What is the recommended next step in evaluating a 24-year-old female with chronic generalized abdominal pain, gas, bloating, and intermittent diarrhea, who has a history of ovarian cysts and appendectomy, with normal laboratory results, including a normal white blood cell (WBC) count, and has been avoiding gluten?

From the Guidelines

The recommended next step in evaluation for this 24-year-old female with chronic generalized abdominal pain, gas, bloating, and occasional diarrhea is to perform a comprehensive evaluation for irritable bowel syndrome (IBS) and consider a trial of soluble fibre, such as ispaghula, as a first-line dietary therapy, as recommended by the British Society of Gastroenterology guidelines 1.

Evaluation Approach

The patient's symptoms, including generalized abdominal pain, gas, bloating, and occasional diarrhea, are consistent with irritable bowel syndrome (IBS), and the normal lab values and WBC count suggest absence of acute inflammation, making functional gastrointestinal disorders more likely than inflammatory conditions.

• The British Society of Gastroenterology guidelines recommend that all patients with IBS should be advised to take regular exercise and offered first-line dietary advice, including the use of soluble fibre, such as ispaghula, which is an effective treatment for global symptoms and abdominal pain in IBS 1.
• A diet low in fermentable oligosaccharides, disaccharides, and monosaccharides and polyols may also be considered as a second-line dietary therapy, but its implementation should be supervised by a trained dietitian 1.

Additional Testing

Given the patient's history of ovarian cysts, a pelvic ultrasound would be appropriate to assess for recurrent ovarian cysts.

• The patient should also complete a symptom diary for 2-4 weeks, documenting food intake, symptoms, and bowel movements to identify potential triggers.
• If celiac testing is negative but symptoms improve with gluten avoidance, non-celiac gluten sensitivity could be considered, although the British Society of Gastroenterology guidelines do not recommend a gluten-free diet in IBS 1.

Treatment

Treatment can then be started and the patient's condition reevaluated in 3-6 weeks, as recommended by the American Gastroenterological Association medical position statement on irritable bowel syndrome 1.

• If treatment is unsuccessful, or if further evaluation seems needed, additional studies based on symptom subtype can then be undertaken, such as a hydrogen breath test to evaluate for small intestinal bacterial overgrowth (SIBO) or lactose intolerance.
• A colonoscopy might be warranted if there are alarm symptoms such as weight loss, rectal bleeding, or family history of colorectal cancer, though these don't appear present in this case.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient Presentation

The patient is a 24-year-old female presenting with generalized abdominal pain, gas, bloating, and occasional diarrhea, which have been ongoing for years. She has a history of ovarian cysts and a previous appendectomy. Laboratory tests, including WBC, are normal. The patient has been avoiding gluten, although it is unclear if this has had any impact on her symptoms.

Relevant Medical History

• Ovarian cysts
• Appendectomy
• Normal laboratory tests, including WBC
• Avoiding gluten

Potential Diagnoses

Based on the patient's symptoms and history, potential diagnoses could include:

• Irritable Bowel Syndrome (IBS)
• Inflammatory Bowel Disease (IBD)
• Celiac disease or non-celiac gluten sensitivity
• Ovarian cysts or other gynecological conditions

Next Steps in Evaluation

Given the patient's symptoms and history, the next steps in evaluation could include:

• Further questioning about the patient's symptoms, including the timing and severity of abdominal pain, gas, and bloating, as well as any factors that exacerbate or relieve these symptoms 2
• Physical examination to assess for any abdominal tenderness or masses
• Laboratory tests, such as stool studies or blood work to evaluate for celiac disease or other conditions
• Imaging studies, such as ultrasound or CT scan, to evaluate for ovarian cysts or other abdominal pathology
• Consideration of a gluten challenge to assess for gluten sensitivity or celiac disease

Consideration of Previous Studies

Previous studies have highlighted the importance of taking a comprehensive patient history 2 and considering a range of potential diagnoses when evaluating patients with abdominal symptoms. The patient's history of ovarian cysts and previous appendectomy should also be taken into account when developing a differential diagnosis. However, there is limited direct evidence to guide the evaluation of this specific patient, and further testing and evaluation will be necessary to determine the underlying cause of her symptoms.