Treatment for Epigastric Pain in an 11-Year-Old with Loose Stools
For this 11-year-old with epigastric pain and loose bowel movements, start with loperamide (2-4 mg up to four times daily) for diarrhea control and an antispasmodic for pain relief, along with dietary modifications and adequate hydration. 1
Immediate Symptom Management
Pain Control
- Provide immediate pain relief with oral NSAIDs (if no contraindications) rather than withholding medication. 2
- Antispasmodics (anticholinergic agents) are effective for epigastric pain, particularly when symptoms worsen with meals, though watch for dry mouth, visual disturbance, and dizziness as common side effects. 1
- Peppermint oil can be effective for global symptoms and abdominal pain, though gastro-esophageal reflux may occur. 1
Diarrhea Control
- Loperamide should be titrated carefully to avoid constipation, bloating, nausea, and abdominal pain as side effects. 1
- For diarrhea-predominant symptoms, consider stool testing for ova and parasites, lactose breath test, and celiac serologies if symptoms persist. 2
First-Line Dietary Modifications
- Start soluble fiber (such as ispaghula/psyllium) at a low dose (3-4 g/day) and gradually increase to avoid bloating; this is effective for global symptoms and abdominal pain. 1
- Avoid insoluble fiber (e.g., wheat bran) as it may exacerbate symptoms. 1
- Focus on regular meals and adequate fluid intake as first-line dietary advice. 1
- Advise regular exercise for all patients with irritable bowel symptoms. 1
Red Flags Requiring Urgent Evaluation
Before initiating symptomatic treatment, assess for:
- Weight loss, fever, vomiting, blood in stool, or urinary symptoms that would require more extensive workup. 2
- Signs of complete intestinal obstruction (distended abdomen, vomiting, absolute constipation) requiring emergency surgical assessment. 3
- Severe underweight status representing profound malnutrition requiring urgent nutritional support. 3
Initial Diagnostic Workup
If symptoms persist beyond initial treatment or red flags are present:
- Complete blood count, erythrocyte sedimentation rate, and stool hemoccult to screen for inflammation and occult bleeding. 2
- Consider fecal calprotectin and colonoscopy if inflammatory bowel disease is suspected. 3
- Symptom monitoring using a diary may help identify triggers to symptom exacerbation. 1
Second-Line Options if First-Line Fails
- Low-dose tricyclic antidepressants (e.g., 10 mg amitriptyline once daily, titrating slowly to 30-50 mg) are effective for global symptoms and abdominal pain when first-line treatments fail. 1
- 5-HT3 receptor antagonists (such as ondansetron, titrated from 4 mg once daily to maximum 8 mg three times daily) are efficacious for diarrhea-predominant symptoms. 1
- A low FODMAP diet can be considered as second-line dietary therapy, but implementation should be supervised by a trained dietitian with gradual reintroduction according to tolerance. 1
Consider Acid Suppression for Epigastric Pain
- Proton pump inhibitors (PPIs) are preferred when epigastric pain is the predominant symptom and may be more efficacious and cost-effective than H2 blockers. 4
- Famotidine (H2 blocker) can be used for symptomatic gastroesophageal reflux disease, with pediatric patients ages 11-15 maintaining gastric pH above 5 for 13.5 ± 1.8 hours at a dose of 0.5 mg/kg. 5
Important Caveats
- Complete symptom resolution is often not achievable; managing patient and family expectations is critical. 1
- Exclude organic disorders that can mimic functional bowel symptoms, such as celiac disease, before settling on a functional diagnosis. 1
- Chronic stress strongly predicts persistence of functional symptoms in children with chronic abdominal pain, so addressing psychosocial factors is essential. 2
- Psychological treatments (cognitive-behavioral therapy, hypnotherapy, stress management) should be considered when symptoms significantly impair quality of life. 1