Title:Abdominal Pain

A 31 year old woman has a 6 year history of abdominal pain and bloating. She has had an
irregular bowel habit with periods of increased bowel actions up to four times a day and periods of
constipation. Opening her bowels tends to relieve the pain which has been present in both iliac fossae
at different times. She had similar problems around the age of 17 years which led to time off school.
She thinks that her pains are made worse after eating citrus fruits and after some vegetables and wheat.
She has tried to exclude these from her diet with some temporary relief but overall there has been no
change in the symptoms over the 6 years. One year previously she was seen in a gastroenterology clinic
and had a sigmoidoscopy which was normal. She found the procedure very uncomfortable and
developed similar symptoms of abdominal pain during the procedure. She is anxious about the
continuing pain but is not keen to have a further endoscopy.
She has a history of occasional episodes of headache which have been diagnosed as migraine and has
irregular periods with troublesome period pains but no other relevant medical history. She is a non-
smoker who does not drink alcohol. Her paternal grandmother died of carcinoma of the colon aged 64
years. Her parents are alive and well. She works as a secretary.

Subjective

PI:
 31 year old woman

Chief Complain:

HPI (History of Present Illness):

 She has had an irregular bowel habit with periods of increased bowel actions up to four times a
day and periods of constipation.
 She had similar problems around the age of 17 years which led to time off school.
 One year previously she was seen in a gastroenterology clinic and had a sigmoidoscopy which
was normal. She found the procedure very uncomfortable and developed similar symptoms of
abdominal pain during the procedure.

PMH(Past Medical History):

 She has a history of occasional episodes of headache which have been diagnosed as migraine and
has irregular periods with troublesome period pains but no other relevant medical history.

Family History:
 Her paternal grandmother died of carcinoma of the colon aged 64 years. Her parents are alive and
well.

Social History:
 She works as a secretary
 She is a non-smoker who does not drink alcohol.

Objective
Laboratory Findings:
Normal
Haemoglobin 11.9 g/dL 11.7–15.7 g/dL

Mean corpuscular volume (MCV) 84 fL 80–99 fL

White cell count 5.3 % 109/L 3.5–11.0 % 109/L

Platelets 244 % 109/L 150–440 % 109/L

Erythrocyte sedimentation rate 8 mm/h <10 mm/h

(ESR)

Sodium 138 mmol/L 135–145 mmol/L

Potassium 4.4 mmol/L 3.5–5.0 mmol/L

Urea 4.2 mmol/L 2.5–6.7 mmol/L

Creatinine 89&mol/L 70–120&mol/L

Glucose 4.6 mmol/L 4.0–6.0 mmol/L

 Examination of the cardiovascular and respiratory systems is normal. She has a palpable,
rather tender colon in the left iliac fossa.

Assessment

 The pattern of the pain, the absence of physical signs, normal investigations and reproduction of
the pain during sigmoidoscopy all make it likely that this is irritable bowel syndrome (IBS).

-This is a very common condition accounting for a large number of referrals to gastroenterology
clinics. IBS is often episodic ( having symptom-free periods that alternate with the presence of
symptoms), with variable periods of relapse and remission. Periods of frequent defaecation alternate
with periods of relative constipation. Relapses are often associated with periods of stress.
-In IBS it is common to have a history of other conditions such as migraine and menstrual
irregularity.Under the age of 40 years with a history of 6 years of similar problems, it would be
reasonable to accept the diagnosis and reassure the patient.
-However, the family history of carcinoma of the colon raises the possibility of a condition such as
familial polyposis coli. The family history, the circumstances of the grandmother’s death and the
patient’s feelings about this should be explored further.

 Anxiety about the family history might contribute to the patient’s own symptoms or her
presentation at this time. If there are living family members with polyposis coli, DNA probing
may be used to identify family members at high risk. If any doubt remains in this woman it would
be sensible to proceed to a barium enema or a colonoscopy to rule out any significant problems.

Plan
The diagnosis of IBS relies on the exclusion of other significant conditions such as inflammatory bowel
disease, diverticular disease or large-bowel malignancy. In patients under the age of 40 years it is
usually reasonable to do this on the basis of the history, examination and a normal full blood count and
ESR. In older patients, sigmoidoscopy and barium enema or colonoscopy should be performed. A plan
of investigation and management should be clearly established. The symptoms tend to be persistent and
are not helped by repeated normal investigations looking for an underlying cause. Symptoms may be
helped by antispasmodic drugs or tricyclic antidepressants. Some patients will benefit from the
consumption of a high-fibre diet.

Irritable bowel syndrome is a common disorder and difficult to treat.

• Explanation of the condition to the patient is an important part of the management.
• Sigmoidoscopy(examination of the sigmoid colon by means of a flexible tube inserted through the
anus) with air insufflation often reproduces the symptoms of IBS.

I’ll suggest her to avoid

 High-gas foods (carbonated, alcoholic beverages and certain foods that may lead to increased
gas)
 gluten (wheat, barley and rye)
 FODMAP - fermentable oligosaccharides, disaccharides, monosaccharides and polyols.
FODMAP- carbohydrates (fructose, fructans, lactose)
- found in certain grains, vegetables, fruits and dairy products.

Medications specially for IBS

 Alosetron(Lotronex)
-relax the colon and slow the movement of waste through the lower bowel.
 -can be prescribed only by doctors enrolled in a special program, it is intended for severe
cases of diarrhea-predominant IBS in woemen who haven’t responded to other treatments (isn’t
approved for use by men).
-should only be considered when other treatments aren’t successful.

 Eluxadoline(Viberzi)
-can ease diarrhea by reducing muscle contractions and fluid secretion in the intestine, and
increasing muscle tone in the rectum.
-side effects (nausea, abdominal pain and mild constipation)

 Rifaximin(Xifaxan)
-antibiotic, can decrease bacterial growth and diarrhea.

 Lubiprostone(Amitiza)
-can increase fluid secretion in your small intestine to help with the passage of stool.
-approved for women who have IBS with constipation, and is generally prescribed only for
women with severe symptoms that haven’t responded to other treatments.

 Linaclotide(Linzess)
-can increase fluid secretion in your small intestiine to help pass stool.
-can cause diarrhea, but taking the medication 30 to 60 minutes before eating might help.