The many faces of abdominal pain in a patient with Inflammatory Bowel Disease Seema Jain and Kristen Lewis MD The Ohio State University College of Medicine, Columbus, OH Introduction Evaluation Discussion The differential of abdominal pain in admitted patients with Inflammatory Bowel Disease (IBD) is broad and often overlaps, thus representing a diagnostic and therapeutic challenge. Vital signs: T 98.1 P 99 RR 18 BP 108/58 Physical Exam General: uncomfortable but distractible Abdomen: soft, non-distended. normoactive bowel sounds. diffuse mild tenderness to palpation, no guarding or rebound tenderness Labs and Imaging Stool studies: negative Inflammatory markers: CRP 20.9, ESR 42 mildly elevated from baseline Symptoms of IBD frequently overlap with coexisting diagnoses. Our patient had multiple contributions to her persistent abdominal pain, which were not fully addressed. Crohn’s disease – evidence of active Crohn’s on imaging. However, inflammatory markers only mildly elevated from baseline. Despite being placed back on maintenance therapy, had continued admissions for similar symptoms. IBS – no current therapy Fibromyalgia – pregabalin started Narcotic-induced constipation – received opioids for each admission and upon discharge. Awareness of risk factors for inpatient narcotic use in patients with IBD helps providers thoroughly assess psychosocial factors and seek alternative options for pain control. Our patient had many of these risk factors: In patients with IBD and concomitant functional diagnoses, consider options such as SNRIs and referral for cognitive behavioral therapy, in order to: Decrease visceral and central hypersensitivity to pain Reduce reliance on narcotics for pain management Help end the cycle of repeat hospitalizations Abdominal Pain in IBD Disease Flare Psychosocial Medication-related Other causes not specific to IBD Patient Presentation History of Present Illness 31 year-old female with history of Crohn’s disease, Irritable Bowel Syndrome (IBS), and fibromyalgia presented to emergency department with 3 days of acute-on-chronic abdominal pain Migratory localized areas of stabbing pain, intensity 9/10 Associated symptoms: intermittent nausea, decreased appetite Bowel movements unchanged from baseline: intermittent nonbloody diarrhea and constipation Oral opioids, prescribed at discharge from previous admission 1 month prior, not relieving pain Past Medical History Diagnosed with IBD at 15 yo. Required ileocecectomy at 24 yo. Persistent abdominal pain despite several trials of immunosuppressive therapy for IBD. Not currently receiving immunosuppressants due to cost Not currently receiving therapy for IBS or fibromyalgia Frequent admissions, averaging 1 per month in past year, for abdominal pain. Symptoms typically attributed to Crohn’s flare, managed with IV and PO steroids and opioids. Appointments for gastroenterology follow-up not consistently kept Crohn’s diagnosis Prolonged duration of IBD Prior psychiatric diagnosis Outpatient narcotic use Current smoker Prior IBD-related surgery Prior IBD-IBS diagnosis MRI enterography showed active Crohn’s disease in distal ileum, without fistulous tracts or fluid collection. Consistent with CT abdomen/pelvis 3 months prior Management and Follow-Up References Received IV and PO steroids and opioids, as with previous admissions Pregabalin started for management of fibromyalgia GI follow-up: Ustekinumab started for Crohn’s maintenance therapy Continued to have frequent admissions for similar symptoms exacerbated by opioid-induced constipation Lee NS, Pola S, Groessl EJ, Rivera-Nieves J, Ho SB. "Opportunities for Improvement in the Care of Patients Hospitalized for Inflammatory Bowel Disease-Related Colitis." Digestive diseases and sciences 61.4 (2016): 1003-1012. Long MD, Barnes EL, Herfarth HH, Drossman DA. "Narcotic use for inflammatory bowel disease and risk factors during hospitalization." Inflammatory bowel diseases 18.5 (2012): 869-876. Long MD, Drossman DA. "Editorial: Inflammatory Bowel Disease, Irritable Bowel Syndrome, or What? A Challenge to the Functional–Organic Dichotomy." The American journal of gastroenterology 105.8 (2010): 1796-1798. Srinath AI, Walter C, Newara MC, Szigethy EM. "Pain management in patients with inflammatory bowel disease: insights for the clinician." Therapeutic advances in gastroenterology 5.5 (2012): 339-357.