Worsening Abdominal Pain and Bloating in a 30-Year-Old Woman

Mohammad Elbatta, MD; Jason Schairer, MD


August 12, 2019

Four subtypes of irritable bowel syndrome are recognized, on the basis of the predominant symptoms during days with abnormal bowel movements. The Bristol Stool Form Scale should be used to record stool consistency. Subtypes can only confidently be established when the patient is evaluated off medications used to treat bowel habit abnormalities, such as antidiarrheal drugs or laxatives.

Irritable bowel syndrome subtypes are defined for clinical practice as follows:

  • Irritable bowel syndrome with constipation.

  • Irritable bowel syndrome with diarrhea.

  • Mixed irritable bowel syndrome: Abnormal bowel movements alternate between constipation and diarrhea.

  • Unclassified irritable bowel syndrome: These are patients who meet diagnostic criteria for irritable bowel syndrome but cannot be accurately categorized into one of the other subtypes.

In this case, the patient does not have any alarming symptoms (eg, blood in the stool, anemia, nocturnal symptoms) and has no family history to suggest Crohn disease. Furthermore, a complete blood cell count in the reference range is unlikely in celiac disease. The patient has not had abdominal surgery or other cause of stasis in the small intestine; thus, SIBO is unlikely.

The patient meets the Rome IV criteria for irritable bowel syndrome. She has had the pain for more than 3 years, with a recent increase in symptoms. She has weekly symptoms of pain, bloating, loose stools, and more frequent bowel movements. The most likely diagnosis in this case is irritable bowel syndrome. Patients with mild and intermittent symptoms that do not impair the quality of life should undergo lifestyle and dietary modification, rather than treatment with medication. Thus, the first step is validating the patient’s symptoms via a therapeutic clinician/patient relationship. In patients with mild to moderate symptoms that fail to respond to initial management with lifestyle and dietary modifications and in patients with moderate to severe symptoms that affect quality of life, adding pharmacologic therapy is suggested. The choice of medication should be based on patient's predominant symptom (constipation or diarrhea). In patients with diarrhea-predominant symptoms, antidiarrheal medication (eg, loperamide) is indicated initially, with bile acid sequestrants (eg, cholestyramine, colestipol, colesevelam) recommended as a second-line therapy.

In patients with irritable bowel syndrome with constipation in whom a trial of soluble fiber (eg, psyllium/ispaghula) has failed, the next step is polyethylene glycol. In patients with persistent constipation despite treatment with polyethylene glycol, lubiprostone or linaclotide may be recommended.

In patients with abdominal pain due to irritable bowel syndrome, the authors use antispasmodics (eg, dicyclomine, hyoscyamine) on an as-needed basis. In patients with irritable bowel syndrome with constipation, antispasmodics are initiated only if the abdominal pain persists despite treatment of constipation.

Because this patient has symptoms that did not impair quality of life, lifestyle and dietary modifications alone were suggested rather than specific pharmacologic agents, with further follow-up for symptomatic treatment as needed.


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