Recurrent Abdominal Pain and Poor Growth in a 10-Year-Old
A 10-year-old girl is referred for evaluation of chronic abdominal pain and poor growth. She has had intermittent periumbilical pain for 6 months, occurring 2–3 times per week, often relieved by defecation. She also reports alternating diarrhea and constipation, and her stools are sometimes described as 'mushy.' She has missed 10 days of school due to pain. Her weight is 28 kg (10th percentile, down from 25th percentile 6 months ago) and height is 135 cm (25th percentile). Physical exam is unremarkable except for mild abdominal tenderness without guarding. Laboratory tests: CBC normal, ESR 25 mm/hr (slightly elevated), CRP normal, celiac serology negative, stool calprotectin 250 µg/g (normal <50).
1. What is the most likely diagnosis, and what further evaluation is needed?
Read the worked answer
The most likely diagnosis is inflammatory bowel disease (IBD), specifically Crohn's disease, given the chronic abdominal pain, altered bowel habits, poor growth, and elevated fecal calprotectin. The normal CBC and only mildly elevated ESR do not rule out IBD. The negative celiac serology makes celiac less likely. Further evaluation should include upper endoscopy and colonoscopy with biopsies to confirm the diagnosis and determine the extent of disease. MR enterography or capsule endoscopy may be used to assess small bowel involvement. The growth failure is a red flag for chronic inflammation. Other considerations include irritable bowel syndrome (but calprotectin is usually normal) and infectious causes (but chronicity makes it less likely). The elevated calprotectin is a sensitive marker for intestinal inflammation.
2. If the endoscopy confirms Crohn's disease with ileocolonic involvement and growth failure, what is the initial therapeutic approach?
Read the worked answer
The initial therapeutic approach should be exclusive enteral nutrition (EEN) for 6–8 weeks to induce remission, especially in a child with growth failure, as it provides nutritional support and mucosal healing without steroid side effects. Alternatively, corticosteroids can be used for rapid induction but may exacerbate growth failure. Anti-TNF therapy (infliximab) should be considered early for moderate-to-severe disease with growth failure, as it is effective and has steroid-sparing effects. Immunomodulators (azathioprine, methotrexate) may be used for maintenance. The choice depends on disease severity, patient preference, and access. Nutritional rehabilitation is crucial. The goal is to induce and maintain remission, promote growth, and prevent complications. A multidisciplinary approach with a gastroenterologist, dietitian, and psychologist is essential.