Cases corner – 21 year old with abdominal pain and bloating

10th February 2021

A 21 year old woman presents with new onset symptoms of crampy lower abdominal pain, bloating and increased flatulence. She reports experiencing these symptoms on average 3-4 times a week. Her diet is mainly fast food and can be erratic since she started university 6 months ago. The symptoms are not related to any particular foods and she is opening her bowels normally with no rectal bleeding. Her weight is normal. No symptoms of fatigue or clinical signs on examination.

What would you do next?

  1. Reassure her that her symptoms are suggestive of IBS with safety netting advice
  2. Order baseline bloods, FBC, U+E, LFT and reassure if normal
  3. Order a Ca125 to evaluate her risk of ovarian cancer and a FIT test for low risk colorectal cancer
  4. Organise an abdominal ultrasound scan and Ca125
  5. Offer dietary advice, gut health and recommend a food diary

This patient has new onset symptoms. Whilst Irritable Bowel Syndrome, diet or another cause could explain her symptoms, best practice would recommend ruling out more sinister diagnoses first. Given that her symptoms are ‘unexplained’ she should be offered both a blood test for a Ca125 for ovarian cancer and a FIT (Faecal Immunochemistry Testing) for low risk bowel cancer.

Both these tests can be ordered from primary care and results followed up accordingly. A positive FIT would support a 2-week-wait colorectal referral or an elevated Ca125 may trigger further investigation with an abdominal and pelvic ultrasound scan.

Almost half of all women diagnosed with ovarian cancer will wait three months or more from first visiting their GP to getting a correct diagnosis. 20% of women with diagnosed ovarian cancer reported bloating as one of their main symptoms.

The number of patients diagnosed with bowel cancer under 50 has increased by 25% since 2004, with 3 out of 5 people being diagnosed with late stage disease in the UK.

It is deemed both cost effective and appropriate to investigate patients with these presentations. For a patient to qualify for a Ca125 or FIT pathway there is no age restriction or limitation. Attention should be focused to the patients symptoms primarily.

Below is the NICE criteria referencing the pathway outlined above:

DG30

The OC Sensor, HM‑JACKarc and FOB Gold quantitative faecal immunochemical tests (FIT) are recommended for adoption in primary care to guide referral for suspected colorectal cancer in people without rectal bleeding who have unexplained symptoms but do not meet the criteria for a suspected cancer pathway referral outlined in NICE’s guideline on suspected cancer (recommendations 1.3.1 to 1.3.3). This is taken from “Quantitative faecal immunochemical tests to guide referral for colorectal cancer in primary care” (DG30) published by NICE in July 2017.

1.5.2

Carry out tests in primary care (see recommendations 1.5.6 to 1.5.9) if a woman (especially if 50 or over) reports having any of the following symptoms on a persistent or frequent basis – particularly more than 12 times per month:

  • Persistent abdominal distension (women often refer to this as ‘bloating’)
  • Feeling full (early satiety) and/or loss of appetite
  • Pelvic or abdominal pain
  • Increased urinary urgency and/or frequency.