Cases corner – 52yr old woman with bloating

21st January 2020

Olga, a 52yr old woman, presents to you with a 3 month history of intermittent lower abdominal pain and bloating. This is the first time Olga has ever experienced this combination of symptoms. She has not noted a pattern to her symptoms and denies any relation to meals, or consumption of particular food. Olga denies any other abdominal or bowel related symptoms, including PR bleeding, and is otherwise feeling well. She has not lost any weight and denies having fevers. She went through the menopause at 50yrs old and denies any gynaecological symptoms, including post menopausal bleeding. Olga has no significant past medical history or family history, has never smoked and rarely drinks alcohol./p>

On examination her abdomen is not distended, and is soft and non tender. Nil masses or organomegaly are felt. Speculum and bimanual examination is normal. Observations are all normal and her weight is stable.

What would you do next?

  1. Ask the patient to keep a symptom diary and review in 4 weeks
  2. Order a routine set of blood tests, including CA125
  3. Order an urgent CA125 and FIT test
  4. Order a routine abdominal ultrasound scan
  5. Refer the patient via the Gynaecology 2 week wait pathway

Olga has unexplained abdominal pain and bloating. This presentation raises the suspicion of more than 1 underlying malignancy: ovarian and colorectal. Let’s start with NICE ovarian cancer guidelines, which recommend the following:

Carry out tests in primary care (see recommendations 1.5.6 go 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. [2011]

The recommendations 1.5.6 to 1.5.9 within the NICE ovarian cancer guidelines that were mentioned above are as follows:

Measure serum CA125 in primary care in women with symptoms that suggest ovarian cancer.

If serum CA125 is 35 IU/ml or greater, arrange an ultrasound scan of the abdomen and ≥pelvis [2011]

If the ultrasound suggests ovarian cancer, refer the women urgently for further investigations [2011]

For any woman who has a normal serum CA125 (less than 35 IU/ml), or CA125 of 35 IU/ml or greater but a normal ultrasound:

  • asses her carefully for other clinical causes of her symptoms and investigate if appropriate
  • if no other clinical cause is apparent, advise her to return to her GP if her symptoms become more frequent and/or persistent. [2011]

Olga’s symptoms also raise suspicions of colorectal cancer. In some areas symptomatic FIT tests (Faecal Immunochemical Test) are now being used as part of the colorectal cancer pathway in adults WITHOUT RECTAL BLEEDING who meet the following criteria:

  • ≥50yrs with unexplained abdominal pain or weight loss
  • <60 years with changes in their bowel habit or iron deficiency anaemia
  • ≥60 years and have anaemia even in the absence of iron deficiency

***NOTE: if FIT testing is not available and there are additional clinical concerns, refer patient as an urgent suspected cancer referral and give full clinical details in ‘additional clinical information’.

If the FIT test is positive then Olga should be referred via the colorectal 2 week wait pathway. If the test is negative then you should review her again and determine whether further assessment, investigation or referral is warranted.