Chronic Functional Abdominal Pain (CFAP).

Patients with chronic functional abdominal pain (CFAP) present particularly challenging management issues for primary care physicians and gastroenterologists. A major objective in the care of patients with CFAP is to develop an understanding of this condition as a biopsychosocial disorder where symptoms can be attributed to "brain-gut" dysfunction rather than to a missed structurally based condition. The foundation of any therapeutic strategy is the patient-physician partnership, probably the hardest element of treatment for most physicians. All treatment programs should be based on a multi-component strategy, with the patient as a full partner. Realistic expectations should be agreed upon for "care" rather than "cure." The patient's preferences should be a major factor in the decision as to whether to recommend pharmacologic or psychological treatment, or a combination of the two. Antidepressant drugs are increasingly being used in CFAP, and well-designed studies are emerging to confirm their clinical effectiveness. Patients' understanding of the indications for and effects of antidepressants must be reframed in order to address barriers and achieve adherence to therapy. The clinical effectiveness of antidepressants can often only be assessed after 3 to 6 weeks of therapy. The side effects, which appear early, are usually transient and often disappear within 1 to 2 weeks. There is no conclusive evidence that one antidepressant drug is more effective than others, although most studies have tested tricyclic agents. The most important factors in the choice of antidepressant medication are side-effect profile, physician familiarity and comfort with the drug, and cost.