What is the next step in managing a 73-year-old non-diabetic patient with weeks of abdominal discomfort and normal amylase and lipase levels?

From the Guidelines

The next step in managing this 73-year-old non-diabetic patient with weeks of abdominal discomfort and normal amylase and lipase levels should be a comprehensive evaluation to rule out potential causes of persistent abdominal pain, including a detailed history and physical examination, complete blood count, comprehensive metabolic panel, and fecal occult blood test, as recommended by the British Society of Gastroenterology guidelines 1. Given the patient's age and symptoms, it is essential to consider the possibility of irritable bowel syndrome (IBS), as well as other conditions such as malignancy, inflammatory diseases, or structural abnormalities.

• A comprehensive abdominal imaging study, such as an abdominal CT scan with contrast, may be necessary to identify potential causes of persistent abdominal pain.
• The patient's symptoms and medical history should be carefully evaluated to determine the need for additional testing, such as upper endoscopy or colonoscopy.
• The American Gastroenterological Association medical position statement on IBS suggests that a thorough evaluation, including a detailed history and physical examination, is essential for diagnosing and managing IBS 1.
• The recent review on IBS and mental health comorbidity highlights the importance of a multidisciplinary approach to management, including dietary counseling, neuromodulators, and brain-gut behavior therapies, and recommends a patient-centered approach to treatment 1.
• The patient's quality of life and symptoms should be carefully monitored, and treatment should be adjusted as needed to ensure optimal management of their condition.

From the Research

Next Steps in Managing Abdominal Discomfort

The patient in question is a 73-year-old non-diabetic individual with normal amylase and lipase levels, experiencing weeks of abdominal discomfort. Given these symptoms, the following steps can be considered:

• Diagnostic Approach: The diagnosis of irritable bowel syndrome (IBS) can be considered based on the patient's symptoms, as suggested by 2. A detailed history, physical examination, and basic laboratory tests can help in the positive diagnosis of IBS and the exclusion of underlying organic diseases, as noted in 3.
• Symptom-Based Diagnosis: Validation studies of consensus symptom-based criteria have identified the importance of predominant symptoms such as abdominal pain, bowel dysfunction, and bloating, along with the exclusion of alarm symptoms, as mentioned in 2.
• Initial Treatment Plan: The initial treatment plan for IBS can include patient education, reassurance, and first-line treatments such as fiber and osmotic laxatives for constipation, opioids for diarrhea, and antispasmodics for pain, as suggested by 2. Loperamide can be considered for patients with painless diarrhea or alternating bowel habits associated with abdominal pain, as shown in 4 and 5.
• Further Evaluation: If the patient's symptoms do not respond to first-line treatments, further evaluation for specific functional disorders such as rectal evacuation disorder, abnormal colonic transit, and bile acid diarrhea may be required, as mentioned in 2. Ultrasound elastography can be a useful non-invasive tool for assessing intestinal changes in inflammatory bowel disease, as discussed in 6.

Key Considerations

• A thorough diagnostic approach is essential to rule out underlying organic diseases.
• Symptom-based diagnosis and treatment can be effective in managing IBS symptoms.
• Further evaluation and individualized treatment may be necessary for patients who do not respond to first-line treatments.
• Non-invasive diagnostic tools like ultrasound elastography can be useful in assessing intestinal changes.