A 32-year-old woman comes to the office for evaluation of intermittent abdominal cramps and diarrhea for the past several years, which are increasing in frequency. Her bowel movements alternate between solid stools and 3 or 4 episodes of watery diarrhea per day, often containing mucus. The diarrhea is frequently preceded by lower abdominal cramps that improve after defecation. The patient also reports an occasional bloating sensation and nausea but has had no fevers, night sweats, hematochezia, melena, vomiting, or weight loss. There are no specific food triggers. Medical history is notable for anxiety during her college years and she takes no medications. Her father was diagnosed with colon cancer at age 62. She smokes 4 or 5 cigarettes daily and drinks alcohol on social occasions. Temperature is 36.9 C (98.4 F), blood pressure is 128/82 mm Hg, pulse is 74/min, and there are no orthostatic changes. On physical examination, the patient is well-appearing with no scleral icterus, and the mucous membranes are pink and moist. There are no oral lesions. Lungs are clear on auscultation and heart sounds are normal. The abdomen is nondistended and soft with mild lower quadrant tenderness on deep palpation. There is no hepatosplenomegaly and bowel sounds are normal. No extremity edema or skin rashes are present. Laboratory testing shows the following. Serum IgA and antitissue transglutaminase levels are within normal limits. Which of the following is the most appropriate next step in management of this patient?

Question

A 32-year-old woman comes to the office for evaluation of intermittent abdominal cramps and diarrhea for the past several years, which are increasing in frequency.  Her bowel movements alternate between solid stools and 3 or 4 episodes of watery diarrhea per day, often containing mucus.  The diarrhea is frequently preceded by lower abdominal cramps that improve after defecation.  The patient also reports an occasional bloating sensation and nausea but has had no fevers, night sweats, hematochezia, melena, vomiting, or weight loss.  There are no specific food triggers.  Medical history is notable for anxiety during her college years and she takes no medications.  Her father was diagnosed with colon cancer at age 62.  She smokes 4 or 5 cigarettes daily and drinks alcohol on social occasions.  Temperature is 36.9 C (98.4 F), blood pressure is 128/82 mm Hg, pulse is 74/min, and there are no orthostatic changes.  On physical examination, the patient is well-appearing with no scleral icterus, and the mucous membranes are pink and moist.  There are no oral lesions.  Lungs are clear on auscultation and heart sounds are normal.  The abdomen is nondistended and soft with mild lower quadrant tenderness on deep palpation.  There is no hepatosplenomegaly and bowel sounds are normal.  No extremity edema or skin rashes are present.  Laboratory testing shows the following.  Serum IgA and antitissue transglutaminase levels are within normal limits.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d3f7_ebdf_bc81_2b0acb5864a2_MD0003_00 This patient most likely has irritable bowel syndrome (IBS), a functional disorder characterized by recurrent abdominal pain and altered bowel habits (eg, diarrhea, constipation) with symptoms that worsen (or improve) with bowel movements. Other common symptoms include bloating, flatulence, nausea, passage of mucus, and tenesmus. The etiology is poorly understood but likely involves visceral hypersensitivity and abnormal gastrointestinal motility. It occurs most commonly in younger women (age <50) and is associated with fibromyalgia, depression, and anxiety. IBS is a clinical diagnosis; the workup is directed at excluding organic disease and typically includes a complete blood count, inflammatory markers (eg, erythrocyte sedimentation rate, fecal calprotectin), and, in patients (such as this one) with diarrhea-predominant disease, celiac serologies (eg, serum IgA and antitissue transglutaminase levels). Further testing is not required unless alarm features are present that suggest an alternate diagnosis. These include older age of onset (age >50), gastrointestinal bleeding, nocturnal diarrhea, unintended weight loss, iron deficiency anemia, elevated inflammatory markers, or a family history of early colon cancer. This patient describes typical symptoms of IBS without alarm features and does not require further testing. (Choice A) A CT scan is indicated in patients with alarm features concerning for malignancy (eg, weight loss, older age) or chronic pancreatitis (eg, epigastric pain worse with eating, steatorrhea). (Choice B) Although this patient's father had colon cancer, it was not diagnosed early (age <50) and therefore is not considered an alarm feature. Colon cancer also typically presents with weight loss, iron deficiency anemia, or gastrointestinal bleeding. In addition, although inflammatory bowel disease (IBD) (eg, Crohn) can cause cramping and diarrhea, the absence of anemia, the normal inflammatory marker (eg, erythrocyte sedimentation level), and the years of symptoms make IBD unlikely. (Choice C) Fecal fat testing can be useful in the evaluation of fat malabsorption and steatorrhea. However, this patient does not present with steatorrhea, which would be characterized by greasy, bulky, foul-smelling stools that are difficult to flush. (Choice D) Jejunal aspiration can be used to diagnose small intestinal bacterial overgrowth, which causes bloating and chronic diarrhea but typically occurs in patients with risk factors (eg, scleroderma, intestinal dysmotility, abnormal anatomy). This woman's presentation is more consistent with IBS. (Choice F) Urea breath testing is used to diagnose Helicobacter pylori, which can cause dyspepsia and abdominal discomfort; however, chronic diarrhea is unexpected. Educational objective: Irritable bowel syndrome is characterized by recurrent abdominal pain and altered bowel habits (eg, diarrhea, constipation) and symptoms that worsen (or improve) with bowel movements. Further workup is not typically required unless alarm features are present, which include older age of onset, gastrointestinal bleeding, nocturnal diarrhea, unintended weight loss, iron deficiency anemia, elevated inflammatory markers, or a family history of early colon cancer. References: Bowel disorders. (http://www.ncbi.nlm.nih.gov/pubmed/27144627)

A 32-Year-Old Woman Comes to the Office for Evaluation of Intermittent