A 34-year-old woman comes to the physician with daily crampy abdominal pain for the last 2 years. The pain sometimes occurs after meals but is not always preceded by eating. It is often accompanied by passage of small, loose stools and mucus, after which she feels significantly better. The patient reports that these symptoms interfere with her daily activities, including work. She has no fever, weight loss, or blood in her stools. She takes over-the-counter medications for gas and constipation. Her mother died of colon cancer at age 65. Which of the following is the most likely finding on further evaluation of this patient?

Question

A 34-year-old woman comes to the physician with daily crampy abdominal pain for the last 2 years.  The pain sometimes occurs after meals but is not always preceded by eating.  It is often accompanied by passage of small, loose stools and mucus, after which she feels significantly better.  The patient reports that these symptoms interfere with her daily activities, including work.  She has no fever, weight loss, or blood in her stools.  She takes over-the-counter medications for gas and constipation.  Her mother died of colon cancer at age 65.  Which of the following is the most likely finding on further evaluation of this patient?

Quizplus · Accepted Answer

11ec25c8_d3f6_b35c_bc81_091e07478e09_MD0003_00 This patient most likely has irritable bowel syndrome (IBS), a functional disorder of the gastrointestinal tract (with no identifiable organic cause). It is the most common gastrointestinal diagnosis in North America, with a prevalence of 10%-15%. IBS presents most commonly in young women as chronic, crampy abdominal pain with alternating episodes of constipation and diarrhea. Passage of stool often relieves the pain. It can also present with nonspecific symptoms such as gastroesophageal reflux, dysphagia, early satiety, and chest pain. IBS is further subclassified as diarrhea-predominant, constipation-predominant, or mixed. IBS was previously considered a diagnosis of exclusion. However, patients with IBS symptoms based on the ROME III criteria, no alarm features, and no family history of inflammatory bowel disease or colorectal cancer do not require extensive workup. Colonoscopy performed on IBS patients typically shows normal colonic mucosa. Warning signs/symptoms such as rectal bleeding, nocturnal or worsening abdominal pain, weight loss, and abnormal laboratory studies (eg, anemia, elevated inflammatory markers) do not suggest IBS. These require further investigation to rule out other etiologies. (Choice A) Crypt abscesses are characteristic for ulcerative colitis, which presents with fever, colicky abdominal pain, chronic diarrhea with bloody stool, and weight loss. (Choice B) A duodenal ulcer typically presents with epigastric pain, gastrointestinal bleeding, and anemia. It is not a common cause of diarrhea. (Choice C) Folic acid deficiency can occur due to poor dietary intake, alcoholism, increased demand (eg, pregnancy), or as a medication side effect. It does not usually cause abdominal pain and diarrhea. (Choice D) Intestinal villous atrophy is the hallmark of celiac disease, an autoimmune disease resulting in gluten intolerance. Classic presentation includes gastrointestinal distress (eg, diarrhea, abdominal distension), malabsorption, and nutritional deficiencies. Atypical presentation includes minor abdominal complaints, iron deficiency anemia, increased transaminases, arthritis, or neurologic symptoms. Symptoms are strongly correlated to dietary intake of gluten-containing foods. (Choice F) Perianal fistulas suggest possible Crohn's disease. These patients typically have abdominal pain, weight loss, and extraintestinal manifestations (eg, arthritis, skin disorders, nephrolithiasis). Educational objective: Irritable bowel syndrome is a functional disorder of the gastrointestinal tract characterized by chronic abdominal pain with diarrhea and/or constipation. Patients with symptoms consistent with the ROME III criteria and no alarm features do not require extensive workup for diagnosis. References: Irritable bowel syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/21872090)

A 34-Year-Old Woman Comes to the Physician with Daily Crampy