A Case Of Irritable Bowel Syndrome

A 52-year-old woman complains of abdominal pain, bloating, and constipation. Her symptoms started about 5 years ago and became more bothersome within the last 6 months. She describes a dull pain in the left lower abdomen. This pain is alleviated by passing gas or having a bowel movement. The pain is generally related to eating, and she has had intermittent diarrhea and constipation with constipation predominating. Two years ago, she underwent a screening colonoscopy, which was completely normal.
Her review of systems is notable for a weight gain of about 5 pounds within the last 3 years. She is taking only amultivitamin daily.
Her physical examination is normal.

Which is the best next step?
A) Defecogram.
B) Barium enema.
C) Anorectal manometry.
D) TSH level.
E) Colonoscopy.

Answer:



The correct answer is “D.” The patient’s presentation with pain and constipation meets criteria for constipation-predominant irritable bowel syndrome (IBS) .
This patient underwent colonoscopy for screening 2 years prior to presentation; so further evaluation for colon cancer (“B”and “E”) can be delayed unless there is another indication.
Secondary causes of constipation, such as hypothyroidism, medication side effects or hypercalcemia, should be ruled out as appropriate. Therefore, a TSH level should be obtained prior to deciding on additional diagnostic or therapeutic steps.
At this point in time, anorectal manometry and defecogram are unnecessarily invasive procedures, and neither will help you to determine if this patient has IBS.

ROME III CRITERIA FOR IRRITABLE BOWEL SYNDROME
Continuous or recurrent abdominal pain or discomfort, at least 3 days per month in the last 3 months, with symptoms starting at least 6 months prior to diagnosis, and associated with at least 2 of the
following:

• Relief with defecation
• Change in stool frequency
• Change in stool form