Medical Mystery | What caused a teenager to writhe with abdominal pain?

A 13-year-old boy who had off-and-on abdominal pain for months came to the emergency room after his condition grew so severe, he was crying and writhing. He also felt nauseated and was barely eating. The triage nurse whisked him to a treatment room to be evaluated by the doctor right away.

The doctor immediately considered causes that would require urgent surgery, such as appendicitis. But the boy’s entire abdomen hurt. His pain was not worse in the right lower abdomen, making appendicitis unlikely. It was also not worse in the right upper abdomen, which would have suggested gallstones or infection of the gallbladder. Twisting of a testicle (testicular torsion) can present with abdominal pain and nausea, but the doctor examined him and found no trouble there, either.

Next, the doctor considered intestinal infections or inflammation, like gastroenteritis or inflammatory bowel disease. But the patient did not have fever, diarrhea, or vomiting, as such conditions might produce. What’s more, blood tests showed that the markers of infection and inflammation (white blood cell count, erythrocyte sedimentation rate, and C-reactive protein) were all normal.

The doctor next asked the patient about his bowel movements, a topic that clearly embarrassed the boy but could provide important clues about abdominal pain.

As it turned out, the teen had bowel movements no more than twice a week. And the few he had were so dry and hard, they caused rectal bleeding.

With that information, the doctor ordered an abdominal x-ray. The teen’s colon was larger than normal because it was so packed with stool.

The colon or large intestine is the last part of the intestine, through which digested food travels. At the end of the colon is the rectum, where stool is stored prior to a bowel movement.

This patient had so much stool that it had backed up through the colon and caused the walls of the colon to stretch. The doctor made the diagnosis of severe constipation. But how did the patient become so constipated?

The reason became clear when the doctor started asking questions about how things were going at school. The teen had just started ninth grade at a new school, and though it was challenging to make new friends, he was happy to be out of middle school.

The doctor asked why middle school was so bad, and learned his patient was badly bullied by boys threatening to take videos of him using the bathroom. So the teen avoided using the toilet at school, a habit that continued in high school.

The doctor explained that resisting the urge to use the toilet created a vicious cycle. Stool would build up and stretch the walls of his colon. Ignoring the urge made it harder to have a bowel movement later. The pain he experienced when passing the hard stools caused him to withhold even more. He also minimized the fluids he was drinking so he rarely even had to urinate, and dehydration made the stools even harder.

The doctor told the teen and his mother that the only way to reset his system would be to get rid of the built-up stool. After the patient received an enema (insertion of fluid directly into the rectum), he was started on polyethylene glycol to bulk up the stool, soften it, and make it easier to pass. He was also given a medication called senna to stimulate his intestines to push the stool out. To prevent further constipation, he also was encouraged to eat a high fiber diet, drink more water, and exercise daily.

The severity of the patient’s pain was unusual, but children avoiding school bathrooms for a variety of reasons is not. Though many parents think children are successful at school if their grades are good, they also should regularly talk with their children about how others treat them, and whether they feel safe in and out of school. Teachers, coaches, and health care providers all need to remind children that it is not acceptable for anyone to make them feel uncomfortable or unsafe. And if they do, they should always tell a trusted adult immediately.

Samantha Starkey is a pediatric resident and Rima Himelstein is an adolescent medicine specialist at Nemours Children’s Hospital in Delaware.