Pain Management

Because abdominal pain in IBD is multifactorial, it requires targeted treatment based on etiology. (Table 1)

Table 1

Etiology

Treatment

Inflammation
  • Standard IBD therapy: (eg, aminosalicylates, antibiotics, corticosteroids, enteral therapy, immunomodulators, biologic medications, potential surgery) during flares.1
  • Antispasmodics during flares, pain from partial obstruction or functional abdominal pain.8 Potential side effects include worsening dysmotility and toxic megacolon.9
  • Nonsteroidal anti-inflammatory drugs (NSAIDS) are not recommended due to risk of potential relapse, increased disease activity, and risk of GI mucosal injury.10,11
  • COX-2 inhibitors are not recommended.1
  • Opiates are not recommended due to potential side effects and narcotic bowel syndrome.12
Strictures/adhesions
  • Dietary modification (low-residue, low-fiber, liquid diet)
  • Antispasmodics1
Small intestinal bacterial overgrowth
Neurobiological
  • Antidepressants
    • Tricyclic antidepressants may be helpful adjunctively.14,15
    • Selective serotonin reuptake inhibitors (SSRIs) are “promising but understudied” in IBD literature.1 While they may be helpful with functional pain, they also carry the emerging risk of GI bleeding.16
    • Serotonin-Norepinephrine-Reuptake Inhibitors (SNRIs) are not recommended as sole treatment of IBD.1
  • Gabapentin and pregabalin are both effective in chronic and/or neuropathic pain and in chronic pancreatitis. They may be effective in patients with IBD and persistent pain/IBS-like symptoms, but may not reduce pain during an active inflammatory episode.1
Psychological
  • Cognitive Behavioral Therapy (CBT) has been shown effective in reducing abdominal pain in IBS patients17 and may be efficacious in IBD.1
  • Hypnotherapy has been shown effective in reducing pain, with effects sustained for up to five years.1
  • Sleep management: Potential sleep dysfunction (eg, insomnia, sleep apnea, daytime sleepiness, and parasomnias) should be evaluated; referrals should be made to sleep specialists when appropriate.1
Psychosocial
  • Coping skill modification as an adjunct to other therapies1
  • Stress management, combining mindfulness meditation with cognitive behavioral therapy (CBT), has been shown to improve quality of life in patients with IBD18
Procedural
  • Acupuncture is not currently recommended due to conflicting data on efficacy in abdominal pain.1
  • Peripheral nerve blocks – in particular, thoracic splanchnic nerve block and radiofrequency thermocoagulation of the thoracic splanchnic nerves – is a promising approach to abdominal pain in patients with IBD.1
  • Transcutaneous electrical nerve stimulation (TENS) might be a helpful adjunctive therapy for visceral hypersensitivity, especially if there are potential contraindications to pharmacologic approaches.1


This article originally appeared on MPR