Abdominal Pain, Chronic Clinical Pathway — Outpatient Specialty Care

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Patient Education

Child with Abdominal Pain for ≥ 8 Weeks

H&P
Assess Red Flags,
Risk for Underlying Disease
Consideration for Laboratory Studies
Behavioral Health Screening

≥ 1 Red Flag Present
More evaluation may
be required

Diagnosis of Functional Abdominal Pain Disorders

Treatment based on predominant symptom and intensity of symptoms
Pharmacologic Treatment Options
Consider Non-pharmacologic Treatment Options

Red Flags

Symptoms
Continued weight loss/growth deceleration
Bloody or significant diarrhea
Consistent right-sided abdominal pain/fullness
Frequent and/or nighttime vomiting
Difficult/painful swallowing
CVA tenderness, dysuria
Extra-intestinal manifestations:
- Unexplained fever
- Rash
- Arthritis
- Secondary amenorrhea
- Oral ulcers
- Delayed puberty
Nocturnal diarrhea
Physical Signs
Perirectal disease
Rashes
Other concerning physical findings
Laboratory Abnormalities
Anemia
Low albumin
Elevated calprotectin
Positive celiac panel
Elevated amylase and lipase
ESR and/or C-reactive protein
Family history
Inflammatory bowel disease
Celiac disease
Peptic ulcer disease

**Treatment Table**
	1^st Line	2^nd Line	3^rd Line	4^th Line	5^th Line	Testing As indicated
Functional Dyspepsia	H2 blockers	Digestive enzymes Proton pump inhibitors	Antihistamine Antispasmodics Tricyclic antidepressant Ondansetron	Referral to Motility Center for possible use of Remeron/Buspar
IBS Constipation	Hydration Fiber Probiotics Stool softeners/osmotic laxatives	Antispasmodics Stimulant	Tricyclic antidepressant Rectal therapy	Refer to Motility Center		Sitz Marker Study (off therapy, if possible)
IBS Diarrhea	Hydration Fiber Probiotics	Antispasmodics Anti-diarrheal Antibiotics	Tricyclic antidepressant	Anti-emetics and further dietary interventions	Refer to Motility Center	Breath test
IBS Mixed	Hydration Fiber Probiotic Stool softeners/osmotic laxatives	Antispasmodics Anti-diarrheal Stimulant (Based on predominant symptom)	Antibiotics	Tricyclic antidepressant	Refer to Motility Center	Breath test Sitz Marker Study
IBS Pain	Hydration Fiber Probiotics	Antispasmodics Peppermint Oil	Tricyclic antidepressant	Pregabalin/Gabapentin	Refer to Motility Center
Abdominal migraine	Hydration CoEnzyme Q Levocarnitine	Amitriptyline Cyproheptadine	Refer to Motility Center
Functional Abdominal Pain NOS	Hydration Symptom-based treatment	Refer to Motility Center

Posted: August 2015
Revised: July 2020
Authors: K. Baber, PHD; P. Bierly, P. CRNP; T. Boyle, MD; K. Fiorino, MD; P. Kapavarapu, MD; A. Nepa RD, A. Moore, PharmD; S. Mayer-Brown, PHD; K. Rodriguez, PHD; N. Stanley, BSN, RN; M. Szabo, PHD; C. Thomas, MS, RD, LDN

Evidence

References

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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Outpatient Specialty Care Clinical Pathway for the Evaluation/Treatment of the Child with Chronic Abdominal Pain

Evidence

References