Irritable bowel syndrome (IBS) remains a clinical challenge in the 21st century with worldwide prevalence rates ranging generally around 10–15%. This is a functional gastrointestinal disorder^[1], many theories have been proposed about its etiology, but the biopsychosocial model is the most currently accepted for IBS^[2].

The complex of symptoms would be the result of the interaction between psychological, behavioral, psychosocial and environmental factors^[3,4].

The diagnosis is clinically based, and the treatment is symptom based.

A case report of a lady who had few abdominal complaints mimicking sigmoid diverticulitis, but frequent emergency department visits with negative radiological investigations to receive a rather delayed clinical diagnosis of IBS in our clinic.

Case Presentation:

29 years old Hispanic female referred to a gastroenterology clinic complaining of episodes of mild to moderate generalized abdominal pain, described as discomfort, relieved after defecation, associated frequently with constipation once / 2-3 days for the past 2 years duration, she also reports occasional bloating sensation, excessive flatulence and urgency going to bathroom with no evacuation.

She denies any fever, fatigue, recent changes in weight or appetite; she also denies rectal bleeding, nausea, vomiting, urinary changes, skin changes, or joint problems. Past medical history includes post-traumatic stress disorder after death of her father and 3 previous emergency department visits for similar complaints within the same duration; emergency department investigations and radiology including ultrasonography (U\S) and computerized tomography (CT scan) were negative.

Surgical and family histories were unremarkable.

Her last menstrual period was 2 weeks ago with no vaginal spotting or discharge.

Her diet is well balanced with daily fruits and vegetables and she works as an administrative assistant in a local company where she admits having a stressful work environment.

On physical exam, she is a well-built lady not in acute distress, vital signs all within normal limits, there is no pallor with unremarkable chest exam.

Abdominal exam revealed soft non distended abdomen without guarding or rigidity, positive bowel sounds in all 4 quadrants with no masses or organomegaly.

Rectal exam was unremarkable.

Complete blood count, basic metabolic panel and contrast CT abdomen and pelvis Figure (1) were unremarkable. Colonoscopy was done on second follow up visit and surprisingly revealed 2 sigmoid diverticula with no other significant changes Figure (2).

Figure 1: Pelvic contrast CT scan images showing sigmoid colon, rectum on S5 section (left) and hip level section (right).

Figure 2: Colonoscope images showing 2 diverticula in sigmoid colon on the left and normal mucosa on the right.

Discussion

Although it is among the most common disorders in gastroenterology clinics, IBS continues to be a diagnostic challenge due to unavailability of a confirmatory test and the diagnosis is often missed or delayed, the key issues are to diagnose IBS through minimal tests and reasonable costs to the patient as recommended by the American College of Gastroenterology (ACG).

Today the Rome IV Criteria are the current gold-standard for the diagnoses of IBS^[5].

In patients complaining of abdominal pain or discomfort, the priority is to rule out any warning signs which include: age over 50 without prior colon cancer screening; the presence of visible rectal bleeding; progressive fatigue; pallor; unintentional weight loss; a family history of colorectal cancer; recent changes in bowel habits; and the presence of a palpable abdominal mass or lymphadenopathy. If these warning signs are absent which is the case here, further history should be obtained to determine whether the patient meets the Rome IV diagnostic criteria. In our case, the patient has reported duration of 2 years, which met the requirement of having an onset greater than 6 months prior to diagnosis. The rationale here is to ensure that the symptoms are recent, and that there is no organic disease manifesting itself over at least 6 months. The final component to applying the criteria involves associating the abdominal pain to bowel habits. The history confirmed that abdominal pain is related to defecation and a change in stool frequencies which fulfill the minimum criteria.

A benign physical exam and a rectal exam further supports the diagnosis of IBS, although the importance of a physical examination cannot be underestimated as this does reassure the patient that her symptoms are being taken seriously by her healthcare provider^[6,7].

Diverticulosis of the colon is mostly asymptomatic in majority of cases or present with left lower quadrant pain as the predominant symptom in minority; However, Acute diverticulitis usually present with left lower quadrant pain associated with constipation. There is a usually systemic symptom and it’s more likely to be age related^[8].

Our patient had chronic symptoms of constipation and generalized type of abdominal pain without systemic symptoms. She is rather young and more importantly has a negative abdominal and pelvic CT scan.

Abdominal and pelvic CT scan is more sensitive and specific than Ultrasonography despite the radiation fact for a woman of child bearing age^[9].The findings on colonoscopy were considered incidental as they are not consistent with clinical presentation. This patient was educated about the nature of her new condition and reassured that no serious pathology exist^[10]. She was instructed to consume fiber rich foods, increase fluid intake and follow a regular exercise aiming to reduce the stress component of her condition.

Conclusion

There is a need for a confirmatory test to establish an early diagnosis of IBS.

It is concluded that such patients meeting the Rome IV diagnostic criteria in the absence of any warning signs, should have only limited testing as possible and be provided with more reassurance and education.

Conflict of interest

None

Acknowledgment

We would like to thank Ibn Sina Foundation Community Clinic for their help and support.

References

1. 1. Drossman, D.A., Corrazziari, E., Delvaux, M., et al. Rome III: The Functional Gastrointestinal Disorders. (2006)  Degnon Associates.

Pubmed| Crossref| Others

2. 2. Chang, J.Y., Talley, N.J. An update on irritable bowel syndrome: from diagnosis to emerging therapies. (2011) Curr Opin Gastroenterol 27(1): 72-78.

Pubmed| Crossref| Others

3. 3. Mayer, E.A., Naliboff, B.D., Chang, L. Basic pathophysiologic mechanisms in irritable bowel syndrome. (2001) Dig Dis 19(3): 212-218.

Pubmed| Crossref| Others

4. 4. Tanaka, Y., Kanazawa, M., Fukudo, S., et al. Biopsychosocial model of irritable bowel syndrome. (2011) J Neurogastroenterol Motil 17(2): 131-139.

Pubmed| Crossref| Others

5. 5. Brian, E. L., Patel, N.K. Rome Criteria and a Diagnostic Approach to Irritable Bowel Syndrome. (2017) J Clin Med 6(11): 99.

Pubmed| Crossref| Others

6. 6. Ford, A.C., Lacy, B.E., Talley, N.J. Irritable Bowel Syndrome. (2017) N Engl J Med 376(26): 2566–2578.

Pubmed| Crossref| Others

7. 7. Lacy, B.E., Mearin, F., Chang, L., et al. Bowel Disorders. (2016) Gastroenterology 150: 1393–1407.

Pubmed| Crossref| Others

8. 8. Linzay, C.D., Pandit, S. Acute Diverticulitis. (2018).

Pubmed| Crossref| Others

9. 9. Kristen, K. D., David, P. Keating. Imaging Update: Acute Colonic Diverticulitis. (2009) Clin Colon Rectal Surg 22(3): 147–155.

Pubmed| Crossref| Others

10. 10. Lacy B.E., Weiser, K., Noddin, L., et al. Irritable bowel syndrome: Patients’ attitudes, concerns and level of knowledge. (2007) Aliment Pharmacol Ther 25(11): 1329-1341.

Pubmed| Crossref| Others