A 16-year-old girl is brought to the office due to abdominal pain over the last 4 months. The patient does not eat lunch due to the intermittent, periumbilical pain that recurs nearly every day, typically beginning mid-morning and lasting 2-3 hours. The patient is an honors student and has missed several days of school due to the pain; she is worried that she will lose weight and not have enough energy for gymnastics practices. She passes 1 or 2 soft stools daily, which does not relieve the pain. The patient has had no associated bloating, flatulence, vomiting, or changes in bowel patterns. Height, weight, and BMI are at the 25th percentile, unchanged from last year. Temperature is 36.7 C (98 F), blood pressure is 110/70 mm Hg, and pulse is 80/min. The patient is alert and appears well. The abdomen has normal bowel sounds and is soft and nontender with no palpable masses. No rebound or guarding is noted. Stool is negative for occult blood. Which of the following is the best next step in evaluation of this patient's abdominal pain?

Question

A 16-year-old girl is brought to the office due to abdominal pain over the last 4 months.  The patient does not eat lunch due to the intermittent, periumbilical pain that recurs nearly every day, typically beginning mid-morning and lasting 2-3 hours.  The patient is an honors student and has missed several days of school due to the pain; she is worried that she will lose weight and not have enough energy for gymnastics practices.  She passes 1 or 2 soft stools daily, which does not relieve the pain.  The patient has had no associated bloating, flatulence, vomiting, or changes in bowel patterns.  Height, weight, and BMI are at the 25th percentile, unchanged from last year.  Temperature is 36.7 C (98 F), blood pressure is 110/70 mm Hg, and pulse is 80/min.  The patient is alert and appears well.  The abdomen has normal bowel sounds and is soft and nontender with no palpable masses.  No rebound or guarding is noted.  Stool is negative for occult blood.  Which of the following is the best next step in evaluation of this patient's abdominal pain?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf33_1880_8f63_f139bd0d428a_MD0005_00 Functional abdominal pain refers to abdominal pain with no identifiable organic pathology and is the most common cause of chronic (≥2 months) abdominal pain in children and adolescents. The pain is often poorly localized or periumbilical and self-resolves within a few hours. History reveals no significant vomiting, diarrhea, or weight loss. Abdominal examination is typically normal with no tenderness or hepatosplenomegaly. The first step in management is documenting the pain pattern through a symptom diary. This is helpful to both families and providers to better characterize the pain (eg, timing, location, severity, exacerbating/relieving factors) and guide treatment (eg, avoiding triggers, symptomatic relief). Reassurance and acknowledgment that the patient's abdominal pain is real and distressing is an essential part of both management and establishment of a therapeutic relationship. A stool guaiac should be obtained to exclude intestinal bleeding. However, further laboratory and imaging studies (eg, abdominal ultrasound) are not recommended unless disease-specific findings are present, such as postprandial pain in peptic ulcer disease or perianal ulcer in inflammatory bowel disease (Choice A). (Choice B) Stool antigen testing for Helicobacter pylori may aid in the diagnosis of peptic ulcer disease, which typically presents with postprandial epigastric pain and early satiety. This patient's symptoms are not temporally related to eating. (Choice D) Tissue transglutaminase antibody is positive in celiac disease, an immune-mediated gluten sensitivity that causes chronic abdominal pain, diarrhea, and weight loss. Celiac disease is unlikely in this patient with normal stools and growth. (Choice E) Upper gastrointestinal series is warranted in patients with bilious emesis to detect small bowel obstruction. This patient has no associated vomiting. Educational objective: Functional abdominal pain is a common cause of chronic abdominal pain in adolescents. Patients have a normal examination and no concerning findings on history (eg, weight loss, vomiting). A symptom diary is recommended to characterize the pain and guide treatment. References: Functional disorders: children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/27144632)

A 16-Year-Old Girl Is Brought to the Office Due to Abdominal