A 10‑year‑old boy with a 3‑month history of recurrent periumbilical abdominal pain, constipation, loss of appetite, weakness, frequent headaches and vertigo, mild C‑reactive protein elevation, white tongue coating, dolichosigmoid with colon looping on barium enema, bronchial asthma, antibiotic allergy, and current use of ursodeoxycholic acid and pancreatin – what is the most likely diagnosis and recommended management?

Diagnosis and Management of Recurrent Abdominal Pain with Dolichosigmoid in a 10-Year-Old

This child most likely has functional abdominal pain (irritable bowel syndrome with constipation) exacerbated by anatomical dolichosigmoid, and should be managed with aggressive constipation treatment, dietary modification under dietitian supervision, and stress-management education rather than surgical intervention.

Primary Diagnosis

The constellation of periumbilical pain, constipation, and systemic symptoms (headaches, vertigo, weakness, appetite loss) in a 10-year-old represents functional abdominal pain—specifically IBS with constipation (IBS-C)—rather than a primary surgical condition. 1, 2

• Periumbilical location is the hallmark of functional abdominal pain in children and strongly predicts non-organic etiology 2
• The 3-month duration with recurrent episodes fits the diagnostic criteria for functional gastrointestinal disorders 1, 3
• Dolichosigmoid is an anatomical variant, not a disease requiring surgery; it predisposes to constipation but does not cause it in isolation 2
• The white tongue coating and mild CRP elevation likely reflect chronic constipation with possible bacterial overgrowth, not inflammatory bowel disease 3

Critical Exclusions Completed

The workup has appropriately ruled out organic causes that would require different management:

• No anemia excludes inflammatory bowel disease, celiac disease, and chronic blood loss 3
• Mild CRP elevation alone without fever, weight loss, or severe systemic symptoms does not indicate IBD 3
• Barium enema showing only dolichosigmoid without strictures, masses, or mucosal abnormalities excludes structural pathology requiring surgery 2

Why Dolichosigmoid Is Not the Primary Problem

Dolichosigmoid is present in many asymptomatic children and does not independently cause the symptom complex described here. 2

• The systemic symptoms (headaches, vertigo, weakness) are not explained by anatomical redundancy but are classic features of functional abdominal pain with somatization 1, 3
• If dolichosigmoid were the primary cause, surgical resection would be indicated—but outcomes are poor because the underlying motility disorder persists 4
• The colon looping seen on imaging represents a consequence of chronic constipation (colonic distension from stool retention) rather than the cause 2

Evidence-Based Management Strategy

First-Line: Aggressive Constipation Management

Initiate polyethylene glycol (PEG/MiraLAX) 17 grams twice daily as the evidence-based first-line agent for pediatric constipation. 5

• Add scheduled stimulant laxative: senna 2 tablets nightly or bisacodyl 10 mg daily for maintenance 5
• Avoid bulk-forming laxatives (psyllium, methylcellulose) as they are ineffective in functional constipation and may worsen bloating 5
• If no bowel movement within 2-3 days, add bisacodyl suppository 10 mg once or twice daily for distal impaction 5
• Consider magnesium citrate 8 oz once daily if renal function is normal (check basic metabolic panel first) 5

Second-Line: Dietary Intervention Under Supervision

Implement a low-FODMAP diet supervised by a specialized dietitian, as this achieves 70-86% symptom resolution in moderate-to-severe IBS. 6

• This addresses fermentable-carbohydrate intolerance present in ~50% of IBS patients with meal-related worsening 6
• Do not allow unsupervised dietary restriction—this risks nutrient deficiencies and gut microbiota disruption 6
• Low-FODMAP therapy is superior to generic fiber supplementation, which may exacerbate diarrhea and bloating 6

Third-Line: Stress Management and Lifestyle

Educate the family that stress triggers measurable physiological effects on colonic motility via corticotropin-releasing factor pathways—this is not "in the head." 6

• Establish a consistent toileting routine with sufficient time for defecation to regulate bowel patterns 6
• Encourage regular physical activity, which has moderate-quality evidence for reducing IBS symptom burden 6
• Promote sleep hygiene and structured stress-management techniques (relaxation training) 6
• Use a symptom diary to identify personal food and stress triggers 6

Fourth-Line: Pharmacologic Symptom Control

If non-pharmacologic measures are insufficient after 4-6 weeks:

• Antispasmodics (dicyclomine or hyoscyamine) for acute cramping episodes 6
• Low-dose tricyclic antidepressants (amitriptyline 10-25 mg nightly) for persistent abdominal pain when first-line interventions fail 6
• Do not use low-dose TCAs to treat comorbid mood disorders—such doses are inadequate for psychiatric indications; prefer SSRIs for mood management 6

Addressing the Asthma Comorbidity

• Asthma and functional GI disorders frequently coexist due to shared autonomic dysregulation 1
• Ensure asthma is well-controlled, as poorly controlled asthma increases systemic inflammation and may worsen GI symptoms 3
• Review current asthma medications for constipating effects (some bronchodilators can slow GI motility) 3

When to Reassess for Organic Disease

Repeat evaluation is warranted only if alarm features develop: 3

• Fever, persistent vomiting, blood in stool, or more than three alarm symptoms 3
• Weight loss or failure to grow 3
• Localized tenderness (especially right lower quadrant), hepatosplenomegaly, or abdominal mass 3
• Nocturnal symptoms that wake the child from sleep 2

Critical Pitfalls to Avoid

• Do not pursue surgical consultation for dolichosigmoid in the absence of true obstruction, volvulus, or failed maximal medical therapy 2, 4
• Do not dismiss stress-related symptoms as purely psychological—stress exerts real physiological effects on gut function 6
• Do not initiate low-FODMAP diet without dietitian supervision—unsupervised restriction risks nutrient gaps and dysbiosis 6
• Avoid exhaustive additional testing (colonoscopy, CT enterography) in the absence of alarm features, as this delays effective management and reinforces illness behavior 7, 3

Expected Trajectory

Substantial improvement in symptoms and quality of life is achievable with targeted interventions, though complete cure is unlikely. 6

• Reassess in 4-6 weeks to evaluate response to constipation management and dietary modification 3
• If symptoms persist despite optimal medical management for 3-6 months, consider referral for cognitive-behavioral therapy or gut-directed hypnotherapy 6
• Long-term prognosis is excellent: functional abdominal pain does not increase risk of colorectal cancer or mortality 6