From the Guidelines
The next best step in managing this 30-year-old woman with celiac disease, history of appendectomy, and symptoms of constipation alternating with diarrhea and abdominal pain would be to evaluate her adherence to a gluten-free diet and consider dietary modification. Given her symptoms of constipation, diarrhea, and abdominal pain, it is essential to first assess her adherence to a gluten-free diet, as ongoing gluten exposure could explain her persistent symptoms 1.
Key Considerations
- A thorough assessment of her diet should be conducted to confirm she is strictly avoiding all products containing wheat, barley, and rye proteins.
- If her celiac disease is well-controlled, other potential causes of symptoms, such as functional bowel disorders, microscopic colitis, pancreatic insufficiency, inflammatory bowel disease, lactose or fructose intolerance, and small intestinal bacterial overgrowth, should be considered 1.
- Implementing a low-FODMAP diet for 4-6 weeks may help identify specific food triggers, as irritable bowel syndrome (IBS) may contribute to persistent symptoms and respond to FODMAP restriction 1.
Management Options
- Dietary modification, including a strict gluten-free diet and potentially a low-FODMAP diet, is the most appropriate next step in management.
- Other management options, such as antispasmodics, polyethylene glycol, and loperamide, may be considered if dietary modifications are ineffective in managing her symptoms.
- Referral to a dietitian with expertise in managing gastrointestinal disorders can be helpful in implementing a low-FODMAP diet 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient Presentation and History
The patient is a 30-year-old woman with a history of appendectomy and celiac disease, presenting with constipation, alternating constipation and diarrhea, and abdominal pain. She has been experiencing a change in bowel movements over the past several months, with 5-6 bowel movements on some days and only 1 bowel movement per day for the past week.
Symptoms and Physical Exam
The patient complains of abdominal pain that radiates to different areas of the stomach, but denies nausea, vomiting, bloating, and bloody or tarry stools. She eats a normal diet but reports that certain foods, such as caffeine, cheese, and watermelon, irritate her abdomen. The physical exam reveals tenderness to palpation in the lower left quadrant (LLQ) of the abdomen, normoactive bowel sounds, and no dullness to percussion.
Management Options
Considering the patient's history of celiac disease and symptoms, the next best step in management is:
- Dietary modification: The patient's symptoms are consistent with celiac disease, and dietary modification is the primary treatment for this condition 2, 3. A gluten-free diet has been shown to improve gastrointestinal symptoms in patients with celiac disease, including diarrhea, constipation, and abdominal pain 3.
- Other options, such as surgical referral, administering ASA and steroids, or ordering a CT scan of the abdomen, are not supported by the evidence as the next best step in management.
Rationale
The patient's symptoms are consistent with celiac disease, and dietary modification is the primary treatment for this condition. While some patients with celiac disease may require additional testing or treatment, such as colonoscopy or pharmacologic therapies, the evidence suggests that dietary modification is the first line of treatment 2, 3. Additionally, the patient's symptoms have been persistent despite her best efforts to follow a gluten-free diet, suggesting that further dietary modification or education may be necessary to achieve optimal symptom control 4.