Chronic Abdominal Pain


Abdominal pain is oftentimes elusive for the practitioner as even after dangerous and other treatable pathologies are ruled out, some patients continue to suffer from chronic pain with no clear etiology.  This has generally been referred to as Functional Abdominal Pain (FAP) and more recently referred to as Central Abdominal Pain Syndrome (CAPS) in GI literature. Understandably, without an etiology, the treatment options are oftentimes limited at best.


Compounding this challenge is that abdominal pain has many potential causes, ranging from indigestion to more urgent conditions such as appendicitis, each with an unique treatment algorithm.  While the location and description of the pain experience can provide important clues, its time course is particularly useful.  Acute abdominal pain develops over a few hours to a few days and should be prioritized—ensuring the absence of a “surgical belly” is compulsory. Chronic abdominal pain on the other hand has been present for months to years, for most, coming and going but not necessarily worsening over time.  While these patients continue to need reassurance and empathy, there is no urgency for repeat work-up unless there is a significant change in presentation.

Additional challenge comes from the interconnect between pain and emotions.  To appreciate the basis for central abdominal pain syndromes it is necessary to understand how the body perceives pain. Nerve impulses travel from the abdomen to the spinal cord and ascends further to various areas of the brain’s cortex for processing. There are several different cortical areas involved in the consciousness of abdominal pain. One of these areas is concerned with the location and intensity of pain (somatosensory cortex), while another area is concerned with memories or emotions (amygdala). Because of this interconnection, the individual’s perception of pain is affected by emotions and past experiences.

Treatment Recommendations

  1. Diet and nutrition directly affects abdominal health
  2. Pain diary can help identify triggers to be avoided
  3. Treatment of underlying depression/anxiety is key
  4. Pain Psychology can improve coping mechanisms: cognitive behavioral therapy, relaxation, hypnosis
  5. Medication management is not benign and comes with side effects but may provide some degree of symptomatic relief.

Special Considerations

The pediatric population deserves particular attention as it poses a diagnostic dilemma—is this medical or surgical warranting diagnostic work-up or is this psychologically rooted? For some, in particular children, overlying anxiety, depression and other psychiatric disorders may manifest in exaggerated pain responses. Neither the parent nor the child may be consciously aware of any associated stress or emotional disturbances. Other possible risk factors are physical or emotional traumatic experiences, such as schoolyard bullying. Despite reassurances that functional abdominal pain is not life threatening, it may still have negative effects on the child’s physical and psychological well-being. The painful symptoms may interfere with attendance at school, participation in sports and involvement in other extra-curricular activities. With time, it will have effects on appetite, sleep and overall mood.


Harrison’s Principles of Internal Medicine Kasper D et al.  McGraw-Hill, 2015, Chapter 20: Abdominal Pain.

International Foundation For Gastrointestinal Disorders: