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July 17, 2009

Aches and Pains

Question from Fayetteville, Tennessee, USA:

My son will soon turn 15. He was diagnosed with type 1 diabetes about five and a half years ago. What could make him have severe stomach cramps? We have been at a restaurant and the smell of food has made his stomach ache and we've had to go to the car. Sometimes smells (any and all) make his stomach ache. Getting too hot will have the same effect on him. He has had friends over and would get a cramp that lasts several minutes! This pain takes his breath and he said that it feels like someone has hit him in his stomach. The pain is below his rib cage, just above his navel. My son has had several tests done, endoscopy and barium, to name a few. I don't know what to do. My son will lie down on a heating pad, take a warm tub soak, just about anything to relieve the pain. He has tried different medications, but nothing helps! I am at wits' end. As a mom, it breaks my heart not to be able to help him. What do you suggest we do?

Answer:

Your descriptions sounds very frustrating to you and your son (and probably his doctors). Although you did not mention the specific duration of the cramps, I gather that they last a long time, longer than “several minutes,” given that he has no relief after time spent with a heating pad, etc.

I presume that your son has been seen by a pediatric gastroenterologist.

I also would want to know about your son’s bowel movement patterns (especially as how they may relate to these cramping episodes). Is there nausea or vomiting? What has his weight been doing? Does he take any medication (besides his insulin) on a regular basis?

It would be difficult to link your teenage son’s cramping abdominal pain (following exposures to odors) to his diabetes. Nevertheless, I would suggest that you check his glucose and check for ketones during the “spells” in order to better eliminate a potential link to his diabetes.

Based on your letter, I believe you mean that an upper endoscopy (hopefully with biopsies) was done and did not show peptic ulcers and there was no evidence of celiac disease (which does occur in higher frequency with type 1 diabetes). Was the barium study a barium enema or an upper intestinal study?

Although “common things happen commonly,” you may have to consider some less common conditions. Things that your doctor and pediatric gastroenterologist have probably considered but you should discuss with them include “abdominal migraines” and forms of “porphyria.” If there were no biopsy during the upper endoscopy (or if no upper endoscopy done), then there should be a screen for celiac with tissue transglutaminase antibodies with concurrent measurement of total IgA. In a patient with type 1 diabetes with odd abdominal pain, I might also consider screening for adrenal insufficiency. A lower endoscopy may be next. There are many less common or atypical presentations of conditions that cause abdominal pain.

Might your son be obtaining any “secondary gain” with these cramps? That means, does he benefit in any odd way from having these spells (more attention, avoids school or less pleasant social situations, etc.)? If so, then your doctor should discuss this also.

DS