Thomas, an 8-year-old boy with a mild to moderate intellectual disability, was brought into the emergency room (ER) by his parents after his abdominal pain of the past several weeks had worsened over the prior 24 hours. His parents reported that he had developed constipation, with only one bowel movement in the past week, and that he had vomited earlier in the day. Teachers at his special education classroom for children with intellectual disabilities had written a report earlier in the week indicating that Thomas had been having difficulties since soon after transferring from a similar school in Florida about 4 months earlier. The teachers and parents agreed that Thomas often looked distressed, rocking, crying, and clutching his stomach.
One week earlier, a pediatrician had diagnosed an acute exacerbation of chronic constipation. Use of a recommended over-the-counter laxative did not help, and Thomas began to complain of nighttime pain. The discomfort led to a diminished interest in his favorite hobbies, which were video games and sports. Instead, he tended to stay in his room, playing with army men figurines that he had inherited from his grandfather's collection. Aside from episodes of irritability and tearfulness, he was generally doing well in school, both in the classroom and on the playground. When not complaining of stomachaches, Thomas ate well and maintained his position at about the 40th percentile for height and weight on the growth curve.
Thomas's past medical history was significant for constipation and stomachaches, as well as intermittent headaches. All of these symptoms had worsened several months earlier, after the family moved from a house in semirural Florida into an old walk-up apartment in a large urban city. He shared a room with his younger brother (age 6 years), the product of a normal, unexpected pregnancy, who was enrolled in a regular education class at the local public school. Thomas said his brother was his "best friend." Thomas was adopted at birth, and nothing was known of his biological parents except that they were teenagers unable to care for the child.
On medical examination in the ER, Thomas was a well-groomed boy sitting on his mother's lap. He was crying and irritable and refused to speak to the examiner. Instead, he would repeat to his parents that his stomach hurt. On physical examination, he was afebrile and had stable vital signs. His physical examination was remarkable only for general abdominal tenderness, although he was difficult to assess because he cried uncontrollably through most of the exam.
An abdominal X ray revealed multiple small metallic particles throughout the gastrointestinal tract, initially suspected to be ingested high-lead paint flakes, as well as three 2-centimeter-long metallic objects in his stomach. A blood lead level was 20 μg/dL (whereas normal level for children is < 5 μg/dL). More specific questioning revealed that Thomas, being constipated, often spent long stretches on the toilet by himself. His parents added that although the bathroom was in the process of being renovated, its paint was old and peeling. Consultants decided that the larger foreign bodies in the stomach might not safely pass and could be accounting for the constipation. Endoscopy successfully extricated three antique toy soldiers from Thomas's stomach.
QUESTION: Which disorder in the Feeding and Eating Disorders category is the best fit for Thomas' symptoms?
