An 18-year-old woman comes to the office due to constipation. For as long as she can remember, she has had hard, lumpy bowel movements that have been difficult to pass without straining. There are periods in which the patient goes several days without defecating, although other times she passes 2 or 3 stools a day. She also reports intermittent left lower quadrant abdominal cramps that usually improve after passing stool. The patient has had no fevers, night sweats, hematochezia, melena, vomiting, or unexpected weight loss. Family history is significant for breast cancer. She does not use tobacco, alcohol, or illicit drugs. Temperature is 37.6 C (99.7 F), blood pressure is 125/76 mm Hg, pulse is 85/min, and respirations are 12/min. The patient is not in acute distress. Heart and lung sounds are unremarkable. The abdomen is mildly tender to palpation in the left lower quadrant but without distension or guarding. Laboratory results are as follows: Which of the following is the best next step in management of this patient?

Question

An 18-year-old woman comes to the office due to constipation.  For as long as she can remember, she has had hard, lumpy bowel movements that have been difficult to pass without straining.  There are periods in which the patient goes several days without defecating, although other times she passes 2 or 3 stools a day.  She also reports intermittent left lower quadrant abdominal cramps that usually improve after passing stool.  The patient has had no fevers, night sweats, hematochezia, melena, vomiting, or unexpected weight loss.  Family history is significant for breast cancer.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.6 C (99.7 F), blood pressure is 125/76 mm Hg, pulse is 85/min, and respirations are 12/min.  The patient is not in acute distress.  Heart and lung sounds are unremarkable.  The abdomen is mildly tender to palpation in the left lower quadrant but without distension or guarding.  Laboratory results are as follows:  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d270_d751_bc81_c38a4d0c1534_MD0003_00 This patient has irritable bowel syndrome (IBS), which is characterized by recurrent abdominal pain typically related to or relieved by defecation and associated with changes in stool frequency or form. IBS can be subclassified as either constipation predominant (IBS-C, as in this patient), diarrhea predominant (IBS-D), or mixed (ie, both constipation and diarrhea). Other common symptoms include bloating, flatulence, nausea, and passage of mucus in the stool. IBS is most frequently diagnosed in young women, and psychiatric comorbidities (eg, anxiety, depression) are common. The diagnosis is made clinically; laboratory abnormalities (eg, anemia, elevated inflammatory markers) or other alarm features (see table) are unexpected and should prompt evaluation for alternative diagnoses. Management of IBS includes reassurance and dietary modification. For IBS-C, fiber supplementation improves constipation and may reduce abdominal pain. IBS-D is usually treated with antidiarrheal agents such as loperamide. (Choice A) Patients with IBS-D should be screened for celiac disease because both disorders may present with abdominal pain, diarrhea, and bloating; screening is not indicated in IBS-C. IBS-D is characterized by a predominance of loose and frequent stools, which is not the case in this patient. (Choice B) Colonoscopy is recommended in patients with alarm features to evaluate for malignancy or inflammatory bowel disease. This young patient has classic symptoms of IBS, and colonoscopy is unnecessary. (Choice C) An abdominal and pelvic CT scan is used to diagnose patients with features suspicious for diverticulitis (ie, left lower quadrant abdominal pain, fever, leukocytosis), malignancy (eg, weight loss, older age), or chronic pancreatitis (eg, steatorrhea, postprandial abdominal pain). Imaging is not required in patients with IBS without alarm features. (Choice D) Fecal calprotectin testing can be used to identify inflammatory causes of diarrhea (eg, infection, inflammatory bowel disease) and may be of value in patients who have fever, leukocytosis, bleeding, or nocturnal diarrhea. (Choice F) Although tricyclic antidepressants are effective for IBS-related abdominal pain, they are associated with side effects (eg, drowsiness, dry mouth) and should be reserved for those who fail to respond to more benign alternatives such as fiber supplementation. Educational objective: Irritable bowel syndrome is characterized by recurrent abdominal pain related to defecation and changes in stool frequency or form. Management includes reassurance, dietary modification, and fiber supplementation (in constipation-predominant disease) or antidiarrheal agents (in diarrhea-predominant disease). References: American Gastroenterological Association medical position statement on constipation. (http://www.ncbi.nlm.nih.gov/pubmed/23261064) AGA clinical practice guidelines on the laboratory evaluation of functional diarrhea and diarrhea-predominant irritable bowel syndrome in adults (IBS-D). (http://www.ncbi.nlm.nih.gov/pubmed/31302098)

An 18-Year-Old Woman Comes to the Office Due to Constipation