How to Manage Common Abdominal and Gastric Symptoms: Expert Pearls

This transcript has been edited for clarity. 

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School. Welcome back to another GI Common Concerns.

In a previous video, I highlighted a fantastic discussion I had with one of my dear friends and former mentors, Dr Alvin Zfass, from Virginia Commonwealth University. We shared a stage and discussed gastrointestinal (GI) "pearls" — lessons we've learned not in a classroom or in books, but from our more than 100 years of combined experience. 

That video focused on valuable esophageal pearls. If you haven't seen it, I recommend you give it a look. 

Today we're going to talk about GI pearls focused on common abdominal and gastric issues. 

Abdominal Pain

As gastroenterologists, we see a lot of patients presenting with abdominal pain. They are often referred to us by ER physicians who ask us to rule out GI sources of pain. If you're astute, you'll find that a lot of times this isn't GI pain but abdominal wall pain. 

A great pearl to use in your physical examination of these patients is Carnett's sign. This was first described back in 1926 by the American surgeon John Berton Carnett. He talked about intercostal neuralgia, which is basically abdominal wall myofascial pain. 

If you get a good history, you may find a precipitating factor that explains why patients developed this myofascial abdominal pain. 

But in the absence of this, I'll have the patient lay back and point to where the pain is. I'll use my fingers to poke in that area and elicit the point of maximum tenderness. Then I have them lift up their shoulders, head, or legs. Doing this will frequently cause the symptom to worsen because you've changed the pressure in that abdominal area and it elicits more of a pain response. That really tells me that this is abdominal wall pain, not a GI-type pain. I explain this to my patients by showing them that I'm lifting my fingers out of the abdominal cavity and just pushing down on the abdominal wall. 

Determining that it's not GI pain means you still have to do something about it. So, I then have the patient stand up straight. I look at their shoulders and their pelvic wing. These will sometimes exhibit a slight tilt, which tells me there's been an axis shift.

If I see that, I'll then look at their spine for the presence of scoliosis. This can certainly become more pronounced with age as patients develop more kyphosis. This changes the abdominal wall axis and the stress on the abdominal wall muscles, turning it into a pain point. 

Treating this requires mitigation strategies. I'll have these patients work on core strengthening and postural changes (eg, moving their shoulders back to a level position). The localized application of heat can be helpful. 

I'll sometimes send them to a physiatrist if it's an ongoing issue that I can't work with them on. Sometimes, but not often, it's necessary and helpful to refer them to a pain specialist, who can treat with a localized injection of bupivacaine with steroids. 

These techniques can help resolve the pain and reassure the patient that they don't need to return to the ER, which is important given that this condition can cost several thousands of dollars to address. 

So, the pearls to remember when presented with abdominal pain are to look for axis shifts and not to forget Carnett's sign. 

Abdominal Pooch

Another condition I frequently encounter is abdominal pooch. This is more common in older women, who report having abdominal pooch despite not gaining weight or changing their diet. 

When I take a closer look, I'll find that most of these patients have a little kyphosis. When they stand up, I'll ask if they've lost some vertical height. They may respond that they're shorter by an inch or two.

I'll show them why their abdominal pooch developed by explaining the relationship between the spine and abdomen muscles. As you lose a little bit of vertical height, you have to distribute that forward, which causes anterior displacement of the abdominal wall. 

To address this, I recommend core strengthening exercises for the trapezius and deltoids to bring their posture back. Adjusting how they sit and stand may also resolve that. 

I can also reassure them that this isn't caused by something more ominous, such as ascites or intra-abdominal displacements, which are things you have to rule out when conducting a good history and physical.

Gastroparesis

Gastroparesis is something that we see much too frequently, particularly among those with diabetes. 

One of the main interventions for addressing gastroparesis is adopting a small-particle, low-fiber, low-fat diet. I generally tend to make this very simple for my patients. I recommend soft, cooked, low-fat food items.

We move onto liquid treatments if they have further trouble. We use metoclopramide, which is still the only medicine that's approved by the US Food and Drug Administration (FDA) for gastroparesis. 

I use a metoclopramide holiday when I can because of the risk for tachyphylaxis. Tardive dyskinesia is another extrapyramidal side effect of this treatment that must be considered. The relative risk for tardive dyskinesia has been quoted in the most recent iteration of the American College of Gastroenterology's clinical guidelines on gastroparesis at 0.1 per 1000 patient years. 

Make sure to document the risks for extrapyramidal side effects, particularly tardive dyskinesia, in the chart. Inform patients that there are medical lawsuits about this association, and to call immediately with any issues or questions. Discuss possible risks/benefits, and make it clear to patients that the use of this medication is a shared decision between them and the prescriber.

Many of us may opt to use domperidone because it's not linked to these side effects. However, domperidone is associated with galactorrhea, which you should warn patients about. 

But the big consideration with domperidone is drug-drug interactions. Domperidone can prolong the QT interval. As such, it's really important to remember that you must do a baseline ECG in these patients. 

This was investigated in a 2017 study of ECG evaluation before and after domperidone therapy in a community-based practice setting. Investigators found that approximately 40% of patients underwent a baseline ECG and, among these, only approximately 25% had a follow-up ECG after starting the medicine. Of the 40% of patients with a baseline ECG, about 15% had a prolongation of the QT interval at initiation. 

This presents a real problem, because QT prolongation in association with complex ventricular tachycardia, including torsades de pointes–type dysrhythmia, is a major cause of sudden cardiac death and nonfatal cardiac events, both of which have been reported to the FDA with this medication.

In addition to routinely looking for QT prolongation, you also must assess cytochrome P450 enzyme 3A4 drug-drug interactions, because that will prolong the clearance of domperidone. Higher levels of domperidone are associated with more of a risk for QT prolongation. 

So, the first pearl to consider here is to get a baseline ECG and follow it up with another ECG. I make the patients come back at least every 6 months. 

You also need to document that they know this is a non–FDA approved drug. Patients routinely get domperidone from sources outside of the country. There is also an investigational new drug application pathway offered by the FDA. 

The next pearl is to tell patients that they must contact you or have their prescriber perform a drug-drug interaction analysis online or with the pharmacist. This is necessary because the drug-drug interaction checkers on most commercial electronic medical records will not pick it up, given that domperidone is not approved by the FDA. So, we must be extra careful of identifying this risk ourselves. 

Gas and Bloating

Another abdominal symptom we see all the time is gas and bloating.

The pearl I'd offer when treating patients with these symptoms is to ask about artificial sweeteners. These are insidious and found in a variety of dietary items, and even in certain medications. It's easy to identify and remove artificial sweeteners as a means of addressing gas and bloating. 

Celiac Disease

The final condition I'd like to discuss is celiac disease. 

In patients with celiac disease who are refractory and still having problems, don't forget that makeup and lipstick balms frequently contain gluten. This is also true of certain soaps and shampoos. 

However, you don't trigger celiac disease unless you ingest the gluten. You don't absorb things from your skin and scalp. But if patients are using gluten-containing soaps and have the residue on their hands, it can cause an issue if they touch their face and put it in contact with the oral cavity. 

This may be a bigger risk factor among children, who are obviously a lot more likely to put things in their mouth. For other patients, it's perhaps an overhyped risk and not necessarily a major consideration in the management of celiac disease. 

I hope you've enjoyed and found helpful part two of this series on GI pearls. I look forward to providing you with more pearls in a future discussion. 

I'm Dr David Johnson. Thanks for listening. See you next time. 

David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.