Pediatric Gastroenterology Case

A 12-year-old girl is referred to the gastroenterology clinic for evaluation of chronic abdominal pain.

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Mar 05, 2019
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She cannot describe the pain and vaguely rubs the center of her abdomen when asked where it hurts. You ask her to point with one finger and she says she can’t. She reports the pain as continuous and 10 out of 10. She has missed school. She denies vomiting, fever, diarrhea, or weight loss. The pain is not associated with eating and does not wake her from sleep. On exam, she appears well but claims to be in pain. She is not tachycardic. She winces in pain when you lightly palpate her abdomen but the pain is distractible. She has no oral ulcers or arthritis, and the rectal exam is normal, with no perianal skin tags or fissures. You suspect functional abdominal pain.

Functional abdominal pain is typically associated with which of the following findings?

A. Involuntary weight loss.

B. Significant vomiting.

C. Nocturnal symptoms.

D. Periumbilical location.

E. Fever.




The correct answer is “D.” The symptoms of functional gastrointestinal (GI) disorders (irritable bowel syndrome, function abdominal pain, abdominal migraine) cannot be explained by an organic cause. Diagnosis of functional abdominal pain can often be made without any specific laboratory testing based on a good history and a thorough physical exam in the absence of red flags, which include abnormal exam, involuntary weight loss, significant vomiting, nocturnal symptoms, growth retardation, delayed puberty, GI blood loss, unexplained fevers, family history of inflammatory bowel disease, and consistent right upper or lower quadrant pain. Between episodes of pain the child is well. The pain is poorly defined and periumbilical or poorly localized. Ask about a family history of irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, and constipation. Patients have often undergone extensive testing. Testing only reenforces the belief that there is something wrong. Parents may have a hard time accepting that the pain is not due to a medical disorder but rather is psychologic. Remember, the pain in functional abdominal pain is real and symptoms are not created intentionally, as in malingering or factitious disorder. Avoid medicalizing patients with these complaints.

Sources:

Question & Explanation: Peterson AR, Wood KE. Pediatrics Examination and Board Review. New York, NY: McGraw-Hill Education; 2017.

Photo: Bishop WP. Pediatric Practice: Gastroenterology; 2010. 

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Leah Carton

Editorial Coordinator , McGraw-Hill Education

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