Compte rendu gastro-entérologue

**<u>Gastroenterologist Consultation Report</u>** **_Reason for consultation:_** * Chronic abdominal pain and alternating bowel habits. **_Medical history:_** * Gastroenterological history: Diagnosed with Irritable Bowel Syndrome (IBS) 5 years ago, managed conservatively. History of gastroesophageal reflux disease (GERD) for 3 years, managed with PPIs. * Surgical history: Appendectomy at age 12. * Other medical history: Mild essential hypertension, well-controlled with medication. **_Family history:_** * Mother has Crohn's disease. Father had diverticulitis. **_Current treatments:_** * Omeprazole 20mg once daily. * Loperamide as needed for diarrhoea. * Hydrochlorothiazide 25mg once daily. **_History of the present illness:_** * Patient reports a 6-month history of worsening intermittent lower abdominal pain, described as cramping, often relieved by defaecation. This is accompanied by alternating periods of constipation (lasting 3-4 days) and diarrhoea (2-3 loose stools per day). Symptoms are more severe after fatty meals and during periods of stress. No fever, weight loss, or nocturnal symptoms. **_Digestive symptoms:_** * Abdominal pain: Intermittent, cramping, lower abdominal pain, 6/10 intensity, relieved by defaecation. Localised to the left lower quadrant primarily. * Bowel habits: Alternating constipation (3-4 days without bowel movement) and diarrhoea (2-3 loose stools/day). Stool consistency varies from Type 1 to Type 6 on Bristol Stool Chart. Occasional mucus in stool. No reported blood. * Other digestive symptoms: Mild bloating and flatulence, particularly post-prandially. No nausea or vomiting. **_Clinical examination:_** * General condition: Appears well, no acute distress. BMI 24.5 kg/m². Blood pressure 128/82 mmHg, heart rate 72 bpm. * Abdominal examination: Abdomen soft, non-distended. Mild tenderness on palpation of the left lower quadrant. No guarding or rebound tenderness. Bowel sounds normoactive. No palpable masses or organomegaly. * Other examinations: No clubbing, jaundice, or peripheral oedema. **_Additional investigations:_** * Laboratory tests: Full blood count normal. C-reactive protein 2 mg/L (normal <5). Faecal calprotectin 45 µg/g (normal <50). Thyroid stimulating hormone normal. Liver function tests normal. * Imaging: Abdominal ultrasound (dated 1 November 2024) showed no structural abnormalities of the liver, gallbladder, pancreas, or kidneys. No signs of inflammatory bowel disease. * Endoscopy: Colonoscopy (dated 1 November 2024) revealed mild diverticulosis in the sigmoid colon. No evidence of inflammatory bowel disease, polyps, or malignancy. Biopsies taken were histologically unremarkable. **_Diagnosis:_** * Irritable Bowel Syndrome with mixed bowel habits (IBS-M), likely exacerbated by diverticulosis. * Gastroesophageal Reflux Disease (GERD). **_Therapeutic plan:_** * Medication treatment: Continue Omeprazole 20mg once daily. Recommend trial of Linaclotide 290mcg once daily for constipation-predominant phases. Advise use of an antispasmodic (e.g., Mebeverine 135mg three times daily) for abdominal pain as needed. * Lifestyle and dietary measures: Recommend a low FODMAP diet trial under guidance of a dietitian. Advise increased fibre intake (soluble fibre preferred) and adequate hydration. Stress management techniques (e.g., mindfulness, yoga) encouraged. * Investigations to schedule: None immediately. Re-evaluate if symptoms change significantly or new alarming symptoms develop. **_Follow-up:_** * Review in 3 months with General Practitioner to assess response to new medication and dietary changes. Specialist follow-up only if symptoms persist or worsen significantly.