1. Hilary Peace
1. IBS is considered to be a functional disorder. What does this mean? How does this
relate to Mrs. Clarke’s history of having a colonoscopy and her physician’s order for a
hydrogen breath test and measurements of anti-tTG?
A functional disorder is one that is diagnosed after other causes of patient’s symptoms
have been dismissed (Nelms M., Sucher, K., Lacey, K., 2016, pp 414). The colonoscopy,
breath test and measurement of anti-tTG were used to dismiss possible other causes of the
symptoms she’s experiencing. A negative colonoscopy rules out things such as
diverticulitis and inflammation or bleeding in the large intestine (Nelms et all, 2016, pp
423). A negative breath test would rule out small intestinal bacterial overgrowth (SIBO).
A negative anti-tTG would rule out celiac disease (Nelms et all, 2016, pp 405).
2. What are the Rome III criteria that were used as part of Dr. Mohammed's diagnosis?
Using the information from Mrs. Clarke’s history and physical, determine how Dr.
Mohammed made his diagnosis of IBS.
The ROME III diagnostic criterion for IBS is as follows:
 Recurrent abdominal pain at least 3 days out of the month in the last 3 months
with 2+ of the following:
 Improvement with evacuating one’s bowels
 Stool frequency change
 Stool appearance change
(Shih, D., Kwan, L., 2007)
Information from the history and physical that could have assisted Dr. Mohammed with
diagnosing IBS are as follows:
 Severe diarrhea followed by days of not having a bowel movement (BM)
 Worsening of diarrhea symptoms and urgency
 Ongoing abdominal pain
 Alternating constipation and diarrhea
 Hyperactive bowel sounds
 Lower abdominal tenderness
(Nelms et al, 2016, pp 414)
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.
Etiological factors in IBS are as follows:
 Altered gut flora or food sensitivity causing an altered immune response
 SIBO – bacterial overgrowth from the colon resulting from disease, surgery or
trauma to GI tract

2. Hilary Peace
 Altered serotonin activity – serotonin stimulation causes either smooth muscle
contraction or relaxation, which could lead to altered gut function causing
diarrhea and/or constipation (Crowell MD, 2004). Serotonin is typically reduced
with IBS-C and increased with IBS-D
 Infection, such as infectious enteritis, causing an elevated inflammatory response
 Hypersensitivity of enteric system
 Abnormal permeability of GI mucosa leading to inflammation
 Altered communication between the brain and gut
 Diet – certain foods can trigger or worsen symptoms
(Nelms et al, 2016, pp 414-415)
 Gender/sex hormones – women are two times as likely to have IBS and research
shows that symptoms worsen during or around their periods
(Mayo Clinic, 2014)
 Genetics – a mutation in the SCN5A has been shown to be a possible cause
(Verstraelen, T. E., Bekke, R. M., Volders, P. G., Masclee, A. A., & Kruimel, J.
W. (2015, July 20), and relatives are twice as likely to have IBS (Saito, Y.A.
2011)
4. Mrs. Clarke’s 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 this medication and what is its mechanism?
Identify any potential drug-nutrient interactions for these medications.
Name Type of drug Mechanism Interactions
Elavil Anti-depressant –
changes in serotonin
levels resulting from
the use of this
medication have
secondary effect
improving IBS
symptoms
Prevents reuptake of
serotonin by
inhibiting
responsible pump
responsible for its
release
Avoid alcohol,
caffeine, St. John’s
Wort. No drug
interactions with
other medicines
she’s taking.
Lomotil - PRN Anti-diarrheal – Slows down the
motility of the gut
and increase stool
consistency
No drug interactions
with current
prescriptions. Avoid
alcohol. Side effects
include N/V, dry
mouth, bloating and
constipation (Nelms
et al, 2016, pp 393).
Metamucil – 1T in 8
oz water daily
Anti-constipation
medication
Regulates bowel
movements
No drug interactions

3. Hilary Peace
(Drug Bank, n.d.)
Lotronex is a medication used to treat IBS-D in women that inhibits serotonin from
binding to receptors, which will decrease its effects allowing slower transit times,
decreased GI secretions and limited abnormal pain signaling (Lotronex, nd).
5. For each of the following foods, outline the possible effect on IBS symptoms:
a. lactose
 Increased gas, bloating (Nelms et al, 2016, pp 417), nausea (Hayes, P.A., Fraher,
M.H., Quigley, E.M.M, 2014)
b. fructose
 Bloating, abdominal pain, diarrhea (Shepherd, S. J., & Gibson, P. R. (2006))
c. sugar alcohols
 Diarrhea, abdominal pain, gas (Hayes, P.A., Fraher, M.H., Quigley, E.M.M,
2014)
6. What is FODMAP? What does the current literature tell us about this intervention?
Fermentable oligo-,di-, and monosaccharides and polyols (FODMAP) is an approach that
research tells us significantly reduces IBS symptoms. The approach entails limiting foods
high in FODMAPs as they’re not digested very well causing distention and gas (Nelms et
al, 2016, pp 416).
7. Define the terms prebiotic and probiotic. What does the current research indicate
regarding their use for treatment of IBS? What guidance would you give Mrs. Clarke for
choosing a probiotic?
 Prebiotic – encourages growth of beneficial bacteria in large intestine
 Probiotic – purchasable food products and supplements that contain beneficial
bacteria
(Nelms et al, 2016, pp 380)
Current research encourages their use to alleviate symptoms such as gas and bloating
(Nelms et al, 2016, pp 417). I would inform her of what to look for when purchasing a
probiotic in order to ensure she is purchasing from a viable source. The guidelines are as
follows:
 Be sure it has the “Live Active Culture” seal

4. Hilary Peace
 Locate the genus, species, and strain, as well as the numbers of each strain, in the
product
 Locate serving size and storage recommendations
 Locate contact details for manufacturer
(Nelms et al, 2016, pp 396)
8. Assess Mrs. Clarke’s weight and BMI. What is her desirable weight?
 Ht: 5’5” = (65 in)2= 4,225
 BMI: (191#s/4,225) * 703 = 31.8 (obese)
 IBW: 5 * 5 = 25 + 100 = 125#s
9. Identify any abnormal laboratory values measured at this clinic visit and explain their
significance for the patient with IBS.
 Elevated glucose
 Elevated in pts with IBS due to of occurrence of prediabetes
 Elevated cholesterol
 Typically elevated in pts with IBS
 Elevated triglycerides
 Can be caused by medical conditions, weight gain, age, heredity, and
insulin resistance. Since pt has other values that indicate prediabetes, this could
explain why triglycerides are elevated.
 Elevated A1C
 Elevated in pts with IBS due to occurrence of prediabetes
 Decreased HDL
 Typically decreased in pts with IBS
Ms. Clarke’s family history and food recall, as well as her dx of IBS, indicate she may be
prediabetic.
(Gulcan, E., Taser, F., Toker, A., Korkmaz, U., Alcelik, A., 2009)
10. List Mrs. Clarke’s other medications and identify the rationale for each prescription.
 Omezaprole – used in the treatment of GERD (pt has dx of GERD)
 Levothryoxine – used in the treatment of hypothyroidism that pt has
 Lomotil prn – anti-diarrheal medicine used to prevent diarrhea that pt has
occasionally
(Drug Bank, n.d.)
11. Determine Mrs. Clarke’s energy and protein requirements. Be sure to explain what
standards you used to make this estimation.

5. Hilary Peace
Energy
 RMR = 10W + 6.25H – 5A – 161
 (191#s/2.2) = 86.8 kg
 (65 in * 2.54 cm) = 165.1 cm
 RMR = (10*86.8) + 6.25(165.1) – 5(42) – 161
 RMR = 868 + 1,032 – 210 – 161 = 1,529
 1,529 * AF 1.1 = 1,682 calories
 1,529 * AF 1.2 = 1,835 calories
 I used Mifflin to ensure accuracy.
Protein
 0.8 g/kg – pt is sedentary
 0.8 * 86.8 kg = 69 g PRO
12. Assess Mrs. Clarke’s recent diet history. How does this compare to her estimated
energy and protein needs? Identify foods that may potentially aggravate her IBS
symptoms.
It is estimated she eats 1,577 calories and 75 grams of protein, both slightly higher than
her recommendations. (Supertracker, n.d.)
Foods that can aggravate her symptoms are as follows:
 Peaches
 Cherries
 Dried fruit
 Yogurt
 Artificial sweeteners (in coffee and Diet Pepsi)
 Cereal
 Kidney beans or lentils
 Asparagus
 Cheese
 Wheat crackers
 Bread/rolls
 Nuts (cashews and pistachios)
 Poultry with skin on
 Pasta
 Ice cream
 Cake
 Cookies
 Sugar-free candy
 Wine or beer

6. Hilary Peace
These foods are all highly fermentable and will worsen her symptoms.
(Nelms et al, 2016, pp 417)
13. Prioritize two nutrition problems and complete the PES statement for each.
Altered GI function related to diagnosis of IBS as evidenced by ROME III criteria being
met due to her abdominal discomfort more than three days per month over the last 3
months along with a change in frequency and form of stool.
Undesirable food choices related to non-compliance as evidenced by food history high in
non-FODMAP-approved foods.
14. The RDN that counsels Mrs. Clarke discusses the use of an elimination diet. How
may this be used to treat Mrs. Clarke’s IBS?
It could be used to determine what foods trigger or worsen her symptoms so she can learn
what to avoid (Nelms et al, 2016, pp 416).
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?
This approach involves eliminating potential triggers for 1-2 weeks and slowly re-
introduces them to determine if they trigger or worsen IBS symptoms. A food diary can
help because it will show her exactly what she ate that day and she can compare that to
her symptoms (Nelms et al, 2016, pp 416).
16. 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 RDN in discussing complementary
and alternative therapies?
I would tell her that there is evidence supporting other methods for controlling her
symptoms, but I would encourage her to speak with her doctor before trying them as they
are out of a RDNs scope of practice.
17. Write an ADIME note for your initial nutrition assessment with your plans for
education and follow-up.
Assessment:
 42 y/o woman dx with hypothyroidism, GERD, obesity
 Height: 5’5”, wt: 191#s, BMI: 31.8
 Stomach and intestinal complaints
 RMR: 1,529 kcal EPR: 69 g

7. Hilary Peace
 Hyperactive bowel sounds, abdominal tenderness, alternating diarrhea and
constipation for as long as she can remember
 Elevated glucose (115 mg/dL), triglycerides, cholesterol, A1C levels
Diagnosis:
 Altered GI function related to diagnosis of IBS as evidenced by ROME III criteria
being met due to her abdominal discomfort more than three days per month over
the last 3 months along with a change in frequency and form of stool.
 Undesirable food choices related to non-compliance as evidenced by food history
high in non-FODMAP-approved foods.
Intervention:
 Focus on alleviating diarrhea, gas, bloating and constipation through changes in
diet, eliminating foods, and probiotic supplementation.
 Nutrition education to focus on FODMAP, normal eating patterns, eliminating
trigger foods, and being sure pt has adequate nutrient intake.
 Nutrition education also on current research regarding fiber intake and its effects
on intestines. Informing her about psyllium husk and importance of water intake.
Monitoring/Evaluating:
 Monitor food diary and symptoms monthly.
Reference List

8. Hilary Peace
Crowell MD. Role of serotonin in the pathophysiology of the irritable bowel
syndrome. Br J Pharmacol. 2004; 141(8):1285-1293.
Drug Bank (n.d.). Retrieved October 12, 2016 from
http://www.drugbank.ca/drugs/DB00321#interactions
Drug bank (n.d.). Retrieved October 12, 2016 from
http://www.drugbank.ca/drugs/DB01081#interactions
Gulcan, E., Taser, F., Toker, A., Korkmaz, U., & Alcelik, A. (2009). Increased Frequency
of Prediabetes in Patients With Irritable Bowel Syndrome. The American Journal
of the Medical Sciences, 338(2), 116-119. doi:10.1097/maj.0b013e31819f7587
Hayes PA, Fraher MH, Quigley EMM. Irritable Bowel Syndrome: The Role of Food in
Pathogenesis and Management. Gastroenterology & Hepatology. 2014;10(3):164-
174.
Lotronex (n.d.). Retrieved October 12, 2016 from
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In Nutrition therapy & pathophysiology. 405). Belmont, CA: Cengage Learning.
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In Nutrition therapy & pathophysiology. 414). Belmont, CA: Cengage Learning.
Nelms, M., Sucher, K. P., Lacey, K. (2016). Diseases of the Lower Gastrointestinal Tract.
In Nutrition therapy & pathophysiology. 416). Belmont, CA: Cengage Learning.
Nelms, M., Sucher, K. P., Lacey, K. (2016). Diseases of the Lower Gastrointestinal Tract.
In Nutrition therapy & pathophysiology. 417). Belmont, CA: Cengage Learning.
Nelms, M., Sucher, K. P., Lacey, K. (2016). Diseases of the Lower Gastrointestinal Tract.
In Nutrition therapy & pathophysiology. 423). Belmont, CA: Cengage Learning.

9. Hilary Peace
Mayo Clinic (2014, July 31). Irritable bowel syndrome. Retrieved October 12, 2016
from http://www.mayoclinic.org/diseases-conditions/irritable-bowel-
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Irritable Bowel Syndrome: Guidelines for Effective Dietary Management. Journal
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Shih DQ, Kwan LY. All Roads Lead to Rome: Update on Rome III Criteria and New
Treatment Options. The gastroenterology report. 2007;1(2):56-65.
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July 20). The role of theSCN5A-encoded channelopathy in irritable bowel
syndrome and other gastrointestinal disorders. Neurogastroenterology & Motility,
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