Recurrent Abdominal Pain

Abstract

Matthew is a 7-year-old, white boy who has experienced crampy, periumbilical, abdominal pain almost daily for the past 2 months. The symptom had not changed his activity level, appetite, or general behavior, so his mother did not make an earlier appointment for an evaluation. A very bright, articulate, and charming child, Matthew has been successful in school and in sports and has several close friends; the belly aches have not altered any of these activities. He denies constipation, diarrhea, nausea, vomiting, dysuria, urinary frequency, trauma, or headaches., Matthew's birth history and developmental course were uneventful. Described by his mother as a calm baby, he was her first child, and she seemed to enjoy nurturing him. An emergency room visit at 2 years of age for a simple chin laceration, a few episodes of reactive airway disease associated with viral illnesses, and an occasional bout with otitis media was the extent of his medical history. A comment in the chart at his 5-year health supervision visit was noted: “Bright and verbal child—inquisitive—enjoys drawing and play with friends—new sibling past year/appears to have adjusted well.”, Family history was negative for gastrointestinal disorders, such as peptic ulcer, inflammatory bowel disease, food intolerance, or irritable bowel syndrome. The parents both worked and were successful in their jobs, and there was no financial stress or marital discord. Matthew, his younger brother, and his parents spent weekends together as a family., When asked to describe the pain, he pointed to the periumbilical region and said it was “like the cramps—achy.” It lasted from 5 to 30 minutes, occasionally several hours. The pain never radiated, never awakened him at night, and was not accompanied by other symptoms. Lying down or sitting quietly usually resolved the pain., Physical examination was normal, including a blood pressure determination, growth measurements, and a digital rectal examination. A mental status and neurodevelopmental screening test were normal. Matthew's family drawing (completed while waiting in the office) revealed visual-motor skills and an active imagination, appropriate for his age and gender. Signs of anxiety or depression were not observed. The following laboratory studies were performed, all with normal results: Complete blood count, erythrocyte sedimentation rate, urinalysis, and a stool examination for ova and parasites and occult blood., At the initial visit and before the laboratory studies, the pediatrician emphasized the normal physical examination findings and the absence of associated symptoms that might suggest a specific cause for his pain. A brief discussion about the connection between “feelings and tummy aches” was initiated. A drawing of a transverse section of the intestinal tract was used to show Matthew how the smooth muscle lining constricts and dilates in response to the signals from the brain. Strong feelings, such as anger or sadness, could “change the tightness” of these muscles, causing pain. It was suggested that sometimes kids with belly aches may feel pain when they are really feeling a strong emotion. Matthew listened attentively and asked a few questions about the illustration of the intestinal tract. Empirical dietary recommendations were written down: Limit dairy products, increase fiber and fresh fruits. A follow-up appointment was made for 2 weeks., At the next visit, the abdominal pain pattern and frequency had not changed; it was neither worse nor improved. The pediatrician then interviewed the mother alone to explore the family constellation further. This 10-minute interview did not reveal any new information; she was given an opportunity to share her concern about her son. The family was emotionally healthy, and Matthew's school performance and social development were on track. Periodic sibling rivalries with his 5-year-old brother were at times troublesome but were manageable and not out of the ordinary., Matthew was then interviewed alone. When asked why he thought he experienced the pain, he said, “I guess some kids just get it. I don't know why.” An assessment of Matthew's affect and interpersonal interactions did not suggest either anxiety or depression., Matthew's pain persisted over the next month. An antispasmodic and antacid did not provide relief. Other symptoms did not surface, and a repeat physical examination was normal. © 1995, Lippincott-Raven Publishers. All Rights Reserved.