Abdominal pain in a child

Of all kids coming to the emergency department complaining of abdominal pain, plain old constipation is to blame 70% of the time. Just such a kid came into the ED, but it turned out to be much more interesting than constipation.

Talking to Mom, I found out that the girl had been having stomach pains intermittently for over a year, that she could be fine one minute but doubled up in pain the next. These episodes came in clusters, were not associated with school, and were separated by months with the last episode happening several weeks ago. She was indeed previously worked up extensively for her abdominal pain ruling out things like appendicitis, pancreatitis, and celiac disease. In fact, an abdominal x-ray a few weeks ago even ruled out constipation.


The little girl last had a bowel movement earlier in the day, and Mom noted it to be soft without excessive straining required to defecate. She also had two bowel movements the previous day. None of this was pointing toward constipation as the cause of this girl's abdominal pain.

My patient was difficult to talk to. She would hardly look at me. Even when I asked her simple questions like "What's your favorite color?" she would look over to Mom, who professed that her daughter was normally very talkative. Mom was also difficult to talk to: she couldn't get words out of her mouth fast enough, she went off on tangents before eventually answering my questions, and she spent a lot of time unloading all her worries about what might be causing her daughter's abdominal pain.

Within a few minutes of entering the room, and without even touching my patient on exam, I was already pretty confident about my diagnosis. This could be delicate and require some tact.

"Are there any significant psychiatric problems in the family?"

Jackpot. Mom described symptoms in herself highly suggestive of no less than three psychiatric diagnoses, all of them undiagnosed and untreated. She also said that the kid's father is on medications for two psychiatric disorders. Further delving into the social history revealed significant turmoil at home, including an absent father and other significant stressors.

After a thorough exam, I explained to Mom that I ruled out the scary stuff that could be causing her kid's tummy pain. I said that the clinical picture doesn't really fit a physical cause and that I thought it was more likely that her daughter's stress or anxiety might be behind her symptoms.

Brace for impact....

But to my surprise, Mom accepted what I had to say: "You know, that makes so much sense. No one has ever suggested that before!" Encouraged, I then explained to her that it is very common for children to convert emotional or psychological stress into physical symptoms and that this is called conversion disorder.

In hindsight, this child in fact didn't have conversion disorder because the diagnostic criteria for conversion disorder require another non-pain neurologic symptom, which this girl did not have. She probably met diagnostic criteria for chronic pain disorder with psychological factors, the treatment of which is psychotherapy and antidepressants.

I explained to Mom that it is really important that her daughter receive prompt treatment for this problem to decrease the chances of her developing other psychiatric problems such as an anxiety disorder. For what it's worth, she said she would follow up with her daughter's primary care physician for a referral to a child psychiatrist. I really hope that actually happens.