The Question
A 38-year-old woman presents with an 8-month history of crampy lower abdominal pain and changes in bowel habits. She reports abdominal pain that is relieved by defecation and associated with 3–5 loose, nonbloody stools per day; symptoms began gradually and have been intermittent but persistent. She has no fever, weight loss, nocturnal diarrhea, family history of inflammatory bowel disease or colorectal cancer, or rectal bleeding. Vital signs are normal. Physical exam is unremarkable without abdominal tenderness or perianal disease. Laboratory studies show hemoglobin 13.2 g/dL, WBC 6.4 x10^9/L, TSH normal, and CRP normal. Stool testing for ova and parasites was negative on prior outpatient evaluation. She meets Rome IV criteria for irritable bowel syndrome with predominant diarrhea. Which of the following is the most appropriate next step in management?
See the answer and explanation below:
Post-Call Recovery Reads
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View on AmazonThe Correct Answer
B
Explanation
High-Yield Pearl: In adults with chronic IBS symptoms, particularly diarrhea-predominant or mixed patterns, testing for celiac disease with IgA anti-tissue transglutaminase plus total IgA should be performed before empiric IBS-directed therapy.
Detailed Reasoning: This patient has a typical IBS presentation by Rome IV criteria but lacks alarm features such as weight loss, GI bleeding, or nocturnal symptoms; guideline-supported evaluation includes targeted testing to exclude conditions that mimic IBS. The American College of Gastroenterology and endorsed guidelines recommend celiac serology in patients with chronic diarrhea or IBS-like symptoms because untreated celiac disease can present similarly and has distinct management. Testing should include anti-tTG IgA with total IgA to avoid false negatives from selective IgA deficiency. Fecal calprotectin is useful to distinguish inflammatory bowel disease from IBS when there is clinical concern for IBD or elevated inflammatory markers, but her normal CRP, absence of alarm features, and chronic noninflammatory labs make celiac testing higher yield first. Colonoscopy with biopsies is warranted if there are alarm features, age-based screening indications, or positive noninvasive testing, but is not the immediate next step here. Initiating loperamide or a low FODMAP diet may provide symptomatic relief, yet treating empirically before excluding celiac disease risks masking or delaying diagnosis; thus serologic testing is the most appropriate next step.
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