Q&A Medicine>>>>>Gastroenterology
Question 5#

A 27-year-old woman presents with diarrhea and abdominal pain for the last 8 months. She denies bloody stools, weight loss, or fatigue. The patient just recently started what she describes as a “stressful” career in investment banking. She is concerned that she might have Crohn disease as both her maternal uncle and maternal grandmother have the disorder. Further questioning reveals that the diarrhea and abdominal pain occur about once per week (generally Friday mornings before she gives her weekly presentation), and the other days she is “constipated.” The abdominal pain is alleviated after defecation. Physical examination is unremarkable.

What is the next best step in management for this patient?

a. Colonoscopy
b. Oral corticosteroids
c. Loperamide
d. Reassurance and recommendation for a high-fiber diet and exercise

Correct Answer is D

Comment:

Reassurance and recommendation for a high-fiber diet and exercise. This is a very common question on the Internal Medicine shelf examination. The patient in this question likely has irritable bowel syndrome (IBS) given that she endorses abdominal pain with altered bowel function (diarrhea and constipation), with complete relief of abdominal pain after defecation. The etiology of IBS is largely unknown, but may be related to psychological factors, autonomic nervous system abnormalities, and altered gut motor function. The patient should be reassured that this is not inflammatory bowel disease (IBD) given that she does not have cramping, bloody diarrhea, or systemic symptoms like weight loss or fatigue. Nonetheless, a high-fiber diet (30 g/d) should be emphasized as well as exercise and sufficient fluid intake. (C) Loperamide is an opioid-receptor agonist used in the treatment of diarrhea. This should only be considered in IBS if the diarrhea persists after the aforementioned recommendations are tried. (A) Colonoscopy can aid in diagnosing IBD (Crohn disease shows skip lesions and ulcerative colitis shows friable mucosa with ulcerations and erosions continuous from the anus). (B) Corticosteroids are used in the treatment of IBD.