Functional abdominal pain and irritable bowel syndrome: Case

This girl shows the Rome IV picture of irritable bowel syndrome: recurrent lower abdominal pain eased by defecation, alternating loose and hard stools, bloating, and urgency, in a well child with steady growth and a normal examination. The mixed stool pattern places her in the IBS-M subtype, and the onset after gastroenteritis fits a post-infectious IBS. Her anxiety, the school avoidance, and the parental worry are the psychosocial drivers that management must address. [1]

Clinical findings

The pattern is strongly functional. Pain relieved by opening the bowels with a change in stool form meets the Rome IV criteria for irritable bowel syndrome, and the normal growth and examination make significant organic disease unlikely. The onset after a bout of gastroenteritis supports a post-infectious mechanism, in which transient gut inflammation sensitises the gut-brain axis. The differential still includes coeliac disease and, given the diarrhoeal component, inflammatory bowel disease, which the workup should exclude before the diagnosis is settled. [2]

Investigations and diagnosis

Investigation should be targeted. A reasonable first-line screen here includes a full blood count, C-reactive protein and erythrocyte sedimentation rate, coeliac serology with total immunoglobulin A, a urinalysis, and a faecal calprotectin, which is pivotal in this diarrhoea-mixed presentation to separate irritable bowel syndrome from inflammatory bowel disease. Extensive imaging and colonoscopy are not indicated in a well child without alarm features. With a normal screen and a normal calprotectin, the diagnosis is irritable bowel syndrome, mixed subtype, made positively rather than by exhaustive exclusion and communicated as a definite diagnosis. [2]

Management and outcome

Management begins with a positive diagnosis and a clear biopsychosocial explanation: the pain is real, the gut-brain connection has become oversensitive after the gastroenteritis, serious disease has been excluded, and irritable bowel syndrome is genuine but benign and does not lead to serious bowel disease. A graded return to school is central, supported by liaison with the school and a plan for managing pain during the day rather than sending her home. Lifestyle measures, good sleep, attention to her anxiety, and a time-limited, dietitian-supervised low-FODMAP trial for the bloating and altered stools complete the base of the plan. [3]

Because anxiety and school avoidance are prominent, referral for gut-directed hypnotherapy or cognitive behavioural therapy is appropriate, as both have strong evidence and treat the gut-brain mechanism directly while building coping skills, and hypnotherapy produced durable benefit in a randomised trial. Peppermint oil is a reasonable option for troublesome IBS symptoms. With early positive diagnosis, family engagement, and psychological support, the outlook is good, and most such children improve within months. Function-focused follow-up with clear safety-netting is arranged, with a low threshold to reassess should new alarm features, rectal bleeding, or nocturnal diarrhoea appear. [3]