What's causing my abdominal pain? When size does matter!

Abdominal pain is a common reason to visit a gastroenterologist's office.  The most common scenario I encounter is a patient presenting with right sided abdominal pain after eating.  The intensity and temporal relationship to their meals often allows me to more easily determine the cause. Patients often report pain within 30 minutes to 1 hr of eating.  They find the discomfort peaks after meals and then decreases towards the start of the next meal. They often wake up feeling well. The pain is also often described as a discomfort rather than pain.  Patients often do not have associated symptoms of reflux such as heartburn or regurgitation.  Warning signs such as vomiting, weight loss, diarrhea, prompt a different conversation and work up.

In the absence of warnings signs or signs suggestive of a peptic process or reflux I typically find these patients are over-eating and/or are eating too quickly. Many have a history of anxiety, depression, or other mood disorder.  I will typically have patients try a proton-pump inhibitor for 2-4 weeks and if there is no improvement I have them focus on portion size, time spent eating, and have them reduce the fat and carbohydrate contents of their meals. 

I hypothesize that many of these patients have visceral hypersensitivity. They further have anxiety and busy jobs that require long hours and little time for relaxation.  These factors lead to overeating and rushing. Latenight overeating is also a factor so I encourage each of these patients to take a good look at the quality of their life and encourage them to take more time for themselves.  I remind them to eat protein and complex carbohydrate rich breakfast (fruits , granola, and yogurt) and to have a good sized lunch. They should be cautious to eat slowly and to chew well. I recommend smaller portions at night so they avoid eating large heavy meals prior to laying down. Avoidance of seltzer and sodas is also helpful.

If medication, life-style changes, or dietary modifications do not help I will obtain an abdominal ultrasound and upper endoscopy to assess for organic causes.  There are a select group of patients who have already had these tests so I do not repeat them.  If these tests are unrevealing I will recommend a 4-8 week trial of a tricyclic antidepressant, which will treat the underlying visceral hypersensitivity by modulating the output of the enteric nervous system to the central nervous system. Signals representing stretching of the walls of the digestive tract will dampen and patients will have less discomfort with meals.