Chronic Abdominal Pain with Negative Initial Workup

Clinical History

‍41-year-old female with four months of intermittent crampy abdominal pain, mostly left lower quadrant. Bloating, alternating bowel habits, constipation-predominant. No alarm features: no weight loss, no bleeding, no nocturnal symptoms, no family history of CRC or IBD. CBC, CMP, CRP, celiac panel all normal. No colonoscopy.

Clinical Question

‍Everything I’ve checked is negative. I’m thinking IBS, but I’m hesitant to make that diagnosis without a colonoscopy. Should I scope her first?

Specialist Guidance

‍You don’t need a colonoscopy to diagnose IBS. IBS is a positive diagnosis based on Rome IV criteria, not a diagnosis of exclusion.

She meets the criteria: recurrent abdominal pain at least one day per week for three months, associated with defecation and change in stool form. She’s under 45, no alarm features, labs are clean. Scoping her won’t change management and adds unnecessary cost and procedure risk.

For treatment, start with diet: increase soluble fiber and try a low-FODMAP elimination for 4–6 weeks. Give dietary changes a real shot before reaching for medications. If diet isn’t enough, linaclotide works well for IBS-C. Refer to GI only if alarm features develop or she’s not responding after 3–6 months of adequate treatment.

Outcome

‍Low-FODMAP diet started. Bloating and pain improved at 4 weeks. No medications needed. Managed entirely in primary care. No referral required.

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