CASE 32: ABDOMINAL PAIN
History
A 31-year-old woman has a 6-year history of abdominal pain and bloating. She has had
an irregular bowel habit with periods of increased bowel actions up to four times a day
and periods of constipation. Opening her bowels tends to relieve the pain which has been
present in both iliac fossae at different times. She had similar problems around the age of
17 years which led to time off school. She thinks that her pains are made worse after eat-
ing citrus fruits and after some vegetables and wheat. She has tried to exclude these from
her diet with some temporary relief but overall there has been no change in the symptoms
over the 6 years. One year previously she was seen in a gastroenterology clinic and had a
sigmoidoscopy which was normal. She found the procedure very uncomfortable and
developed similar symptoms of abdominal pain during the procedure. She is anxious
about the continuing pain but is not keen to have a further endoscopy.
She has a history of occasional episodes of headache which have been diagnosed as
migraine and has irregular periods with troublesome period pains but no other relevant
medical history. She is a non-smoker who does not drink alcohol. Her paternal grandmother
died of carcinoma of the colon aged 64 years. Her parents are alive and well. She works as
a secretary.
Examination
Examination of the cardiovascular and respiratory systems is normal. She has a palpable,
rather tender colon in the left iliac fossa.
NormalHaemoglobin 11.9 g/dL 11.7–15.7 g/dL
Mean corpuscular volume (MCV) 84 fL 80–99 fL
White cell count 5.3% 109 /L 3.5–11.0% 109 /L
Platelets 244 % 109 /L 150–440% 109 /L
Erythrocyte sedimentation rate (ESR) 8 mm/h !10 mm/h
Sodium 138 mmol/L 135–145 mmol/L
Potassium 4.4 mmol/L 3.5–5.0 mmol/L
Urea 4.2 mmol/L 2.5–6.7 mmol/L
Creatinine 89 &mol/L 70–120&mol/L
Glucose 4.6 mmol/L 4.0–6.0 mmol/LINVESTIGATIONS
Question
- What is the most likely diagnosis and what investigations should be performed?