Case 4: Recurrent Abdominal Pain and Vomiting in a 13-year-old Boy

Presentation

A 13-year-old boy presented to the pediatric gastroenterology clinic due to chronic abdominal pain and vomiting. He reported several years of recurrent periumbilical pain, nausea, and vomiting, with increasing frequency during the previous year. Episodes would occur postprandially every 1 to 2 months, primarily in the evenings, and would last for approximately 1 day. Emesis was occasionally bilious, never bloody, and would alleviate his abdominal pain. There was tenderness to palpation during the episodes that resolved when the pain resolved. Review of medical records showed multiple emergency department and outpatient visits, with increasing frequency. The patient had been diagnosed as having cyclic vomiting syndrome by his primary care provider and was managed with ondansetron/cyproheptadine. His medical and family histories were normal. Physical examination findings were normal at the time of the visit. Previous laboratory test results were all within their respective reference ranges and were notably negative for celiac or inflammatory bowel disease. Review of previous imaging was significant for a computed tomographic (CT) scan obtained during a typical episode of pain that did not identify any acute abnormalities but did identify a left paraduodenal hernia (Figs 1–3). This was reported as a congenital abnormality, and no further evaluation was suggested because there was no sign of obstruction or ischemia. An upper gastrointestinal series …