A 36-Year-Old Lawyer With Blood-Streaked Loose Stool

Neil Khoury, MD; John W. Birk, MD


July 11, 2023

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


A 36-year-old woman with irritable bowel syndrome (IBS) who recently moved to work in a law firm presents as a new patient to establish care. Her chief report is loose stools (three to four episodes per day), with occasional streaks of bright red blood in them, for the past 6 months. She also describes intermittent episodes of abdominal pain relieved by defecation.

Five months ago, a colorectal surgeon performed a rigid sigmoidoscopy, which revealed internal hemorrhoids. The patient was instructed to take a fiber supplement, which slightly reduced her stool frequency, although she continued to have small amounts of blood in her stool. About 4 months ago, she went to a rheumatologist because of knee and hip pain. The rheumatologic workup was largely unrevealing. The rheumatoid factor, antinuclear antibody, and C-reactive protein (CRP) levels and the erythrocyte sedimentation rate (ESR) were all within normal limits, and the radiographs were normal. She was told that her pain was likely due to jogging on paved streets.

She reports no nausea, vomiting, early satiety, vision changes, rash, low back pain, unintentional weight loss, fecal urgency, or episodes of nocturnal diarrhea or fecal incontinence. She has no family history of celiac disease, colorectal cancer, or inflammatory bowel disease. She does not use aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or illicit drugs.


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