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

Presentation and diagnosis
Symptom history

35-year-old woman with a 1-year history of constipation associated with abdominal pain and bloating

Typically has a bowel movement every 3-4 days and complains of a feeling of incomplete evacuation

Stools are hard and pebble-like (Bristol Stool Form Scale 1) and require excessive straining to pass

Complains of abdominal bloating and general abdominal pain which is relieved after a bowel movement

Dietary habits

Eats at irregular intervals and typically eats poorly balanced meals, particularly when working

Social history

Works overnight shifts which she began prior to the onset of her symptoms

Sleep patterns are altered with change in working hours and her job is extremely stressful

Used to exercise regularly but since her change in job has found it hard to find the time

Impact of symptoms on patient’s life

Concerned because she feels uncomfortable and bloated all of the time

Doesn’t know what she should or should not be eating

Feels embarrassed that her clothes don’t fit properly because of the bloating

Family history and comorbidities

No family history of any GI disorders or malignancies

No past medical history and is otherwise healthy

Physical examination and laboratory tests

Physical and rectal exam unremarkable

CBC and iron studies normal. Guaiac negative

No red-flag signs or symptoms that would indicate a need for imaging or endoscopic evaluation of the GI tract

Previous treatments

Tried fiber gummies and osmotic laxatives with limited relief

Uses a stimulant laxative or suppository on an as-needed basis

Patient expectations

Would like to know why she is unable to go to the bathroom regularly on her own anymore

Does not want to become dependent on stimulant laxatives or suppositories but wants to have regular bowel movements and get rid of the abdominal pain and bloating

Differential diagnosis

No red-flag signs or symptoms

Symptoms meet the Rome criteria for a diagnosis of IBS-C

Management
Patient education and reassurance

Discuss diagnostic criteria for IBS-C

Review the Bristol Stool Form Scale to help the patient understand her current symptoms and to help set patient expectations for management

Reassure the patient that she does not have any red-flag signs or symptoms that warrant further diagnostic testing at this time, and that IBS is an affirmative diagnosis based on her symptoms

Lifestyle and diet

Attempt to establish a schedule in order to eat well-balanced meals at regular intervals

Increase fluid intake

Discuss ways the patient could re-establish a regular exercise schedule

Consider if keeping a food/symptom diary would help determine if there are any dietary triggers of bloating

Psychosocial considerations

Consider options for management of stress, such as yoga or meditation

Pharmacological management

Discuss options for treatment that avoid regular use of OTC stimulant laxatives

Options include daily linaclotide or lubiprostone in an effort to establish bowel movements at regular intervals, as opposed to treating the constipation as needed

Reassessment/follow up

Patient should return in 4-6 weeks to assess response to lifestyle changes and any pharmacologic treatment, if given

Review food diary to discuss any obvious dietary triggers and consider referral to a registered dietitian

Reassess quality and frequency of bowel movements using the Bristol Stool Form Scale, and revaluate impact of symptoms on daily life

If patient’s symptoms are not improved, consider alternative or additional treatment options based on persistent symptoms

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

37-year-old woman whose symptoms (nausea, epigastric pain, post-prandial fullness/bloating, constipation, and left lower quadrant pain with bowel movements) started 4 years ago following an episode of severe diarrhea after a family picnic

Usually has 2-3 small hard stools per week, generally mid-day, and feels she is never completely emptied

Pain is improved when she has a bowel movement, but she often strains to have a bowel movement

Dietary habits

Often gets abdominal pain which is even worse when she forgets to take her fiber and drink plenty of water

Has tried a paleo diet but felt it only helped for a few months

Social history

Floor nurse at a busy community hospital

Married; does not have children

Former smoker, quit over 10 years ago

Impact of symptoms on patient’s life

Calls in sick and misses shifts because she feels she cannot give her patients the attention they need when she feels sick

Family history and comorbidities

No family history of any GI disorders or malignancies

Sees a psychiatrist for depression and is on an SSRI

Sees an acupuncturist for self-diagnosed fibromyalgia

Physical examination and laboratory tests

Had a colonoscopy for the episode of diarrhea 4 years ago by another gastroenterologist which was non-diagnostic

Recent H. pylori breath testing was negative

Previous treatments

Fiber, osmotic laxatives

Patient expectations

Comes to you via her gynecologist after presenting to him thinking something might be wrong with her ovaries since other GI medications have not helped her

Differential diagnosis

Peptic ulcer disease, gastroparesis, IBS-C, and possibly a GYN-related disorder are on the differential. There are no risk factors for peptic ulcer disease or gastroparesis, and a GYN-related disorder should not be qualitatively affected by bowel movements

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

Management
Patient education and reassurance

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

It is important to discuss that setting realistic expectations to better manage symptoms and improve daily functioning is more effective than anticipating complete resolution of symptoms

Lifestyle and diet

The patient could consider a low-FODMAP diet, but a consultation with a registered 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, could 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 linaclotide or lubiprostone should be considered

If there are ongoing symptoms of pain, consider switch from SSRI to TCA with approval from a psychiatrist

Reassessment/follow up

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

Assess whether the dietary plan has reduced symptoms of bloating

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

Assess whether the patient’s quality of life has improved (e.g. is she finding it easier to complete her work tasks?)

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

32-year-old woman with mixed constipation and diarrhea bowel pattern

Reports that she “either can’t go or can’t stop going to the bathroom”

In college, she experienced stomach aches and intermittent constipation. After business school, her GI symptoms progressed and she developed chronic constipation and more frequent crampy lower abdominal pain which seemed to be worsened by stress

She was referred to a gastroenterologist who did a “full work-up” including blood testing for celiac disease, abdominal and pelvic ultrasounds, colonoscopy with biopsies, and abdominal and pelvic CT scans. All tests were unremarkable. She was diagnosed with IBS with constipation and began treatment with laxatives

Over the past year, she has developed intermittent urgent diarrhea every 7-10 days, having 6-12 semi-formed/watery BMs/day. Other days, her BMs are irregular; either she “can’t go” at all or has lumpy or formed BMs. She has been straining, has had a sense of incomplete evacuation, lower abdominal cramping, and bloating

Dietary habits

Has been trying a low-FODMAP diet for 2 months

Diarrhea seems to occur no matter what she eats

Stopped drinking alcohol 6 months ago as it worsened her diarrhea

Social history

Married for 5 years and has a 2-year-old son who is in daycare

Works long hours as a financial analyst but has weekends off

Impact of symptoms on patient’s life

Having unpredictable BMs makes it difficult for her to conduct meetings at work (because she never knows when “diarrhea will strike”) and to engage in activities with her son and husband (her husband “has to step in”)

Has become more anxious

Family history and comorbidities

No history of celiac disease or inflammatory bowel disease

Has had intermittent nausea occurring after diarrheal episodes, as well as fatigue

Moderately anxious

Physical examination and laboratory tests

BP 120/80; HR 84; 5’4”; 155 lbs

On abdominal exam, she had firm palpable stool in right lower quadrant (indicative of fecal loading) and some stool in left lower quadrant. She was moderately tender in lower abdomen

Rectal exam showed stool without blood

CBC, chemistry profile, serum IgA, tTG IgA, TSH, CRP, vitamin B12 all within normal limits

Stool testing using PCR showed no pathogens

Previous treatments

Used Milk of Magnesia or Senna tea when she was constipated and used loperamide on rare occasions when she had severe diarrhea

Patient expectations

Struggling with GI symptoms and wants “help to manage them” better

Differential diagnosis

Celiac disease, inflammatory bowel disease (Crohn’s disease in particular), parasitic infestation, or bacterial infection

Given lack of alarm features and no foreign travel, symptoms meet the diagnostic criteria for a diagnosis of IBS-M

Management
Patient education and reassurance

Discuss diagnosis of IBS-M in detail; explain that IBS-C can turn into another IBS subtype

Lifestyle and diet

Patient should consider continuing a low-FODMAP diet as it had improved her bloating and lower abdominal pain

Should also try to incorporate exercise and yoga into her activities

Psychosocial considerations

The role of the brain–gut interaction should be discussed, and non-pharmacological treatments such as cognitive behavior therapy should be considered

Pharmacological management

Treatment of IBS with mixed bowel habit pattern has not been addressed in clinical trials because treatment of one bowel habit pattern may lead to the opposite bowel habit pattern (diarrhea to constipation, constipation to diarrhea) and it is then difficult to assess efficacy and side effects

In clinical practice, it is often helpful to treat constipation first in an effort to prevent “overflow diarrhea” because the GI tract tends to be very reactive to constipation in patients with IBS-M

Reassessment/follow up

Patient should be reassessed after 4-8 weeks and management plan re-evaluated as necessary

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 2017; 10: 253-275.