PANCE Blueprint GI and Nutrition (9%)

Patient will present as → a 40-year-old woman who comes to your office with a several-year history of lower abdominal pain associated with constipation (one hard bowel movement every 3 days) and frequent mucous discharge. She states that her abdominal pain is better after a bowel movement. She has never passed blood per rectum. She describes no fever, chills, weight loss or gain, jaundice, or any other symptoms. There is no relationship between the abdominal pain and specific food intake. On physical examination, the abdomen is scaphoid, and no hepatosplenomegaly or masses are palpated. There is a mild generalized abdominal tenderness, but it does not localize.

The Rome criteria are standardized symptom-based criteria for diagnosing IBS

The Rome criteria require the presence of abdominal pain or discomfort for at least 3 days/mo in the last 3 mo along with ≥ 2 of the following:

• Improvement with defecation
• Onset (of each episode of discomfort) associated with a change in frequency of defecation
• Change in consistency of stool

IBS subtypes are defined for clinical practice as follows:

• IBS with predominant constipation: Patient reports that abnormal bowel movements are usually constipation
• IBS with diarrhea: Patient reports that abnormal bowel movements are usually diarrhea
• Mixed IBS: Patient reports that abnormal bowel movements are usually both constipation and diarrhea (more than one-fourth of all the abnormal bowel movements were constipation and more than one-fourth were diarrhea)
• Unclassified IBS: Patients who meet diagnostic criteria for IBS but cannot be accurately categorized into one of the other three subtypes

The cause is unknown, and the pathophysiology is incompletely understood

• Bloating and N/V are common
• Pain often relieved by defecation
• BM's are irregular and vary from constipation to diarrhea

The diagnosis of IBS can reasonably be made using the Rome criteria as long as patients have no red flag findings, such as rectal bleeding, weight loss, and fever, or other findings that might suggest another etiology.

• Patients with one of these red flag findings require further imaging studies and/or colonoscopy
• Routine laboratory studies (complete blood count, chemistries) are normal in IBS

Treatment is symptomatic, consisting of dietary management and drugs, including anticholinergics and agents active at serotonin receptors.

• Increased fiber, decrease dietary fat, drug therapy
• Drug therapy is directed toward the dominant symptoms. Anticholinergic drugs (eg, hyoscyamine 0.125 mg po 30 to 60 min before meals) may be used for their antispasmodic effects.