A 34-year-old woman comes to the physician with complaints of abdominal pain, bloating, and cramping for the past year. Her bowel movements fluctuate between constipation for several days and then 3-4 loose bowel movements in a single day. She often awakens at night with abdominal cramps followed by diarrhea and cannot fall back to sleep for hours. Her symptoms are significantly affecting her life, and she says that stress at work may be the cause. The symptoms are not exacerbated by any particular food and her appetite fluctuates. The patient does not have weight loss, blood in the stool, or a poor energy level. She has no medical problems and takes a daily multivitamin. She does not use tobacco, alcohol, or illicit drugs.
Her blood pressure is 100/52 mm Hg, pulse is 60/min, and respirations are 12/min. Her BMI is 22 kg/m². Examination shows moist mucous membranes. The abdomen is nontender without hepatosplenomegaly. Rectal examination shows normal rectal tone and brown stool in the rectal vault that is guaiac negative.
Laboratory results are as follows:

Which of the following is the most appropriate next step in management of this patient?

Question

A 34-year-old woman comes to the physician with complaints of abdominal pain, bloating, and cramping for the past year. Her bowel movements fluctuate between constipation for several days and then 3-4 loose bowel movements in a single day. She often awakens at night with abdominal cramps followed by diarrhea and cannot fall back to sleep for hours. Her symptoms are significantly affecting her life, and she says that stress at work may be the cause. The symptoms are not exacerbated by any particular food and her appetite fluctuates. The patient does not have weight loss, blood in the stool, or a poor energy level. She has no medical problems and takes a daily multivitamin. She does not use tobacco, alcohol, or illicit drugs.
Her blood pressure is 100/52 mm Hg, pulse is 60/min, and respirations are 12/min. Her BMI is 22 kg/m². Examination shows moist mucous membranes. The abdomen is nontender without hepatosplenomegaly. Rectal examination shows normal rectal tone and brown stool in the rectal vault that is guaiac negative.
Laboratory results are as follows:

Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9808_2195_853d_69a83515707b_MD0002_00 Irritable bowel syndrome (IBS) is the most common gastrointestinal diagnosis in North America, with a prevalence of 10%-15%. IBS presents more commonly in younger women as chronic, crampy abdominal pain with alternating episodes of constipation and diarrhea that improve the pain. It is further sub-classified as diarrhea predominant, constipation predominant, or mixed. IBS can also present with nonspecific symptoms such as gastroesophageal reflux, dysphagia, early satiety, and chest pain. Warning signs/symptoms such as rectal bleeding, nocturnal or worsening abdominal pain, weight loss, and abnormal laboratory studies (eg, anemia) usually do not suggest IBS and require further investigation to rule out other etiologies. IBS treatment is usually dependent on the patient's symptoms and specific subtype. This patient's nocturnal diarrhea and laboratory abnormalities (anemia and hypokalemia) are concerning for other etiologies and require further diagnostic evaluation with imaging studies and colonoscopy (Choice D). (Choices B, C, and E) Low-dose tricyclic antidepressants can relieve global IBS symptoms, lubiprostone would improve constipation-predominant IBS, and rifaximin would improve diarrhea-predominant IBS. However, this patient's symptoms require further evaluation to rule out other causes. Educational objective: Irritable bowel syndrome (IBS) usually presents with chronic abdominal pain with alternating episodes of constipation and diarrhea. Warning signs/symptoms (eg, nocturnal or worsening abdominal pain, weight loss, rectal bleeding, and laboratory abnormalities) do not usually suggest IBS and require prompt investigation to rule out other etiologies. Underlying celiac disease is commonly misdiagnosed as irritable bowel disease. __________ References: Irritable bowel syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/21872090)

A 34-Year-Old Woman Comes to the Physician with Complaints of Abdominal