What is the best course of action for a 50-year-old female patient with anorexia, bloating, and abdominal pain in the right hypochondrium and right iliac fossa, who experiences relief after bowel movements, and has a history of anal fissure treated with lactitol (osmotic laxative) powder, lumbar arthritis, and hemorrhoids surgery?

Immediate Referral to Gastroenterology for Colonoscopy and Comprehensive Evaluation

This patient requires urgent gastroenterology referral for colonoscopy to exclude inflammatory bowel disease (particularly Crohn's disease), colorectal malignancy, and other organic pathology before attributing symptoms to functional disorders. The combination of right-sided abdominal pain (both hypochondrium and iliac fossa), anorexia, and complex anorectal history with failed hemorrhoid surgery warrants systematic exclusion of serious pathology 1.

Critical Red Flags Present

Your patient has multiple concerning features that mandate specialist evaluation:

• Age 50 years: This is the threshold age where colorectal cancer screening becomes mandatory, and any new gastrointestinal symptoms require complete colonic evaluation 1.
• Anorexia: This is a red flag symptom that suggests organic disease rather than functional bowel disorder 1.
• Right-sided abdominal pain: Pain in both the right hypochondrium and right iliac fossa raises concern for hepatobiliary pathology, inflammatory bowel disease (particularly Crohn's with ileocecal involvement), or right-sided colonic pathology 1.
• Complex anorectal surgical history: The failed hemorrhoid surgery with suture dehiscence requiring re-operation suggests either technical complications or underlying pathology (such as Crohn's disease) that impairs healing 1, 2, 3.

Why Gastroenterology First (Not General Surgery)

Colonoscopy must precede any further anorectal surgical intervention because perianal fistulas and complex anorectal disease occur in 13.7-37% of Crohn's disease patients, and can be the initial manifestation in up to 81% of those who develop perianal disease 2. The presence of multiple anorectal problems (fissure, hemorrhoids requiring surgery with complications) at age 50 with new systemic symptoms (anorexia) strongly suggests underlying inflammatory bowel disease rather than simple cryptoglandular disease 2, 3.

• Crohn's disease changes surgical management: If Crohn's disease is present, standard hemorrhoidectomy or fissure surgery can lead to severe complications including non-healing wounds, fistula formation, and fecal incontinence 1, 3.
• Endoscopic assessment determines treatment strategy: Active rectal inflammation must be identified before any surgical intervention, as this fundamentally alters the approach from simple surgical repair to combined medical-surgical management 1, 2.

Specific Diagnostic Workup Required

The gastroenterologist should perform:

1. Complete colonoscopy with ileoscopy: To evaluate for Crohn's disease, ulcerative colitis, or colorectal malignancy 1, 2.
2. Laboratory evaluation: Complete blood count (to assess for anemia), inflammatory markers (ESR, CRP), and celiac serologies if diarrhea is present 1.
3. Contrast-enhanced pelvic MRI: If colonoscopy reveals inflammatory bowel disease or if complex perianal disease is suspected, MRI is the gold standard for assessing perianal fistulas and abscesses 2.

What NOT to Do

• Do not assume irritable bowel syndrome: While IBS is common in 50-year-old females and can present with bloating and pain relieved by defecation, the presence of anorexia and complex anorectal history makes this diagnosis premature without excluding organic disease 1.
• Do not continue only symptomatic treatment with lactitol: While osmotic laxatives are appropriate for constipation and anal fissure management, they do not address the underlying pathology if Crohn's disease or malignancy is present 1.
• Do not refer to colorectal surgery first: Surgical intervention without endoscopic evaluation risks catastrophic complications if underlying IBD is present 1, 2, 3.

Interim Management While Awaiting Gastroenterology

• Continue lactitol powder: This is appropriate for managing constipation and supporting anal fissure healing 1.
• Add dietary fiber and increased fluid intake: These are first-line conservative measures for constipation-predominant symptoms 1.
• Avoid NSAIDs: These can exacerbate inflammatory bowel disease if present 1.
• Document weight: Any weight loss would further elevate concern for malignancy or inflammatory bowel disease 1.

Common Pitfall to Avoid

The most dangerous error would be attributing all symptoms to "hemorrhoids" or "IBS" without complete evaluation. Both patients and physicians tend to ascribe all anorectal symptoms to hemorrhoids, but many are caused by other conditions 1, 4. Current practice guidelines advocate minimum anoscopy and flexible sigmoidoscopy for rectal bleeding, with complete colonoscopy indicated when bleeding is atypical, no source is evident on anorectal examination, or the patient has significant risk factors (age ≥50 years) 1.

The combination of systemic symptoms (anorexia), age 50, right-sided abdominal pain, and complicated anorectal history creates a clinical picture that demands exclusion of serious pathology before any functional diagnosis can be entertained 1, 2.