MEDizzy - A 29-year-old woman comes to see you in the clinic because

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A 29-year-old woman comes to see you in the clinic because of abdominal discomfort. She feels abdominal discomfort on most days of the week, and the pain varies in location and intensity. She notes constipation as well as diarrhea, but diarrhea predominates. Compared to 6 months ago, she has more bloating and flatulence than she has had before. She identifies eating and stress as aggravating factors, and her pain is relieved by defecation. You suspect irritable bowel syndrome. Laboratory data include: WBC count 8000/μL, hematocrit 32%, platelets 210,000/μL, and erythrocyte sedimentation rate (ESR) 44 mm/hr. Stool studies show the presence of lactoferrin but no blood. Which intervention is appropriate at this time?

ExplanationAlthough this patient has signs and symptoms consistent with IBS, the diferential diagnosis is large. Few tests are required for patients who have typical IBS symptoms and no alarm features. In this patient, alarm features include anemia, an elevated erythrocyte sedimentation rate, and evidence of white blood cells in the stool. Alarm features warrant further investigation to rule out other GI disorders such as colonic pathology including diverticular disease or IBD. In this case, colonoscopy to evaluate for luminal lesions and mucosal characteristics would be the logical frst step. At this point, with the warning signs, empiric therapy for IBS is premature. Reassurance, stool-bulking agents, and antidepressants are all therapies to consider if a patient does indeed have IBS.