Cases corner – 30 year old with change in bowel habit

19th April 2019

Jane, a 30 year old women, presents with an 8 month history of change in bowel habit and abdominal pain. She describes the abdominal pain as a constant, dull ache with no localising features. Her bowels go from regular, to constipated to loose. She denies any rectal bleeding, weight loss, nausea or vomiting. She reports no dietary changes and has kept a food diary for you to review. Her periods are regular. She has no past medical history to note, is a non-smoker and has no relevant family history. You conduct an abdominal examination and a pelvic examination which is unremarkable. She is up to date with her smear tests.

What should you do next?

  1. Organise an abdominal and pelvic ultrasound
  2. Organise a coeliac screen, inflammatory markers and a full blood count
  3. Order a Ca125
  4. Order a Faecal Immunochemistry Test (FIT)
  5. Diagnose her with Irritable bowel Syndrome

Jane is a young women with vague and non-specific symptoms. There are several common conditions that could account for Janes symptoms; the majority of which would be benign. There are also many routes you can take to investigate Jane for her symptoms – all of them would be appropriate to ‘rule in or out’ each of the differential diagnoses Jane could have.

Of the options given, each one of these would be seen as an appropriate next step to investigate Jane. However, there are two conditions which Jane is at risk of, where she could benefit from having these tests prioritised in order to rule out a more sinister diagnosis: a CA125 and a Faecal Immunochemistry Test (FIT).

Whilst these tests may not typically first in your first line investigations, it is important to recognise that Jane does qualify for these investigations based on her clinical presentation. Her risk of Ovarian Cancer and Bowel Cancer is significantly lower than her risk of IBS, IBD, benign ovarian cysts, menstrual disorders, coeliac or food intolerance. However, without considering these tests early, it could lead to a delay in the diagnosis which can significantly reduce survival.

Let’s have a look at the guidelines – to note – for both pathways, there are no age restrictions of when a patient should qualify for a CA125 or FIT test:

Ovarian pathway

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.

1.5.3

Consider carrying out tests in primary care (see recommendations 1.5.6 to 1.5.9) if a woman reports unexplained weight loss, fatigue or changes in bowel habit.

Low risk bowel cancer Pathway

DG30

The OC Sensor, HM JACKarc and FOB Gold quantitative faecal immunochemical tests 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.