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The following case study is based on a common patient profile using epidemiological data and the following references and any similarity to individual cases is purely coincidental.
Mrs Smith is 46 and in 1997 had an episode of traveller’s diarrhea while on vacation. She was referred by her GP to the gastroenterologist for investigation in 1998 after presenting with weight loss, diarrhea and abdominal pain. Her tissue transglutaminase (IgA tTG) celiac screen was negative and small bowel biopsy was normal while consuming a gluten containing diet for at least six weeks. She had no bowel infection or parasitic infestation. Her inflammatory markers and fecal calprotectin test (showing bowel inflammation), which were tested more recently, were normal. Her colonoscopy, SeHCAT test, fecal elastase and lactose breath test were also normal. She has no history of eczema, asthma or atopy and had no previous abdominal surgery.
She was discharged to primary care after extensive work up with a diagnosis of IBS-D and prescribed Loperamide Hydrochloride and Mebeverine Hydrochloride for symptomatic control, she used these occasionally. She is a frequent user of primary care services and found the process of reaching a diagnosis caused anxiety at the time and was both frustrating and unhelpful for her.
On her last visit to her GP, Mrs Smith informed the GP that she had tried the Low FODMAP diet after researching it on the internet. While she felt her symptoms had improved to a small degree, the information she downloaded on the diet was often inconsistent and confusing. She therefore requested a referral to a FODMAP trained dietitian to try the diet in a more systematic manner. On initial assessment by the specialist dietitian, Mrs Smith was given an explanation of IBSD as a functional gut disorder and the role of gastroenterology and the Rome III criteria in the positive diagnosis of IBS and asked if she was happy to discuss her symptoms. Her symptoms were assessed using a symptom assessment tool based on the gastrointestinal symptom rating scale (GSRS, Svedlund et al., 1988), the Bristol stool chart and a global symptom question (see symptom chart) her current medical, family and social history were queried; weight, weight history, diet and any foods avoided were also queried and discussed. She was prescribed 2 months exclusion of high FODMAP foods except lactose, which was not problematic.