Chronic Lower Abdominal Pain with Normal Bowel Movements: What to Know

Normal bowel movements, but experiencing chronic lower abdominal pain?

Hello, Doctor.
I started experiencing lower abdominal pain (cramping) in January 2022, and I cannot determine if it is in the left lower or right lower quadrant (lower middle).
Generally, my bowel movements are normal in frequency, color, and size.
The abdominal pain does not improve after bowel movements, but it gradually shifts from the lower abdomen to the upper abdomen.
Before going to bed at night, the abdominal pain usually feels better, but I tend to wake up with slight pain around 7 to 8 AM.
The symptoms have persisted for a year, but they have worsened recently.
In March, I underwent an abdominal ultrasound, and the liver, gallbladder, intestines, pancreas, and kidneys were all normal.
The hospital physician diagnosed me with irritable bowel syndrome (IBS).
The treatment primarily involved the use of loperamide, acetaminophen, and probiotics.
However, after a few months of medication, I found that only the pain reliever was effective, so I stopped taking the medication in June.
I noticed gradual improvement afterward, but by August, the symptoms worsened again.
The hospital physician arranged for a colonoscopy, and the results were good with no issues found, attributing it again to IBS and recommending the same treatment of loperamide and probiotics.
I also consulted a traditional Chinese medicine practitioner, but there was no significant improvement.
To this day, the symptoms have persisted for a year without resolution.
I would like to ask the doctor: 1.
Are there any recommended tests I should undergo? 2.
I have researched many symptoms of IBS, and most indicate changes in bowel habits, but mine are quite normal, with only lower abdominal pain.
Is this still considered a manifestation of IBS? Thank you.

O, 30~39 year old female. Ask Date: 2023/01/03

Dr. Lin Minghui reply Gastroenterology and Hepatology

Normal bowel movements but persistent lower abdominal pain.
After defecation, the pain shifts from the lower abdomen to the upper abdomen.
There is no pain at night, but pain occurs in the morning upon waking.
Abdominal ultrasound and colonoscopy show no issues.
Treatment for irritable bowel syndrome with antispasmodics and probiotics has not improved symptoms, but pain relief medications are effective.
There is a correlation between the gut-brain axis.
In cases of irritable bowel syndrome, it is important to rule out organic diseases and other warning signs (such as anemia and weight loss).
Typically, irritable bowel syndrome presents with abdominal pain and abnormal bowel habits, with relief after defecation.
The pain is related to bowel movements, which may be abnormal in frequency or consistency.
It is recommended to arrange for stool tests to check for abnormalities or infections.
Urinalysis may reveal issues with the urinary tract system.
CT scans and gastroscopy may also be considered.
Wishing you good health!

Reply Date: 2023/01/03

More Info

Chronic lower abdominal pain can be a perplexing issue, especially when bowel movements remain normal. Your symptoms, which have persisted for over a year, warrant a thorough understanding of potential causes and appropriate management strategies.
Firstly, it’s important to recognize that Irritable Bowel Syndrome (IBS) can manifest in various ways. While many individuals with IBS experience changes in bowel habits, such as diarrhea or constipation, others may present primarily with abdominal pain and discomfort without significant alterations in their bowel patterns. Your description of pain that does not improve after bowel movements, and the fact that it sometimes radiates from the lower abdomen to the upper abdomen, aligns with the non-specific pain often associated with IBS.
The fact that your abdominal pain worsens in the morning and improves at night could suggest a few things. One possibility is that the pain may be related to gastrointestinal motility, which can vary throughout the day. Stress and anxiety can also exacerbate IBS symptoms, leading to increased perception of pain. Given your history of anxiety, it may be beneficial to explore stress management techniques, as they can have a significant impact on gastrointestinal health.

Regarding your questions:
1. Recommended Tests: Since you have already undergone abdominal ultrasound and colonoscopy with normal results, further imaging may not be necessary at this point. However, if your symptoms persist or worsen, you might consider additional evaluations such as:
- CT Scan of the Abdomen: This can help rule out any structural abnormalities that may not have been visible on ultrasound.

- Hydrogen Breath Test: This test can help diagnose conditions like lactose intolerance or small intestinal bacterial overgrowth (SIBO), which can mimic IBS symptoms.

- Food Sensitivity Testing: Identifying potential food intolerances (e.g., gluten, lactose) may provide insight into your symptoms.

2. IBS Symptoms without Bowel Habit Changes: Yes, it is entirely possible to have IBS characterized primarily by abdominal pain without significant changes in bowel habits. The Rome IV criteria for diagnosing IBS include abdominal pain that is associated with changes in stool frequency or form, but it does not strictly require these changes to be present. Your experience of chronic pain, especially if it is relieved by bowel movements or associated with bloating, can still fit within the IBS diagnosis.

In terms of management, since you’ve found that pain relief medications are the most effective, it may be worth discussing with your healthcare provider about a tailored pain management plan. Additionally, dietary modifications, such as following a low-FODMAP diet, may help alleviate symptoms for some individuals with IBS. This diet involves reducing certain carbohydrates that can ferment in the gut and lead to symptoms.

Lastly, consider integrating lifestyle changes such as regular exercise, adequate hydration, and mindfulness practices, which can all contribute positively to gut health and overall well-being. If your symptoms continue to be bothersome, seeking a second opinion from a gastroenterologist or a specialist in functional gastrointestinal disorders may provide further insights and alternative treatment options.

In conclusion, while chronic lower abdominal pain can be frustrating, understanding the nature of your symptoms and exploring various management strategies can lead to improved quality of life. Always keep an open line of communication with your healthcare provider to ensure that your concerns are addressed and that you receive the most appropriate care.

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