What are the differential diagnoses for post‑prandial crampy epigastric pain with nausea and a sensation of urinary pressure in a 6‑year‑old girl?

Differential Diagnosis for Post-Prandial Crampy Epigastric Pain in a 6-Year-Old Girl

In a 6-year-old girl with crampy epigastric pain after eating, nausea without vomiting, and sensation of abdominal pressure, the primary differential diagnoses are functional dyspepsia (specifically postprandial distress syndrome), constipation with fecal stasis, eosinophilic esophagitis, and less commonly peptic ulcer disease or gastroenteritis. 1, 2, 3

Age-Appropriate Differential Considerations

Most Likely Diagnoses

Functional Dyspepsia (Postprandial Distress Syndrome)

• The crampy, post-prandial nature of pain with nausea strongly suggests postprandial distress syndrome, which requires bothersome postprandial symptoms at least 3 days per week. 1
• Postprandial epigastric pain, nausea, and bloating are supportive criteria for this diagnosis. 1
• This is the most common cause of epigastric pain in community settings, accounting for the majority of cases after organic disease is excluded (which occurs in less than 1% for malignancy, 8% for peptic ulcer, and 13% for erosive esophagitis). 1
• Female sex is a modest risk factor for dyspepsia. 1

Constipation with Fecal Stasis

• The sensation of abdominal pressure and crampy pain pattern may indicate functional ileus with fecal stasis, which commonly presents with epigastric discomfort in children. 2
• Constipation is one of the most common causes of abdominal pain in school-aged children. 4
• The urinary pressure sensation may reflect mechanical compression from fecal loading. 2

Eosinophilic Esophagitis (EoE)

• Children aged 9-10 years commonly present with abdominal pain as the primary manifestation of EoE, and approximately 8% of children with EoE present with epigastric pain. 3
• Nausea and food-related symptoms are characteristic, and 21% of children with biopsy-proven EoE have normal-appearing esophagus on endoscopy. 3
• This diagnosis requires endoscopic biopsies and cannot be excluded clinically. 3

Less Common but Important Diagnoses

Peptic Ulcer Disease

• While less common in children, peptic ulcer accounts for approximately 8% of dyspepsia cases in population studies. 1
• Post-prandial pain with nausea can occur with both gastric and duodenal ulcers. 5

Gastroenteritis

• Acute viral gastroenteritis commonly causes epigastric pain and nausea in children. 2, 6
• Most cases are self-limited and resolve spontaneously. 7

Irritable Bowel Syndrome

• IBS frequently coexists with functional dyspepsia (42-87% overlap), and epigastric pain, nausea, and early satiety are common. 1
• Urinary symptoms including frequency, urgency, and incomplete bladder emptying are associated non-gastrointestinal symptoms in IBS. 1

Critical Red Flags Requiring Urgent Evaluation

Immediate surgical consultation is needed if any of the following are present:

• Bilious vomiting (indicates potential malrotation or obstruction). 5, 6
• Peritoneal signs: abdominal rigidity, rebound tenderness, or absent bowel sounds (suggests perforation with 30% mortality if delayed). 5
• Vital sign abnormalities: tachycardia ≥110 bpm, fever ≥38°C, or hypotension. 2, 5
• Hematochezia or hematemesis. 5, 6

Other alarm features warranting investigation:

• Persistent vomiting (suggests disorder beyond functional dyspepsia). 1, 5
• Documented weight loss. 5
• Anemia on complete blood count. 5
• Nocturnal symptoms. 1

Diagnostic Approach

Initial Clinical Assessment

History specifics to elicit:

• Duration of symptoms (Rome IV requires 6 months for formal diagnosis, but clinical criteria allow 8 weeks). 1, 3
• Frequency and timing relative to meals (postprandial distress syndrome requires symptoms ≥3 days/week). 1
• Bowel movement patterns to assess for constipation. 2
• Presence of any alarm features listed above. 1, 5
• Associated atopic conditions (increases likelihood of EoE). 3

Physical examination priorities:

• Check vital signs immediately for tachycardia, fever, or hypotension. 2, 5
• Palpate for epigastric tenderness (suggests organic pathology rather than functional disease). 5
• Assess for peritoneal signs: rigidity, rebound tenderness, absent bowel sounds. 5, 6
• Evaluate for signs of constipation with abdominal palpation. 2

Laboratory and Imaging

Initial laboratory tests if organic disease suspected:

• Complete blood count (to assess for anemia). 2, 5
• Urinalysis (to exclude urinary tract infection). 6, 4
• Serum electrolytes, liver and renal function tests if functional ileus suspected. 2

Imaging considerations:

• Ultrasonography is the preferred initial imaging modality in children due to lack of ionizing radiation. 6, 4
• Abdominal radiography can diagnose constipation or obstruction. 4
• CT abdomen with IV contrast is gold standard when diagnosis is unclear (identifies perforation in 97%, fluid/fat stranding in 89%). 5

Endoscopy indications:

• Not immediately indicated unless symptoms persist despite 4 weeks of adequate PPI trial or alarm features are present. 2
• All children undergoing endoscopy for upper GI symptoms should have biopsies taken to diagnose EoE (strong recommendation). 3
• Approximately 70% of children with EoE had previously failed PPI treatment, making endoscopy essential when empirical therapy fails. 3

Management Algorithm

Step 1: Rule Out Emergencies

• Assess vital signs and examine for peritoneal signs immediately. 2, 5
• If any red flags present, obtain urgent surgical consultation. 5, 6

Step 2: Empirical Treatment for Most Likely Diagnoses

For suspected functional dyspepsia:

• Start empirical PPI therapy with omeprazole 1 mg/kg once daily for 4-8 weeks. 2
• Simultaneously test for H. pylori using breath or stool testing (part of "test and treat" strategy). 2

For suspected constipation:

• Osmotic laxatives are the most effective medication for functional constipation in children when used with behavioral interventions. 2
• Maintain adequate fluid intake to support laxative efficacy. 2

For nausea management:

• Ondansetron 0.15 mg/kg (maximum 8 mg per dose) every 4-6 hours reduces vomiting and facilitates oral rehydration. 5
• Obtain baseline ECG before administration due to QTc prolongation risk. 5

Step 3: Reassessment and Escalation

• Reassess at 2-4 weeks to evaluate response to empirical therapy. 2
• If symptoms persist beyond 4-8 weeks despite adequate PPI trial, proceed to endoscopy with biopsies to exclude EoE and other organic pathology. 2, 3

Common Pitfalls to Avoid

• Do not attribute persistent vomiting to functional dyspepsia—this mandates investigation for organic causes including bile reflux or anatomical abnormalities. 1, 5
• Do not assume all epigastric pain is acid-related—consider age-appropriate differentials including EoE, which requires endoscopic biopsies for diagnosis. 2, 3
• Do not rely on endoscopic appearance alone—21% of children with biopsy-proven EoE have macroscopically normal esophagus, making biopsies essential. 3
• Do not delay endoscopy if alarm features develop or symptoms persist despite adequate empirical therapy, as missing serious pathology can lead to poor outcomes. 2, 5