All These Gut Feelings: A 10-Year Old With Belly Pain

Today I saw my young adult patient with a distant history of Crohn’s disease and new, chronic abdominal pain. Amitriptyline, 10 mg twice a day, has worked like a charm with no pain remaining, confirming my diagnosis of visceral hyperalgesia.

A few hours later I saw a 10-year old girl who has been to the emergency room several times with belly pain. Her family moved to this area a few months ago and we still don’t have the pediatric gastroenterology records her parents had signed a release for.

This girl has depression, anxiety and maybe more, and quickly established with a mental health provider in the area. She is on several medications. Today’s visit was an emergency room followup with labwork and a CT scan showing nothing abnormal.

Heather will double up with poorly localized belly pain most mornings, many evenings and not infrequently during her school day. The pains start and stop fairly suddenly and can last a couple of hours, sometimes more. Her bowels used to be on the constipated side for most of her life, but someone started her on Miralax and this has helped.

As I talked with Heather and her mother I learned she is often nauseous and pale looking during her attacks. And she sometimes has a very slight headache.

Her mother is on topiramate for migraines. That clinched it for me. I think little Heather has what people call abdominal migraines. I didn’t feel comfortable starting her on topiramate because she’s on the thin side, but as her mother had told me her hay fever wasn’t controlled by cetirizine, cyproheptadine seemed like a good place to start. This lesser known antihistamine is the second choice according to most experts. And for some reason, propranolol is the first choice for abdominal migraines, not topiramate. My thinking was that a nonselective beta blocker might worsen Heather’s depression.

We shall see. Is my gut feeling going to help modify hers? Just like it did for Wanda, who got her diagnosis ten years after I first met her.

The Correct Diagnosis – Ten Years Later

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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