GI Consult - General patient in person

Date: 01 November 2024 REASON FOR CONSULTATION Chronic Abdominal Pain and Suspected Irritable Bowel Syndrome HISTORY OF PRESENTING ILLNESS: Patient John Smith, a 45-year-old male, was referred by his General Practitioner, Dr. Alice Brown. Mr. Smith presents with a 6-month history of intermittent abdominal pain, bloating, and altered bowel habits. The pain is typically described as a dull ache, located in the lower abdomen, and tends to improve after defecation. He experiences episodes of both constipation (passing stools every 3-4 days) and loose stools (2-3 times a day) which alternate every few weeks. He reports significant bloating, particularly in the evenings, which causes discomfort and limits his clothing choices. He also reports occasional urgency and incomplete evacuation. The current issues include persistent abdominal discomfort impacting his quality of life and anxiety about the underlying cause. He is seeking a definitive diagnosis and management plan for his symptoms. The patient is particularly concerned about potential inflammatory bowel disease, given his aunt's history. Detailed history reveals that the symptoms began insidiously, with gradual worsening over the last six months. Pain severity is usually 4/10 but can spike to 7/10 during exacerbations. Aggravating factors include stress and consumption of large meals. Alleviating factors include bowel movements and warm compresses. He denies any fever, weight loss, nocturnal symptoms, or blood in stools. He has tried over-the-counter anti-spasmodics (Buscopan) with minimal relief and has attempted a low FODMAP diet briefly, which he found difficult to adhere to. Prior treatments include a 2-week course of mebeverine prescribed by his GP, which provided temporary relief. He also tried a gluten-free diet for a month without significant improvement. No other specific diets or medications have been consistently used. PAST GI HISTORY: No prior gastrointestinal surgeries. History of occasional heartburn, managed with Gaviscon as needed. PAST HISTORY: Hypertension, diagnosed 5 years ago, well-controlled with medication. Seasonal allergies. MEDICATIONS: Lisinopril 10mg once daily Cetirizine 10mg once daily (as needed for allergies) Gaviscon (as needed for heartburn) No herbal supplements reported. ALLERGIES: Penicillin (rash) FAMILY HISTORY: Mother: Type 2 Diabetes Father: Myocardial Infarction at age 60 Aunt (paternal): Crohn's Disease SOCIAL HISTORY: Mr. Smith is married with two children. He lives in a semi-detached house. He describes his social life as active, but his symptoms have recently curtailed some activities. He smokes 5 cigarettes per day for the last 20 years. Drinks alcohol socially, approximately 4-5 units per week. Denies illicit substance use. He is employed as an accountant, working full-time in an office environment, which he describes as moderately stressful. PHYSICAL EXAM: The abdomen was soft, mildly distended, with mild tenderness on deep palpation in the left lower quadrant, without rebound or guarding. No hepatosplenomegaly or masses were palpable. Bowel sounds were normoactive. Rectal examination was deferred. Cardiovascular, respiratory, dermatological, and lymph node examinations were normal. INVESTIGATIONS: - Laboratory results: Full blood count, inflammatory markers (CRP, ESR), thyroid function tests, coeliac serology, and stool occult blood were all within normal limits from previous GP investigations. - Colonoscopy results: N/A - Upper endoscopy results: N/A - Imaging results: Abdominal ultrasound performed 3 months ago showed no significant abnormalities. ASSESSMENT AND PLAN: 1. Chronic Abdominal Pain and Altered Bowel Habits, suggestive of Irritable Bowel Syndrome (IBS) Assessment: Mr. Smith presents with classic symptoms of IBS, including chronic abdominal pain relieved by defecation, associated with a change in bowel frequency and stool consistency. The absence of alarm features (e.g., weight loss, nocturnal symptoms, GI bleeding, family history of colorectal cancer) makes inflammatory bowel disease or malignancy less likely, though a colonoscopy may be considered to rule out microscopic colitis given the alternating bowel habits. His symptoms significantly impact his quality of life and he reports stress as an aggravating factor. Differential diagnosis: Inflammatory Bowel Disease (less likely given negative inflammatory markers and absence of alarm symptoms), microscopic colitis, small intestinal bacterial overgrowth (SIBO), coeliac disease (ruled out by serology). - Investigations planned: Stool calprotectin to further rule out inflammatory bowel disease. Consider a breath test for SIBO if symptoms persist after initial management. Flexible sigmoidoscopy/colonoscopy will be discussed if stool calprotectin is elevated or if symptoms do not respond to conservative management. - Medical treatment planned: Initiate a trial of linaclotide 290 mcg daily for constipation-predominant symptoms, or adjust based on predominant bowel pattern. Prescribe an antispasmodic (e.g., mebeverine or peppermint oil capsules) to be taken as needed for acute pain. Advise on soluble fibre supplementation. - Lifestyle modifications: Reinforce adherence to a modified low FODMAP diet with reintroduction phases under dietician guidance. Stress management techniques (e.g., mindfulness, relaxation exercises). Gradual increase in physical activity. Counsel on smoking cessation and reduction of alcohol intake. - Follow-up appointments: Review in 6-8 weeks to assess response to treatment and diet. Further follow-up if investigations reveal significant findings. - Relevant referrals: Referral to a dietician for detailed dietary advice and guidance on FODMAP reintroduction. Consider referral to a smoking cessation clinic. Additional Notes: - Patient education on the diagnosed condition, including explanation of IBS as a functional bowel disorder, reassurance regarding the benign nature of the condition, and the importance of symptom management through diet and lifestyle changes. Discuss potential triggers and coping strategies. - Instructions for symptom monitoring and when to seek immediate care: Advise patient to monitor for any new alarm symptoms such as unexplained weight loss, rectal bleeding, persistent fever, severe abdominal pain, or nocturnal bowel movements, and to contact the clinic immediately if these occur. - Any specific patient or family concerns addressed during the consultation: Patient's concern regarding inflammatory bowel disease was addressed with reassurance and explanation of current investigation findings. His anxiety about the condition was acknowledged, and stress management was highlighted as a key component of his care plan.