Gastrointestinal and Abdominal Pain Practice Standard Summary
The Gastrointestinal and Abdominal Pain (GI) Practice Standard supports the diagnosis and treatment of gastrointestinal and abdominal pain conditions. These include infectious gastroenteritis, traveler’s diarrhea, some abdominal pain conditions, dyspepsia, acid reflux, and constipation. It obtains medical history for some gastrointestinal conditions that may require in person evaluation including upper and lower gastrointestinal bleeding, and gastrointestinal symptoms during pregnancy.
Background
The GI Practice Standard will launch if all of the following criteria are met:
Patient is greater than or equal to 18 years of age
Based on the patient’s Chief Complaint, the diagnoses presented for the provider’s consideration by machine learning relate to nausea, gastroenteritis, vomiting, diarrhea, abdominal pain, epigastric pain, acid reflux, and constipation
Clinical Content
Medical Interview Summary
The GI Practice Standard asks every patient about the presence of each of the following:
A patient who is AFAB (Assigned Female At Birth) is asked about pregnancy status.
Abdominal pain or discomfort
If present, follow-up questions will be asked including onset, the location of most of the pain, quality, duration, and the pain intensity level.
Based on the location of the pain, the patient will receive additional follow-up questions relevant for the reported location.
Constipation
If present, follow-up questions will be asked, including last bowel movement, duration of constipation, and status of passing gas currently.
Nausea or vomiting
If either is present, follow-up questions will be asked, and may include onset, number of episodes of emesis in the past 24 hours, and whether they are able to keep down fluids.
If the patient is pregnant, the standardized PUQE-24 question set is asked to assess severity.
GERD / acid reflux
If present, follow-up questions will be asked, including onset, frequency of symptoms, cardiac red flags (radiation to left chest, worsening with exertion), non-emergent red flags (dysphagia, early satiety, unexplained weight loss), medication trial history, and EGD history.
Diarrhea
If present, follow-up questions will be asked, including onset, appearance, and number of episodes in the past 24 hours.
Gastrointestinal bleeding
Every patient is asked about rectal bleeding and melena.
Any patient with vomiting, epigastric pain location, or acid reflux is asked about vomiting blood or coffee-ground emesis.
The remainder of the GI Practice Standard questions are dependent upon the responses to the questions above. Areas of questioning may include:
Volume status
Lightheadedness or dizziness, postural changes, presyncope, syncope.
Further details and risk factors
Recent fever, change of symptoms after eating or drinking, recent history of international travel, recent use of antibiotics or hospitalization, exposure to others with similar symptoms or suspicious food intake.
At the end of the automated interview, a diagnosis will be presented for the provider’s consideration, along with relevant prescription medication(s), and documentation to support the provider’s medical decision making. In addition, referrals and lab suggestions will be displayed. Some symptom combinations will recommend an in person exam or testing. Based on the diagnosis selected by the provider, some care plans will be entered in for the patient’s education. The provider can choose to use the suggestions provided, or change them based on their clinical decision making.
Virtual Care Management Pearls
General guidelines
Abdominal pain intensity
Abdominal pain intensity is asked as follows: On a scale of 1 to 10, with 1 being very mild discomfort and 10 being the worst pain you can imagine: What level is your abdominal pain right now? Very mild: 1-2 | Mild: 3-4 | Moderate: 5-6 | Severe: 7-8 | Very severe: 9-10
In general, the GI Practice Standard will recommend in person urgent or emergent care for a reported pain intensity level of Severe or Very severe (7-10 / 10).
Volume status
One question asks if the patient is lightheaded or dizzy. If they respond “yes”, they are asked two additional questions, one asking if they have had postural lightheadedness, and one asking if they have had a presyncopal or syncopal episode.
In general, the GI Practice Standard will recommend in person urgent or emergent care for presyncopal or syncopal responses, and at times for postural lightheadedness depending on the additional specifics of the presentation.
Localized abdominal pain
Right upper quadrant
Urgent or emergent in person care is recommended for:
RUQ Pain without a history of cholecystectomy.
Nearby pain radiating to the right upper back or with the presence of jaundice without a history of cholecystectomy. (Clinical concern: Cholecystitis or a related gallbladder, biliary, or pancreatic issue.)
Non-urgent, urgent, or emergent care referral is recommended depending on the specifics of the presentation for:
A similar presentation as above, but with a past history of cholecystectomy.
Epigastric
Urgent or emergent in person care is recommended for central or epigastric pain with:
Radiation straight through to the back. (Clinical concern: pancreatitis, perforating ulcer, aortic dissection or aneurysm.)
Jaundice. (Clinical concern: Cholecystitis or a related gallbladder, biliary, or pancreatic issue.)
Chest pain. (Clinical concern: Cardiac, pulmonary or other thoracic etiology.)
Vomiting blood or coffee grounds, bloody stool, or melena. (Clinical concern: Esophageal, gastric, or small intestinal bleeding.)
Moderate intensity pain with postural lightheadedness.
Referral to non-urgent in person care (PCP or Gastroenterology) is recommended for central or epigastric pain with:
Dysphagia or odynophagia
Unexplained weight loss
Family history of gastric cancer
Age ≥ 60 without a past EGD
Empiric treatment or testing of unexplained epigastric pain / dyspepsia is not recommended, and in person care with PCP is recommended.
Left upper quadrant
Urgent or emergent in person care is recommended for LUQ pain with:
A history of recent mono infection or abdominal trauma. (Clinical concern: Splenic pain.)
Left lower quadrant
Urgent or emergent in person care is recommended for LLQ pain with:
A history of diverticulitis in the past, with current symptoms feeling similar to or the same as their past episode of diverticulitis. (Clinical concern: Recurrent diverticulitis.) Empiric treatment of recurrent diverticulitis without an in person evaluation is not recommended.
Right lower quadrant
Emergent in person care is recommended for:
RLQ pain or nearby pain migrating toward the RLQ and without a history of appendectomy. (Clinical concern: Appendicitis.)
Non-urgent, urgent, or emergent care referral is recommended depending on the specifics of the presentation for:
A similar presentation as above, but with a past history of appendectomy.
Lower abdomen
Patients with lower abdominal pain are asked gender-specific questions about the presence of bladder or genitourinary symptoms that might be presenting as an abdominal concern. These are screening questions, and additional details of positive responses are not pursued.
Urgent or emergent in person care is recommended for:
Lower abdominal pain with the presence of genitourinary symptoms. (Clinical concern: Cystitis, bladder outflow obstruction, vaginitis, prostatitis, sexually transmitted infection, PID.)
Infectious gastroenteritis
Acute gastroenteritis:
Diarrhea, with duration of all symptoms < 2 weeks.
May have nausea, vomiting, abdominal pain, fever, or bloody stools.
Urgent or emergent in person care is recommended for acute gastroenteritis with:
Bloody or brown discoloration of urine. (Clinical concern: Hematuria or hemoglobinuria concerning for hemolytic uremic syndrome.)
Supportive home care is recommended, without testing, for:
Abdominal pain level is between none and moderate.
Volume status is normal, lightheaded, or postural without presyncope or syncope.
No bloody stools or hematemesis.
Optional prescription antiemetic may be considered for nausea or vomiting.
Consider traveler’s diarrhea if recent international travel.
Consider C. difficile colitis if recent antibiotics or hospitalization.
Food poisoning may present with nausea or vomiting without diarrhea, and is often more rapid in onset after a potential exposure than acute gastroenteritis.
Food poisoning is not differentiated from acute gastroenteritis, and similar supportive home care is recommended for stable cases.
Traveler’s diarrhea
For a patient with diarrhea who has recently traveled internationally, recommendations are made based on combinations of: duration of diarrhea, presence of fever, presence of blood in the stool, abdominal pain intensity, and volume status.
In person urgent or emergent care is recommended for:
Severe or very severe abdominal pain.
Presyncope or syncope.
Selected combinations of duration of diarrhea, fever, blood in stool, and volume status.
In person PCP or Urgent Care is recommended for:
Selected combinations of duration of diarrhea, fever, blood in stool, and volume status.
Supportive home care without antibiotic treatment is recommended when:
Duration of diarrhea is < 1 week, and:
The patient has not had fever or bloody stools, abdominal pain level is between none and moderate, and volume status is normal, lightheaded, or postural without presyncope or syncope.
Empiric antibiotic treatment for traveler’s diarrhea is recommended when:
Duration of diarrhea is >1 week, and:
The patient has not had any fever, bloody stools, abdominal pain level is between none and moderate, and volume status is normal, lightheaded, or postural without presyncope or syncope.
Gastrointestinal bleeding
With the exception of hemodynamically stable slight upper or lower bleeding, all cases of gastrointestinal bleeding and melena are referred to in person urgent or emergent care.
Constipation
Constipation is considered when the patient states they have, or they are not sure if they have, constipation and their last bowel movement was 2 days ago or more.
Urgent or emergent in person care is recommended for constipation with any of these:
Constipation or possible constipation, passing no gas or less gas than usual, and nausea or vomiting (Clinical concern: Bowel obstruction.)
Abdominal pain level between moderate and very severe.
Nausea or vomiting.
Presyncope or syncope.
Unexplained weight loss.
Supportive home care is recommended, without testing, for constipation with:
Duration < 2 months, abdominal pain level between none and mild, and no nausea or vomiting.
In person PCP or Gastroenterology referral is recommended for constipation with:
Duration > 2 months, abdominal pain level between none and mild, and no nausea or vomiting.
GERD / acid reflux
Emergent in person care is recommended for GERD with:
Radiation of discomfort to the left chest or worsening of discomfort with exertion. (Clinical concern: Cardiac pain.)
In person PCP or Gastroenterology referral is recommended for GERD with:
Daily treatment for > 2 months without control of symptoms (Clinical concern: Refractory to treatment.)
Dysphagia, odynophagia, or unexplained weight loss. (Clinical concern: Complication such as esophagitis, malignancy, or other esophageal disorder.)
Acute onset (< 2 months) with age >60.
Supportive home care is recommended, without testing, for GERD with:
Mild and intermittent symptoms: Frequency of symptoms < 2x per week
Severe symptoms: Frequency of symptoms > 2x per week
Pregnancy
In person urgent or emergent care is recommended for:
Abdominal pain intensity severe or very severe.
Postural lightheadedness, presyncope, or syncope.
Nausea, vomiting, or diarrhea with lightheadedness.
Rectal bleeding, melena, or vomiting blood.
Vaginal bleeding.
In person non-urgent Ob/Gyn care is recommended for:
Morning sickness: Nausea or vomiting without fever, diarrhea, or abdominal pain.
Morning sickness severity (PUQE-24): Moderate or severe.
No lightheadedness, or if the recommended morning sickness treatments are not effective.
Supportive home care is recommended for:
Morning sickness: Nausea or vomiting without fever, diarrhea, or abdominal pain.
Morning sickness severity (PUQE-24): Mild.
No lightheadedness.
All other gastrointestinal cases including infectious gastroenteritis are referred for non-urgent, urgent, or emergent in person care depending on the specifics of the presentation.
Medication Guidelines
Nausea and vomiting associated with infectious gastroenteritis, food poisoning, and other non-pregnancy related conditions
Ondansetron 4mg ODT. Dissolve 1 tablet on the tongue every 8 hours PRN nausea and vomiting.
Ondansetron HCL 4mg tablet. Take 1 tablet by mouth every 8 hours PRN nausea and vomiting.
Pregnancy: Morning sickness
Mild morning sickness without vomiting: OTC pyridoxine (Vitamin B6) 10-25 mg every 6-8 hours PRN. Max 100 mg pyridoxine per day.
Mild morning sickness with vomiting: Prescription doxylamine 10 mg/pyridoxine 10 mg delayed release tablet. 2 tabs qHS x 2d. Day 3: 1 tab AM and 2 tabs HS PRN. Day 4: 1 tab AM, 1 tab mid-day, and 2 tabs HS PRN morning sickness. Max 4 tabs per day.
Mild morning sickness with vomiting, if doxylamine-pyridoxine is not helping enough: Stop doxylamine-pyridoxine, start OTC diphenhydramine 25-50 mg every 4-6 hours PRN.
Moderate or severe morning sickness, or if the recommended treatments are not effective: Refer to in person Ob/Gyn provider. Prescription ondansetron is not recommended.
Diarrhea associated with infectious gastroenteritis, food poisoning, and other non-pregnancy related conditions
OTC loperamide, follow package instructions.
Traveler’s Diarrhea
OTC loperamide, follow package instructions.
Azithromycin 500 mg tablet. 1 tablet once a day for 3 days.
GERD / Acid reflux
Mild and intermittent : <2 episodes / week, 1st line
OTC Famotidine 20 mg tablet 1 tablet by mouth twice a day PRN acid reflux x 4 weeks.
Mild and intermittent : <2 episodes / week, 2nd line
OTC Omeprazole 20 mg delayed release tablet. 1 tablet by mouth once a day x 4 weeks.
Prescription Omeprazole 40 mg delayed release tablet. 1 tablet by mouth once a day x 4 weeks.
Severe : > 2 episodes / week, 1st line
Prescription Pantoprazole 40 mg delayed release tablet. 1 tablet by mouth once a day x 4-8 weeks.
Constipation
1st line treatment
Dietary modification and/or bulk-forming laxative (high-fiber / psyllium)
Fluid supplementation
2nd line treatment (those who respond poorly to fiber, cannot tolerate, or patient preference)
OTC docusate
OTC polyethylene glycol
OTC bisacodyl, short-term use
Follow-up Recommendations to be Discussed with the Patient
Infectious gastroenteritis
Acute gastroenteritis treated with supportive home care:
Follow up with in person PCP if symptoms still present after 7 days.
Traveler’s diarrhea
Treated with supportive home care:
Virtual follow up in one week to ensure improvement.
Virtual follow up if symptoms last longer than 7 days to discuss possible antibiotics.
Follow up in Urgent Care if the patient develops fevers, worsening abdominal pain, or bloody stools.
Follow up in the Emergency Room if abdominal pain becomes severe or severely dehydrated or feeling faint.
Treated with empiric antibiotics:
Virtual follow up in one week to ensure improvement.
Follow up in Urgent Care if the patient develops fevers, worsening abdominal pain, or bloody stools.
Follow up in the Emergency Room if abdominal pain becomes severe or severely dehydrated or feeling faint.
GERD / Acid reflux
Mild and intermittent, treated with supportive home care:
Virtual follow up in 4 weeks.
Follow up with in person PCP for worsening symptoms or persistent symptoms after 2 months of treatment.
Severe, treated with supportive home care:
Follow up with in person PCP for persistent symptoms after 2 months of treatment.
Pregnancy
Morning sickness treated with supportive home care:
In person urgent or emergent care is recommended for any fever, diarrhea, abdominal pain, vaginal bleeding, tachycardia, lightheaded or feeling dehydrated.
ICD-10 Codes Provided
Associated Available TextExpanders (if needed)
Please see your institution's Text Snippet document on available options.
Chat and Documentation Suggestions
In addition to presenting diagnostic and treatment suggestions for consideration by the provider, the GI Practice Standard presents chat and documentation suggestions to the provider for consideration based on previous machine learning. The suggestions are tied to the selection of a diagnosis suggested for consideration by the provider. For example, if the GI Practice Standard suggests Infectious gastroenteritis and colitis, unspecified as the ICD-10 diagnosis AND the provider selects Infectious gastroenteritis and colitis, unspecified as their diagnosis, the chat and documentation suggestions for consideration will relate primarily to Infectious gastroenteritis and colitis, unspecified diagnosis and treatment.