Battle of the Bloat: What is the Right Rx for IBS? – Clinical Advisor

Posted: December 17, 2019 at 1:43 am

Case Presentation

A 56-year-old white woman with a history of fibromyalgia and anxiety presentsto her primary care physician (PCP) for follow-up to review abnormal laboratoryfindings. During her visit she mentions worsening digestive problems includingbloating and frequent diarrhea. The patient denies abdominal pain, nausea, andvomiting. Her digestive symptoms began approximately 3 years ago and have waxedand waned in severity. She believes certain foods intensify her symptoms but cannotpinpoint exactly which foods are the triggers.

The patient is not on any long-term prescription medications but occasionally takes an antacid. She recently finished courses of trimethoprim and sulfamethoxazole for a urinary tract infection.

Upon physical examination, the patients abdomen is extremelydistended with hyperactive bowel sounds and hyper-resonance with percussion inall 4 quadrants. The abdomen is non-tender to palpation and the spleen andkidneys are non-palpable. Neitherpulsatile mass nor ascites are present.

Laboratory tests are ordered: white blood cell count is 4.3 K/L andlymphocytes are 1.2 K/L. The patients calcium level is 10.3 mg/dL, but wasreduced to 9.7 mg/dL following correction of albumin of 4.8 g/dL. Vitamin D25-hydroxy is 20.9 ng/mL. Additional tests were within normal limits.

Differential diagnoses include antibiotic-induced Clostridium difficile colitis, food intolerance, irritable bowel syndrome (IBS), diverticulitis, and inflammatory bowel disease.

Additional tests are ordered, including thyroid-stimulating hormone, antinuclearantibody, erythrocyte sedimentation rate, and C-reactive protein, which are allwithin normal range. Stool guaiac and culture are also negative, ruling out C difficile infection.

The patient is referred to gastroenterology for further testing.Gallbladder ultrasound was normal with no stones or sludge identified in thegallbladder lumen. Endoscopy and colonoscopy images and biopsies wereunremarkable.

The patient is then referred to an allergist. Food allergy testing wasnegative. The patient was instructed to try a dairy-free diet for 1 month andsubsequently a gluten-free diet for 1 month. The patient did not experiencerelief from either elimination phase diets.

The patient returned to her PCP and was told she likely suffered fromdiarrhea-predominant irritable bowel syndrome (IBS-D); her demographics as a womanwith fibromyalgia and anxiety and recent antibiotic use made the diagnosis evenmore likely. However, no specific test was performed to confirm the diagnosis.

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Battle of the Bloat: What is the Right Rx for IBS? - Clinical Advisor

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