I recently presented a clinical scenario on a patient of mine named Brenda, in Constipation and Cramping: A Slam-Dunk Diagnosis? This 35-year-old woman came to me with symptoms that had already lasted for a year. I asked readers for feedback on my handling of Brenda.
I appreciate the feedback I have received regarding this case. The most common suggestion was to encourage Brenda to exercise, and a systematic review of randomized clinical trials published in 2019 supports this recommendation. This review included nine studies with a total of 680 participants, and the overall effect of exercise was a two-fold improvement in symptoms associated with constipation. Walking was the most common physical intervention, and along with qigong (which combines body posture, breathing, and meditation), both modes of exercise were effective in improving constipation. However, the only study evaluating resistance training failed to demonstrate a significant effect. Importantly, the reviewers considered the collective search to be at high risk of bias.
Exercise will likely help Brenda, although some brainstorming may be needed to help her fit exercise into her busy schedule. Another suggestion related to its risk of colorectal cancer, and both Drs. Cooke and Boboc cleverly noted that colorectal cancer is increasingly common in adults in their early 50s. This contrasts with a steady decline in prevalence of colorectal cancer in American adults at age 65 or older. While colorectal cancer declined by 3.3% per year among American seniors from 2011 to 2016, this favorable trend reversed among people aged 50 to 64, with rates increasing by 1% per year.
The increase in the incidence of colorectal cancer in adults aged 50 to 64 was exceeded by the increase in adults under 50, who experienced a 2.2% annual increase in the incidence of colorectal cancer between 2012 and 2016. Previously, the increase in colorectal cancer in young middle-aged adults was driven by higher rates of rectal cancer, but more recently this trend has included higher rates of proximal and distal colon tumors. In 2020, 12% of new colorectal cancer cases were expected to be in people under the age of 50.
So, how to act on this context in the case of Brenda? Her history does not suggest any overt warning signs of cancer. The story did not address a family history of gastrointestinal symptoms or colorectal cancer, which is a significant omission.
Although the number of cancer cases in people under the age of 50 may be increasing, the overall prevalence of colorectal cancer in young adults is well below 1%. At 35, Brenda does not need to be evaluated for colorectal cancer. However, persistent or worsening symptoms may result in a referral for colonoscopy at a later time.
Finally, let’s discuss how to practically handle Brenda’s case, as there are plenty of options available. I would start with recommendations for her lifestyle, including regular exercise, adequate sleep, and anything else she can achieve on the FODMAP diet. I would also recommend psyllium as a soluble fiber and expect these changes to help his constipation. But they might be less effective for abdominal cramps so I would also recommend peppermint oil right now.
If Brenda commits to following these recommendations, she will most likely improve. If she doesn’t, I’ll be more concerned about the anxiety and the Depression complicating his illness. Treating these disorders can make a big difference.
Additionally, if there is an inadequate response to initial treatment, I will initiate linaclotide Where lubiprostone. Plecanatide is another reasonable option. At this point I will also consider referring a recalcitrant case to a gastroenterologist and will definitely refer if any of these specific treatments fail Brenda. Conditions such as pelvic floor dysfunction can mimic irritable bowel syndrome with constipation and deserves consideration.
However, I do believe that Brenda will feel better. Thank you for all these insightful and interesting comments. It’s easy to see how invested we are all in improving the lives of patients.