27: 8-year-old female with abdominal pain

Question 1

Functional abdominal pain generally can be diagnosed correctly by the primary care clinician in children 4 to 18 years of age with chronic abdominal pain, without the requirement of additional diagnostic evaluation, when:

Answer 1

• There are no alarming symptoms or signs
• The physical examination is normal, and
• The stool sample tests are negative for occult blood.

Question 2

For the pediatric patient with abdominal pain, there are several concerning symptoms or signs that indicate the need for further evaluation. These symptoms or signs include, but are not limited to:

Answer 2

Involuntary weight loss 
Deceleration of linear growth 
Gastrointestinal blood loss 
Significant vomiting
Chronic severe diarrhea
Persistent right upper or right lower quadrant pain 
Unexplained fever
Family history of inflammatory bowel disease Abnormal or unexplained physical findings

Question 3

most common cause of microcytic anemia in children

Answer 3

iron deficiency

Question 4

Red flags are raised to the possibility of Crohn’s disease when a child with abdominal pain experiences any of the following:

Answer 4

• Pain that awakens the child at night
• Pain that can be localized
• Involuntary weight loss or growth deceleration
• Extraintestinal symptoms (e.g., fever, rash, joint pain, aphthous ulcers, or dysuria)
• Sleepiness after attacks of pain
• Positive family history of inflammatory bowel disease (although only positive in about 30% of patients)
• Abnormal labs such as guaiac-positive stool, anemia, high platelet count, high ESR, hypoalbuminemia
• Abnormalities in bowel function (e.g., diarrhea, constipation, incontinence)
• Vomiting
• Dysuria

Question 5

Clinical history that can point one in the direction of disease severity in Crohn’s is shown below:

Answer 5

Number of diarrheal stools per day
Daily abdominal pain ratings
Ratings of well being
Presence of other symptoms or findings related to Crohn's disease 
Abdominal fullness/palpable mass
Hematocrit
Height growth velocity 
Weight

Question 6

“PQRST, AAA” may be useful in remembering the specific qualities or characteristics to ask the patient (or caregiver) about:

Answer 6

P=Position
Q=Quality
R=Radiation
S=Severity
T=Timing
A=Alleviating factors A=Aggravating factors A=Associated symptoms

Question 7

Laboratory Evaluation of Abdominal Pain and Bloody Stools

Answer 7

• CBC
• ESR
• LFTs
• IgA tissue tranglutaminase Ab (TTG)
• stool O&P
• stool culture

Question 8

Ulcerative colitis

Answer 8

• In UC, relatively generalized inflammation is confined to the mucosa, starting in the rectum and involving a variable extent of colon proximally.
• Crypt abscesses are common.
• Rarely, patients may have discontinuous inflammation at diagnosis or even relative rectal sparing.
• Over the course of the illness, however, the inflammation becomes more confluent.

Question 9

Crohn’s

Answer 9

• -The inflammation associated with CD may involve any portion of the alimentary tract, from mouth to anus.
• -Mucosal inflammation may become more generalized or remain patchy and may extend gradually into the submucosa, muscularis, and serosa.
• -Transmural inflammation can result in fistula formation.

Question 10

Differential Diagnosis of Abdominal Pain and Bloody Stools

Answer 10

• IBD
• Celiac disease
• bacterial gastroenteritis
• Giardiasis
• PUD
• HSP

Question 11

An 11-year-old male comes to the clinic with a chief complaint of abdominal pain for three months. The pain is not associated with eating. Sometimes he feels full and nauseated, along with the pain, but then it resolves on its own. He denies diarrhea, vomiting, and bloody stools. His mother is primarily concerned because his abdominal pains cause him to miss school quite often now. ROS is otherwise negative and the only pertinent issue is his pain. When you evaluate his growth curves, he is progressing at the 60th percentile for height and weight and you do not notice a change since birth. Through a social history you ascertain that he is quite intelligent and has recently been advanced to 7th grade from 5th grade. Vital signs are within normal limits for his age and physical exam (including rectal and genital) are unremarkable. Stool sample was sent in anticipation of today’s visit and was negative for occult blood. What is the most likely cause for his abdominal pain?

Answer 11

Functional abdominal pain would be the most likely diagnosis in this setting at this time. History in this setting is not suggestive of any other diagnosis directly causing his abdominal pain, except a change in his social setting. For better understanding of the nature of this child’s pain, it would be best to talk to him alone, without his mother present, to determine if he is having trouble adjusting to school and to assess whether he has a stable home environment. His pain is chronic, with no other symptoms (diarrhea, bloody stools, growth failure), making a functional issue most likely.

Question 12

8-year-old Jenny presents complaining of intermittent, crampy abdominal pain that has persisted over the last three months. The pain is nonspecific, nonfocal, and not associated with any other systemic symptoms such as fever, chills, weight loss, nausea, vomiting or diarrhea. The pain also seems to occur more frequently during the week and not as often on weekends. The abdominal exam is normal. Jenny is given a diagnosis of functional abdominal pain and scheduled for a one-month follow-up. Six months later, she returns to the clinic complaining of more frequent, more severe abdominal pain that is waking her up at night. She also reports a week of diarrhea containing mucus and blood without associated fever or vomiting. Review of her growth chart demonstrates a slowing of weight gain and a drop in height velocity. What is the most likely diagnosis?

Answer 12

Crohn’s disease is most consistent with this presentation, as it affects GI tract from mouth to anus, leading to abdominal pain, diarrhea (can be bloody), vomiting, or weight loss. Extraintestinal symptoms include skin rashes, arthritis, and fatigue. Fever, fistula, and perianal complications are also common

Question 13

Kenny is a 12 year-old male who comes to your clinic with a chief complaint of crampy abdominal pain. His mother tells you that sometimes he wakes up from sleep due to the pain. He also has diarrhea that sometimes has blood in it. When asked about stressors in his life, his mother sighs and tells you that she is recently divorced and had to move Kenny to a new school. On physical exam, he appears small for his age. Abdomen is soft, non-distended, but tender to palpation at the RUQ. On rectal exam, you note anal skin tags and an anal fistula. Skin exam shows red tender nodules on his shins. Labs show a microcytic anemia. What is the next best step in management?

Answer 13

Colonoscopy is the best answer. Kenny likely has IBD (Crohn’s disease or ulcerative colitis [UC]). He has crampy abdominal pain and intermittently bloody diarrhea, crampy abdominal pain (that wakes him up at night), perianal disease, and erythema nodosum. He also has microcytic anemia, likely from chronic blood loss. Colonoscopy with biopsies will allow you to diagnose Crohn’s disease (or UC) prior to treating it. The diagnosis begins with a colonoscopy to obtain tissue biopsies as well as blood tests (p-ANCA, ASCA).