1. 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
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