A 20-year-old previously healthy woman comes to the office due to intermittent diarrhea and abdominal pain over the past several months. The patient has had bouts of diarrhea alternating with normal bowel movements, but lately the diarrhea has become more persistent. She reports 4-6 loose brown stools each day, which frequently awaken her at night. The diarrhea is associated with crampy abdominal pain in both lower quadrants that subsides after a bowel movement. Both the pain and the diarrhea frequently occur after eating. There are also days when she feels constipated and passes a small amount of mucus only. The patient has not had hematochezia, melena, or weight changes. There is no family history of gastrointestinal diseases. She does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. Physical examination, including abdominal and rectal examination, shows no abnormalities. Stool testing for occult blood is negative, and blood cell counts and serum chemistry studies are within normal limits. C-reactive protein is normal. Serologic testing for celiac disease is negative. Further testing may be indicated in this patient due to which of the following findings?

Question

A 20-year-old previously healthy woman comes to the office due to intermittent diarrhea and abdominal pain over the past several months.  The patient has had bouts of diarrhea alternating with normal bowel movements, but lately the diarrhea has become more persistent.  She reports 4-6 loose brown stools each day, which frequently awaken her at night.  The diarrhea is associated with crampy abdominal pain in both lower quadrants that subsides after a bowel movement.  Both the pain and the diarrhea frequently occur after eating.  There are also days when she feels constipated and passes a small amount of mucus only.  The patient has not had hematochezia, melena, or weight changes.  There is no family history of gastrointestinal diseases.  She does not use tobacco, alcohol, or illicit drugs.  Vital signs are within normal limits.  Physical examination, including abdominal and rectal examination, shows no abnormalities.  Stool testing for occult blood is negative, and blood cell counts and serum chemistry studies are within normal limits.  C-reactive protein is normal.  Serologic testing for celiac disease is negative.  Further testing may be indicated in this patient due to which of the following findings?

Quizplus · Accepted Answer

11ec25c8_d3f7_4f9d_bc81_350d3b542973_MD0003_00 Irritable bowel syndrome (IBS) is the most common gastrointestinal complaint in the United States. It classically presents with recurrent abdominal pain (eg, once a week for ≥3 months), typically related to (or relieved by) defecation and associated with alternating episodes of diarrhea and constipation. Other common symptoms include abdominal bloating, belching, flatulence, tenesmus, or a mucus discharge with stooling. IBS can be further classified as diarrhea predominant, constipation predominant, or mixed. It most commonly affects young women, and symptoms usually worsen during times of psychosocial stress. Acute gastroenteritis can also induce postinfectious IBS, which may last for months to years. IBS is a clinical diagnosis and management includes a limited workup (eg, complete blood count, serologies for celiac disease, inflammatory markers) and reassurance. However, the presence of alarm features suggests organic disease and requires further evaluation. These features include older age of onset (≥50), gastrointestinal bleeding, nocturnal diarrhea, worsening pain, unintended weight loss, concerning laboratory findings (eg, iron deficiency anemia, elevated C-reactive protein), or a family history of inflammatory bowel disease or early colon cancer. The presence of nocturnal diarrhea suggests secretory diarrhea. Unlike osmotic causes of diarrhea, patients with secretory diarrhea develop symptoms while fasting, often in the middle of the night. Etiologies include chronic infection, microscopic colitis, bile salt diarrhea, or a hormone-secreting tumor (eg, gastrinoma, VIPoma). Appropriate laboratory testing and a colonoscopy should be considered. (Choice A) IBS most commonly affects younger individuals. New-onset IBS in patients age ≥50 is considered an alarm feature that warrants further workup. (Choices B, C, and E) IBS is often episodic with alternating bowel habits and varying bowel movement frequency. Postprandial symptoms are common and likely due an exaggerated gastrocolic reflex. These features are expected and do not require additional testing. Educational objective: The management of irritable bowel syndrome includes limited testing (eg, complete blood count, serologies for celiac disease, inflammatory markers) and reassurance. However, the presence of alarm features requires further workup; these include older age of onset (≥50 years), nocturnal diarrhea, gastrointestinal bleeding, worsening pain, unintended weight loss, abnormal laboratory tests (eg, iron deficiency anemia, elevated inflammatory markers), or a family history of inflammatory bowel disease or early colon cancer. References: Bowel disorders. (http://www.ncbi.nlm.nih.gov/pubmed/27144627)

A 20-Year-Old Previously Healthy Woman Comes to the Office Due