A 61-year-old woman comes to the office due to 3 months of constipation and pain in the left lower abdomen. The pain is crampy, continuous, and nonradiating and is not affected by bowel movements or meals. The patient reports hard, pelletlike stools and early satiety but no vomiting, hematochezia, melena, or weight changes. The patient does not have a history of chronic constipation. She is postmenopausal and has not had a period in 5 years. Medical history is significant for hypertension. Family history is unremarkable, and the patient does not use tobacco or alcohol. Temperature is 37.5 C (99.5 F), blood pressure is 145/87 mm Hg, pulse is 80/min, and respirations are 12/min. No scleral icterus or palpable lymphadenopathy is present. Cardiopulmonary examination is unremarkable. The abdomen is mildly distended and tender to palpation in the left lower quadrant without rebound or guarding. Rectal examination is unremarkable and negative for fecal occult blood. Colonoscopy results are unremarkable. Which of the following is the best next step in management?

Question

A 61-year-old woman comes to the office due to 3 months of constipation and pain in the left lower abdomen.  The pain is crampy, continuous, and nonradiating and is not affected by bowel movements or meals.  The patient reports hard, pelletlike stools and early satiety but no vomiting, hematochezia, melena, or weight changes.  The patient does not have a history of chronic constipation.  She is postmenopausal and has not had a period in >5 years.  Medical history is significant for hypertension.  Family history is unremarkable, and the patient does not use tobacco or alcohol.  Temperature is 37.5 C (99.5 F), blood pressure is 145/87 mm Hg, pulse is 80/min, and respirations are 12/min.  No scleral icterus or palpable lymphadenopathy is present.  Cardiopulmonary examination is unremarkable.  The abdomen is mildly distended and tender to palpation in the left lower quadrant without rebound or guarding.  Rectal examination is unremarkable and negative for fecal occult blood.  Colonoscopy results are unremarkable.  Which of the following is the best next step in management?

Quizplus · Accepted Answer

11ec25c8_d81c_de09_bc81_8db1a6262e60_MD0003_00 Constipation is common and is often benign, but it can be associated with more concerning etiologies (eg, malignancy). Onset of constipation at an older age (eg, age ≥50), particularly when accompanied by early satiety or pain unrelated to bowel movements (as in this patient), is an alarm feature that should raise suspicion for malignancy. Other alarm features (not seen in this patient) include weight loss, hematochezia, and a family history of malignancy or inflammatory bowel disease. Colon cancer should be ruled out with colonoscopy, as occurred in this case. Given the unremarkable colonoscopy, this patient should be evaluated for ovarian cancer. Ovarian cancer, the second most common gynecologic malignancy in the United States, often presents subacutely with subtle, nonspecific symptoms (eg, lower abdominal pain, bloating, early satiety, constipation). Examination often demonstrates abdominal distension or an adnexal mass but may remain normal until late in the disease course. Because of the vague presentation and high mortality associated with ovarian cancer, pelvic examination and imaging should be considered in older women (eg, postmenopausal, age ≥50) with new-onset abdominal symptoms, particularly in the absence of any other obvious cause (eg, colon cancer). Pelvic ultrasound is inexpensive, rapidly performed, and has high specificity for the detection of malignant sonographic features (eg, thick septations, solid components). (Choice A) Abdominal x-ray can be used to assess stool burden in patients with constipation; however, it cannot detect ovarian cancer and would likely delay the diagnosis. (Choice B) Barium enema is sometimes used to evaluate diverticular disease or polyps. However, this patient has normal colonoscopy results and should undergo pelvic imaging to rule out ovarian cancer. (Choices C, D, and E) Biofeedback therapy and pelvic floor muscle exercises are used to treat dyssynergic defecation, a common cause of functional constipation in the elderly due to the inability to relax pelvic floor muscles during bowel movements. Fiber supplementation is often used to treat constipation-predominant irritable bowel syndrome (IBS). Although both dyssynergic defecation and IBS could be considered if ovarian cancer is ruled out, initiating therapy before performing pelvic imaging may delay the diagnosis, potentially increasing morbidity and mortality. Educational objective: Alarm features for constipation include acute onset at an older age, weight loss, and hematochezia. Ovarian cancer has nonspecific symptoms (eg, lower abdominal pain, bloating, early satiety, constipation). Therefore, older women (eg, postmenopausal, age ≥50) with new-onset abdominal pain and/or concerning gastrointestinal symptoms, ovarian cancer should be considered. References: Symptoms associated with ovarian cancer. (http://www.ncbi.nlm.nih.gov/pubmed/22343227)

A 61-Year-Old Woman Comes to the Office Due to 3