Chronic and recurrent abdominal pain: Viva

Branch 1: History and distinguishing functional from organic pain

The candidate should begin by acknowledging the parents' worry and then take a structured history rather than immediately ordering tests. Characterise the pain by site, timing, and its relationship to meals, defecation, and activity, and note that poorly localised periumbilical pain in a well child is typical of a functional disorder. The key task is to screen actively for alarm features: weight loss or growth faltering, gastrointestinal bleeding, night waking with pain, dysphagia, fever, joint or mouth symptoms, and a family history of coeliac disease or inflammatory bowel disease. [2]

A strong candidate gives equal weight to the psychosocial history, asking about school, sleep, mood, anxiety, and how the family responds to the pain, and frames these questions as routine so the family does not feel accused. If the history is typical, growth is normal, and no alarm features are present, the candidate should be prepared to make a positive functional diagnosis rather than treat it as a diagnosis of exclusion. Recurrent abdominal pain that eases at weekends and on holidays supports a functional origin. [1]

Branch 2: Investigation and the request for a scan

If the examiner presses on the parents' request for a scan and extensive bloods, the candidate should explain that investigation must be targeted, because over-testing in a well child without alarm features rarely changes the diagnosis and can reinforce the search for disease. A reasonable first-line screen includes a full blood count, inflammatory markers, coeliac serology with total immunoglobulin A, and a urinalysis, with faecal calprotectin when inflammatory bowel disease is a concern. [2]

The candidate should justify why an abdominal ultrasound is low-yield in typical central functional pain and is reserved for focal, right-sided, biliary, renal, or gynaecological features. A good answer also names the negative-test spiral: repeated normal investigations can deepen rather than relieve family anxiety, so the correct step after a normal targeted screen is a positive diagnosis and treatment. The candidate must retain a low threshold to re-investigate if the pattern changes or alarm features emerge. [2]

Branch 3: Management and counselling

If asked about management, the candidate should build the plan on a positive diagnosis delivered with a clear biopsychosocial explanation: the pain is real, the gut-brain connection has become oversensitive, serious disease has been sensibly excluded, and the goal is to restore normal function. A graded return to school and activity is part of the treatment. The candidate should describe lifestyle and dietary measures and time-limited, supervised dietary trials where appropriate. [1]

For persistent or disabling symptoms, the candidate should recommend psychological therapy, explaining that cognitive behavioural therapy and gut-directed hypnotherapy have the best evidence and directly treat the brain-gut mechanism rather than implying the pain is imaginary. Pharmacology is reserved for severe or refractory cases and is used alongside these measures. The candidate should finish with function-focused follow-up, school liaison, and clear safety-netting, showing they can pair confident reassurance with ongoing vigilance. [3]