Ruth grew up in Alabama and ended up in northern Maine last year. We still don’t have her medical records, but she says she was diagnosed with Crohn’s disease when she was a teenager. She has had six months of constant abdominal pain that gets worse when she eats. She seldom has diarrhea but sometimes feels constipated. She often has dry heaves and sometimes vomits.
Her bloodwork is normal and the CT scan that was done in our emergency room had only mild signs of thickened wall of her colon. Her upper and lower endoscopes had very modest abnormalities with nonspecific findings on biopsies.
She has seen a gastroenterologist downstate and is waiting to have an MRI of her small intestine.
Meanwhile, her constant abdominal pain is keeping her from holding down her new job. Hydrocodone has helped her, but that was a stopgap measure from one of her emergency room visits. Now the hospital doctors have labeled her a drug seeker.
As I listened to her story and watched her healthy appearance I began to wonder.
“Has your weight changed during all of this?” I asked.
“Not really.”
“And you have no blood or mucous in your stool?”
“No.”
“And you’re in pain every single day?”
“Just about.”
“And this started when you left Alabama? Was that a stressful move, a stressful time?”
“It was huge. And I’m still stressed out. I mean I can’t work and I’m not making any money. Does that matter?”
“I don’t know, I’m just looking for clues…”
I went over what lab tests had been done. Her inflammatory markers were only slightly elevated.
I had asked her to avoid milk and gluten containing foods when I first met her. She told me that made no difference.
The only symptom she has, really, is constant pain, I thought to myself. What if this is functional, an upregulation of pain signaling – the intestinal equivalent of fibromyalgia?
I have been vaguely aware of this condition, this scenario, but have no experience treating it. A quick search suggests the only treatment options are psychological and lifestyle interventions.
If this is neuropathic, would medications like amitriptyline or gabapentin or duloxetine work? Could they replace her hydrocodone?
She was willing to try.
A few days later she told me her nights are pain free on 10 mg of amitriptyline. But she’s too tired to take that medication during the day.
So, while the downstate gastroenterologists pursue their testing for where there might be physical disease pockets, I am looking in a different direction. They aren’t ready to do that yet and they may never be. Functional conditions receive little attention in medically underserved areas.
A Country Doctor Writes: 
I have had luck with functional abdominal pain syndromes with SSRIs – I tell patients it is an antidepressant, but that does not mean that I think their problem is “in their head” – as there is more serotonin in the gut’s nervous system than in the brain. You might also consider alpha-gal syndrome (I presume tick bites are not uncommon in Maine?) or (if she is on an ACEI or ARB) intestinal angioedema (or a sprue-like syndrome, if she happened to be on olmisartan).
LDN ( low dose naltrexone) studies have shown remarkable success in treating GI “issues” from IBS to fibromyalgia abdominal pain.
Have you considered porphyria?
I had not but a former colleague messaged me about that on LinkedIn
We in primary care are often the ones who recognize and treat functional diseases. The brain ‘makes it real’, the patient is suffering, and we should be familiar and comfortable with the safer alternatives. Patients are grateful for comfort even if we cannot tell them why.