# Situation: A 29-year-old office worker has had recurrent crampy lower abdominal pain for 7 months. The pain occurs about twice a week, eases after she passes stool, and comes with looser, more frequent stools; she has had no hard or lumpy stools. She has no fever and no night-time symptoms. Her results are shown with normal ranges in parentheses. Hemoglobin: 9.8 g/dL (12–16) Mean corpuscular volume (MCV): 72 fL (80–100) C-reactive protein (CRP): 3 mg/L (below 5) Tissue transglutaminase immunoglobulin A (IgA): negative, with normal total IgA Which finding calls for further investigation before her symptoms are attributed to a functional bowel disorder?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630484  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 29-year-old office worker has had recurrent crampy lower abdominal pain for 7 months. The pain occurs about twice a week, eases after she passes stool, and comes with looser, more frequent stools; she has had no hard or lumpy stools. She has no fever and no night-time symptoms.

Her results are shown with normal ranges in parentheses.
Hemoglobin: 9.8 g/dL (12–16)
Mean corpuscular volume (MCV): 72 fL (80–100)
C-reactive protein (CRP): 3 mg/L (below 5)
Tissue transglutaminase immunoglobulin A (IgA): negative, with normal total IgA
Which finding calls for further investigation before her symptoms are attributed to a functional bowel disorder?

## 보기

1. Pain that eases after passing stool
2. Symptoms that worsen near work deadlines
3. A negative celiac blood test result
4. Anemia with small red blood cells **✔ 정답**

**정답: 4**

## 해설

Iron-deficiency anemia (low hemoglobin with small red cells) is an alarm feature that points to organic disease such as occult bleeding, celiac disease, or inflammatory bowel disease and must be investigated before IBS is accepted. Pain eased by defecation and stress-related worsening fit IBS.

## 심화 해설

The alarm feature in her results
Her hemoglobin is 9.8 g/dL (normal 12–16) and her mean corpuscular volume (MCV) is 72 fL (normal 80–100). Low hemoglobin with small red cells is a microcytic anemia, most often iron-deficiency anemia. In a client with bowel symptoms, iron deficiency is an alarm feature: it suggests chronic blood loss or malabsorption, which irritable bowel syndrome does not cause. A functional diagnosis such as IBS is accepted only after alarm features have been investigated.

What the anemia could mean
Iron-deficiency anemia with lower abdominal pain and loose stools raises the possibility of organic disease such as occult gastrointestinal bleeding, celiac disease, or inflammatory bowel disease. Her C-reactive protein of 3 mg/L is normal, which makes active inflammation less likely but does not exclude these causes. In a young woman, heavy menstrual losses and diet also contribute to iron deficiency, but the finding must still be evaluated before her symptoms are labeled functional. The nurse reports it so that the provider can arrange further investigation, such as iron studies and endoscopic evaluation as indicated.

| Finding | Fits IBS? | Significance |
| --- | --- | --- |
| Pain eased by defecation | Yes | Part of the Rome IV criteria |
| Worse near work deadlines | Yes | Stress commonly worsens IBS |
| Negative tissue transglutaminase IgA with normal total IgA | Reassuring | Makes celiac disease less likely |
| Hemoglobin 9.8 g/dL, MCV 72 fL | No | Alarm feature; needs investigation |

Why the other findings are not alarms
Pain that eases after passing stool is one of the defining features of IBS. Worsening with stress, such as work deadlines, is typical of IBS because the gut-brain axis influences motility and sensitivity. A negative tissue transglutaminase IgA test with a normal total IgA level is a reliable screening result for celiac disease; the normal total IgA confirms the test was valid, since IgA deficiency can cause a false negative. Watch out! Do not read "negative celiac test" as a reason to investigate further; it is reassuring here.

Exam takeaway
Alarm features that call for investigation before IBS is accepted include anemia, rectal bleeding, unintended weight loss, nocturnal symptoms, fever, a family history of colorectal cancer or inflammatory bowel disease, and onset at an older age. Key point! Iron-deficiency anemia in a client with bowel symptoms is never attributed to IBS without further work-up.

## 임상 시나리오

Alarm Features Before an IBS DiagnosisMicrocytic anemia needs investigation
Hemoglobin 9.8 g/dL with MCV 72 fL indicates iron-deficiency anemia, an alarm feature pointing to possible occult bleeding, celiac disease, or inflammatory bowel disease.

Pain eased by defecation and stress-related worsening are typical of IBS. A negative tissue transglutaminase IgA with normal total IgA is reassuring.

Other alarm features: rectal bleeding, weight loss, nocturnal symptoms, fever, and a family history of bowel cancer.

CautionDo not label symptoms as functional until anemia and other alarm features have been reported and evaluated.

## 핵심 개념

- **Microcytic anemia** — Anemia with smaller than normal red blood cells (low MCV), most commonly from iron deficiency.
- **Alarm feature** — A sign or symptom that suggests organic disease and requires investigation before a functional diagnosis is made.
- **Tissue transglutaminase IgA** — A blood antibody test used to screen for celiac disease, valid when total IgA is normal.
- **Mean corpuscular volume** — The average size of red blood cells, used to classify anemia as microcytic, normocytic, or macrocytic.

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