Case Study #3

Irritable Bowel Syndrome (IBS)

Ashley J. Trey-Roush
MNT I
Dr. Ali
November 13, 2014
T/Th 1:40pm

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Irritable Bowel Syndrome

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Understanding the Diagnosis and Pathophysiology

1. IBS is considered to be a functional disorder. What does this mean? How does this
relate to Mrs. Clarkes history of having a colonoscopy and her physicians order for
a hydrogen breath test and measurements of anti-tTG?
A functional disorder can also be referred to as a functional disease or functional illness.
These terms denote a general term for inorganic disease or a disease in which organic
changes are not evident; a disturbance of the function of any organ.1 In common
language, this definition can be translated as, a medical condition that impairs the
normal function of a bodily process, but where every part of the body looks normal
under examination, dissection or even under a microscope.
Since Mrs. Clarkes colonoscopy test returned to the doctor showing no signs of active
disease, the physician ordered a hydrogen breath test and to get the measurements of
anti-tTG. The hydrogen breath test is a simple and safe test that provides the physician
with the information he/she needs to explain the symptoms the patient is experiencing
that are otherwise difficult to diagnose and pinpoint. Studies have shown that the
lactose hydrogen breath test is often positive in irritable bowel syndrome (IBS)
patients.2 So, by the doctor ordering this test the results will help him further confirm or
deny the original hypothesis that the patient is suffering from IBS-D. Another reason to
order the hydrogen breath test is to confirm there is no sign of small intestinal bacterial
overgrowth (SIBO). SIBO is when bacteria enters the sterile environment of the small
intestine and it begins to colonize. Studies show that up to 80% of patients with IBS may
in fact have SIBO. SIBO can be easily determined by performing a hydrogen breath
test.2
Celiac disease is common in patients with presumed IBS.3 The antibody anti-tissue
transglutaminase (tTG) is tested when looking for celiac disease.4 IBS can sometimes be
difficult to distinguish clinically from adult-onset celiac disease.3 By the physician
ordering an anti-tTG test, the results from this test will aid the physician in making the
proper diagnosis. Many people with celiac disease are misdiagnosed at first with stating
they have IBS.
2. What are the ACG and the Rome III criteria? Using the information from Mrs.
Clarkes history and physical, determine how Dr. Cryan made her diagnosis of IBS-D.
The American College of Gastroenterology defines Rome III, IBS as: the basis of the
presence of:
Recurrent abdominal pain or discomfort at least three days per month in the
past three months associated with two or more of the following:
Improvement with defecation
Onset associated with a change in frequency of stool
Onset associated with a change in form (appearance) of stool5
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These criteria should be fulfilled for the past three months with symptom onset at least
six months before diagnosis.5
Rome III defines functional constipation as: the presence of two or more of the
following:
Straining during at least 25% of defecations
Lumpy or hard stools in at least 25% of defecations
Sensation of incomplete evacuation for at least 25% of defecations
Sensation of anorectal obstruction/blockage for at least 25% of
defecations
Manual maneuvers to facilitate at least 25% of defecations (e.g.,
digital evacuation, support of the pelvic floor)
Fewer than three defecations per week.5
In Rome III, IBS is subtyped according to predominant bowel habit as IBS with
constipations (IBS-C), IBS with diarrhea (IBS-D), mixed type (IBS-M), and unclassified
(IBS-U).5
Dr. Cryan used the Ms. Clarkes history and medical records to determine IBS-D was the
cause for her discomfort. Ms. Clarke states she has suffered from diarrhea and
constipation for many years. The family physician found negative stool cultures and her
colonoscopy was clear. Since IBS is a functional disease the stool test and colonoscopy
would be clear. The patient also describes times when she would go days without have
a bowel movement. And then there are days when she has uncontrollable diarrhea.
Ms. Clarke meets the above criteria for IBS. She also said that diarrhea is more
predominant lately, leading Dr. Cryan to sub-classify her IBS as IBS-D.
3. Discuss the primary factors that may be involved in IBS etiology. You must include
in your discussion the possible roles of genetics, infection, and serotonin.
The specific cause of IBS is unknown. Current research is focusing on multiple factors
that include:
-genetic predisposition
-altered immune response stimulated by food sensitivity and altered microbial
environment
-an elevated inflammatory response to gastroenteritis
-small intestinal bacterial overgrowth (SIBO)
-abnormal release, transport, or recognition of serotonin
-increased sensitivity of the enteric nervous system that causes abnormal
motility and pain.6
The Mayo Clinic recently published an article to their News Network online regarding a
current study that was published in the journal Gastroenterology. This article stated
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that researchers have reported a defined genetic defect that causes IBS. Researchers
found that patients with a subset of IBS have a specific genetic defect, a mutation of the
SCN5A gene. This defect causes patients to have a disruption in bowel function, by
affected the Nav1.5 channel, a sodium channel in the gastrointestinal smooth muscle
and pacemaker cells. Researchers were able to restore function to a patient with IBS-C
that had a defective SCN5A gene. They used a drug called mexiletine, which restored
the function of the sodium channel and reversed the patients symptoms of constipation
and abdominal pain. This research is still in the early stages, but it gives us hope into
finding cures for patients that suffer from subsets of IBS.7
Irritable bowel syndrome is the most common gastrointestinal disorders. Within this
large group of people affected, there is a small subgroup whos IBS symptoms began
suddenly. It happens after what appears to be a bout of infection in the stomach and
intestines and is termed post-infectious IBS (PI-IBS).8 PI-IBS seems uncommon after a GI
infection cause by a virus; its more common in a bacterial agent. Infections from
bacterial infections like Campylobacter, Salmonella, and Shigella are among those that
are common for causing PI-IBS.8 Inflammation is a way the body reacts to unwanted
germs as part of the immune response. The immune system needs to turn on and turn
off at the right times to fight infection and not cause harm to the body. A delay in
turning off the normal inflammatory response after an initial infection may be one cause
for PI-IBS.8 A low-grade inflammation may persist for years. These inflammatory
changes in IBS are very subtle and not routinely detectable. Infection may also cause
injury to the nerves in the guy that are responsible for gut motility and sensation. 8 The
nerve damage could also result in altered bowel movements and abnormal awareness
of pain in the GI tract.8
IBS is commonly described as a brain-gut disorder because of the association with
serotonin.9 Serotonin is an important brain neurotransmitter that is relevant to
depression, migraine, and other neuropsychiatric illnesses.10 It is estimated that 95% of
the bodys serotonin is found in the GI tract.10 The serotonin is found in small cells that
line the gut. Serotonin senses what is going on and through receptors signals nerves
that stimulate a response and it will be released to activate the nerves. Then we have to
get rid of the serotonin thats in the gut. To do that we must then reabsorb the
serotonin a process called re-uptake into the cells. This process appears to be
disrupted in people with IBS. Therefore, the serotonin remains in the gut and the
sponge or the proteins that need to take serotonin back to the cells arent working
properly. Having too much serotonin in the gut may cause waste to move too quickly
through the colon, so that the intestines cannot fully absorb liquidsleading to
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diarrhea. With the serotonin in the gut it keeps activating and over-stimulating
responses and reflexes and at times can just deactivate the nerve, killing it.11
4. Mrs. Clarkes physician prescribed two medications for her IBS. What are they and
what is the proposed mechanism of each? She discusses the potential use of
Lotronex if these medications do not help. What is the medication and what is its
mechanism? Identify any potential drug-nutrient interactions for these
medications.
Dr. Cryan prescribed Ms. Clarke to begin Elavil 25 mg daily and to take Metamucil 1 tbsp
in 8 ounces of liquid twice a daily. Elavil is a Tricyclic Antidepressant that is commonly
used to help with IBS, especially the pain and discomfort.12 Antidepressant medications
can reduce the intensity of pain signals going from the gut to brain. It is generally given
to IBS patients in lower doses than those given to depressed patients. Low-dose tricyclic
antidepressants, such as Elavil and Nopramin, have been shown to be effective in
treating IBS, particularly in those with mainly diarrhea.12 Tricyclic antidepressants
reportedly have central nervous system and peripheral effects that relieve abdominal
pain and reduce diarrhea.12 As far as drug-nutrient interactions go its recommended to
limit the amount of caffeine and there might be an increase appetite especially for
sweets.13 This should be disclosed to the patient as she is currently obese and has been
trying to cap her sweet tooth.
With the Metamucil, the drug-nutrient interactions are obsolete. The only mentioned is
a decrease in appetite. So hopefully the increase from the Elavil and the decrease from
the Metamucil will balance itself out and Ms. Clarke will not have any effects appetite
wise. Fiber supplements, like Metamucil, help control constipation.
Lotronex is used for female sufferers of irritable bowel syndrome with diarrhea (IBS-D)
who have difficulty controlling their bowel movements.13 Lotronex stops serotonin from
binding to the receptors resulting in a reduction of some of the severe symptoms that
come from have IBS-D.13 Lotronex can cause serious side effects: serious complications
of constipation and reduced blood flow to the bowel (ischemic colitis). 13 According to
their website there werent any listed drug-nutrient interactions and this drug is not
listed in assigned text for Food Medication Interactions.
II.

Understanding the Nutrition Therapy

5. For each of the following foods, outline the possible effect on IBS symptoms.
There is little scientific evidence for restricting particular foods when dealing with IBS. 9
However, patients that consume large meals and certain foods may be poorly tolerated,
such as excess quantities of dietary fat, caffeine, lactose, fructose, sorbitol, and alcohol. 9
This is especially true in patients with IBS-D or IBS-M, like Ms. Clarke.
a. Lactose
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According to a study published in 2001, a large majority of the patients with IBS
had improved symptoms after adopting a lactose-restricted diet.14 The patients
symptoms were monitored and evaluated before the diet was implemented,
during the first few days, 6 weeks into the diet, and 5 years into the new lifestyle
change. There were a few patients that chose not to follow the diet in the long
term and they reported five years later that they still had discomfort caused by
lactose intake.14 With this information, we are led to believe that limited or
excluding lactose items in the diet helps with reduce the uncomfortable
symptoms of IBS.
b. Fructose
Fructose, the type of sugar found in fruits and some vegetables could have
unpleasant digestive symptoms for those suffering from IBS. Fructose
malabsorption occurs when fructose is not fully absorbed in the small intestine
and then the sugar travels into the large intestine where it is fermented by
intestinal bacteria.15 This process effects GI motility and contributes to gas and
bloating. In some individuals its reported that fructose malabsorption may be
the result of small intestine bacterial overgrowth (SIBO).15 In many studies,
about half of patients with IBS also have fructose malabsorption based upon
hydrogen breath testing.15 When these patients consume fructose this sugar
increases and contributes to the symptoms that are associated with IBS.
c. Sugar Alcohols
Sugar alcohols are also known as polyols and are classified as a carbohydrate.
They are famously known to be in sugar-free and reduce-sugar foods and
beverages. Sugar alcohols are proven to cause bloating, flatulence and
diarrhea.16 These are the same symptoms that go along with IBS. So indulging in
sugar-free items causes those who are diagnosed with IBS to suffer increased
symptoms. The reason for the discomfort is due to sugar alcohols not being fully
absorbed in the digestive system and fermentation occurs in the colon producing
short-chain fatty acids, which are converted to energy.16 However, when a
person ingests a large amount of non-digestible sugar substitutes regularly, this
causes overt diarrhea and cramping.
d. High-fat Foods
When a person who is diagnosed with IBS intakes a meal that is high in fat it will
cause abdominal cramps and diarrhea.17 Symptoms of bloating are commonly
reported after consuming a high-fat meal.18 Research has shown that after an
infusion of enteral fat, the volume of retained gas increased from 298 to 505
ml.18 Its recommended that IBS patients should aim for only 40-50 grams of fat

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per day to help avoid the discomfort and pain that comes with consuming large
amounts of fat.18
6. What is FODMAP? What does the current literature tell us about this intervention?
FODMAP is an acronym that stands for: Fermentable Oligosaccharides, Disaccharides,
and Monosaccharides And Polyols.9 The low FODMAP diet limits foods that contain
fructose, lactose, fructo- and galactooligosaccharides (fructans and galactans), and sugar
alcohols (sorbitol, mannitol, xylitol and maltitol).9 Current research shows that limiting
the amount of FODMAPs per meal has been shown to reduce GI symptoms in patients
with IBS. Patients that avoid foods that contain fructose in excess, avoid foods that
contain significant amounts of fructans and galactans, eliminating consumption of polyol
containing foods and restricting lactose containing foods have less gastrointestinal
stress. Foods that are high in fructose are fruits and fruit juice as well has honey and
that hidden sweetener, high fructose corn syrup. Lactose is found in milk, ice cream,
cheeses. Oligosaccharides (fructans or galactans) are found in beets, broccoli, leeks,
okra, peas, wheat and rye, watermelon, apples, peaches and persimmons. Polyols are
the sugar alcohols and can be found in some fruits and vegetables. These items should
be avoided or consumed in small amounts.
7. Define the terms prebiotic and probiotic. What does the current research indicate
regarding their use for treatment of IBS?
The term prebiotic is defined as substances in food that stimulate the beneficial flora of
the large intestine.6 The term probiotics describes products containing microorganisms
manufactured and sold as food products and supplements.6 Some probiotic
supplements may offer benefits in IBS. The randomized controlled trails that have
conducted this have been small and have produced variable results depending on the
type and dose of the probiotic. Researchers have found that in a group of women with
diagnosed IBS that a higher dose of probiotic reported a significant improvement in
abdominal pain or discomfort, bloating and distension, sensation of incomplete
evacuation, passage of gas, straining, and bowel habit satisfaction.9 Prebiotic foods such
as foods with fiber, resistant starches, and oligosaccharides favor the maintenance of
healthy microflora. Prebiotics are preparations of complex sugars that the beneficial
species of good bacteria (probiotics) feed on. Clinical studies have been small and few,
and the results are mixed. Patients that were given a combination of probiotics and
prebiotics experienced significant improvements in abdominal pain, bloating, and
constipation. Another study showed prebiotics had no effect on IBS.
8. Assess Mrs. Clarkes weight and BMI. What is her desirable weight?
Mrs. Clarkes weight is 191 lbs.
BMI: 31.78
o This was calculated by using the following formula:
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BMI = Weight (lb) Height [in]2 X 7039

BMI = 191 [65]2 X 703
BMI = 191 4,225 X 703
BMI = 0.0452 X 703
BMI = 31.78
Desirable Weight (more commonly termed as ideal body weight) is 125 lbs.
o This was calculated by using the following formula:
IBW = 100 lbs for the first 5 feet then an additional 5 lbs per inch 9
IBW = 100 lbs + 5 lbs(5)
IBW = 100 lbs + 25 lbs
IBW = 125 lbs

9. Identify any abnormal laboratory values measured at this clinic visit and explain
their significance for the patient with IBS.
Ms. Clarkes blood work showed some results that need to be addressed with her.
Ms. Clarke needs to be aware that her HbA1C level has her listed at pre-diabetic. Her
mother and sister are type II diabetic. Diabetes is linked as hereditary and common in
those who suffer from IBS. Losing a few pounds could help get this level stable again.
The patient also is reporting high cholesterol levels that she should be concerned with.
High cholesterol can increase your risk of heart disease. When you have high
cholesterol, developing fatty deposits in your blood vessels is common. These deposits
make it difficult for blood to flow through your arteries, which could result in a heart
attack or stroke. A healthy diet, regular exercise can help in reducing this level.
The lab results report a high triglyceride level. High levels of triglycerides raise her risk
for heart disease and may be a sign of metabolic syndrome. High triglycerides are
caused by obesity, underactive thyroid and regularly eating more calories than you
burn. Ms. Clarke is labeled obese due to her BMI, has hypothyroidism and we dont
have records of her activity level. Lowering this level is completely manageable by
losing weight, limiting fats and sugars in the diet, being more active and limiting alcohol.
High blood glucose is also known as hyperglycemia. This is what happens when the
body has too little insulin or when the body cant use the insulin you have properly. If
hyperglycemia goes untreated it could lead to a diabetic coma. Blood glucose level is
easily managed by exercise and diet.
Speaking to Ms. Clarke about these levels is very important. She has two children to live
for and see grow up. The conversation with Ms. Clarke shouldnt be negative and a
downer. She needs to be reminded that all four of these levels can be changed with
lifestyle changes. Incorporating an exercise regime into her life will help these levels
and maybe even her IBS. Plus exercise is a great stress reliever. Stress is known to
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make IBS symptoms worse. Reminding Ms. Clarke that as her RD you are here for her to
encourage her and help her to live the healthiest life she can is important. Discouraging
is not what the tone of the conversation should be. It should be concerning but you
want to build her self-efficacy and let her know she can achieve healthier lab values.
10. List Mrs. Clarkes other medications and identify the rationale for each prescription.
Are there any drug-nutrient interactions you should discuss with Mrs. Clarke?
Ms. Clarke is currently taking the following medications at:
Omeprazole 50 mg daily
o Is a proton pump inhibitor. Must be taken 30-60 minutes before a
meal and take with an acidic juice.19
o This drug decreases the amount of acid produced in the
stomach.19 Its also used to treat gastroesophageal reflux
disease.20 Ms. Clarke has a history of gastroesophageal reflux
disease.
o Omeprazole can decrease the absorption of calcium by 61%.19
o May also decrease the absorption of iron and vitamin B12.19
Levothyroxine 25 mg daily
o Is a thyroid hormone. It must be taken on an empty stomach with
a full glass of water before breakfast to increase absorption.19
o Ms. Clarke has a history of hypothyroidism and this drug is given
when the thyroid is not producing enough of this hormone on its
own.
o There might be appetite changes when taking this drug and its
rarely reported with some GI discomfort such as nausea and
diarrhea.19
o Should be cautious of her blood pressure, because this medication
could increase it.
Vitamin D 600 IU daily
o Vitamin D is needed to absorb the calcium.
o This supplement and the calcium supplement is needed due to
the proton pump inhibitor medication that she is on.
Calcium 800 mg daily
o This vitamin supplement is given because of the proton pump
inhibitor that she is on. It is recommended that a supplement be
taken while on omeprazole.19
Lomotil (Pro re nata=As Needed)
o Lomotil is a medication prescribed to help with diarrhea.21
o There were no listed drug-nutrition interactions listed.21

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11. Determine Mrs. Clarkes energy and protein requirements. Be sure to explain what
standards you used to make this estimation.

Energy requirements 1,695 kcal per day. (Sedentary)

o Following formula was used:
o EER = 10 (WT)kg + 6.25 (HT)cm 5(age)yr + 59
I chose to use this formula because text states that the Mifflin-St.
Jeor equation was most accurate in estimating REE in both normal
weight and obese people.9 Ms. Clarke is obese due to her BMI.
o EER = 10 (191/2.2) + 6.25 (165.1) 5(42) + 5
o EER = 10 (86.82) + 1,031.88 210 + 5
o EER = 868.2 + 1,031.88 210 + 5
o EER = 1,900.08 210 + 5
o EER = 1,695.08

Protein Requirements
o Protein RDA for women in the ages 31-50 are 0.80 g/kg/day.22
o Ms. Clarke is 42 years old so this equation will be most appropriate
for her.
o Grams per day = 0.80g X 86.82kg
o Grams per day = 69.5g

12. Assess Mrs. Clarkes recent diet history. How does this compare to her estimated
energy and protein needs? Identify foods that may potentially aggravate her IBS
symptoms.
After inputting Ms. Clarkes average diet into the USDAs website to analyze food
groups, its noted that she is under on her protein intake. Her vegetable intake is good,
reaching over 3 cups a day. Her fruit intake is low according to recommendations, as
well as dairy and grains. The yogurt in the morning, the beans and asparagus at lunch
are concerns that I would address with her. Lactose, as previously mentioned
aggravates IBS. The peaches in the morning smoothie and the artificial sweetener in the
coffee are on the High FODMAP list. Kidney beans, asparagus are also on the high
FODMAP list. These foods could be contributing to her irritability.
13. Prioritize two nutrition problems and complete the PES statement for each.
Altered GI function related to suspected IBS as evidenced by diarrhea and constipation
for several months.
Inappropriate weight related to hypothyroid as evidenced by BMI.
14. The RD that counsels Mrs. Clarke discusses the use of an elimination diet. How may
this be used to treat Mrs. Clarkes IBS?
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An elimination diet would be helpful in Ms. Clarkes situation. Each IBS patient is
different, hence the different subunits of IBS and the different etiologies. A certain food
may bring discomfort to one IBS patient but another it might go unnoticed. With the
elimination diet, suspect foods are eliminated from the diet for a specified period,
usually 4 to 12 weeks, followed by a reintroduction.9 If, multiple foods are suspected, a
variation of the strict elimination diet could be used. By taking out the foods that are
suspected to cause symptoms of IBS we can access how she feels before taking the out
and then weeks after elimination access her again to determine if there is any
difference.
15. The RD discusses the use of the FODMAP assessment to identify potential trigger
foods. Describe the use of this approach for Mrs. Clarke. How might a food diary
help her determine which foods she should avoid?
Describing the use of a FODMAP could be confusing to a client that doesnt have a
nutritional background. The first thing to help Ms. Clarke feel comfortable using this
system is to introduce her to the acronym then explains to her what each means. Then
identify foods for each category, so she understands which family or group of foods to
avoid. Giving her a guide to go by when she leaves would also be helpful. Many people
are visual learners, so by providing her with a handout to guide her would be most ideal.
Something like the item23 below would aid her through the grocery store.

A food diary would be helpful in the same what an elimination diet would be. By Ms.
Clarke writing down everything she eats and her symptoms throughout the day
pinpointing a food group or type of sugar will help determine what is irritating her IBS.
Identifying the foods that are causing the symptoms and reassuring Ms. Clarke that the
hard work of detailing her diet will greatly improve her quality of life.
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16. Should the RD recommend a probiotic supplement? If so, what standards might the
RD use to make this recommendation?
Probiotics are increasingly being used for a variety of GI disorders. There are many
species of probiotics and they not all are created equal. Bifidobacterium infantis was
significant in decreasing the IBS symptoms in a research study.24 No other probiotic,
including isolated Lactobacillus species showed significant improvement in IBS
symptoms. However, in another systematic review, the use of probiotics (containing
Bifidobacteria and Lactobacilli) revealed significant effect in reducing IBS symptoms.24
These studies show that Bifidobacteria may be the active treatment in probiotic
combinations.
Bifidobacteria belongs to a group of bacteria called lactic acid bacteria. 25 Lactic acid
bacteria are found in fermented foods like yogurt and cheese. Ms. Clarke is already
eating yogurt daily. The staffed RD shouldnt recommend a probiotic supplement right
away. With Ms. Clarke adjusting her diet by incorporating the low FODMAP diet,
keeping a food dairy and possibly even the elimination diet these items alone might be
able to soften the symptoms of her IBS. The research of probiotic supplements isnt
complete at this time and her diet should be adjusted first.

17. Mrs. Clarke is interested in trying other types of treatment for IBS including
acupuncture, herbal supplements, and hypnotherapy. What would you tell her
about the use of each of these in IBS? What is the role of the RD in discussing
complementary and alternative therapies?
Hypnotherapy: There are many systematic reviews stating hypnotherapy may be a
helpful treatment for managing IBS symptoms. This involved a trained hypnotist or
hypnotherapist. While the patient is in deep relaxation, gut-directed hypnotherapy is
used. This form of hypnosis uses hypnotic induction with progressive relaxation and
other techniques, followed by imagery directed toward the gut. Several studies of
hypnotherapy for IBS have shown substantial long-term improvement of GI symtoms.26
Herbal Remedies: These are commonly used, however there is little reach and most is
done over seas and the quality was poor.26
Peppermint Oil: Peppermint oil shows much promise in improving GI quality.9
There is some evidence that peppermint oil capsules may be effective in
reducing abdominal pain, bloating, and gas.26 Non-enteric coated forms of
peppermint oil may cause or worsen heartburn symptoms.26 Due to Ms. Clarkes
gastroesophageal reflux disease, she should not consider this type of peppermint
oil.

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Acupuncture: There is no positive evidence that acupuncture helps those who suffer
from IBS.26
The field of integrative medicine is rapidly growing and it seeks to combine the best of
both worldsappropriate components of conventional medicine and alternative
medicine (known as CAM).27 Nutrition plays an important role in integrative medicine
and has branched a new field that blends the use of food and supplements to promote
optimal health and help treat disease. Sometimes this is called holistic nutrition. Food
and supplements arent meant to replace traditional medicine but RDs should
understand how this emerging area might help their clients and consider how to
incorporate it into their professional lives. The role the RD should play in this area is
first be able to grasp the concept of integrative medicine. The idea of integrative
medicine treatments are comprised of three categories: mind, body and community. 27
So the idea of integrative or holistic nutrition, goes deeper that macro- and
micronutrients, energy expenditure and food labels. An RD should be knowledgeable of
these new ideas and treatments and possibly should have a contact in the integrative
nutrition field to refer patients with further questions.

18. Write an ADIME note for her initial nutrition assessment with her plans for
education and follow-up.
Assessment: Referral from family practice physician after experiencing both diarrhea
and constipation for many years. History of hypothyroidism, gastroesophageal reflux
disease and obesity. Divorced mom of two ages 12 & 14. Kindergarten teacher. Lives
with children and her mother.
41 yo Female 55 191 lbs
Meds: Omeprazole, Levothyroxine, Vit D, Calcium, Lomotil
Labs: Glucose 115; cholesterol 201; triglycerides 171; Hba1C 6.1
EER: 1695 kcal EPR: 69.5 g protein
Diagnosis: Altered GI function related to suspected IBS as evidenced by diarrhea and
constipation for several months.
Inappropriate weight related to hypothyroid as evidenced by BMI.
Intervention:
1. Begin Elavil 25 mg daily and Initiate Metamucil 1 tbsp in 8 ox of liquid twice
daily.
2. Introduce the FODMAP Assessment to client and initiate a low FODMAP diet to
patient.
3. Consult patient to keep a food dairy and also track symptoms in dairy.
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4. Provide patient with information on how to choose low FODMAP foods so her
lifestyle can be change.
Monitoring/Evaluation:
1. Relief of IBS symptoms upon altering diet and beginning of medications.
2. Patient will state understanding of current nutritional needs during treat of IBS.
Signature:
Ashley J. Trey-Roush, RD

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References
1. Venes, D., Tabers Cyclopedic Medical Dictionary. Philadelphia: 22nd Edition; PA;
2013.
2. Simren M., Stotzer P-O. Use and Abuse of Hydrogen Breath Tests. Gut 2006. 55(3):
297-303.
3. Jadallah KA, Khader YS. Celiac disease in patients with presumed irritable bowel
syndrome: A case-finding study. World Journal of Gastroenterology 2009. 15(42):
5321-5325.
4. U.S. Department of Health and Human Services Website. Available at:
http://digestive.niddk.nih.gov/DDISEASES/pubs/celiactesting/index.aspx.
Accessed November 11, 2014.
5. Ford AC, Moayyedi P, Lacy BE, Lembo, AJ, et al. American College of Gastroenterology
Monograph on the Management of Irritable Bowel Syndrome and Chronic Idiopathic
Constipation. American Journal of Gastroenterology. 2014; 109:S2-S26.
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