Your 3:30 appointment is a 10-year-old boy, whom you’ve never met, with a chief complaint of “stomach pain.” You head to the exam room knowing this may be a 5-minute visit, but fearing that it may be a 45-minute visit.
Your patient is quietly sitting on the exam table in no distress playing a game console, and for a moment you think this may be easy. Then you get the history.
For the past 2 to 3 years, this young man has been plagued with repeated midline stomach pains, which (once he turns off his game) he describes as dull and achy. The pain is associated with nausea and usually vomiting. The vomitus is non-bloody, non-bilious. He denies diarrhea or other stool changes. He has a normal appetite between bouts, but has no appetite when he is in pain. He denies increased belching or sour brash. The pain is bad enough for him to miss school. His mother adds that he looks “drained” when he is ill.
He saw one of your partners several months ago who referred him to a gastroenterologist.
His work up has included CBC and differential, sedimentation rate, liver function tests, electrolytes, amylase and lipase, stool guaiac, urinalysis, a workup for celiac disease, and Mono and Hepatitis screens—all normal. He has had an upper GI with small-bowel follow through, a barium study, an abdominal ultrasound, endoscopy and a colonoscopy—again all normal.
His mother is frustrated and sure it must be some kind of cancer.
What do you think might be going on here, and what are you going to do?