I recently presented a clinical scenario about a patient of mine named Brenda. This 35-year-old woman came to me with symptoms that had been going on for a year already. I asked for readers’ comments about my management of Brenda.
I appreciate the comments I 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 twofold improvement in symptoms associated with constipation. Walking was the most common exercise intervention, and along with qigong (which combines body position, breathing, and meditation), these two modes of exercise were effective in improving constipation. However, the one study evaluating resistance training failed to demonstrate a significant effect. Importantly, the reviewers considered the collective research to be at a high risk of bias.
Exercise will probably help Brenda, although some brainstorming might be necessary to help her fit exercise into her busy schedule. Another suggestion focused on her risk for colorectal cancer, and Dr. Cooke and Dr. Boboc both astutely noted that colorectal cancer is increasingly common among adults at early middle age. This stands in contrast to a steady decline in the prevalence of colorectal cancer among U.S. adults at age 65 years or older. Whereas colorectal cancer declined by 3.3% annually among U.S. older adults from 2011 to 2016, there was a reversal of this favorable trend among individuals between 50 and 64 years of age, with rates increasing by 1% annually.
The increase in the incidence of colorectal cancer among adults 50-64 years of age has been outpaced by the increase among adults younger than 50 years, who have experienced a 2.2% increase in the incidence of colorectal cancer annually between 2012 and 2016. Previously, the increase in colorectal cancer among early 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 cases of colorectal cancer were expected to be among individuals younger than 50 years.
So how do we act on this context in the case of Brenda? Her history suggests no overt warning signs for cancer. The history did not address a family history of gastrointestinal symptoms or colorectal cancer, which is an important omission.
Although the number of cases of cancer among persons younger than 50 years may be rising, the overall prevalence of colorectal cancer among younger adults is well under 1%. At 35 years of age, it is not necessary to evaluate Brenda for colorectal cancer. However, persistent or worsening symptoms could prompt a referral for colonoscopy at a later time.
Finally, let’s address how to practically manage Brenda’s case, because many options are available. I would begin with recommendations regarding her lifestyle, including regular exercise, adequate sleep, and whatever she can achieve in the FODMAP diet. I would also recommend psyllium as a soluble fiber and expect that these changes would help her constipation. But they might be less effective for abdominal cramping, so I would also recommend peppermint oil at this time.
If Brenda commits to these recommendations, she will very likely improve. If she does not, I will be more concerned regarding anxiety and depression complicating her illness. Treating those disorders can make a big difference.
In addition, if there is an inadequate response to initial therapy, I will initiate linaclotide or lubiprostone. Plecanatide is another reasonable option. At this point, I will also consider referral to a gastroenterologist for a recalcitrant case and will certainly refer if one of these specific treatments fails in Brenda. Conditions such as pelvic floor dysfunction can mimic irritable bowel syndrome with constipation and merit consideration.
However, I really believe that Brenda will feel better. Thanks for all of the insightful and interesting comments. It is easy to see how we are all invested in improving patients’ lives.
Dr. Vega is a clinical professor of family medicine at the University of California, Irvine. He reported disclosures with McNeil Pharmaceuticals. A version of this article first appeared on Medscape.com.