15. IBS, IBD and gastroenteritis Flashcards by Anthony Barlow

In a patient who presents with abdo pain ad diarrhoea what red flags would warrant an urgent referral

aged over 60
rectal bleeding 
anaemia 
weight loss
family history of colorectal cancer 
abdo/rectal mass 
raised CRP/ESR or faecal calprotectin

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in women over 50 with persistent bloating what is mandatory to rule out ovarian cancer

USS of ovaries

Ca125 levels

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What is IBS

it is a functional bowel disorder (FBD)
this means that there is no identifiable organic disease underlying the symptom
‘diagnosis of exclusion’ is the old term

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how common is IBS

very common and occurs in 20% of the population
affects women more than men
more common in younger adults

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what are the symptoms of IBS

Diarrhoea
Constipation
Fluctuating bowel habit (diarrhoea, constipation or alternating)
Abdominal pain
Bloating or distention
Worse after eating
Improved by opening bowels

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NICE guidelines: criteria for diagnosis

other pathology should be excluded. Which tests do you need to carry out to exclude other pathology

Normal FBC, ESR and CRP blood tests
Faecal calprotectin negative to exclude inflammatory bowel disease
Negative coeliac disease serology (anti-TTG antibodies)
Cancer is not suspected or excluded if suspected

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NICE guidelines: what are the symptoms that suggest IBS

abdo pain/discomfort that is relived on opening bowels or associated with a change in bowel habit 
AND 2 of;
abnormal stool passage 
bloating 
worse symptoms after eating 
PR mucus

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what general advice can you give after a diagnosis of IBS

General healthy diet and exercise advice:
• Adequate fluid intake
• Regular small meals
• Reduced processed foods
• Limit caffeine and alcohol
• Low “FODMAP” diet (ideally with dietician guidance)
• Trial of probiotic supplements for 4 weeks

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what is a FODMAO diet

stands for fermentable oligo-, di-, mono-saccharides and polyols)

Oligosaccharides: Wheat, rye, legumes and various fruits and vegetables, such as garlic and onions.

Disaccharides: Milk, yogurt and soft cheese. Lactose is the main carb.

Monosaccharides: Various fruit including figs and mangoes, and sweeteners such as honey and agave nectar. Fructose is the main carb.

Polyols: Certain fruits and vegetables including blackberries and lychee, as well as some low-calorie sweeteners like those in sugar-free gum.

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what is the first line medications used for IBS

Loperamide for diarrhoea
Laxatives for constipation. Avoid lactulose as it can cause bloating. Linaclotide is a specialist laxative for patients with IBS not responding to first-line laxatives
Antispasmodics for cramps e.g. hyoscine butylbromide (Buscopan)

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why do you avoid lactulose in patients with IBS

can cause bloating

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what is the second line medication for IBS

tricyclic antidepressants eg amitriptyline 5-10mg at night

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what is the third line medication for IBS

SSRI antidepressants

important to tell the patient that this is not to treat the brain but used for the gut at a much lower dose

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name some extra intestinal manifestations associated with IBS

o	Nausea
o	Thigh pain 
o	Backache 
o	Lethargy 
o	Urinary symptoms 
o	Gynaecological symptoms (dyspareunia- pain during sexual intercourse)

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What is the main issue with an IBS amongst society

stigmatised
inadequacies of treatment
hopelessness and suicide

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Give some examples of antispasmodics that are anticholinergic

o	Dicycloverine (merbentyl)
o	Hyoscine (buscopan) 
o	Propantheline (probanthine)

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give some examples of antispasmodics that are anti-smooth muscle

o	Mebeverine (colofac)
o	Alverine (spasmonal) 
o	Peppermint (colpermin)

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Give some examples of antidiarrhoeals

o Loperamide – the best one

 It improves anal tone, regular use low dose is safe and can take inn combination with antispasmodics

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apart from medication, what else can be advised to see if it helps with IBS

CBT, hypnotherapy, acupuncture and probiotics

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What are the benefits of probiotics in IBS

o Enhances host anti-inflammatory and immune response
o Stimultate anti-inflammatory cytokines
o Restore the balance between pro and anti-inflammatory cytokines
o Improves epithelial cell barrier
o Epithelial adhesion

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What advice can you give to patients about IBS

too long winded answer, look at page 2 of your notes

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What is IBD and what is it split into

Inflammatory bowel disease is the umbrella term for two main diseases causing inflammation of the GI tract: Ulcerative Colitis and Crohn’s disease. They both involve inflammation of the walls of the GI tract and are associated with periods of remission and exacerbation.

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What are the key differentiating factors with chrons

Chrons- think crows NESTS

N – No blood or mucus (less common)
E – Entire GI tract
S – “Skip lesions” on endoscopy
T – Terminal ileum most affected and Transmural (full thickness) inflammation
S – Smoking is a risk factor (don’t set the nest on fire)

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what are the key differentiating factors with ulcerative colitis- remember U C CLOSEUP

C – Continuous inflammation
L – Limited to colon and rectum
O – Only superficial mucosa affected
S – Smoking is protective
E – Excrete blood and mucus
U – Use aminosalicylates
P – Primary Sclerosing Cholangitis

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how does IBD usually present

* Diarrhoea * Abdominal pain * Passing blood * Weight loss

what tests would you perform when investigating IBD

* Routine bloods for anaemia, infection, thyroid, kidney and liver function * CRP indicates inflammation and active disease * Faecal calprotectin (released by the intestines when inflamed) is a useful screening test (> 90% sensitive and specific to IBD in adults) * Endoscopy (OGD and colonoscopy) with biopsy is diagnostic * Imaging with ultrasound, CT and MRI can be used to look for complications such as fistulas, abscesses and strictures.

what is diagnostic for IBD

endoscopy with biopsy.

What drugs are used for inducing remission in Chrons

• First line: Steroids (e.g. oral prednisolone or IV hydrocortisone) do not use steroids to maintain remission

which class of drugs can be used to induce remission if steroids are not sufficient and also used to maintain remission

thiopurines (azathioprine, mercaptopurine) or methotrexate (second-line)

which class of immunosuppressive drugs increases your risk of non-melanoma skin cancer

theopurines

give some alternative Biologic therapy drugs that can be used if the conventional therapy for chrons isn't effective

anti-tumour necrosis factor alpha monoclonal antibody agents infliximab and adalimumab

What is the treatment for inducing remission of ulcerative colitis

* First line: aminosalicylate (e.g. mesalazine oral or rectal) * Second line: corticosteroids (e.g. prednisolone

what is the treatment for inducing remission of ulcerative colitis in severe disease

* First line: IV corticosteroids (e.g. hydrocortisone) | * Second line: IV ciclosporin

what is the main treatment for maintaining remission in ulcerative colitis

* Aminosalicylate (e.g. mesalazine oral or rectal) * Azathioprine * Mercaptopurine

what is the main area that ulcerative colitis affects

40-50% of people have proctitis

what is the main area affected in chrons

the Ileum/ileoclonic 40% | 30-40% have skip lesions in the small intestine

for the next set of questions decide if the answer is ulcerative colitis or chrons; smoking and appendectomy are protective

ulcerative colitis

for the next set of questions decide if the answer is ulcerative colitis or chrons -affects mainly the distal colon

ulcerative colitis

for the next set of questions decide if the answer is ulcerative colitis or chrons -affects the distal ileum and caecum

chrons

for the next set of questions decide if the answer is ulcerative colitis or chrons - patchy gut inflammation with skip lesions

chrons

for the next set of questions decide if the answer is ulcerative colitis or chrons -superfical inflammation

ulcerative colitis

for the next set of questions decide if the answer is ulcerative colitis or chrons - complications include severe bleeding, toxic megacolon, rupture of bowel and colon cancer

ulcerative colitis

for the next set of questions decide if the answer is ulcerative colitis or chrons - complications include stenosis, abscess formation, fistulas, colon cancer

chrons

what is carnets signs (not that this is not done in actual practice very often at all)

determines whether the pain originates from the viscera or myofascia/abdo wall test is positive if this manoeuvre exacerbations pain, which indicates an abdo wall pain origin

what are the reasons for a DRE

``` o Suspected appendicitis o PR bleed o Change in bowel habits o As part of abdo exam o Genitourinary problems o Pelvic or spinal trauma ```

when doing a DRE what are you looking for in he perianal area

 Haemorrhoids  Fistulae  Lesions  Warts

what kind of diarrhoea tends to have a sudden onset

infectious diarrhoea

when exploring diarrhoea what questions do you want to ask about regarding the stools

frequency, consistency, presence of blood, presence of mucus

what are the key risk factors for someone having suspected c difficult infection

antibiotic exposure, advanced age, hospitalisation or residence in a nursing home and a history of C.diff disease

what is the most important advise in regards to infective diaarhoea

• Most important advice is on fluid management, including oral rehydration such as dioralyte or simple oral rehydration solution aka ORS

how do you define diarrhoea

production of more than 2 unformed stools per day

at what point in time does diaarhoea change from being acute to chronic

4 weeks

What are the main bacteria causative agents of infective diarrhoea

Campylobacter, shigella, salmonella, c.difficle

what are the main viral causes of infective diaarhoea

Norovirus, rotavirus

what is dysentry and what are the symptoms

diarrhoea with visible blood in the stools | symptoms are fever, tenesmus and blood/pus in the stools

what are some of the main risk factors for having infectious diaarhoea

* Travel * Employment (food-handler, caregiver) * Consumption of unsafe foods * Swimming in/drinking untreated fresh surface water * Animal contact * Contact with other ill persons * Recent medication (antibiotics, antacids, antimotility agents) * Underlying HIV, immunosuppression, gastrectomy, extremes of age * Receptive anal intercourse or oral-anal sexual contact

If you suspect someone has community acquired or travellers diarrhoea what cultures would you test for

``` salmonella shigella campylobacter E.coli 0157:H7 C. difficult toxins ```

if patient has nosocomial diarrhoea ie onset if after more than 3 days in hospital then what is the most important culture to test for

c difficle | consider discontinuing antimicrobials and consider metronidazole if illness worsens for persists

what are hte indications for stool culture after 3 days in hospital

older than 645 cormorbid disease neutropenia HIV infection

note that most gastroenteritis is self limiting; | treatment of Coli H7:O157 enteritis may increase the risk of developing which diseases

HUS- haemolytic ureic syndrome | TTP - thrombotic thrombocytopenia purapura

what kind of antibiotics are good at treating campylobacter

macrolide such as azithromycin clarithromycin erythromycin

Why do you not give codeine to someone with infective diarrhoea

codeine reduces peristalsis

Give some examples of invasive bacteria

* Shigella * E coli * Salmonella * Campylobacter * Yersinia * C.difficile * Entamoeba histolytica

name some common complications with severe campylobacter infection

• Can cause toxic megacolon, pancreatitis, cholecystitis, peritonitis, arthritis ( HLA-B27)

Go over the rest of the infective bacteria from your notes page 14

go over the rest of infective bacteria from your notes page 14

Why do persons with IBS often suffer from Iatrogenesis (medical treatment/intervention worsens the disease)

* Increasingly invasive investigations * Unnecessary surgery * Opiates

name some causes of constiaption

``` o IBS o Drug induced o Slow transit o Dysinergic defecation o Enterocele o Rectocele o Normal transit ```

The chronic pain pain use neuropathic pain drugs to substitute narcotic bowel syndrome. Name the 4R principle

Recognition relationship replacement reduction

what medications can be used to replace opioids

TCA, A2D ligands, SSRI linaclotide mu opioid antagonists psychological therapies

``` what condition does IBS overlap with Rheumatoid arthritis . Colorectal cancer . Fibromyalgia . Crohns disease . Porphyria ```

Fibromyalgia

``` which of the following is not a red flag for cancer Rectal bleeding . Age over 50 . Raised CRP . Weight loss . Family history of colorectal cancer ```

age over 50

15. IBS, IBD and gastroenteritis Flashcards

(71 cards)