharmacological treatments have been ineffective for 12 months and the patient has a continuing symptom profile (refractory IBS) ⁴. Referral to mental health services for psychological support and intervention is strongly recommended if symptoms remain refractory to drug treatment for 12 months, or earlier depending on local availability and patient preference ². If constipation is a primary issue, biofeedback training by a physiotherapist may be considered for certain defecation disorders like pelvic floor dyssynergia ³.

Specialist referral is often necessary. A gastroenterologist should be considered if there is uncertainty about the underlying diagnosis, if symptoms are severe or refractory to optimal primary care management, or if the person requests a specialist opinion ². For persistent or refractory constipation, specialist advice or referral should be sought ³. Additionally, chronic pancreatitis should be considered as a possible diagnosis for individuals presenting with chronic or recurrent episodes of upper abdominal pain, and referral should be made accordingly ⁵.

Throughout the management process, a patient-centred approach is vital. Discuss a care and support plan with the person, exploring their priorities, abilities, goals, and preferred approach to treatment ¹,⁶. Explain the evidence for possible benefits, risks, and uncertainties of all management options ¹,⁶. It is also important to discuss the likelihood of symptom fluctuation, the possibility that a reason for the pain or flare-up may not be identified, and that while pain may not improve, improvements in quality of life are still possible ¹.