Everything You Need To Know About Abdominal Pain

Podcast Transcript

Scott Steele:  Butts & Guts, a Cleveland Clinic Podcast, exploring your digestive and surgical health from end to end.
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Welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the Chairman of Colorectal Surgery here at Cleveland Clinic in beautiful Cleveland, Ohio. And we're very pleased to have Dr. Bradley J. Champagne, who is the Director of Operations for DDSI West Region. He's also the Chief of Surgery at Cleveland Clinic Fairview Hospital. Brad, welcome to Butts & Guts.

Bradley Champagne:  Oh, thanks so much, Scott. It's a real pleasure to be on.

Scott Steele:  So we always like to start out with all of our guests with you giving us a little bit of background about yourself, where you're from, where did you train and how did it come to the point that you're at the Cleveland Clinic?

Bradley Champagne:  Well, Scott, I grew up in Upstate New York, Syracuse, New York. I did the majority of my surgery training around Albany, New York, and then I traveled down South for fellowship in Atlanta at Georgia Colorectal. And then I came back to Cleveland, worked at Case University Hospital for a little over 10 years. And then about two to three years ago I came over to the Cleveland Clinic primarily to help build DDSI Services in our West Region for the Cleveland Clinic.

Scott Steele:  Well, we're super glad to have you and, Brad, today we're going to talk about something that is very hard to get specific on because it is so broad and that's the concept of abdominal pain. So let's start really basic. How do you think about abdominal pain and, if you will, how do you classify abdominal pain?

Bradley Champagne:  That's a really great question. I think, just to start simply, we as surgeons and docs, we think algorithmically a lot, breaking things up into two. So right out, I think of chronic, kind of acute. So chronic being something that a lot of patients and people just overall say that they've had something kind of nagging at them over the course of months or weeks or even years.

And then a different category is a sudden onset, very intense, doesn't come and go. And it's just constant, and they've never had something like that before. So that's more of the acute side. And so I think when you are able to break those up into those categories, it really helps both from, not just a doctor's standpoint, but a patient perspective, know you know when to seek attention and how urgently they need to be seen.

Scott Steele:  So, Brad, there's a lot of different ways to do exactly what you're doing to break them up. Let's start off with a couple of quick questions. How common is abdominal pain? Is this something, when patients come to you, or your family or friends or anybody, and they're like, "Hey listen, I've been having a little belly pain." Is that common? Is it not uncommon?

Bradley Champagne:  Yeah, I think it's extremely common. I think we all would probably acknowledge that we've had abdominal pain at some point in our lives. So I think everybody at some point for the most part has had some kind of abdominal pain in their lives, which helps, again, beg the question of why is it happening and what are we doing, what are we putting into our bodies, et cetera, to cause abdominal pain? Or is it more of a condition? Is it something genetic? Is it something acquired? But I think everybody at some point has had abdominal pain.

Scott Steele:  So let's focus first on those patients that are a little bit more in the chronic-type setting or at least not in the acute setting where this is really, really bad, and let's talk about that. How do you go about determining the most common causes? Do you divide it up by the location or the characteristics of that abdominal pain? How do you work your way through that?

Bradley Champagne:  Some of the very principles that we learned in the beginning of med school are very effective in lay conversations, the public, and as well for early on in training of physicians and for patients, and that is the characteristics of the abdominal pain. And more specifically, how intense is the pain compared to pains you've had in the abdomen or elsewhere in your body? Does it come and go or is it constant? How long does it last when it comes on?

I like to know what other symptoms are associated with it. Is there some weight loss? Is there any kind of bleeding? Is there fatigue? Is there fevers? And then the other thing is what makes it better and what makes it worse and how does it relate, again, to prior episodes in the past? So I think that overall general five or six questions, you're kind of building a picture of this abdominal pain and then you can start to narrow down possible causes from that.

And then, just to follow that up, after the questioning is around the character of the pain, I think the most important next question is what are you putting into your body, literally? So what food are you putting into your body and what are you drinking? You know, from that perspective. So are you having too much caffeine? Are you having too many sweets or sugar or artificial foods? So I think when you start asking what you're putting into your body, what's coming out of your body in the sense of frequency of bowel movements and then the character of the pain, you can glean a lot of information and start to narrow it down.

Scott Steele:  So let's take a stroll around the abdomen. You tell me some of the more common causes of abdominal pain based on the location that patients may have and how you think about them. So I'm a patient, I come and see you and I've got some right upper quadrant abdominal pain. So up underneath that rib cage over on that right side by your liver. How do you approach that?

Bradley Champagne:  The majority of patients with pain in the right upper side is probably related to the gallbladder. So in medical jargon, biliary colic. What we're trying to rule out in that setting is, is this something that is more of a colicky-type pain where it comes and goes, which is very, very common. A lot of times that's very common, based on our diet. If you are overweight you're at higher risk for that as well.

And if it's more acute and intense, it can be a more acute condition of the gallbladder called cholecystitis. So what we're trying to determine with a right-sided pain is, is it gallbladder related or not? But that's the most common cause of upper right pain. If it's intense, it's more likely cholecystitis, which is inflammation of the gallbladder. If it's coming and going and more intermittent then it's much more likely biliary colic. And we might be able to get by without an emergency-room visit or visit to a physician.

Scott Steele:  So how about the patient who presents with right lower pain, in that right lower quadrant down by the hipbones or maybe even by the belly button that kind of goes into that section of the abdomen?

Bradley Champagne:  The most common presentation on the right side would be appendicitis. So the classic description for appendicitis is that it kind of starts in the center, then migrates to the right side. But a lot of patients may just notice the pain when it becomes more severe and intense and it's just on the right side alone. There's other less common pains on the right side, more related to possible inflammatory bowel disease or Crohn's disease and potentially right-sided colon cancer as well. Much less commonly right-sided diverticulitis. But for the most part on the right side, we're basically appendicitis until proven otherwise.

Scott Steele:  And then now migrating over to the left side of the belly. How do you situate that out? What are some of the more common things?

Bradley Champagne:  So if we're still staying up on the abdominal side, we're looking more at a diagnosis of a diverticulitis. The most common left-sided and left lower quadrant pain, in somebody that's over the age of 40 would, would probably be diverticulitis. And typically that'd be related to a fever. Sometimes a change in bowel habits as well. And that's more typically a pain that comes on because of inflammation and is relatively constant.

It depends also if it's a male or a female. So from a female, the pathology and the differential is a little more deep in that you have to include and think about ovarian issues such as a ovarian cyst rupture, endometriosis, et cetera. So I think the questioning on the lower, both the left and right lower, is trying to distinguish true left and right lower from more centralized and pelvic-type pain or pressure.

Scott Steele:  Brad, there's a lot of patients out there that may present with abdominal pain and associated back pain. Either it goes to the back, through to the back, around to the back, or it starts in the back and goes into the belly or goes into the groin. How does that come into play and how does that kind of change the way you think about the potential sources?

Bradley Champagne:  So I think the way to think about it from a patient perspective is if the pain is radiating to the back, there's an increased chance or increased risk that one of the organs in kind of this retroperitoneum or that more lay towards the back of the abdomen on the posterior side are inflamed or contributing to this pain. You can have centralized pain from the aforementioned diagnosis referred to the back. However, when they start talking about back pain, we start to think about those different organs.

So the pancreas is more commonly something that when it's inflamed because it lies on the backside of our abdomen that can cause pain more in the back. The kidneys sit in that retroperitoneal space. So renal colic or kidney stones can also cause back pain. Again, diverticulitis, depending on the true location, can cause inflammation, not just in an anterior or forward position but towards the back as well. Or it could be a less common presentation of appendicitis where it's lingering out in that back space, that retroperitoneal space as well. But you start to add things to your differential like pancreas and kidney when the back is involved.

Scott Steele:  So, Brad, I know that a lot of the listeners out there may recognize that you're a surgeon, and you see a lot of different abdominal pain, but is the majority of abdominal pain surgical or is it medical?

Bradley Champagne:  The overwhelming majority of abdominal pain is medical. Your question up front was spot on, saying how often do people have abdominal pain or who gets abdominal pain. When we think about everybody having abdominal pain, the majority of people haven't had major or even minor abdominal surgery related to their pain. So I think that goes back to those really important questions of what are we eating specifically and what are our sensitivities potentially, to food? Is this irritable bowel-type symptoms? So all the medical causes of abdominal pain fall under gastroenterology, primarily IBS, constipation, reflux. So I think the majority would fall into that category.

Scott Steele:  And obviously, Brad, I gave you a very difficult and very broad topic to talk about today and we could talk about peptic ulcer disease and all sorts of different things, constipation. So what are the tools that you've used in the past to say what is surgical? What is medical? Is it just constipation or is there something more that would need an intervention?

Bradley Champagne:  When someone presents with abdominal pain... So I think the first questions are asking themselves what is the severity? And then the chronicity of it. So if it's severe enough to seek treatment or it's just something that they've had for a long enough period of time that it's impacting the quality of their life and they're being seen, that first step again is making sure it's not surgical and to see if it's something more chronic. So we almost rule things out, for lack of a better expression.

And to do that, the first thing is to make sure their vital signs are okay. If their vital signs are okay and it's not something that is constant or there all the time, but it's still impacting the quality of their life, I want to ask about their bowel habits. So if they're straining with their bowel habits and they're having trouble using the restroom and it's a chronic problem for them, it might be constipation. And if they're over the age of 40 and 45 we also have to consider that they could have something within their colon like a colon neoplasm or polyps.

So that's an age of patients that I would order a colonoscopy on and if the colonoscopy is negative, then we can much more comfortably say that it's true constipation, it's not related to a neoplasm and we're going to continue to treat them. If they're younger and they're not at age risk for colorectal cancer, then much more likely to make dietary adjustments and make suggestions around their diet, increasing water, increasing fiber, having more natural food in their diet to try to eliminate constipation in the future.

Scott Steele:  So I know there's a lot of different medications and everything that patients may be on, and a lot of them have side effects that can induce constipation or diarrhea or anything like that. But are there medications that pop into your mind that right away you're going to ask about as a provider to see, "Hey listen, are you taking a lot of these or a little of these?" and see if that weighs into your specific causes?

Bradley Champagne:  Yeah, absolutely. So pain medication tends to kind of wreak havoc in gut and GI motility both on the foregut and the hindgut side. So from taking nonsteroidals, so ibuprofen, whether you're taking it for abdominal pain, or you're taking it for other reasons. There's a tendency for a lot of use of aspirin and ibuprofen without food or off label in our country for sure. And that can lead to ulceration of the stomach. It can lead to gastritis, peptic ulcer disease.

Narcotics, as I mentioned, are one of the most common causes of constipation in patients. Patients that are on medicines also for depression and other psychiatric illness as well also commonly disrupt GI motility and can lead to constipation as well. So it's really important to look at those medications just alongside with the food and asking those questions, what's disturbing the GI tract?

I think there's a tendency to label diseases quickly. We're physicians so we have a problem, we want to fix it. That's the mindset of medical school. Things are changing a little. But from that perspective, we try to get to an answer quickly and we want to try to provide a solution. But I think there's room with abdominal pain to really think of root cause analysis, personalized medicine, and try to spend a lot of time with patients talking about medications, diet. And then a third component is stress. While we're talking about these other causes of abdominal pain, stress and what's happening in their life at that time is often, etiology, probably not as a sole factor for abdominal pain, but I think if there's underlying conditions, we certainly see that stress and increased anxiety can make it worse.

Scott Steele:  So when you talk a little bit about the input in terms of diet and medications, you also talked about bowel movements. So how do you talk about bowel movements in terms of things that are a little bit more red flags or things that are a little bit more normal and weigh that in your decision making, in terms of the need for an extensive workup for abdominal pain or is this something that is just a little bit more routine.

Bradley Champagne:  And so I think there's a lot of ideas and myths there about bowel movements. You have to go once a day, you have to go three times a day, et cetera. I think the most important thing to remember is that we're really looking for changes. So I think the red flags are when you've kind of always been one way and you haven't made a lot of changes in your diet and all of a sudden you're either having readily loose stool or bowel movements or you're not going, or there's a change in the caliber of the bowel movements, or you're starting to see blood, or your bowel movements are associated with crampy abdominal pain. So really changes in the pattern and frequency of bowel movements without really changing your diet or with other findings such as blood are really the causes for concern.

Scott Steele:  So when you have just an approach for the patients that aren't surgical options, we recognize if you've got a gallbladder problem, it may need to come out or you may need to change your diet. If you have appendicitis you may need a surgery. If you have diverticulitis, you may need to have either medical management or surgical management. And I refer the listener to all the different podcasts we've had on each of these individual topics.

But, Brad, let's focus on the more difficult person. How do you deal with a patient without a set known diagnosis where they've just got belly pain and it's affecting the patient's quality of life. How do you go about managing these patients?

Bradley Champagne:  So I think patience is really important from a physician standpoint and on the other end, as a patient within these workups and after we've kind of ruled out more of the acute causes from that by questioning and vitals, et cetera, and it's something though that the patient is impacting their quality of life and it's affecting them at work, at that first and sometimes second visit is the time when we can't figure it out that we need to start using other modalities or tools as you had asked about before.

And the tools that are most valuable for that workup would be a CT scan on the abdomen and then upper and lower endoscopy. So if their symptoms are what we're thinking more hindgut-related, colonoscopy is essential. If it's more upper pain and they're higher risk, so if they have risk factors such as smoking or nonsteroidal use, then an upper endoscopy is essential on those patients. With a negative upper and lower endoscopy and vague sources of abdominal pain or in patients with weight loss, we will get a CT scan to make sure that we're not missing something.

Scott Steele:  So what type of symptoms of abdominal pain, to kind of go to that acute abdominal pain, would you say this is a red flag you need to go in? When should patients be of concern? Because I know that even the briefest abdominal pain and some patients can be fairly severe.

Bradley Champagne:  Yeah. So the red flag for a patient to go seek care, whether it's an emergency room or with their primary physician or with a gastroenterologist or surgeon, are if the pain is persistent and it's not remitting and it's intense. So if the level is intense and it's constant, it's different than they've ever had before in their life, I would seek attention. If the pain is associated with nausea and vomiting or fevers and chills, that's another reason to seek immediate attention.

Scott Steele:  Well, Brad, we sure appreciate you coming on and I know this is a very difficult topic with a lot of broadness to it, but we appreciate your walk through the patient with abdominal pain.

So we'd like to end up with some couple of quick hitters to get to know you a little bit better. So what's your favorite meal?

Bradley Champagne:  If I had one meal, I would probably have a lobster roll.

Scott Steele:  And what is your favorite sport?

Bradley Champagne:  Oh, favorite sport to play is baseball and to watch is basketball.

Scott Steele:  Syracuse Basketball. The last nonmedical book that you've read?

Bradley Champagne:  Nonmedical. I'm challenged on that. Probably Talent is Never Enough, by John Maxwell.

Scott Steele:  And then finally, being a longtime Clevelander, although not from here, what is one thing that you like about Cleveland?

Bradley Champagne:  So what I love about Cleveland is I love that it has an identity. I love that a lot of people that are here have grown up here and have raised their families here and that their kids have gone away and come back through generations and so there's really a true Cleveland population.

Scott Steele:  Fantastic stuff. So for more information about Cleveland Clinic’s Digestive Disease and Surgery Institute, including material on abdominal pain, please visit Clevelandclinic.org/digestive. That's Clevelandclinic.org/digestive and to make an appointment with a Cleveland Clinic digestive specialist, please call (216) 444-7000. That's (216) 444-7000. Brad, thanks so much for joining us on Butts & Guts.

Bradley Champagne:  Thanks so much for having me on.

Scott Steele:  That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.