Question

A 25 year old graduate student returns to her physician with complaints of abdominal pain and diarrhea, which have been persistent nearly a year. She continues to experience nearly-daily episodes of postprandial abdominal pain and visible abdominal distension, which are relieved by the passage of stool. During these episodes, her stools are loose and gassy, and while she denies ever passing blood in her stool, she has periodically noticed large quantities of mucus. Workup to this point has been unrevealing, and has included thyroid function tests, colonoscopy, celiac sprue antibodies, and fecal occult blood testing. She denies fevers, weight loss, nausea and vomiting, and reflux symptoms. The patient's

past medical history is significant only for depression, which is well controlled with sertraline. On physical examination, the patient appears healthy. She has normoactive bowel sounds and a nontender abdomen. Hemoccult is negative. Which of the following is the most appropriate next step in the management of this patient?
A. Reassurance, education, and dietary modification
B. Barium enema
C. Culture of the stool for ova and parasites
D. Mesalamine
E. Exploratory laparotomy

Answer 1

The patient's symptoms and normal workup suggest IBS, for which the best next step would be reassurance, education, and dietary modification, as opposed to invasive procedures or medications not indicated without alarm features.

Step-by-step explanation:

The patient's symptoms, including persistent abdominal pain and diarrhea without blood or weight loss, suggest a diagnosis of irritable bowel syndrome (IBS), especially due to the absence of findings from various tests including thyroid function tests, colonoscopy, celiac antibodies, and fecal occult blood testing. At this point in the workup, the most appropriate next step is A. Reassurance, education, and dietary modification. Exploratory procedures or medications like mesalamine are indicated in the presence of alarm features or confirmed inflammatory conditions, which are not present here. As for the stool studies mentioned, these would be more useful if an infectious etiology were suspected, but given the chronic nature and absence of fever or bloody diarrhea, they are less likely. Since diet can play a significant role in IBS symptoms, a prudent approach focusing on dietary changes would be appropriate to manage this patient's symptoms.