Case 15: Chronic abdominal pain

Opening scenario

The father of Leo Morris, a 6-year-old male; , consults you because his child has persistent episodes of abdominal pain.

Vital signs

Not available.

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

For telephone cases, you can complete the focused history as you normally would, but you will not conduct a physical examination and can leave this section of the patient note blank.

Patient instructions

• You are frustrated about your son's problem and the fact that nothing you have done so far has helped.
• You are not aware of the meanings of medical terms (e.g., transglutaminase antibodies) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: When the examinee finishes asking you all her/his questions, say “I feel bad because sometimes I lose my temper with him. I am just so frustrated because it seems like he is really not acting his age right now.”

Hovering over or clicking on the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form or the abbreviation list will not interrupt your progress.

History of present illness

• Chief complaint
• My son says he has belly pain every morning, and then he says does not want to go to school because of it. It has become a real ordeal to get him out of the house and to the bus stop in the morning.
• Location
• He cannot really show me where – he just says his whole belly hurts.
• Intensity (on a scale from 0–10)
• He is not here right now, so I cannot ask him. If I was to guess I would say about a 5 because if I distract him from it he seems able to forget it for a few minutes.
• Quality
• It seems to be a dull pain.
• Onset
• He has had it on and off for about 8 months now.
• Precipitating events
• Well my wife and I got divorced 2 years ago, and she finally moved out around the time when it started.
  • Symptoms associated with consumption of certain foods
  • No, I have not been able to connect his stomach ache with any particular kind of food.
• Progression/constant/intermittent
• It started off with just a few episodes last spring. Then it went away during summer break, but it came back again in September. Since then, there is not a week that goes by without at least one difficult day. But he only has the pain in the morning as far as I can tell, and the rest of the day he is fine.
• Previous episodes
• Not before last spring.
• Radiation
• Not that I know of.
• Alleviating factors
• Nothing seems to influence it at all. It is really frustrating for me as a father, trying to figure out how to help.
• Aggravating factors
• Well he does not have it on the weekends, so I guess school mornings make it worse.
• Associated symptoms
• It is really strange, but I notice that he soils his underwear a couple times a week, too, almost like he forgot to go to the bathroom or made it too late. It smells bad, and I am worried the other kids will notice and he will get bullied or lose friends.
  • Frequency
  • This week it happened on 3 days! And it has been like that for about 3 weeks now. Before that it would only happen about once a month. It started around the same time as the belly pain.
  • Diarrhea
  • Well, his stools have always been more liquid than solid, I would say, but he only goes once a day.
  • Constipation
  • No.
  • Color
  • Light yellow; . And it smells really bad too.
  • Blood
  • No.

Review of systems specific to chronic pediatric abdominal pain

• Fever
• No.
• Vomiting
• Last spring he had about 3 days of feeling sick to his stomach. He had a fever and felt really rotten.
• Rash/skin changes
• Actually, he seems awfully pale to me, but then again, it is winter.
• Crying/irritable
• Just this whining when he climbs stairs and has to walk more than a couple of blocks. He is not a little kid anymore, but he complains like a toddler when we are out walking around town.
• Urinary problems/bedwetting
• No.
• Sleep problems
• No.
• Activity (playful)
• Well, he has felt really tired lately, now that you mention it. Going up the stairs to our apartment he has started crying a few times and wanted a break. He never did that before.
• How does the issue affect the child
• He seems more irritable now. I do not remember him being like this before all these symptoms started.
• How does the issue affect the parent
• Well I am feeling frustrated about it. My wife moved out, so I am a single parent, and getting him off to school in time for me to get to the office has become really difficult.
• Punishment for symptoms
• No, but I have gotten angry about it and snapped at him.
• Reward for symptoms
• Well I let him stay home sometimes because he seems really upset.

Past medical history, family history, and social history

• Past medical history
• None.
• Past surgical history
• No.
• Previous hospitalizations
• No.
• Prenatal history
• My wife had a normal pregnancy and birth at the hospital.
• Allergies
• No.
• Medications
• No.
• Ill contacts
• Lice and chicken pox are going around at school right now.
• Family history
• I have a peanut allergy.
• Immunizations
• They are up-to-date.
• Growth and Development
• Everything has been normal.
• Daycare
• He has been going to school since the fall, when he started first grade.
  • Problems in school/grades
  • He seems happy; and his performance has been good so far.
• Eating habits
• He eats everything. His favorite food is pizza.
• Appetite
• It has been great.
• Last checkup
• We were at the doctor for a checkup before he started school, and everything was fine.

Not available in telephone cases.

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's and caregiver's names.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the caregiver).
• Examinee showed interest in the patient and the caregiver as persons (i.e., appeared caring and showed respect).
• Examinee demonstrated ability to support the caregiver's emotions (i.e., offered words of support, asked for clarification).
• Examinee discussed initial diagnostic impressions with the caregiver.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the caregiver's agreement with the next diagnostic steps.
• Examinee asked for concerns or questions.

Counseling and challenge

• Examinee reacted appropriately to challenge.

Suggested response to challenge: “Mr. Morris, I can understand your frustration. The symptoms your son has have been going on for quite some time now, and nothing you do seems to help, which puts you as a caregiver in a difficult and even frightening position. You did the right thing in calling me. You can support him right now by keeping calm when the belly pain and accidents occur. I would also recommend bringing him in for a few tests so we can look for a physiological cause of his symptoms such as a food intolerance. After we get the test results back, we can discuss what steps we can take to help him get better. Do you have any other questions?”

Patient note

Differential diagnoses

1. Celiac disease: This child presents with persistent abdominal pain and steatorrhea, which are symptoms of celiac disease, the most likely diagnosis in this case. His pallor and fatigue are likely symptoms of iron-deficiency anemia, a common manifestation of celiac disease that is due to malabsorption of iron in the intestinal tract.
2. Separation anxiety disorder: Separation anxiety disorder is characterized by fear, anxiety, or avoidance of separation from major attachment figures. This child is asking to stay home from school several mornings every week, and symptoms began around the same time as the child's mother moved out of the house, both of which would support a diagnosis of separation anxiety disorder. This patient's normal growth and development would be in line with a psychiatric disorder, and encopresis and the patient's abdominal pain could be psychological in origin. However, his steatorrhea, pallor, and fatigue are physical symptoms that are likely to have a physiological cause.

Diagnostic studies

• Physical examination: Always note physical examination as part of the workup in a telephone case.
• IgA (anti‑)tissue transglutaminase antibodies (tTG): the gold standard for diagnosing celiac disease; also used for following up post-diagnosis and gluten-free diet
• Quantitative IgA: IgA deficiency is relatively common (approx. 3% of patients) and can result in false negative tTG results. In patients with quantitatively low IgA, IgG-deamidated gliadin peptide (DGP) can be used to test for celiac disease instead of tTG.
• CBC, MCV, MCH: Low hemoglobin is a criterion for anemia. Hypochromic, microcytic anemia would suggest iron deficiency anemia.
• Pediatric allergy IgE panel: Ruling out other dietary allergens (despite no association of the symptoms with the consumption of certain foods) is important in this case, since there is a family history of food allergy.

In telephone cases, physical examination is not possible. Leave the “physical examination” section blank in your patient notes.

Other differential diagnoses to consider

• Food allergy (allergic enteritis)
• Cystic fibrosis
• Malabsorption
• Pancreatic insufficiency
• Other anxiety disorders (e.g., generalized anxiety disorder, social anxiety disorder)