Case studies

Case 1

Case 2

Case 3

‘Second spike at 60’ – diagnosing older-onset inflammatory bowel disease

Presentation

A 62-year-old man presented with a 4-month history of loose bowels (passing stool 3–5 times daily), urgency and occasional incontinence if unable to reach a toilet on time. On several occasions over the past 6 weeks, he had noticed fresh blood mixed with stool and mucus on the toilet paper. He had mild, cramping lower abdominal pain, which worsened before bowel opening and partially relieved afterwards. He had lost around 3kg unintentionally and felt more fatigued than usual.

Medical history

Medications

Work context

Exclusions

Hypertension, knee and lumbar spine osteoarthritis (no regular painkillers)

Assessment

On examination, he was afebrile, with mild pallor, a soft abdomen and mild LLQ tenderness. On rectal exam, there was fresh blood on the glove but no palpable mass. FCP was not indicated, as the GP suspected colorectal cancer and ordered relevant investigations. Initial primary care investigations showed:

FBC

Hb 108 g/L; MCV 79

Ferritin

CRP

30mg/L

Coeliac screen

Normal

TFTs

Normal

Renal function

Normal

Liver function

Normal

FIT

Negative

Stool cultures

Negative (ordered due to new onset bloody diarrhoea, rule out atypical infection)

The combination of chronic diarrhoea, rectal bleeding, iron deficiency anaemia, raised inflammatory markers and weight loss should have triggered suspicion of both colorectal cancer and IBD. However, the GP did not initially consider IBD due to the patient’s age and thus only made a red-flag referral for colonoscopy. Neither colorectal cancer nor IBD was excluded by the negative FIT, which is a cancer triage tool, not an IBD rule-out test.

outcome

Colonoscopy was macroscopically abnormal with continuous distal colitis and friable mucosa, but no suspicion of malignancy. While awaiting histology results, the surgeons referred the patient to gastroenterology. After 3 weeks, the biopsies confirmed UC. He was commenced on mesalazine, and at review he showed clear symptom improvement.

If the colonoscopy had appeared normal and the patient was discharged back to primary care, the next steps would have been to revisit the history, re-examine for evolving signs or symptoms and consider arranging FCP testing.

Clinicians often associate IBD exclusively with younger adults, and altered bowel habit in older patients often results in red-flag referrals for colonoscopy intended to exclude bowel cancer, rather than investigate for IBD. In a macroscopically normal colonoscopy, persistent diarrhoea may be attributed to IBS or medication side effects. However, this kind of anchoring bias should be avoided, as older age does not exclude IBD. IBD has a bimodal age distribution, and new diagnoses in older adults are well recognised.

‘Common things are common’ – confidently diagnosing irritable bowel syndrome

Presentation

A 31-year-old woman presented with an ongoing 7-year history of intermittent crampy lower-abdominal pain associated with bloating. Her bowel habit alternated between diarrhoea-predominant episodes and periods of constipation. The pain worsened during working weeks and improved on defecation, while her bloating, bowel noises and flatulence increased by late afternoon.

Medications

Work context

Diet

Exclusions

Combined oral contraceptive pill continuously; over-the-counter loperamide for diarrhoea episodes and peppermint oil capsules for bloating as required

Assessment

A normal examination found a soft abdomen, with mild generalised tenderness and no focal peritonism or masses. A PR exam was declined, with no rectal bleeding reported. FIT, stool culture and colonoscopy were not indicated. Testing showed:

FBC

Normal

Ferritin

Normal

CRP

Normal

Coeliac screen

Normal

TFTs

Normal

Renal function

Normal

Liver function

Normal

FCP

22 µg/g (ordered to rule out IBD)

The assessment supported a positive diagnosis of IBS, due to a long history (>6 months) of fluctuating symptoms, abdominal pain related to defecation, alternating bowel habit and clear association with stress, no red flags, and low FCP. IBD was unlikely due to normal inflammatory markers, low FCP and absence of red flags (absence of nocturnal symptoms, weight loss, bleeding or anaemia).

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intervention

Primary care intervention sought to:

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Explain IBS as a disorder of gut–brain interaction

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Acknowledge the impact of symptoms on quality of life

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Reassure that tests do not suggest inflammation or cancer, therefore avoiding the need for further invasive investigations

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Signpost to local stress control services

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Encourage to avoid known triggers, reduce caffeine and to eat regular, small, varied meals throughout the day

•

Offer referral to dietitian for long-term strategies to control symptoms

•

Agree planned follow up at 8 weeks

She was given explicit advice to re-present if she develops rectal bleeding, nocturnal diarrhoea, unintentional weight loss, persistent worsening of symptoms.

outcome

At 8-week review, symptoms were improved with dietary changes and reduced caffeine. She had had her first dietitian appointment and was on the waiting list for stress control classes. She felt reassured by a clear diagnosis and safety-netting plan. The case demonstrates how:

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IBS can be made as a positive diagnosis with strong history-taking and focussed non-invasive investigations

•

A colonoscopy is unnecessary to confirm diagnosis of IBS

•

Normal CRP and low FCP make IBD very unlikely in the absence of red flags

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Clear explanation and reassurance reduce repeat consultations, although safety-netting and planned follow-up are essential to avoid missing evolving pathology in a minority

A confident IBS diagnosis reduces anxiety, unnecessary referrals, invasive investigations and repeat attendances, while encouraging self-management.

‘Could this be IBD?’ – revisiting an established diagnosis

Presentation

A 26-year-old presented with a 5-year history of abdominal symptoms (‘nervous tummy’) that had recently worsened. Over the past 6 months, he had been experiencing persistent diarrhoea, bloating and crampy lower abdominal pain, which improved after defecation, as well as a sensation of incomplete emptying and some rectal discomfort. The diagnosis of IBS was reaffirmed after normal blood tests at a walk-in centre 3 months previous. Since that visit, he had developed nocturnal diarrhoea once or twice weekly, worsening fatigue, worsening urgency and reduced appetite, with slightly looser clothes. He did not see blood in stool but noticed mucous on a few occasions.

Psychosocial context

Work context

Exclusions

Felt frustrated and dismissed, stating 'they told me it’s IBS and stress, but this feels different’

Assessment

On examination, observations were normal, with mild generalised abdominal tenderness without peritonism, no masses and maximal tenderness at the right iliac fossa and umbilical regions. A chaperoned rectal examination was painful, with no blood on glove or mucous noted. FIT and stool culture were not indicated. Initial primary care investigations showed:

FBC

Hb 118

Ferritin

Normal

CRP

Coeliac screen

Normal

TFTs

Normal

Renal function

Normal

Liver function

Normal

FCP

280µg/g

The existing IBS diagnosis was not consistent with features including anaemia, raised inflammatory markers, elevated FCP and evolving symptom pattern. Therefore, the patient’s diagnosis was revisited, and he was referred for colonoscopy.

outcome

Colonoscopy showed patchy terminal ileal inflammation, and biopsies confirmed CD. The patient was started on induction therapy and referred to gastroenterology. IBD and IBS overlap symptomatically early on, and it is worth asking ‘Could this be IBD?’ before diagnosing IBS to prevent delays in diagnosis. This case shows how patients diagnosed with IBS require clear safety netting, with explicit advice to actively recognise and re-present in red-flags signs of IBD, such as nocturnal diarrhoea, worsening or persistently changing symptoms, or raised FCP, which can be a valuable triage test in chronic diarrhoea. Once a patient is labelled with IBS, subsequent symptoms are often attributed to stress and anxiety, which may delay re-investigation to challenge the diagnosis. Safety netting could have led to earlier reconsideration of the original diagnosis and faster referral for urgent lower-GI assessment, altering the patient’s course.