Chronic Abdominal Pain Primary Care Pathway

Quick
links: Pathway primer Expanded details Advice options Patient pathway

1. Diagnostic criteria
Must have the following for 3 months prior, with symptom onset ≥ 6 months ago:
• Continous or near continuous abdominal pain
• No, or only occasional relationship of, pain with physiological events
• Pain limits some aspect of daily functioning
• Pain is not feigned
• Pain is not explained by another structural or functional GI disorder or medical condition

2. Symptoms better explained by another GI disorder?

Is it GERD? Is it IBS? Is it dyspepsia?
Predominant heartburn or Pain related to defecation or • Epigastric discomfort
regurgitation change in stool form/frequency • Upper abdominal pain/bloating
Yes Yes Yes

Follow GERD pathway Follow IBS pathway Follow Dyspepsia pathway

No

3. Alarm features?
• Family history (first degree relative) of IBD or colorectal cancer
• Onset of symtoms after age 50
Yes
7. Refer for
• Unintended weight loss (> 5% over 6-12 months) consultation/
• Persistent vomiting endoscopy
• Visible blood in stool
• Iron deficiency anemia (see Iron Primer)
No
If unsatisfactory
4. Optimize management of alternate diagnosis or secondary causes response to
• Consider referred pain from other systems management,
• Review medications and discontinue or reduce dose of culprit medications consider using an
advice service
• Identify and eliminate dietary triggers and allergens
before referring

5. Baseline investigations Consider based on clinical context

Initital work up • Celiac disease screen Abnormal
• CBC, electrolytes (Na, K, Cl, Ca, Mg, P), creatinine • Thyroid test (TSH) results Treat or
• Liver enzymes (ALT, ALP), albumin, bilirubin, lipase • H. pylori test (HpSAT or UBT) refer for
• CRP - if suspecting inflammatory or infectious conditions • Urinalysis
consultation
• C. difficile, ova and parasites • Pregnancy test (β-hCG)
• Ferritin and transferrin saturation (see Iron Primer) • Abdominopelvic ultrasound
Consistent with Centrally Mediated Abdominal Pain Syndrome (CAPS)

6. Management
• Patient reassurance: reassessment and reappraisal to establish therapeutic relationship
• Lifestyle modifications: stress reduction may include physical activity, mindfulness, meditation, hypnotherapy, and acupuncture
• Dietary modifications: assess common food triggers and keep a food journal. Consider referral to a Registered Dietitian.
• Psychological therapy: refer to behavioural health specialist. If psychiatric symptoms predominate, consider psychiatry.
• Pharmacological therapy: for moderate to severe CAPS symptoms only (antispasmodics, TCAs, SNRIs, or SSRIs)

Provider resources Background

Patient resources Updated: October 2021

Pre-referral checklist
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 This primary care pathway was co-developed by primary and specialty care and includes input from multidisciplinary
teams. It is intended to be used in conjunction with specialty advice services, when required, to support care within
the medical home. Wide adoption of primary care pathways can facilitate timely, evidence-based support to
physicians and their teams who care for patients with common low-risk GI conditions and improve appropriate access
to specialty care, when needed. To learn more about primary care pathways, check out this short video.

CHRONIC ABDOMINAL PAIN PATHWAY PRIMER

 Chronic abdominal pain is a challenging complaint for primary care and specialist physicians. The multitude
of patients presenting with this problem reflects the many causes and non-specific nature of abdominal pain.
 In the absence of alarm features, the majority of patients with chronic abdominal pain will have a benign
cause. These patients can be safely observed and symptoms can treated within the Patient Medical Home.
 Centrally Mediated Abdominal Pain Syndrome (CAPS): Formerly known as functional abdominal pain
syndrome, this chronic condition is characterized by continuous or near-continuous, often severe abdominal
pain, not due to an organic cause, and rarely associated with disturbances in gastrointestinal (GI) function.
o CAPS is distinguished from other functional GI disorders, such as irritable bowel syndrome (IBS)
and functional dyspepsia, by the predominance of pain as the central complaint and the lack of a
consistent relationship of pain with food intake or defecation. It may be associated with other
somatic disorders such as fibromyalgia and chronic fatigue syndrome.
o CAPS is less common than other functional GI disorders, affecting approximately 0.5-2.1% of the
general population.1 It is 1.5-2 times more common in women than in men.2 Prevalence reaches
a peak at age 40 and decreases with age.3
o Many patients with CAPS will seek consultation with different specialists, have repeated imaging
or endoscopic procedures, and undergo invasive surgeries (most often being hysterectomy and
exploratory laparotomy) without benefit.4
o CAPS can significantly impact quality of life.

Checklist to guide in-clinic review of your patient with Chronic Abdominal Pain
CAPS diagnostic criteria (Rome IV) must have the following for 3 months prior, with symptom onset ≥ 6 months ago:
 Continuous or near continuous abdominal pain
 No, or only occasional relationship of, pain with physiological events (e.g. eating, defecation, or menses)
□  Pain limits some aspect of daily functioning (e.g. work, intimacy, social/leisure, family life, and care giving for self or
others)
 Pain is not feigned
 Pain is not explained by another structural or functional GI disorder or other medical condition

□ Ensure symptoms are not better explained by another GI disorder (see algorithm Box 2).
Confirm absence of alarm features (see algorithm Box 3).
□ If alarm features are identified, refer for specialist consultation

□ Exclude alternate diagnoses and/or secondary causes (see algorithm Box 4).
Evaluate for underlying organic causes with baseline investigations (see algorithm Box 5).
□ If other causes identified, treat or refer for specialist consultation.
If unsatisfactory response to management (see algorithm Box 6), consider using an advice service before referring.
□ Otherwise, continue care in the Patient Medical Home.

1
Drossman, D. A., Li, Z., Andruzzi, E., Temple, R. D., Talley, N. J., Thompson, W. G., ... & Koch, G. G. (1993). US householder
survey of functional gastrointestinal disorders. Digestive diseases and sciences, 38(9), 1569-1580.
2
Thompson, W. G., Irvine, E. J., Pare, P., Ferrazzi, S., & Rance, L. (2002). Functional gastrointestinal disorders in Canada: first
population-based survey using Rome II criteria with suggestions for improving the questionnaire. Digestive diseases and
sciences, 47(1), 225-235
3
Bharucha, A. E., & Camilleri, M. (2001). Functional abdominal pain in the elderly. Gastroenterology Clinics of North America, 30(2),
517-529.
4
Maxton, D. G., & Whorwell, P. J. (1992). Use of medical resources and attitudes to health care of patients with ‘chronic abdominal
pain’. Br J Med Econ, 2, 75-79.

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EXPANDED DETAILS
1. Diagnostic criteria
 CAPS diagnostic criteria (Rome IV) must have the following for 3 months prior, with symptom onset ≥ 6
months ago:
o Continuous or near continuous abdominal pain
o No, or only occasional relationship of, pain with physiological events (e.g. eating, defecation, or
menses)
o Pain limits some aspect of daily functioning (e.g. work, intimacy, social/leisure, family life, and care
giving for self or others)
o Pain is not feigned
o Pain is not explained by another structural or functional GI disorder or other medical condition
 The biologic etiology of CAPS is thought to be similar to that of other chronic visceral pain disorders,
including IBS, functional dyspepsia, and interstitial cystitis. An abnormality in central pain processing signals
and modulation of pain regulatory pathways in the brainstem results in an exaggerated sensitivity to both
noxious and innocuous stimuli.
o Predisposing factors are likely to include a combination of genetic, environmental, and behavioural
traits. Alterations in serotonin reuptake, disruption of mucosal barrier function, and changes in the
balance of pro- and anti-inflammatory cytokines have been implicated in the development of
functional GI disorders.5
o Psychological factors, such as the presence of psychosocial stressors, underlying depression,
anxiety, somatic disorders, history of trauma, eating disorders, and poor coping skills can all trigger
or amplify the pain experience. 6,7
 Initial work-up should consist of a detailed history and physical examination, thorough medication review,
and, in the absence of alarm features, a conservative approach to exclude other medical conditions.
o History should include assessment of pain duration and quality, and a review of any patterns in
presentation or associated symptoms.
o Assessment should include screening for underlying sleep or mood disorders. Patients with mental
health issues, such as depression and anxiety, often have refractory symptoms until those issues
are addressed.
o A significant percentage of patients with chronic abdominal pain or other functional GI disorders
have a history of trauma (e.g. sexual assault or physical and psychological abuse) or PTSD. This
type of trauma may contribute to symptoms through the brain-gut axis, so it is important to explore
this in a compassionate manner. Undergoing endoscopy may trigger a negative response in
survivors of trauma; addressing this possibility may be appropriate if considering a referral for
endoscopy when the clinician is aware of a history of trauma. For additional information, see
Abuse, Trauma, and GI Illness: Is There a Link? and Trauma-informed care.
o It is important to recognize states of immunosuppression. Whether comorbid or drug related,
immunosuppression may mask other important clinical signs of significant pathology (e.g. poorly
controlled diabetes, cirrhosis, chronic kidney disease, human immunodeficiency virus (HIV), and
use of immunosuppressive agents, such as glucocorticoids, chemotherapy, and some biologics).
o A physical exam, including a complete abdominal assessment, should be performed to clarify pain
location and radiation, rule out significant pathology, and legitimize symptoms.
o If abdominal pain is suspected to be abdominal wall in origin (MSK), the Carnet's test may be
useful. Raise the head or the feet to contract the musculature of the abdominal wall, and the pain

5
Mayer, E. A. & Collins, S. M. (2002). Evolving pathophysiologic models of functional gastrointestinal disorders. Gastroenterology,
127(7), 2032-2048.
6
Wegener, S. T., Castillo, R. C., Haythornthwaite, J., MacKenzie, E. J., Bosse, M. J., & LEAP Study Group. (2011). Psychological
distress mediates the effect of pain on function. Pain, 152(6), 1349-1357.
7
Drossman, D. A. (2011). Abuse, trauma, and GI illness: is there a link? American Journal of Gastroenterology, 106(1), 14-25.

Last Updated: October 2021 Page 3 of 14 Back to Algorithm

 stays the same or is worse is suggestive. Pain improvement or resolution with abdominal wall
injections with lidocaine confirms the diagnosis.

2. Symptoms better explained by another GI disorder?

 There is significant overlap of CAPS and other functional GI disorders, such as functional dyspepsia, IBS,
gastroesophageal reflux disease (GERD).
 Typically, CAPS is distinguished by the absence of, or only occasional relationship with, pain associated
with other physiologic events, such as eating or defecation. A careful history is essential to determine if
symptoms are more consistent with one of these other disorders:
o Does the patient suffer from associated heartburn or regurgitation that suggests GERD? See
GERD pathway.
o Is the pain related to defecation or associated with change in stool form/frequency that is more
consistent with IBS? See IBS pathway.
o Is there post-prandial epigastric discomfort, upper abdominal pain, and/or bloating that is more
typical of dyspepsia? See Dyspepsia pathway.
3. Alarm features
If any of the following alarm features are identified, refer for consultation/endoscopy. Include any and all identified
alarm features in the referral to ensure appropriate triage.
 Family history (first-degree relative) of inflammatory bowel disease (IBD) or colorectal cancer
 Onset of symptoms after age 50
 Unintended weight loss (> 5% over 6-12 months)
 Persistent vomiting
 Visible blood in stool
 Iron deficiency anemia (see Iron Primer)

4. Optimize management of alternate diagnoses and/or secondary causes

 Many disorders can produce chronic abdominal pain (Table 1), so it is important for the clinician to consider
a broad diagnostic differential before concluding on a functional disorder.
 A careful review of medications should be performed to identify ones that may be causing GI side effects.
Discontinue use or reduce dose of culprit medications.
o A multitude of over-the-counter and prescription medications can cause GI upset (e.g. iron,
potassium, and calcium supplements, antidiarrheals, laxatives, antibiotics, statins, metformin, and
bisphosphonates). If coincident timing of initiation or dose escalation is suspicious, the drug
monograph should be consulted.
o Non-steroidal anti-inflammatory drugs (NSAIDs), tobacco, and alcohol may cause injury to GI
mucosa.
o Narcotics can alter gut motility and paradoxically worsen pain (narcotic bowel syndrome).
o Long-term habitual cannabis usage can sometimes lead to cannabinoid induced gut dysfunction
and colicky abdominal pain. It is often associated with nausea and vomiting, which may be relieved
by hot showers. Treatment includes gradual dose reduction, followed by discontinuation of
cannabis.
 Dietary history is also key in identifying triggers and allergens. These will not cause chronic abdominal pain,
but may cause bloating and gas that can exacerbate abdominal pain.
o Ingestion of large amounts of carbonated beverages and fruit juices (which may contain significant
quantities of fructose and sugar alcohol), or gas-producing foods (e.g. beans, onions, cabbage, and
cauliflower).8

8
Gotfried, J. (2020). Chronic abdominal pain and recurrent abdominal pain. Merck Manual.

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 o Other dietary culprits include gluten (found in wheat, barley, oats, rye, and triticale; is associated
with gluten intolerance or celiac disease), lactose (milk and ice cream; is associated with lactose
intolerance), and other high FODMAPS foods (associated with IBS).
o Dietary allergens/sensitivities such as milk protein, wheat (gluten), soy, eggs, fish, shellfish,
peanuts, and tree nuts are rarely causes of isolated chronic abdominal pain, in the absence of
other signs or symptoms. True allergies, like milk protein allergies, are extremely rare. Most food
related symptoms are not true allergies.
Table 1. Major differential diagnoses to consider in the evaluation of chronic abdominal pain
System Differential diagnosis
 GERD  Peptic ulcer disease
 NSAID-related gastritis  Alcohol induced gastritis
Gastric
 Helicobacter pylori gastritis  Gastroparesis, impaired emptying, accommodation
 Gastric malignancy  Parasitic infection
 Peptic (duodenal) ulcer disease  Celiac disease
 Small intestinal bacterial overgrowth (SIBO)  IBD
Small bowel
 Chronic mesenteric ischemia  Incomplete obstruction
 Small bowel malignancy  Parasitic infection
 IBD  Recurrent episodes of diverticulitis
 Recurrent ischemic colitis  Incomplete obstruction and pseudo-obstruction
Colon
 Chronic constipation  Colon malignancy
 Parasitic infection
Hepatic-  Biliary colic, sphincter of Oddi dysfunction  Hepatitis
pancreatic-  Liver abscess  Chronic pancreatitis
biliary  Pancreatic or biliary tree malignancy
 CAPS  Functional dyspepsia
Functional GI  IBS  Abdominal migraine
 GERD
 Cardiac - angina
 Endocrine - adrenal insufficiency, hypothyroid, hypercalcemia
 Gynecologic - pregnancy complications, pelvic inflammatory disease, endometriosis, fibroids,
ovarian malignancy
 Hematologic - porphyria, sickle cell, angioedema, familiar Mediterranean fever
 Musculoskeletal - bony pain, muscular strain or spasm, abdominal wall pain, costochondritis
Non-GI
 Dermatologic - post herpetic neuralgia
 Psychological - somatic disorders, anxiety, depression, post-traumatic stress disorder (PTSD),
eating disorders
 Spleen - splenomegaly
 Urogenital - kidney stones, urinary retention
 Vascular - abdominal aortic aneurysm
 Cannabinoid hyperemesis syndrome  Iron, potassium, calcium supplements
 Narcotic bowel syndrome  Antidiarrheals
 NSAID-related gastropathy, enteropathy,  Laxatives
Medications/
colopathy  Antibiotics
supplements
 Bisphosphonates  Statins, metformin
 Immunosuppression medications (can mask other etiologies and alter presentation)
Allergens/
 Food antigen  Environmental exposure
sensitivities

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5. Baseline Investigations
 The appropriateness of a limited diagnostic workup and avoidance of unnecessary (repeated) endoscopic
procedures is supported by a low miss rate for significant GI pathology9 and a failure of a negative
endoscopy to provide reassurance or improve health-related quality of life.10
 Assessment of historical investigations should be completed to rule out other medical disorders (e.g.
colonoscopy, gastroscopy, ultrasound, abdominopelvic computerized tomography (CT)).
o Note: It may be reasonable that these investigations are at least done once depending on the
clinical presentation.
 Initial investigations include:
o CBC
o Electrolytes - sodium, potassium, chloride, calcium, magnesium, phosphate
o Creatinine
o Liver enzymes (alanine aminotransferase (ALT), alkaline phosphatase (ALP)), albumin, bilirubin,
lipase
o C-reactive protein (CRP) if suspecting inflammatory or infectious conditions
o C. difficile or ova and parasites if there has been recent travel
o Ferritin and transferrin saturation if GI bleeding or iron deficiency anemia is suspected (see Iron
Primer).
 Based on clinical context, additional investigations may be warranted:
o Celiac disease screen
o Thyroid testing (TSH)
o Depending on local availability, test with the [Link] Stool Antigen Test (HpSAT) or the Urea
Breath Test (UBT)
 HpSAT is the primary test for H. pylori in the Edmonton, Calgary, and South Zones, as
well as selected sites in the North and Central Zones.
o Urinalysis
o Pregnancy test (β-hCG)
o Note: The fecal immunochemical test (FIT) is for colorectal cancer screening. It has NOT been
validated for investigation of GI symptoms. Ordering FIT in this circumstance is inappropriate. GI
malignancies are very uncommon in those meeting usual criteria for functional GI disorders.11
 Abdominopelvic ultrasound is commonly performed and helps to rule out common pathology.
o If clinical suspicion remains elevated despite other normal tests, limited cross-sectional imaging
(e.g. abdominopelvic CT scan) may be considered, if not ordered within the timeframe of symptom
onset/change in symptom pattern.

9
Chey, W. D., Nojkov, B., Rubenstein, J. H., Dobhan, R. R., Greenson, J. K., & Cash, B. D. (2010). The yield of colonoscopy in
patients with non-constipated irritable bowel syndrome: results from a prospective, controlled US trial. The American Journal of
Gastroenterology, 105(4), 859.
10
Spiegel, B. M., Gralnek, I. M., Bolus, R., Chang, L., Dulai, G. S., Naliboff, B., & Mayer, E. A. (2005). Is a negative colonoscopy
associated with reassurance or improved health-related quality of life in irritable bowel syndrome? Gastrointestinal
Endoscopy, 62(6), 892-899.
11
Vanner, S. J., Depew, W. T., Paterson, W. G., DaCosta, L. R., Groll, A. G., Simon, J. B., & Djurfeldt, M. (1999). Predictive value
of the Rome criteria for diagnosing the irritable bowel syndrome. The American journal of gastroenterology, 94(10), 2912-2917.

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 6. Management
Treatment options (non-pharmacological)
These modifications may be all that is required in those with mild or intermittent symptoms.

 A key to effective long-term management of chronic abdominal pain is to provide patients

reassurance after their initial diagnosis and offer points of reassessment and reappraisal to
establish a therapeutic relationship. This will allow the patient to report changes in symptom
Patient reassurance frequency, severity, and development of alarm features.
 Changes in the character of the pain, basic investigations, or physical exam should warrant
reconsideration of attribution of the abdomen pain to CAPS.
 Emphasize managing symptoms rather than completely resolving them.

 Stress reduction: Regular physical activity, mindfulness ([Link]), meditation,

hypnotherapy, and acupuncture is foundational.
 Additional therapies are based on symptom severity and degree of disability.
Lifestyle
o Note: Stress can contribute to functional GI disorder symptoms, but does NOT cause them.
modifications
 Physical Activity: 20+ minutes of physical activity/day, aiming for 150 min/week is known to be
an effective strategy for stress reduction.
o See the Canadian 24-Hour Movement Guidelines.

 Assess common food triggers: Follow a systematic approach of removing each trigger for 1-2
weeks and assessing symptoms before permanent elimination is recommended.
 Consider avoidance of:
o Gas producing foods (beans, lentils, onions, cabbage, and cauliflower)
o Large amounts of sugar (fructose) or sugar alcohols (sorbitol) from carbonated beverages
or fruit juices (regular or sugar-free)
o Caffeine
Dietary modifications o Lactose, if lactose intolerant
o Food allergens, if clear symptom correlation (milk protein, wheat (gluten), soy, eggs, fish,
shellfish, peanuts, and tree nuts)
 It may be helpful for patients to use the Food, Lifestyle, and Symptom Diary to understand their
symptoms, food triggers, and stressors. Use the diary to determine how dietary modifications,
psychological, and pharmacological therapies impact their symptoms.
 Assess dietary intake compared to Canada’s Food Guide.
 Referral to a Registered Dietitian can be helpful to support dietary changes.

 Referral to a behavioral health specialist can be helpful in managing pain and reducing emotional
Psychological
distress associated with symptoms. If psychiatric symptoms predominate, consider psychiatry
therapy
referral.

Treatment options (pharmacological)

The use of pharmaceuticals is generally reserved for those who have not adequately responded to dietary and lifestyle
interventions, or in those with moderate or severe symptoms that impair quality of life.
 Clinical trials specific for CAPS are limited, so treatment recommendations for patients with CAPS often relies on
observations from IBS.
 Centrally acting pharmacologic agents, such as tricyclic antidepressants (TCAs) or serotonin norepinephrine reuptake
inhibitors (SNRIs), can be used alone or in combination for their pain modulating effects. TCAs and SNRIs are thought to
be more effective than selective serotonin reuptake inhibitors (SSRIs) due to their additional noradrenergic effects.
 Avoid narcotics as they can cause narcotic bowel syndrome and paradoxically worsen pain.

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  Evidence: May reduce symptoms of abdominal pain, however, it is not clear if one agent is more
effective than another.12
 Place in therapy: May provide symptom relief. Consider peppermint oil as first line as it is generally
well tolerated and appears to be effective.
 Mechanism of action: Smooth muscle relaxation by various mechanisms.
 Adverse effects: Anticholinergic reactions with some agents (CNS depression, xerostomia),
dyspepsia (peppermint oil).13
 Dose: A reasonable trial is 1-2 agents (not at once) given for 4 weeks as listed below. Could use
Antispasmodics regularly or PRN.
Recommended Medications:
 Enteric coated peppermint oil capsules (0.2-0.275 mL caps). 2 capsules BID ($20-25/month, unlikely
to be covered by insurance providers).
 Trimebutine (Modulon®) - 100-200 mg TID ($40-80/month).
 Pinaverium Bromide (Dicetel ®) - 50-100 mg TID ($50-75/month).
 Hyoscine Butylbromide (Buscopan®) - 10 mg TID-QID ($25-40/month).
 Dicyclomine hydrochloride (Bentylol ®) - 20 mg TID-QID ($25-40/month).

 Evidence: The most studied antidepressant class for treatment of abdominal pain.14
 Mechanism of action: Suggested to be beyond serotonin and norepinephrine, and as a result of
blocking voltage-gated ion channels, opioid receptor activation and potential neuro-immunologic anti-
inflammatory effects.14
 Place in therapy: May be particularly useful for patients with CAPS, as well as sleep issues, anxiety,
or depression.
 Adverse effects: Anticholinergic and antihistaminic (drowsiness/insomnia, xerostomia, palpitations,
weight gain, constipation, urinary retention).14
 Use with caution in patients at risk of prolonged QT.
Tricyclic
antidepressants  It can take 2-3 months to reach maximum effect.
(TCA)  The lowest effective dose should be used. Reassess therapy after 6-12 months.
 Dose should be gradually reduced if discontinuing.
Recommended Medications
 Nortriptyline - 10-25 mg qhs. Increase dose by 10-25 mg every 3-4 weeks (due to delayed onset).
May require 25-75 mg/day. Often takes 2-3 months for peak effect. ($20-60/month).
 Amitriptyline - 10-25 mg qhs. Increase dose by 10-25 mg every 3-4 weeks (due to delayed onset).
May require 25-75 mg/day. Often takes 2-3 months for peak effect. ($15-20/month).
 Desipramine - 25 mg qhs. Increase based on response and tolerability. Doses up to 150 mg daily have
been evaluated for IBS (~$25/month).

 Evidence: Duloxetine is marketed for chronic pain, neuropathic pain, and fibromyalgia. Venlafaxine
Serotonin may alter GI compliance, tone and reduce colonic contraction. There are no high quality studies to
norepinephrine guide SNRI therapy recommendations for CAP at this time.
reuptake
inhibitors  Mechanism of action: Proposed to modulate pain sensation by blocking presynaptic serotonin and
(SNRIs) norepinephrine transporters.13 This mechanism along with the advantageous adverse effect profile
(compared to TCAs) make this class ideal in theory.

12
Ruepert, L., Quartero, A. O., de Wit, N. J., van der Heijden, G. J., Rubin, G., & Muris, J. W. (2011). Bulking agents,
antispasmodics and antidepressants for the treatment of irritable bowel syndrome. Cochrane database of systematic reviews, (8).
13
Lexicomp, Inc., Lexi-Drugs Online, Hudson, Ohio: UpToDate, Inc; 2013; [cited 27 Apr 2021].
14
Törnblom, H., & Drossman, D. A. (2016). Centrally targeted pharmacotherapy for chronic abdominal pain: understanding and
management. Gastrointestinal Pharmacology, 417-440.

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  Place in therapy: For patients in which TCAs are contraindicated or not tolerated, SNRIs may
provide benefit, especially in the setting of concurrent chronic pain, diabetic neuropathic pain, or
fibromyalgia.
 Adverse effects: nausea, agitation, dizziness, sleep disturbance, fatigue, and liver dysfunction.
Serotonin  It can take 2-3 months to reach maximum effect.
norepinephrine
reuptake  Lowest effective dose should be used. Reassess therapy in 6-12 months.
inhibitors  Dose should be gradually reduced if discontinuing.
(SNRIs)
cont’d Recommended Medications
 Venlafaxine (Effexor®) - 37.5 mg daily. May dose escalate by 37.5 mg/week to max 225 mg
(~$20/month).
 Duloxetine (Cymbalta®) - 30-60 mg daily. May dose escalate by 30 mg/week to max 60 mg BID ($15-
65/month).

 Evidence: Limited data to support use of SSRIs for abdominal pain.

 Place in therapy: Include patients with concurrent depression or anxiety-specific GI symptoms.
 Adverse effects: Nausea, diarrhea, weight gain, sexual dysfunction, tremor, insomnia.
Selective
serotonin  Caution with citalopram in patients with prolonged QT.
reuptake  Lowest effective dose should be used. It can take 2-3 months to reach maximum effect. Reassess
inhibitors therapy in 6-12 months. Dose should be gradually reduced if discontinuing.
(SSRIs)
Recommended Medications
 Fluoxetine (Prozac®) - 10 mg daily. May dose escalate up to 60 mg daily (~$25/month).
 Citalopram (Celexa®) - 10-20 mg daily. May dose escalate up to 40 mg daily (~$15/month).

7. When to refer for consultation and/or endoscopy

 If alarm features are identified.
 If investigations reveal iron deficiency anemia, a positive celiac disease screen, high clinical suspicion of
IBD, or cancer of the GI tract.
 If recommended strategies have not led to satisfactory treatment or management of symptoms.
 Provide as much information as possible on the referral form, including identified alarm feature(s), important
findings, and treatment/management strategies trialed with the patient.

Still concerned about your patient?

The primary care physician is typically the provider who is most familiar with their patient’s overall health and knows
how they tend to present. Changes in normal patterns, or onset of new or worrisome symptoms, may raise suspicion
for a potentially serious diagnosis, even when investigations are normal and typical alarm features are not present.
There is evidence to support the importance of the family physician’s intuition or “gut feeling” about patient symptoms,
especially when the family physician is worried about a sinister cause such as cancer. A meta-analysis examining the
predictive value of gut feelings showed that the odds of a patient being diagnosed with cancer, if a GP recorded a gut
feeling, were 4.24 times higher than when no gut feeling was recorded.15
When a “gut feeling” persists in spite of normal investigations, and you decide to refer your patient for specialist
consultation, document your concerns on the referral with as much detail as possible. Another option is to seek
specialist advice (see Advice Options) to convey your concerns.

15
Friedemann Smith, C., Drew, S., Ziebland, S., & Nicholson, B. D. (2020). Understanding the role of General Practitioners’ gut
feelings in diagnosing cancer in primary care: A systematic review and meta-analysis of existing evidence. British Journal of General
Practice, 70(698), e612-e621.

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PRIMERS
Iron Primer
Evaluation of measures of iron storage can be challenging. Gastrointestinal (occult) blood loss is a common cause of
iron deficiency and should be considered as a cause when iron deficiency anemia is present. Menstrual losses
should also be considered.
There are two serological tests to best evaluate iron stores (ferritin, transferrin saturation) - neither of which are
perfect.
The first step is to evaluate ferritin:
 If the ferritin is low, it is diagnostic of iron deficiency with high specificity (98% specificity).
 Ferritin is an acute phase reactant which may be elevated in the context of acute inflammation and infection.
If ferritin is normal or increased, and you suspect it may be acting as an acute phase reactant, order a
transferrin saturation test (see below).
o However, if the ferritin is > 100 µg/L and there is no concurrent significant chronic renal
insufficiency, iron deficiency is very unlikely - even in the context of acute inflammation/infection.
The second step is to evaluate transferrin saturation:
 The transferrin saturation is a calculated ratio using serum iron and total iron binding capacity. Serum iron
alone does not reflect iron stores.
 Low values (< 10%) demonstrate low iron stores in conjunction with a ferritin < 100 µg/L.
In the absence of abnormal iron indices, anemia may be from other causes other than GI (occult) blood loss (e.g.
bone marrow sources, thalassemia, and sickle cell anemia).

BACKGROUND
About this Pathway
 Digestive health primary care pathways were originally developed in 2015 as part of the Calgary Zone’s
Specialist LINK initiative. They were co-developed by the Department of Gastroenterology and the Calgary
Zone’s specialty integration group, which includes medical leadership and staff from Calgary and area
Primary Care Networks, the Department of Family Medicine, and Alberta Health Services.
 The pathways were intended to provide evidence-based guidance to support primary care providers in
caring for patients with common digestive health conditions within the patient medical home.
 Based on the successful adoption of the primary care pathways within the Calgary Zone, and their impact on
timely access to quality care, in 2017 the Digestive Health Strategic Clinical Network (DHSCN) led an
initiative to validate the applicability of the pathways for Alberta and to spread availability and foster adoption
of the pathways across the province.

Authors & Conflict of Interest Declaration

This pathway was reviewed and revised under the auspices of the DHSCN in 2021 by a multi-disciplinary team led by
family physicians and gastroenterologists. For more information, contact the DHSCN at
[Link]@[Link].

Pathway Review Process

Primary care pathways undergo scheduled review every three years, or earlier if there is a clinically significant
change in knowledge or practice. The next scheduled review is April 2024. However, we welcome feedback at any
time. Please email comments to [Link]@[Link].

Copyright Information

This work is licensed under a Creative Commons Attribution-Non-commercial-Share Alike 4.0 International license.
You are free to copy, distribute, and adapt the work for non-commercial purposes, as long as you attribute the work to
Alberta Health Services and Primary Care Networks and abide by the other license terms. If you alter, transform, or

Last Updated: October 2021 Page 10 of 14 Back to Algorithm

 build upon this work, you may distribute the resulting work only under the same, similar, or compatible license. The
license does not apply to content for which the Alberta Health Services is not the copyright owner.

Disclaimer
This pathway represents evidence-based best practice but does not override the individual responsibility of health
care professionals to make decisions appropriate to their patients using their own clinical judgment given their
patients’ specific clinical conditions, in consultation with patients/alternate decision makers. The pathway is not a
substitute for clinical judgment or advice of a qualified health care professional. It is expected that all users will seek
advice of other appropriately qualified and regulated health care providers with any issues transcending their specific
knowledge, scope of regulated practice or professional competence.

PROVIDER RESOURCES
Advice Options
Non-urgent advice is available to support family physicians.
 Gastroenterology advice is available across the province via Alberta Netcare eReferral Advice Request
(responses are received within five calendar days). View the Referring Provider – FAQ document for more
information.
 Non-urgent telephone advice connects family physicians and specialists in real time via a tele-advice line.
Family physicians can request non-urgent advice from a gastroenterologist:
o In the Calgary Zone at [Link] or by calling 403-910-2551. This service is available from
8:00 a.m. to 5:00 p.m. Monday to Friday (excluding statutory holidays). Calls are returned within
one (1) hour.
o In the Edmonton and North Zones by calling 1-844-633-2263 or visiting [Link]. This
service is available from 9:00 a.m. to 6:00 p.m. Monday to Thursday and from 9:00 a.m. to 4:00
p.m. Friday (excluding statutory holidays and Christmas break). Calls are returned within two (2)
business days.

References
Keefer, L., Drossman, D. A., Guthrie, E., Simrén, M., Tillisch, K., Olden, K., & Whorwell, P. J. (2016). Centrally mediated
disorders of gastrointestinal pain. Gastroenterology, 150(6), 1408-1419.
Resources
[Link]/idbl/[Link]?reset=true&_cid=095cf5f4-30b5-
Interactive Drug Benefit List (iDBL)
4bd6-b960-a0c72669cd7e
Poverty: A Clinical Tool for Primary Care Providers (AB) [Link]/media/uploaded/Poverty_flowAB-[Link]
Nutrition Guideline: Household Food Insecurity [Link]/assets/info/nutrition/[Link]

Last Updated: October 2021 Page 11 of 14 Back to Algorithm

 PATIENT RESOURCES
Information
Description Website
Functional Abdominal Pain Syndrome
[Link]/lower-gi-disorders/functional-abdominal-pain-
(International Foundation for Gastrointestinal Disorders
[Link]
(IFFGD))

Common Questions About Functional Abdominal Pain [Link]/gi-disorders/functional-abdominal-pain-syndrome/common-

Syndrome (IFFGD) questions/

Patient Resource Centre: Abdominal Pain Syndrome

[Link]/topics/abdominal-pain/
(American College of Gastroenterology)
The Science of Pain [Link]/information-centre/a-z-digestive-topics/the-science-of-
(GI Society & Canadian Society of Intestinal Research) pain/

Dealing with Chronic Pain

[Link]/information-centre/a-z-digestive-topics/chronic-pain/
(GI Society & Canadian Society of Intestinal Research)
Food, Lifestyle, and Symptom Diary [Link]/assets/info/nutrition/[Link]
Fibre Facts [Link]/assets/info/nutrition/[Link]

Nutrition Education Material [Link]/NutritionResources

9c849905-3a37-465a-9612-
Gut Health Patient Journal
[Link]/ugd/7b74c1_81f1695f08214a66bc3394
(Physician Learning Program)
[Link]

Services available
Description Website
Services for patients with chronic conditions
[Link]/info/[Link]
(Alberta Healthy Living Program - AHS)
Supports for working towards healthy lifestyle goals and [Link]/info/[Link]
weight management (Weight Management - AHS)

Better Choices, Better Health® Program [Link]/services/[Link]

 Visit Alberta Referral Directory and search for nutrition
counselling.
 To learn more about programs and services offered in your zone,
Referral to a Registered Dietitian visit Nutrition Services.
 Health Link has Registered Dietitians available to answer nutrition
questions. If a patient has nutrition-related questions, they can call
8-1-1 and ask to talk to a Dietitian.

Last Updated: October 2021 Page 12 of 14 Back to Algorithm

 Tell your healthcare providers if you
Your Pathway for 1. Check your symptoms have these symptoms:
Managing Chronic
Abdominal Pain (adults) Do you have the following symptoms for • Family history of colon cancer
at least 3 of the last 6 months? • Losing weight without meaning to
What is chronic abdominal pain? • Pain or discomfort that is present • Repeated or unexplained vomiting
every day or almost every day • Stool that is black in colour or has blood
• Means belly pain that is troublesome, is
present every day (or almost every day) • Pain that impacts your every day in it
for months, and is not explained by other activities (e.g. work, sex, leisure
medical conditions. activities, family life, ability to care for Talk to your healthcare providers if your
yourself or others) symptoms don’t improve, get worse, or keep
• The cause of chronic abdominal pain can • No other medical conditions that might interfering with your everyday activities.
be challenging to determine and treat. explain your abdominal pain
• Treatments focusing on improving your
symptoms are usually all that is needed.
2. Make lifestyle changes to manage
• It can affect your every day activities and Once you find something that works for
your symptoms (see over for details) you, stick with it.
have a negative impact on quality of life.
• Usually cared for by healthcare providers You may need to keep trying other
in your family doctor’s office. • Identify what causes you stress and options to find what works best to
seek ways to manage it manage your symptoms.
• Try to get at least 20 minutes of
What is the chronic abdominal pain physical activity daily. Aim for 150
patient pathway? minutes each week
It is a map for you and your healthcare • Identify foods that cause symptoms
providers to follow. It makes sure the care and try to limit or avoid them 4. Medicine that may be tried
you are getting for chronic abdominal pain is
safe and helpful in managing your
symptoms. • Many options can be used to reduce
3. Tests that may be done chronic abdominal pain and improve
You and your healthcare providers may
your symptoms
modify the pathway to best suit your
healthcare needs. • Talk with your healthcare providers
• Blood and stool tests about what medicines may be right for
If symptoms cannot be managed over time, • Urine tests, on occasion you
you and your healthcare providers may • Other tests may be needed
decide a referral to a specialist would be
helpful.

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What do I need to know about my
Seeing a specialist is only recommended if:
symptoms and chronic abdominal
• Your symptoms continue or get worse after following treatment and
pain? management options in the chronic abdominal pain pathway.
• You and your healthcare providers identify concerning symptoms or
Working through the chronic abdominal pain patient test results.
pathway can take several months:
You can find more information in the great resources
• Your healthcare providers will ask you questions about your below:
health and do a physical exam. They will also review any
• International Foundation for Gastrointestinal Disorders (IFFGD)
medicines you are taking.
[Link]
• They may suggest certain tests to learn more about possible o GI Disorders → Functional Abdominal Pain Syndrome
causes of your symptoms.
• They will talk with you about possible lifestyle habits that may be • Alberta Healthy Living Program • Nutrition Education Materials
causing your symptoms and how you can make changes that [Link]/info/[Link] [Link]/NutritionResources
could help you feel better. o Workshops on chronic pain
and stress reduction
• You may find it helpful to write down your symptoms and what
seems to cause them (e.g. certain foods or stress). You and your
healthcare providers can make a plan to help manage your Write any notes or questions you may have here:
symptoms using this information.
• Together, you may decide to try certain dietary changes and/or
medicines to help in treating your symptoms.
• You may use medicines for a short amount of time (or possibly
longer) depending on whether your symptoms improve.

To manage your symptoms, try to: Please provide feedback about this patient pathway by completing a short
survey ([Link]/DHSCNsurvey) or email us at [Link]@[Link]
• Identify what causes you stress and work on reducing it. You may
want to try yoga, meditation, counselling, or a stress reduction
program.
• Identify foods that may cause your symptoms. You may want to
keep track of the foods you eat and how they affect your pain. This is general information and does not replace the advice of a health professional. AHS does
• Get at least 20 minutes of physical activity daily. Aim for 150 not make any representation or warranty as to the accuracy, reliability, completeness, or
applicability of the information. AHS disclaims liability for the use of this information and claims
minutes each week (e.g. walking, biking, gardening, stairs, or your arising thereof.
favourite sports). © 2021 Alberta Health Services, Digestive Health Strategic Clinical Network.
[Link] The license does not apply to Alberta
Health Services logos, trademarks, or content for which AHS is not the copyright owner.

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