GI Consult - General patient telehealth

Date: 01 November 2024 REASON FOR CONSULTATION Chronic abdominal pain and altered bowel habits HISTORY OF PRESENTING ILLNESS: Patient name: Sarah Jenkins, Age: 45, Gender: Female, Referring clinician: Dr. Emily White (GP) Current issues, reasons for visit, discussion topics, history of presenting complaints: Ms. Jenkins presents with a 6-month history of intermittent lower abdominal pain, predominantly left-sided, described as cramping and occasionally sharp. The pain is often relieved by defecation. She also reports alternating constipation and diarrhoea, with stools sometimes being loose and frequent, and at other times hard and difficult to pass. She has noted increased bloating and occasional mucus in her stools, but denies blood. She has tried over-the-counter antispasmodics and a low-FODMAP diet without significant improvement. Reason(s) for consultation, including specific gastrointestinal concerns or symptoms: Evaluation of chronic abdominal pain, irritable bowel syndrome (IBS) symptoms, and exclusion of inflammatory bowel disease (IBD). Detailed history of the complaint(s), including duration, severity, aggravating/alleviating factors, associated symptoms, bowel habits, previous treatments, and responses: The pain started approximately 6 months ago, gradually worsening over time. Severity is rated 5/10 on average, occasionally reaching 7/10 during flare-ups. Aggravating factors include stress and certain foods (dairy, high-fibre vegetables). Alleviating factors include defecation and warm compresses. Associated symptoms include bloating, flatulence, and a sensation of incomplete evacuation. Bowel habits vary significantly, alternating between periods of constipation (3-4 days without a bowel movement) and diarrhoea (3-4 loose stools per day). Previous treatments include Mebeverine (no significant relief) and a self-initiated low-FODMAP diet (mild, temporary improvement). Prior treatments, diets, and medications used for the problem: Mebeverine 135mg TID (trialled for 2 months, discontinued due to ineffectiveness); low-FODMAP diet (followed for 1 month, some symptom reduction but not sustained). PAST GI HISTORY: No significant past GI history. PAST HISTORY: Mild anxiety (managed with meditation) Seasonal allergies MEDICATIONS: None regularly prescribed. Vitamin D supplement (OTC) daily. ALLERGIES: Penicillin (rash) FAMILY HISTORY: Mother: Irritable Bowel Syndrome (IBS) Father: Hypertension No family history of inflammatory bowel disease or colorectal cancer. SOCIAL HISTORY: Lives with partner in a detached house. Works as a primary school teacher. Smoking, alcohol, and substance use: Non-smoker. Consumes alcohol socially (1-2 units per week). No illicit substance use. Employment or work performed: Primary school teacher (full-time). PHYSICAL EXAM: Deferred as consultation done over telemedicine. INVESTIGATIONS: - Laboratory results: Full blood count (normal), C-reactive protein (normal), Faecal calprotectin (50 mcg/g – within normal limits, ruling out active IBD). - Imaging results: Abdominal ultrasound (performed 3 months prior, no significant findings). ASSESSMENT AND PLAN: 1. Chronic abdominal pain and altered bowel habits consistent with Irritable Bowel Syndrome (IBS) Assessment, including the likely diagnosis and rationale based on subjective and objective findings: The patient's presentation with chronic, recurrent abdominal pain relieved by defecation, associated with a change in bowel habits (alternating constipation and diarrhoea), bloating, and mucus in stool, strongly suggests Irritable Bowel Syndrome (IBS) based on ROME IV criteria. The normal inflammatory markers (CRP, faecal calprotectin) and absence of alarm symptoms (weight loss, rectal bleeding, nocturnal symptoms, family history of IBD/CRC) make IBD and other organic pathologies less likely. Psychological factors (anxiety) may exacerbate symptoms. Differential diagnosis, considering other potential gastrointestinal or systemic conditions: Inflammatory Bowel Disease (Crohn's disease, Ulcerative Colitis) – largely ruled out by normal calprotectin; Coeliac disease – not yet investigated, but unlikely given predominant symptom pattern; Lactose intolerance – partially addressed by low-FODMAP diet; Small Intestinal Bacterial Overgrowth (SIBO). - Investigations planned, specifying any additional endoscopic procedures, imaging, or tests needed for a definitive diagnosis or treatment planning: Hydrogen breath test for SIBO if symptoms persist despite initial management. Consider coeliac serology if diet modification is not effective. - Medical treatment planned, detailing the type of medication, dosage, expected outcomes, and potential side effects: Initiate Linaclotide 290mcg daily for constipation-predominant symptoms, or Rifaximin 550mg TID for 14 days if SIBO confirmed. Discuss trial of low-dose tricyclic antidepressant (e.g., Amitriptyline 10mg nocte) if pain remains refractory. - Lifestyle modifications, including dietary advice, alcohol and tobacco cessation, and physical activity recommendations: Reinforce continued use of low-FODMAP diet principles, focusing on individual triggers. Recommend stress management techniques (e.g., mindfulness, yoga). Encourage regular physical activity (e.g., walking 30 minutes daily). Advise against excessive caffeine and alcohol intake. - Follow-up appointments, covering the expected timeline for review, monitoring response to treatment, and adjustment of management plans: Follow-up in 6 weeks via telehealth to assess response to treatment and discuss further management. Adjust medication or consider additional investigations based on symptom improvement. - Relevant referrals for multidisciplinary care or further evaluation: Consider referral to a dietitian for structured low-FODMAP diet guidance if patient struggles with implementation. Additional notes - Patient education on the diagnosed condition, including explanation of the condition, potential complications, and the importance of treatment adherence: Explained IBS is a functional gut disorder, not associated with structural damage or increased risk of cancer, but can significantly impact quality of life. Emphasised adherence to dietary and lifestyle changes, and the importance of medication as prescribed. Discussed the brain-gut axis and the role of stress. - Instructions for symptom monitoring and when to seek immediate care: Advised to monitor symptom diary (pain, bowel habits, bloating). Instructed to seek immediate care for alarm symptoms: unexplained weight loss, new onset nocturnal diarrhoea, rectal bleeding, severe abdominal pain, or fever. - Any specific patient or family concerns addressed during the consultation: Patient expressed concern about potentially having a more serious condition like Crohn's. Reassured her based on current symptoms and normal investigations.