Functional abdominal pain and irritable bowel syndrome: SAQ

This girl fits the Rome IV picture of irritable bowel syndrome: recurrent abdominal pain relieved by defecation, a change between hard and loose stools, bloating, and a well child with normal growth and examination. The absence of alarm features and preserved growth allow a positive diagnosis, and the mixed stool pattern places her in the IBS-M subtype. [1]

Question 1 (10 marks)

Explain how the Rome IV criteria let you make a positive diagnosis of irritable bowel syndrome in this child, and outline the investigations you would arrange. [2]

Irritable bowel syndrome is diagnosed positively when recurrent abdominal pain is related to defecation and is accompanied by a change in stool form or frequency, present over an adequate period without alarm features. This girl meets that pattern: pain relieved by opening her bowels, stools swinging between hard and loose, and bloating, with a well appearance, normal growth, and a normal examination. Her mixed hard and loose stools make this IBS-M, and the subtype is judged from the abnormal stools using the Bristol stool scale and reassessed over time. Because the pattern is typical and there are no alarm features such as weight loss, rectal bleeding, night waking, or nocturnal diarrhoea, this is a positive diagnosis rather than one reached by exhausting every organic possibility. [1]

Investigation should be targeted. A reasonable first-line screen 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 especially useful here to separate irritable bowel syndrome from inflammatory bowel disease given the diarrhoeal component. Stool studies for giardia are added if the history suggests infection. Endoscopy, colonoscopy, and imaging are reserved for alarm features or an abnormal screen, because over-testing a well child rarely changes the diagnosis and reinforces the search for disease. [2]

Question 2 (10 marks)

Assuming her investigations are normal, describe your management and how you would counsel her parents. [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 irritable bowel syndrome is a genuine but benign disorder that does not turn into cancer or serious bowel disease. Emphasise that a return to normal school and activity is part of the treatment and that improvement is usually gradual. This explanation and reassurance is itself therapeutic. [3]

Add lifestyle and dietary measures tailored to the mixed subtype: regular meals, adequate fibre and fluid, good sleep, treatment of the constipated phases, and a time-limited, dietitian-supervised low-FODMAP trial for ongoing bloating and pain. Where symptoms persist or disability is significant, offer psychological therapy, because gut-directed hypnotherapy and cognitive behavioural therapy have the strongest evidence and directly treat the gut-brain mechanism. Reserve pharmacology such as peppermint oil for troublesome IBS symptoms, use any tricyclic selectively given the large placebo response in trials, and arrange regular function-focused review with clear safety-netting to reassess if new alarm features or nocturnal diarrhoea emerge. [3]