Chronic and recurrent abdominal pain: SAQ

This girl presents the classic picture of a functional abdominal pain disorder: recurrent central pain over months, clustering with school-related stress and easing on holidays, with a well child, normal growth, and a normal examination. The absence of alarm features and preserved growth allow a positive diagnosis rather than an open-ended search for organic disease. [1]

Question 1 (10 marks)

Describe how you would assess this child to decide whether her pain is functional or organic, and outline the investigations you would arrange. [2]

Take a structured history that characterises the pain by site, timing, radiation, and its relationship to meals and defecation, and then actively screen for alarm features: weight loss or growth faltering, gastrointestinal bleeding, pain that wakes her from sleep, dysphagia, fever, joint or mouth symptoms, and a family history of coeliac disease, inflammatory bowel disease, or peptic ulcer. Give equal weight to the psychosocial history, asking about school attendance, sleep, mood, anxiety, life events, and how the family responds to the pain. Examine her fully, plot growth, assess pubertal stage, and inspect the abdomen and perianal area. A well child with normal growth, a normal examination, and no alarm features has a functional disorder by positive diagnosis. [2]

Investigation should be targeted rather than exhaustive, because over-testing reinforces illness behaviour and rarely changes the diagnosis. A reasonable first-line screen includes a full blood count, C-reactive protein and erythrocyte sedimentation rate, coeliac serology with total immunoglobulin A, and a urinalysis, with faecal calprotectin if inflammatory bowel disease is a concern and stool studies if the history suggests infection. Second-line tests such as ultrasound, endoscopy, or colonoscopy are reserved for children with alarm features or an abnormal screen. Normal results in this well child support a confident functional diagnosis. [2]

Question 2 (10 marks)

Assuming her investigations are normal, describe your management and how you would counsel her mother. [3]

Begin with a positive diagnosis and a clear biopsychosocial explanation. Tell the family that the pain is real, that it arises from an oversensitive gut-brain connection rather than damage, that serious disease has been sensibly excluded, and that the goal is to restore normal function while symptoms settle. Emphasise that a graded return to school and activity is part of the treatment, not something to wait for, and that improvement is usually gradual. This explanation and reassurance is itself therapeutic and often reduces symptom severity. [3]

Add lifestyle and dietary measures such as regular meals, adequate fibre and fluid, good sleep, treatment of any constipation, and time-limited, dietitian-supervised dietary trials if indicated. Where symptoms persist or disability is significant, offer psychological therapy, because cognitive behavioural therapy and gut-directed hypnotherapy have the strongest evidence and directly treat the brain-gut mechanism. Reserve pharmacology for severe or refractory cases, using it alongside these measures, and arrange regular, function-focused review with clear safety-netting to re-assess if new alarm features or a changed pain pattern emerge. [3]