Intended for healthcare professionals

Endgames Case Report

Persistent diarrhoea in a young woman

BMJ 2009; 339 doi: (Published 16 September 2009) Cite this as: BMJ 2009;339:b3369
  1. Rene Ramnarace, specialist registrar,
  2. James Ricketts, foundation year 1, medicine,
  3. Harry Dalton, consultant gastroenterologist
  1. 1Department of Medicine, Division of Gastroenterology, Royal Cornwall Hospital, Truro TR1 3LJ, Cornwall
  1. Correspondence to: R Ramnarace rene_ramnarace{at}

    A 25 year old woman presented with repetitive diarrhoea associated with a mucous discharge and abdominal pain for the past six months. She passed five to 10 stools a day, with urgency and a sensation of incomplete emptying. Her symptoms were aggravated by episodes of interpersonal stress and improved after defecation. She had no history of nocturnal diarrhoea, rectal bleeding, or weight loss. Simple analgesia improved her symptoms. Her illness was eroding her confidence and negatively affecting her social life. Clinical examination, including a rectal examination, was normal.


    • 1 What is the likely diagnosis?

    • 2 What investigation, if any, would confirm the diagnosis?

    • 3 Which symptoms should prompt further evaluation?

    • 4 What new treatments are available?


    Short answers

    • 1 Irritable bowel syndrome with predominance of diarrhoea.

    • 2 The Rome III criteria encourage clinicians to make a positive diagnosis of irritable bowel syndrome on the basis of validated symptom criteria rather than make a diagnosis of exclusion. Tests recommended by National Institute for Health and Clinical Excellence (NICE) guidelines are a full blood count, erythrocyte sedimentation rate or plasma viscosity, C reactive protein, and antibody tests for coeliac disease (endomysial antibodies or anti-tissue transglutaminase).

    • 3 The presence of alarm signs warrants further evaluation. Such signs include rectal bleeding, short history of symptoms, documented weight loss, nocturnal symptoms, male sex, family history of colon cancer, recent use of antibiotics, and age greater than 50 years.

    • 4 Treatment relies on a strong doctor-patient relationship and pharmacotherapy aimed at symptom control. New drugs include …

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