Case studies

Select a case study below for more information

Presentation and diagnosis
Symptom history

22-year-old woman with a 2-year history of abdominal pain and diarrhea

Experiences intermittent episodes of lower abdominal cramping and bloating associated with 4-6 loose bowel movements occurring ~2 days per week

Abdominal pain seems to occur shortly after meals or at times of increased stress, and subsides after a bowel movement

Dietary habits

Drinks coffee daily and likes to chew gum. Regularly eats protein bars and probiotic yoghurts

No obvious triggers for onset of symptoms

Social history

Symptoms first began after breakup with boyfriend

Mild anticipation anxiety around symptoms; no personal history of anxiety or depression

Impact of symptoms on patient’s life

Recently started to reduce activities such as hiking and jogging and worries about the availability of bathrooms

Has not dated for the past 6 months over concerns that fecal urgency may interfere with intimacy

Family history and comorbidities

No family history of any GI disorders or malignancies

Physical examination and laboratory tests

Physical and rectal exam unremarkable

No red-flag symptoms or signs necessitating structural evaluation of the GI tract

CBC and laboratory tests negative for celiac serologies or any other abnormalities

Previous treatments

Took fiber supplements but these did not improve symptoms

Patient expectations

Would like to find out what is causing symptoms and how to get rid of them, and is worried the symptoms could lead to cancer

Differential diagnosis

No red-flag symptoms and no evidence of celiac disease or lactose intolerance

Symptoms meet the diagnostic criteria for an affirmative diagnosis of IBS-D

Management
Patient education and reassurance

As the patient was unable to predict episodes, providing a symptom diary to help identify potential symptom triggers should be considered

Reassure patient that IBS does not lead to cancer or colitis and does not decrease life expectancy

Emphasize that you will work with her to better manage symptoms, acknowledging the impact that the condition has on her day-to-day life

Lifestyle and diet

Patient should be encouraged to reduce her caffeine intake, as it stimulates gut motility, and to avoid chewing gum, as fructose or sorbitol may worsen GI symptoms

As the patient’s symptoms often start after meals, a low-FODMAP diet may potentially be suggested, although as her IBS symptoms are relatively infrequent and this diet is quite restrictive and difficult to maintain, this may not be appropriate at this stage. If the patient is interested in a low-FODMAP diet, a consultation with a registered dietitian may be appropriate

Psychosocial considerations

No significant psychiatric comorbidity warranting further assessment or treatment

Pharmacological management

In this patient with relatively mild and infrequent symptoms, an antispasmodic such as dicyclomine, which blunts the gastrocolonic reflex responsible for the postprandial urge to defecate, may be an appropriate first-line pharmacologic treatment

These agents would be preferably used on an as-needed basis, and potentially taken 30 min before meals to help reduce or prevent postprandial symptoms

Over-the-counter enteric-coated peppermint oil may alternatively be suggested as this may have a beneficial effect on the patient’s symptoms, such as bloating and fecal urgency

Reassessment/follow up

The patient should be reassessed approximately 4-6 weeks after agreeing a management plan

Assess whether reducing caffeine has reduced stool urgency

Assess whether antispasmodic treatment has adequately alleviated abdominal pain and cramping and whether stool consistency has improved

Assess whether the patient’s QoL has improved (e.g. would she now consider dating?)

If patient’s symptoms are not improved, consider alternative options, such as a low-FODMAP diet, rifaximin, or eluxadoline

This case study is for discussion purposes only. This information is not a substitute for clinical judgment. Each healthcare provider is solely responsible for any decisions made or actions taken in reliance of this information

Presentation and diagnosis
Symptom history

45-year-old woman with a 25-year history of recurrent abdominal pain, fecal urgency, and loose stools

Over the past 1-2 years, her GI symptoms have worsened and she now experiences severe abdominal pain and fecal urgency associated with 6-8 loose-to-watery BMs/day, 4-5 days/week

Has experienced a few episodes of fecal incontinence when she could not reach a bathroom in time

Dietary habits

Does not drink alcohol; no other notable dietary habits

Social history

Symptoms have worsened in recent years in conjunction with increased stress in her professional and personal life

Symptom-specific anxiety due to the severity and unpredictability of her symptoms

Exhibits somewhat flat affect

Impact of symptoms on patient’s life

Job requires a lot of travel and she worries about prolonged travel because she needs to be near a bathroom; she now misses work several days per month

Family history and comorbidities

No family history of IBD, celiac disease, or colon cancer

Recently diagnosed with fibromyalgia

Physical examination and laboratory tests

Moderate lower abdominal tenderness

No blood in stool or weight loss

CBC and laboratory tests negative for celiac serologies or any other abnormalities

Colonoscopy with biopsies was negative

Fecal protectin negative

Previous treatments

Has recently been trying a low-FODMAP diet with modest improvement in symptoms

Has tried loperamide and antispasmodics in the past with very limited success

Patient expectations

Patient mostly wants to resolve urgency/incontinence but also hopes for a solution to her other symptoms

Differential diagnosis

Microscopic colitis is a consideration, which has a higher prevalence in middle-aged women; however, her colonoscopy with biopsies was negative

Patient’s symptoms meet the diagnostic criteria for an affirmative diagnosis of IBS-D

Management
Patient education and reassurance

Reassure the patient that together you will work to better manage her symptoms; establishing a therapeutic patient–provider relationship is a cornerstone of IBS therapy, especially in cases of severe disease

It is important to discuss that learning to better manage symptoms and improve daily functioning is a more realistic expectation than anticipating complete resolution of symptoms

Lifestyle and diet

The patient should consider continuing her low-FODMAP diet but a consultation with a dietitian should be recommended to ensure she is meeting her nutritional requirements and to help gradually reintroduce certain foods into her diet

Psychosocial considerations

Based on this patient’s history, psychological therapies, such as CBT, should be considered in conjunction with pharmacological treatments. The choice of psychological therapy is dependent on the patient’s interest and motivation, time, cost, and availability of a trained therapist

Pharmacological management

In this patient who has severe symptoms and has tried OTCs, the FDA-approved therapies rifaximin or eluxadoline should be considered

Reassessment/follow up

Reassessment should be conducted ~4-6 weeks later

Assess if the patient’s diarrhea, abdominal pain, urgency, and incontinence have improved and if the number of “bad days” she experiences has decreased

Assess if CBT has helped alleviate her anxiety and stress management

Assess if the current management plan has improved her QoL

If patient’s symptoms are not improved, consider alternative options, such as an alternative FDA-approved treatment not already tried

This case study is for discussion purposes only. This information is not a substitute for clinical judgment. Each healthcare provider is solely responsible for any decisions made or actions taken in reliance of this information

Learn more about IBS

References

  1. Lucak S et al. Therap Adv Gastroenterol 2016; in press.