Chronic abdominal pain and nausea?

[CarabinerSD]

I'm taking care of an outpatient patient: 60y/o woman with chronic abdominal pain with prior history of gastric bypass, appendectomy, incisional hernia repair. Her pain had been previously controlled with oxycodone 10mg a couple times a day, but recently less effective due to emesis. GI is following now, has her on Zofran, Reglan, Promethazine but the nausea is still pretty severe. Patient is cachectic and having trouble with PO intake. Utox is appropriate.

I'm considering a Fentanyl patch to avoid aggravating her n/v with PO intake & losing pain pills through emesis. Possibly celiac plexus block. GI is going to re-image her abdomen. Any other medications I should consider in managing someone with chronic abdominal pain now with nausea / emesis?

---

Members don't see this ad.

 

[lobelsteve]

No, no, no.

What are you treating with opiates? If pain is the answer, drop the pen.
If cancer is the answer, fentanyl is appropriate.
Phenergan is not appropriate. Synergy with percs for her high or to avoid the stress of life.
Chronic abdominal pain is a symptom, not of a disease or syndrome or process that requires or should be treated with opiates.

 

[RoloTomassi]

Marinol, Megace, anabolic?

 

[nerve zapper]

Sublingual buprenorphine? As a means of weaning and eventually transitioning off opioid. Disclaimer, I’m just a lowly pm&r resident interested in pain.

 

[bedrock]

Only chronic opioid I would ever consider in such as a case is bup.

absolutely no role for standard opioids in abdominal pain and they often aggravate the underlying pathology.

 

[Agast]

What is the actual cause of the abdominal pain (before the nausea/vomiting started). Incisional hernia repair and scar tissue? Is there something wrong with the gastric bypass site? I'm assuming they scoped her. I have a lady who developed an ulceration near the Roux en Y junction and the pain improved with starting sucralfate. I would wean down from oxycodone and if you're in a medical marijuana state try that instead.

 

[Ferrismonk]

Nausea, vomiting, emesis? Stopping the opiates is the first thing you should do, it is exacerbating, and maybe causing, her symptoms. If unable to tolerate PO and she's cachectic from this (not cancer I assume?) then she needs a dobhoff or TPN.

I agree with Steve. Chronic nausea/vomiting/pain is a symptom and you need to know why. Gastric bypass, incisional hernia repair, and appendectomies don't cause this symptom. I could give you a ddx, but that's GI's job. First step, stop the opiates and give her nutrition.

 

[NJPAIN]

I agree wholeheartedly that opioids should be stopped. However, let’s take this discussion to the next place that the situation will go.

“But, but, but what about the pain??” says the patient, says GI and says the PCP. What if Buprenorphine isn’t covered by the pharmacy plan or doesn’t work?

I know we have one or two among us who trained with Leo Kapural. Would he be giving her opioids until her differential spinal/splanchnic RF/HF 10?

These are among the most difficult cases to deal with in this field.

 

[Agast]

I’m assuming they did a gastric emptying study?

 

[bedrock]

I agree wholeheartedly that opioids should be stopped. However, let’s take this discussion to the next place that the situation will go.

“But, but, but what about the pain??” says the patient, says GI and says the PCP. What if Buprenorphine isn’t covered by the pharmacy plan or doesn’t work?

I know we have one or two among us who trained with Leo Kapural. Would he be giving her opioids until her differential spinal/splanchnic RF/HF 10?

These are among the most difficult cases to deal with in this field.

The butrans excuse no longer works as a months supply can be purchased for 50-60 with the right discount cards. This is because butrans became much cheaper due to the competition of belbucca.

I don’t let any patient give me that excuse any longer re butrans.

 

[Timeoutofmind]

Wean her

Examples of meds with evidence for chronic visceral pain:
Cymbalta
Gab
Low dose naltexone less evidence but worth a shot

figure out if prominent abdominal wall component (positive Carnets, etc)
If so, consider TPI, dry needling, TAP block etc

but most importantly, GI needs to figure out why she is wasting away and not tolerating PO and painful belly.

 

[TIVAndy]

nothing 10KHz can't fix.

 

[Ducttape]

Opioids may be the cause for her chronic nausea and vomiting.

She isn't also using marijuana for pain, is she? Think cyclic vomiting syndrome...

check a uDS.

Tell her that her nausea and vomiting should improve off the oxycodone. You can have her taper from 20mg a day to off, over a short period of time, but it's unlikely she will have significant withdrawal symptoms from 30 MED.

No to fentanyl patch.

Any way you cut it, she is failing opioid treatment. Rotation or dose increase wouldn't help that...

 

[Orin]

60y/o woman with chronic abdominal pain with prior history of gastric bypass, appendectomy, incisional hernia repair. Her pain had been previously controlled with oxycodone 10mg a couple times a day, but recently less effective due to emesis. GI is following now, has her on Zofran, Reglan, Promethazine but the nausea is still pretty severe. Patient is cachectic and having trouble with PO intake. Utox is appropriate.

Any other medications I should consider in managing someone with chronic abdominal pain now with nausea / emesis?

Chronic post-operative abdominal pain without clear structural pathology is a challenge. I'm appreciative someone is trying to help these folks.

We can agree that opioids aren't ideal. I would transition though to liquid methadone as that cheaper and absorbs quickly in the proximal upper GI tract. You don't have to stress emesis issues. Buprenorphine is fine too but harder to transition on/off for opioid tolerant patients.

I agree though that you're playing with fire and may be treating a somatic symptom with dissociative medications. In addition to the above, I would consider atypical agents such as olanzapine which is used for nausea in cancer patients, generally start at 5 mg QHS. There's an ODT version if they can't swallow.

 

[kstarm]

Needs work-up to determine nothing new is going on, though flares are very common in chronic abdominal pain. Usually there is a myofascial component due to the amount of guarding that happens. Consider a muscle relaxer and teaching her to stretch her belly-daily self care is really important. No opioids. Very often a trauma history in bypass patients. If unaddressed PTSD would get that to be the focus of treatment. Lots of non-opioid options already stated. If people have food aversions (food taste/smell causes nausea) you could send them to an eating disorder clinic to work on making food less problematic.

 

[painfree23]

Chronic post-operative abdominal pain without clear structural pathology is a challenge. I'm appreciative someone is trying to help these folks.

We can agree that opioids aren't ideal. I would transition though to liquid methadone as that cheaper and absorbs quickly in the proximal upper GI tract. You don't have to stress emesis issues. Buprenorphine is fine too but harder to transition on/off for opioid tolerant patients.

I agree though that you're playing with fire and may be treating a somatic symptom with dissociative medications. In addition to the above, I would consider atypical agents such as olanzapine which is used for nausea in cancer patients, generally start at 5 mg QHS. There's an ODT version if they can't swallow.

More than half this thread is saying no opiates (which I agree with) and then we have a post like this encouraging liquid methadone. This is the problem with pain.

 

[lobelsteve]

Chronic post-operative abdominal pain without clear structural pathology is a challenge. I'm appreciative someone is trying to help these folks.

We can agree that opioids aren't ideal. I would transition though to liquid methadone as that cheaper and absorbs quickly in the proximal upper GI tract. You don't have to stress emesis issues. Buprenorphine is fine too but harder to transition on/off for opioid tolerant patients.

I agree though that you're playing with fire and may be treating a somatic symptom with dissociative medications. In addition to the above, I would consider atypical agents such as olanzapine which is used for nausea in cancer patients, generally start at 5 mg QHS. There's an ODT version if they can't swallow.

You are insane. Chronic abd pain on methadone sounds like a never event. EVERRRR.

 

[PainRehabMD]

Olanzapine and liquid methadone? Wow.

 

[NJPAIN]

Put this on the Google DRG forum and she gets lots of opioids until the pump goes in. Quite a different crowd with a very different idea of how to manage chronic pain. Who is correct? Are some of us just a bunch of wimps denying this patient the benefit of the latest technology? Who’s outcome is better?

Anyone have the answer?

 

[Agast]

What does her physical exam actually look like? I’ve done anterior cutaneous nerve blocks and TAP blocks with success for abdominal wall pain.

 

[CarabinerSD]

I do agree with what a lot of you guys are saying. I inherited this patient from my colleague so I cannot say I have a full understanding of her chronic abdominal pain or her opioid regimen. She does appear to be in pain...but exam is just vague abdominal pain around the umbilicus (where incisional hernia repair was done). However there is probably a myofascial / psych / anxiety component with her chronic abdominal pain as well. The oxycodone is not a new medication to her, and the n/v is more recent. GI is aggressively working her up with imaging (emptying test, CT, etc) and scoping, but my impression is from their notes they're not conclusive about the etiology.

I have made it clear to her that I am not escalating her opioid regimen at all since I cannot find a distinct etiology for the pain. I have titrated her down to Norco which she is actually tolerating better (using a pill crusher with sips of water). Will eventually try Buprenorphine / Butran patch, and possibly non-opioid adjuvants. Not my favorite diagnosis to manage, just like pelvis pain after inguinal hernia repairs....

 

[soccrwz]

I do agree with what a lot of you guys are saying. I inherited this patient from my colleague so I cannot say I have a full understanding of her chronic abdominal pain or her opioid regimen. She does appear to be in pain...but exam is just vague abdominal pain around the umbilicus (where incisional hernia repair was done). However there is probably a myofascial / psych / anxiety component with her chronic abdominal pain as well. The oxycodone is not a new medication to her, and the n/v is more recent. GI is aggressively working her up with imaging (emptying test, CT, etc) and scoping, but my impression is from their notes they're not conclusive about the etiology.

I have made it clear to her that I am not escalating her opioid regimen at all since I cannot find a distinct etiology for the pain. I have titrated her down to Norco which she is actually tolerating better (using a pill crusher with sips of water). Will eventually try Buprenorphine / Butran patch, and possibly non-opioid adjuvants. Not my favorite diagnosis to manage, just like pelvis pain after inguinal hernia repairs....

I also like to add liquid gabapentin to these regimens, seems to be better tolerated. Can consider recurs sheath blocks for these. or injection of incision if beneficial cryo with iovera. Psych stuff needs to be figured out, cbt or act can be useful. Splanchnic have been beneficial but be careful if functional abdominal pain

 

[Orin]

You are insane. Chronic abd pain on methadone sounds like a never event. EVERRRR.

Whoa, I thought it was the person and not the drug?

Agreed that opioids are a bad idea for chronic abd pain, but the right drug for emesis/short gut.

Antipsychotics for Pain Management

www.uspharmacist.com

 

[lobelsteve]

Whoa, I thought it was the person and not the drug?

Agreed that opioids are a bad idea for chronic abd pain, but the right drug for emesis/short gut.

Antipsychotics for Pain Management

www.uspharmacist.com

It is the person. And the drug. Not this person. And never this drug. No benefit for opiate in this patient with unknown dx. No benefits for mtd, demerol, darvocet for pain over conventional opiates and significant increased risk.

 

[geauxg8rs]

Just don’t see abdominal or pelvic pain. It’s not worth it

 

[ziggyziggy]

I do agree with what a lot of you guys are saying. I inherited this patient from my colleague so I cannot say I have a full understanding of her chronic abdominal pain or her opioid regimen. She does appear to be in pain...but exam is just vague abdominal pain around the umbilicus (where incisional hernia repair was done). However there is probably a myofascial / psych / anxiety component with her chronic abdominal pain as well. The oxycodone is not a new medication to her, and the n/v is more recent. GI is aggressively working her up with imaging (emptying test, CT, etc) and scoping, but my impression is from their notes they're not conclusive about the etiology.

I have made it clear to her that I am not escalating her opioid regimen at all since I cannot find a distinct etiology for the pain. I have titrated her down to Norco which she is actually tolerating better (using a pill crusher with sips of water). Will eventually try Buprenorphine / Butran patch, and possibly non-opioid adjuvants. Not my favorite diagnosis to manage, just like pelvis pain after inguinal hernia repairs....

Anyone can write opioids and pain management does not have any special privileges. Why don't send the patient to GI as patient is anyway is being worked u by them? If not, push GI to give you very specific recommendation regarding opioids. They need to spell out the dose and medication. Nothing less. You can minimize your risk by involving other specialities. Especially when you say that "I don't understand or have full understanding of her chronic abdominal pain".
Will you put your needle in spine if you did not know what you are treating? Same goes for opioids.

 

[NJPAIN]

Anyone can write opioids and pain management does not have any special privileges. Why don't send the patient to GI as patient is anyway is being worked u by them? If not, push GI to give you very specific recommendation regarding opioids. They need to spell out the dose and medication. Nothing less. You can minimize your risk by involving other specialities. Especially when you say that "I don't understand or have full understanding of her chronic abdominal pain".
Will you put your needle in spine if you did not know what you are treating? Same goes for opioids.

Exactly. This is the problem with a specialty based on a symptom. Especially a symptom that could be indicative of a serious underlying problem. Makes about as much sense as GI doc consulting diarrhea management.

 

[RoloTomassi]

Collaboration is the key. Some GI don't know much about post herniorrhaphy pain, anterior cutaneous nerve entrapment, etc., and I don't know much about endometriosis and whatnot. I don't think we can just say, since it's in the abdomen it's their problem to figure out. We are supposed to be diagnosticians of pain in any body part, but some are less familiar territory and collaboration would help.

 

[lobelsteve]

Collaboration is the key. Some GI don't know much about post herniorrhaphy pain, anterior cutaneous nerve entrapment, etc., and I don't know much about endometriosis and whatnot. I don't think we can just say, since it's in the abdomen it's their problem to figure out. We are supposed to be diagnosticians of pain in any body part, but some are less familiar territory and collaboration would help.

sounds great as long as the referring docs and the patients understand that narcotics are not part of the treatment for unexplained pain syndromes and often not the treatment for explained pain syndromes.

 

[Taus]

Not my circus. Not my monkey.

 

[Multimodal]

Wean her

Examples of meds with evidence for chronic visceral pain:
Cymbalta
Gab
Low dose naltexone less evidence but worth a shot

figure out if prominent abdominal wall component (positive Carnets, etc)
If so, consider TPI, dry needling, TAP block etc

but most importantly, GI needs to figure out why she is wasting away and not tolerating PO and painful belly.

agree with this approach and avoiding opiates regardless of how much the patient thinks they may help. I had to show a lady that the product insert for oxycodone that warns against its use in spinchter of oddi spasm cases, which she has.....I offered her the above and havent seen her since. a win in my book 🙂

 

[Dawkter]

What does her physical exam actually look like? I’ve done anterior cutaneous nerve blocks and TAP blocks with success for abdominal wall pain.

If you have temporary success with a TAP block how do you transition to a more permanent therapy?