Functional Gastrointestinal Syndromes

Question 1

What is the difference between IBS-C and Chronic Constipation?

Answer 1

Diagnostic Criteria for IBSa Diagnostic Criteria for
Recurrent abdominal pain or discomfortb at least 3 days/month in the last 3 months associated with 2 or more of the following:

Improvement with defecation
Onset associated with a change in frequency of stool
Onset associated with a change in form (appearance) of stool

Diagnostic Criteria for Functional Constipationa
Recurrent abdominal pain or discomfortb at least 3 days/month in the last 3 months associated with 2 or more of the following:

Improvement with defecation
Onset associated with a change in frequency of stool
Onset associated with a change in form (appearance) of stool
Must include 2 or more of the following:
Straining during at least 25% of defecations
Lumpy or hard stools in at least 25% of defecations
Sensation of incomplete evacuation for at least 25% of defecations
Sensation of anorectal obstruction/blockage for at least 25% of defecations
Manual maneuvers to facilitate at least 25% of defecations (eg, digital evacuation, support of the pelvic floor)
Fewer than 3 defecations per week
Loose stools are rarely present without the use of laxatives
Insufficient criteria for irritable bowel syndrome

Question 2

What are the 3 types of of IBS?

Answer 2

IBS is classified into 3 subtypes based on the predominant symptom: recurrent bouts of constipation (IBS-C), diarrhea (IBS-D), or mixed symptoms (IBS-M) of constipation and diarrhea

Question 3

What is the main differentiation between IBS-C and CC?

Answer 3

all patients with IBS-C must have abdominal pain or discomfort. In contrast, neither abdominal pain nor discomfort is included in the criteria for functional constipation, and is the most important primary differentiator between IBS-C and functional or chronic constipation.

Question 4

What is the work up for suspected IBS-C?

Answer 4

If the patient fits the criteria for IBS-C then:further diagnostic testing (eg, laboratory tests, colonoscopy) is indicated only if clinical evidence suggests organic disease, or if “red flags” are present. [Longstreth 2006; Brandt 2009; Black 2012] As noted by the American College of Gastroenterology Task Force on Irritable Bowel Syndrome, “the absence of selected alarm features, including anemia, weight loss and a family history of colorectal cancer, inflammatory bowel disease or celiac sprue, should reassure the clinician that the diagnosis of IBS is correct.” [Brandt 20

Question 5

What are the “Red Flags” that warrant further workup?

Answer 5

History

Unintentional weight loss (>10% of ideal body weight)
Onset in older patient (>50 y)
Family history of gastrointestinal malignancy or irritable bowel disease/celiac disease
Rectal/gastrointestinal bleeding
Recurrent nausea and vomiting
Physical Exam Findings

Rectal bleeding/obstruction
Positive fecal occult blood test
Laboratory Results

Decreased hemoglobin
Increased white blood cell count
Increased C-reactive protein
Abnormal chemistries
Abnormal thyroid stimulating hormone

Question 6

What are some common myths regarding use of stimulant laxatives?

Answer 6

A review of myths and misconceptions related to chronic use of stimulant laxatives indicates that: [Müller-Lissner 2005; Wald 2003]
• There is no convincing evidence that chronic use causes structural or functional impairment of enteric nerves or intestinal smooth muscle
• There is no reliable data to link chronic use of stimulant laxatives to colorectal cancer and other tumors
• Some patients with CC are dependent on laxatives to achieve satisfactory bowel function, but this is not the result of prior laxative intake
• Tolerance to stimulant laxatives is uncommon
• There is no evidence for occurrence of “rebound constipation” after stopping laxative intake
• While laxatives may be misused, no potential for addiction exists
In addition to the evidence summarized above, a recent randomized, double-blind, parallel-group study specifically evaluated the efficacy and safety of bisacodyl (10 mg once daily) versus placebo in patients with CC (Rome III criteria) in 27 centers in the United Kingdom. At 4 weeks, patients treated with bisacodyl had statistically significant improvement in complete spontaneous bowel movements (CSBMs), and improvement in overall Patient Assessment of Constipation quality of life (PAC-QOL) score and all subscales (satisfaction, physical discomfort, psychosocial discomfort, worries and concerns). Treatment with bisacodyl was well tolerate

Question 7

What is the current thinking Re: pathophysiology of IBS?

Answer 7

Current thinking about the pathophysiology of IBS is based on the psychosocial model, which focuses on the role of multiple factors that appear to interact to increase the predisposition for developing IBS in susceptible individuals, including genetic factors, early learning, and family influences.

Question 8

What role does Stress play in the pathophysiology of IBS?

Answer 8

Stress causes:

• imbalances or disruptions in endocrine function
• changes in the normal gastrointestinal –
• microbiota associated altered immune function
• changes in permeability
• changes in gastrointestinal motility

Question 9

Whats the Rx for mild IBS?

Answer 9

For patients with mild symptoms, one of the most important steps is to confirm a positive diagnosis of IBS and explain that the condition is chronic but manageable. Depending on their symptoms, patients with mild symptoms may be effectively managed with dietary and lifestyle changes and education

Question 10

Whats the Rx for moderate IBS?

Answer 10

Stress management is important, and they often require treatment with medication regimen that is proven to improve symptoms of IBS-C and QOL that is tailored to their individual needs

Question 11

What is the Rx for severe IBS?

Answer 11

Management of patients is similar to those with moderate symptoms, however providing continuity of care and psychological interventions becomes very important in addition to effective pharmacologic therapy. It is also important to set realistic expectations their IBS will not be cured, but their symptoms, daily functioning and QOL can be significantly improved

Question 12

How do physicians measure up in Functionnal GI patients eyes regards addressing their needs?

Answer 12

They come close to meeting expectations in describing IBS and medication. But they fall far short in:

• providing support
• providing hope
• listening
• being accessible (returning phone calls, Emails)

Question 13

Recommendations re: Amitiza (Lubiprostone)

Answer 13

Do not use. Only minimal evidence of efficacy. Frequent side effects. **May cause abortions(does so in mice)

Question 14

What is the contraindication for Linaclotide(Linzess)?

Answer 14

Don’t use under 18 y/o. Causes sudden death in young mice!!

Question 15

What are the sub-types of CC?

Answer 15

functional constipation consists of 2 subtypes:

1)Slow-transit constipation, characterized by:
Significant impairment of phasic colonic motor activity both in stationary and in prolonged 24-hour ambulatory colonic motility recordings
Significantly diminished gastrocolonic responses following a meal, and morning waking responses
Underlying neuropathy, as demonstrated by a paucity of interstitial cells of Cajal.

2)Patients with dyssynergic defecation, characterized by:
Abnormal coordination of abdominal, rectoanal, and pelvic floor muscles during attempted defecation
Impaired rectal sensation

Question 16

What are the mechanics involved in having a normal BM?

Answer 16

Having a bowel movement is a difficult event for many patients because so many things have to happen in the exact right order in this well-coordinated series of events. As shown in Figure 6, left, it is clear that stool has to move down into the rectum, called normal transit. The rectum then has to sense that stool and as that sensation occurs the puborectalis muscle should relax; that should open up the anorectal angle. The external anal sphincter muscle should relax; the internal anal sphincter muscle should reflexively relax, and as your patient takes a breath and bears down the patient should be able to evacuate stool. But all those things have to happen in a very carefully synchronized sequence.

As illustrated in Figure 6, right, if stool does not get delivered to the rectum, or if the rectum is hyposensitive—the puborectalis does not relax, if the internal anal sphincter muscle remains tight or the patient inappropriately contracts the external anal sphincter muscle. Patients are trying to expel stool but what they’re doing is bearing down and clamping and contracting that muscle. This results in a lot of symptoms of straining and incomplete evacuation.

Question 17

What can the digital rectal exam show?

Answer 17

A simple 30-second test to identify floor dyssynergia, which is commonly considered in women but may also occur in men, is to perform a complete rectal exam, which can be as informative as anorectal manometry. With the patient’s in the left lateral recumbent position, insert the examining finger, and evaluate how tight the puborectalis muscle is, as well as the tone of the external anal sphincter muscle. Note that the anorectal angle is about 90°. After checking for sensation, ask the patient to try to push out the examining finger. In a normal healthy volunteer the pelvic floor drops down a little bit, 1 to 2 centimeters, as the puborectalis muscle relaxes, and they relax the external anal sphincter muscle. But in someone with pelvic floor dysfunction the most common finding will be that the patient will clamp down on the external anal sphincter muscle rather than relaxing it, and they can’t push the finger out.

Question 18

What are some of the secondary causes of CC?

Answer 18

Endocrine: DM, Hypothyroid, Hypercalcemia
Neurologic: spinal cord, MS,Hirschsprung’s, Parkinsons
Anorectal: fissure,stricture,IBD, rectocele, rectal cancer
Enteric Myopathy/Neuropathy: scleroderma, amyloidoosis
Medications
Depression, eating disorders

Question 19

What OTC meds cause constipation?

Answer 19

Antacids(esp. calcium containing)
Calcium supplements
Iron
NSAIDS
Anti-diarrheal meds

Question 20

What Rx meds cause constipation?

Answer 20

opioids,
calcium channel blockers
TCAs
anticholinergics
statins
anti-parkinson drugs
antihistamines
diuretics
antipsychotics
sympathomimetics

Question 21

What are some treatments for CC?

Answer 21

Effective therapeutic options include biofeedback (for dyssenergia), fiber, osmotic laxatives, stool softeners, stimulant laxatives, lubricants, lubiprostone, and linaclotide.