PATIENT PROFILE: A 22-year-old female presents with recurrent episodes of nausea and vomiting, accompanied by severe, non-localized abdominal pain unexplained by infection or other illness. She has a history of appendectomy and exploratory laparoscopy. Extensive clinical laboratory tests reveal no pathology. She has comorbid generalized anxiety, treated with venlafaxine, but is otherwise healthy.
“Patients with chronic abdominal or pelvic pain may suffer for years through misdiagnoses, incomplete diagnoses and possibly multiple, ineffective surgeries. By the time they are referred to us, they are desperate for relief,” says Deborah M. Bethards, M.D., Penn State Hershey Gastroenterology and Hepatology.
In addition to gastroenterology, the Penn State Hershey Chronic Abdominal and Pelvic Pain (CAPP) Group includes health care providers from anesthesia and pain management, general surgery, gynecologic surgery, physical therapy and pediatric chronic pain. This team helps patients obtain multidisciplinary treatment that may be more effective. With many similar, mutual patients, CAPP meets monthly to discuss cases and present topics.
Bethards notes, “For many patients with chronic pelvic or abdominal pain, multiple conditions may be present, with overlapping symptoms. They are usually referred to someone in our group because prior treatments have not led to any improvement. Use of pain medications is very common, along with a history of multiple abdominal surgeries.”
The case profiled was diagnosed with abdominal migraine and has experienced significant improvement with a treatment plan that includes a combination of preventive anti-migraine therapies such as tricyclics, Coenzyme Q-10, as well as complete alcohol and marijuana avoidance. An aggressive abortive protocol was specifically designed for that patient, which assists emergency rooms in treatment of these difficult cases (i.e., the use of D5W for hydration instead of normal saline).
With CAPP members each bringing their own unique clinical expertise, the perspective on any individual patient’s spectrum of problems becomes much broader than is encountered in community practice settings. “At our meetings, we often inter-refer after a case is discussed. We ask what could have been done differently. A big focus is on avoiding needless surgeries and reducing use of opioid analgesics, and instead we integrate other, non-invasive approaches, like physical therapy, biofeedback, and lifestyle modification.”
Opioid medications may exacerbate GI problems like constipation, abnormal motility and pelvic floor disorders. They are also associated with the risks of dependence and abuse, potentially complicating medical treatment. Bethards adds, “We’re hoping to bring a psychologist into the group in the near future. Many patients with chronic pain endure comorbid psychological, social and relationship problems that go largely unaddressed in the typical medical setting. These issues can impact underlying medical diagnosis, as well as how the patient copes with symptoms day-to-day.”
A long-term goal of the group is to develop standards of care and systematic protocols for patient management, so that all patients with chronic pelvic and abdominal pain are asked the same sets of questions and undergo appropriate diagnostic evaluations. Currently, there are few tertiary care centers in the U.S. with established protocols for evaluating and treating these patients, and a multidisciplinary approach including psychological help.
Bethards comments, “As a starting point, I think we can learn and borrow from what has been done to manage chronic pain in other therapeutic areas. These approaches may be adapted to address the needs of our patients. It is a work in progress.”
Deborah M. Bethards, M.D.
Associate Professor of Medicine
Medicine Director, Medicine Suite
Penn State Hershey Gastroenterology
Fellowship: Gastroenterology and hepatology, Penn State Milton S. Hershey Medical Center, Hershey, PA
Residency: Internal Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA
Medical School: George Washington University School of Medicine, Washington, District of Columbia