Key Feature 7a: In a patient with chronic or recurrent abdominal pain: Ensure adequate follow-up to monitor new or changing symptoms or signs.
Skill: Clinical reasoning
Key Feature 7b: In a patient with chronic or recurrent abdominal pain: Manage symptomatically with medication and lifestyle modification (ex: for irritable bowel syndrome).
Skill: Clinical reasoning, Communication
Let's return one more time to the case of the 13 year old female who presented to the office with abdominal pain. In my assessment of her pain I applied a broad differential diagnosis to thinking about what could be going on: She described a recurrent pattern of this pain over the past month or so, maybe once a week, but this new episode started this same morning, so I had to keep both chronic and acute causes on my differential. I also needed to keep the differential for pediatric abdominal pain at the forefront, given differences in incidence and prevalence of diseases in pediatric compared to adult populations. This patient was otherwise well, but if she had been previously diagnosed with a chronic disease that can manifest with abdominal pain, I would've needed to consider an exacerbation of that disease as a possible contributor to the pain as well. As a female who was now postmenarchal, I needed to consider the possibility of gynecological causes of pain, including the possibility of pregnancy. Given the details of the account her pain story, and her localisation of pain in her abdomen as generalised rather than localised to the lower abdominal area, my suspicion for gynecological etiologies, and pregnancy in particular, was low. Given this diminutive pretest probability, and the fact that she appeared well on general physical examination, I deferred performing a pelvic exam. As I clinically worked through my differential, finding facts on history and exam to make my suspicion of different etiologies more or less pronounced, I arrived at my working diagnosis, which was constipation.*
Now constipation in and of itself is not a diagnosis, but rather a symptom, and it is important to address the underlying reason(s) for this. Given this patient's history and physical exam, my working diagnosis was functional constipation rather than constipation secondary to an organic etiology. The management for this centres on patient education and recommendations for behavioural and specific dietary interventions, and so we chatted and came to a shared understanding of lifestyle modifications that could be realistically adopted by this patient. No investigations needed to be ordered, at least not yet. In the setting of constipation that is seemingly functional and without alarm features, lifestyle changes are the first-line intervention. But this also means that as a clinician I must arrange followup to assess whether or not the intervention was successful, and to further intervene and possibly investigate if indicated. According to the UpToDate article Constipation in infants and children: Evaluation (2017), "Organic causes are responsible for fewer than 5 percent of children with constipation." Given her clinical assessment, this patient was unlikely to be in that 5%, but not definitively so. With any disease presentation, it is important to keep the possible worrisome diagnoses it could represent in your mind, to be able to counsel patient on associated symptoms to watch for. Sometimes serious diseases first present in a benign way, and only the passage of time and development of more serious symptoms or signs will provide information that declares them.
My general approach to the closing any patient encounter, including followup recommendations, is as follows:
For the patient with constipation, I explained that her presentation was in keeping with a diagnosis of functional constipation. I asked what she knew about this and explained what it means (not a default diagnosis, but actually having criteria that she met). I explained that it was a clinical diagnosis, which was great because it meant we wouldn't have to wait for the results of any investigations before starting treatment. I presented that the most evidence-based treatment for this diagnosis is lifestyle modifications, specifically by increasing physical activity and consumption of dietary fibre and water. We discussed what she thought she could do to get more physical activity and what sorts of foods she could see herself eating to increase the fibre intake. I gave her a number for how many grams of fibre in a day to shoot for, to help her get a sense of just how much fibre is recommended**, and explained what the expected benefits (decreased constipation), risks and how to mitigate them (increasing fibre quickly can cause bloating, so I recommended she go up gradually in her daily consumption of fibre), and logistics (taking time to think about packing her lunch differently for school, for example) of these lifestyle interventions would be. If these changes were to be effective, we would likely see a benefit in 2 weeks or so, so we planned for follow up then. I also warned her that if she develops worsening or new symptoms not to hesitate to make an appointment sooner. (There was nothing I was seriously worried about in her case to provide more specific anticipatory advice.) I then provided a handout on Constipation in Children as published by UpToDate and said that I looked forward to seeing how she would be doing at the follow-up appointment :)
*You may be thinking, but what about irritable bowel syndrome?? Let's explore that a little bit. Like functional constipation, irritable bowel syndrome is also a functional disease in that there is no organic findings of disease on physical exam or investigations. (The best way I've heard someone explain functional disease is to use a headache for analogy. We can see evidence of a headache on physical exam, nor are there any tests we can use to prove that it is there, but we certainly experience the pain as real regardless. It is not just "in one's head.") Sometimes patient's may seem to have what could be considered functional constipation and irritable bowel syndrome, at least if they have the IBC-C (for constipation) subtype. But the diagnostic criteria are different, and patients will fall into one or the other. This is has important ramifications, as labelling a patient with a particular diagnosis sticks to their medical chart like superglue, and more importantly it affects their understanding of their body and what they need to do to keep it functioning. So what are the diagnostic criteria for functional constipation and irritable bowel syndrome?
Rome IV criteria for functional constipation
Rome IV criteria for irritable bowel syndrome
**A general rule of thumb: For children 2 years and older, take the age and add 5-10 for the number of grams of daily fibre to incorporate in the diet. For example, a 13 year old patient would be advised to consume between 18-23 g of fibre daily. Once people reach adulthood, the rule of thumb is to aim for 20-35 g per day.