Center for Digestive Health & Nutritional Excellence | Medical Conditions
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Medical Conditions

Abdominal Pain

Abdominal pain is among the most common complaints that present to our office. Abdominal pain varies in character, location, and accompanying symptoms. A careful history will usually reveal “red flags” that warrant a more aggressive intervention.

Case Study: 6 yr old boy with intermittent abdominal pain

A 6-year-old boy is brought to the office with 6 months of episodic belly pain. The mother states that the child complains mostly in the afternoon and evening. The pain usually lasts a few minutes and can be severe. Bowel movements have been irregular. Otherwise, the child is healthy, growing and developing normally, and is in first grade. On examination, vital signs and growth parameters are normal. On questioning the child as to the specific location of her pain, he points to the umbilicus. On deep palpation there is a firm mass in the left lower quadrant; it is non-tender and the abdomen is otherwise soft. The rest of the examination is normal.


Diarrhea is a concerning complaint as it can result in dehydration and poor weight gain. An important measure of hydration is urine output, which should be carefully noted by the parents. Stool tests are important in the evaluation of diarrhea and will help determine the nature of the condition.

Constipation

Up to 25% of all visits to Pediatric Gastroenterologists are for functional constipation. It is important to note that constipation, if left untreated, can result in co-morbid conditions such as fissures, hemorrhoids, and encopresis (inappropriate control of bowel habits).

Case Study: 4-year-old girl with constipation

A 4-year-old girl presents to the office with a history of hard, pellet-like stools that are painful to pass. Mom reports seeing some bright-red blood with the stools. The child has been refusing to use the toilet and has been displaying stool-withholding behavior.


The differential diagnosis of constipation is usually pretty limited and related to stool withholding after an inciting event, such as a cold or viral syndrome, which results in hard stools that are painful to pass. Therapy involves laxatives, dietary changes, and regular toileting.

Diarrhea

Diarrhea is usually categorized into either malabsorptive type (i.e. osmotic) or secretory type (e.g. inflammatory or infectious). Malabsorptive diarrhea implies poor digestion and/or absorptive capacity. Secretory diarrhea implies compromise of the mucosal barrier and active loss of intestinal fluid.

Case Study: 8-year-old with diarrhea

8-year-old girl with a 6-month history of diarrhea and abdominal distention after drinking milk or eating ice cream. The family is of Southeast Asian background and report a strong family history of lactose intolerance. Symptoms seem to resolve with the exclusion of dairy.


Diarrhea is a concerning complaint as it can result in dehydration and poor weight gain. An important measure of hydration is urine output, which should be carefully noted by the parents. Stool tests are important in the evaluation of diarrhea and will help determine the nature of the condition.

Gastroesophageal Reflux

Gastroesophageal reflux (GER) is a very common condition in which stomach contents reflux back up into the esophagus. Gastric contents can be quite corrosive and irritating to the esophageal mucosa and symptoms, such as chest pain, heartburn, and nighttime cough, should not be ignored.

Case Study: 3-month-old with spit-ups

A 3-month-old baby boy presents to the office with his mom reporting significant spit-ups after every meal. Mom has been nursing exclusively and child has been growing and gaining weight normally until recently. Mom now reports fussiness with feeds and reports that he will throw up the majority of the milk up to an hour or two after feeds. His length and head circumference are normal, but his weight gain has slowed down over the past month.


GER is differentiated from GERD (gastroesophageal reflux disease) by the presence of co-morbid conditions such as chronic cough, recurrent ear or sinus infections, dental caries, weight loss in infants, and mucosal changes in adults. GERD is a risk factor for Barrett esophagus and cancer and thus should not be ignored. Medications can help neutralize acid or reduce acid production, promote gastric motility, or promote lower esophageal sphincter (LES) function. Dietary antigens (e.g. cow’s milk protein allergy) can affect gastric motility in infants, with removal resulting in significant improvement. In adults or nursing moms, reducing intake of spicy food, gas-promoting foods, dairy, coffee, and preserved foods may help alleviate symptoms. Other lifestyle measures, such as smoking cessation and weight loss may offer significant relief.

Hepatitis

Hepatitis is a generic term for inflammation of the liver. This can be the result of an infection (e.g. hepatitis A, EBV), an autoimmune process, or due to insulin resistance (a component of the metabolic syndrome).

Case Study: 16-year-old male with elevated liver enzymes

A 16-year-old young man present to the office due to elevated liver enzymes that were noted on a routine lab test. He is moderately overweight and has a strong family history of type 2 diabetes. On exam, his neck and underarm creases show dark, velvety discoloration. Dietary history is revealing of a high-sugar, high-fat diet rich in fast food.


The differential diagnosis of elevated liver enzymes in an adolescent male is broad and includes infectious hepatitis, autoimmune hepatitis, and non-alcoholic steatohepatitis. The strong family history of diabetes and the dark, velvety discoloration on the neck and flexure creases (aka: acanthosis nigricans) are highly suggestive of insulin resistance, a pre-diabetic condition that can result in end-organ damage (e.g. to the liver).

Inflammatory Bowel Disease

Inflammatory bowel disease includes Crohn Disease and Ulcerative Colitis. They are chronic conditions that wax and wane depending on activation of our immune system. Diet and nutritional status, as well as general healthy habit, render great influence on the inflammatory process in the gut.

Case Study: 16-year-old female with intermittent abdominal pain, irregular bowel habits, and weight loss

16-year-old female with a 6-month history of intermittent abdominal pain accompanied by bloating, irregular bowel movements that are periodically loose, and poor appetite that has lead to a 10-pound weight loss. There is no significant past medical or surgical history. The child has also been complaining of elbow and knee pain and has reported sores in her mouth.


The differential diagnosis of abdominal pain is quite extensive, but the presence of weight loss and extraintestinal manifestation, such as join pain and mouth sores, raise the suspicion of an inflammatory process. The gold standard for diagnosis and clinical management is colonoscopy and histological analysis of mucosal biopsies.

Irritable Bowel Syndrome

Irritable bowel syndrome is a very common condition that affects 10-20% of the general population. It presents with abdominal pain and irregular bowel habits (e.g. constipation, diarrhea). Bloating, gassiness, and urgency are accompanying symptoms, which can cause awkward social situations. Therapy is largely dietary, with elimination of certain foods and the addition of fiber, prebiotics, and probiotics. Antibiotics and other medications may offer relief.

Case Study: 19-year-old woman with recurrent abdominal pain

A 19-year-old woman is a first-year college student who has been experiencing recurrent abdominal pain for several years. She reports irregular bowel habits and feeling bloated after meals. She denies weight loss and is otherwise healthy. A colonoscopy performed last year was normal, but she feels debilitated in social situations and seeks further advice.


Irritable bowel syndrome normally responds to dietary modification, by substituting calorically dense and processed food with fiber-rich and whole food. Simple measures, like steaming vegetables and pealing fruit, may help alleviate symptoms. Treatment of bacterial overgrowth in the small intestine may help with gassiness and bloating. Probiotics and prebiotics are helpful in achieving bowel regularity and enhancing digestive function.

Nausea and Vomiting

Nausea and vomiting is controlled by both central and peripheral nervous mechanisms. The brain has a center devoted to nausea and vomiting and receives signals from the enteric nervous system. Bad or contaminated food or poorly prepared food will be rejected through a mechanism that elicits reverse peristaltic force, in order to purge the body of the offending food. Some individuals may have sensitive stomachs, some may be allergic to certain foods, still others will send aberrant signals to the brain.