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CMPP > Intestinal Diseases 2 (part 1) > Flashcards

Intestinal Diseases 2 (part 1) Flashcards

1
Q

Irritable Bowel Syndrome

A

Chronic abd pain and altered bowel habit without an organic cause identified

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2
Q

IBS prevalence in US

A

10-15%

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3
Q

who does IBS affect?

A

everyone, but mostly
younger patients
women

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4
Q

diagnosis of exclusion

A

consider other things before diagnosing with IBS

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5
Q

what is the second most common cause of absenteeism after the common cold?

A

IBS

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6
Q

what is the predominant pattern of motor activity in IBS?

A

there is none

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7
Q

components of IBS

A

abnormal motor patterns (increased frequency and irregularity of luminal contractions, ^ peristalsis but not effective

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8
Q

in patients with constipation predominant IBS what is altered with their transit time?

A

it is prolonged

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9
Q

what comes of exaggerated motor response to CCK and meal ingestions in IBS

A

diarrhea predominant IBS

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10
Q

visceral hypersensitivity in IBS

A

distension occurs at lower balloon volumes in IBS patients

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11
Q

intestinal inflammation in IBS

A

increased number of lymphocytes in the colon and small intestine
release NO and histamine > activate visceral response
more proinflammatory cytokines (TNF)

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12
Q

psychosocial dysfunction

A

pts have more stressful life style

increased anxiety, depression, phobias, somatization (physical evidence of mentally being stressed)

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13
Q

what is released from the paraventricular nucleus and plays as a major mediatory of the stress response

A

corticotropic releasing factor

higher in IBS patients and causes overactivity in the brain

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14
Q

chronic abdominal pain in IBS

A 
crampy
variable intensity
periodic exacerbation (waxes and wanes)
emotional stress and eating exacerbates pain
defecation may provide relief
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15
Q

abd pain features that DO NOT contribute to IBS

A

pain w/ anorexia, malnutrition, or weight loss
people who can’t eat anything
progressive pain
pain which awakens from sleep

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16
Q

what should you ask about diarrhea predominant IBS

A

stools of small or moderate size
does it occur during waking hours? (unusal to have IBS wake one up at night)
associated with lower abd cramps or urgency prior to BM
tenesmus
mucus in stools

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17
Q

diarrhea symptoms that DO NOT contribute to IBS

A

large volumes
blood
nocturnia diarrhea
greasy

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18
Q

constipation and IBS

A

lasts days to months
could have periods of diarrhea or normal bowel habits
sense of incomplete evacuation (tenesmus)

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19
Q

other vague GI complaints of IBS

A 
GERD
dysphagia
early satiety
intermittent dyspepsia
nausea
non-cardiac chest pain
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20
Q

extraintestinal symptoms of IBS

A 
dysparunia
lack of sexual function
dysmenorrhea
increased urinary frequency or urgency
fibromyalgia
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21
Q

rome III criteria for IBS

A

recurrent abd pain/discomfort for at least 3 days/month
last 3 months associated with 2 of the following
improvement with defecation
onset associated with change in frequency of stool
onset associated with change of consistency of stool

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22
Q

other supportive symptoms of IBS

A 
abnormal stool frequency < or = 3BM/wk or >3BM/day
abnormal stool form
defecation straining
urgency
feeling of incomplete BM
passing mucus
bloating
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23
Q

4 subtypes of IBS

A

IBS with constipation
IBS with diarrhea
Mixed IBS
Untyped IBS

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24
Q

IBS w/ constipation

A

> 25% lumpy stools, <25% loose, watery stools

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25
Q

IBS w/ diarrhea

A

> 25% loose, watery stools, <25% lumpy stools

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26
Q

mixed IBS

A

> 25% loose, watery stools, >25% lumpy stools

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27
Q

untyped IBS

A

doesn’t meet any of the >/<25% criteria

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28
Q

treatment for IBS

A

relief of symptoms

addressing patients concerns

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29
Q

cure for IBS

A

there is none

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30
Q

pt education on IBS

A

emphasis that this is a chronic illness, but it is benign

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31
Q

dietary considerations with IBS diagnosis

A 
do a diary of diets
consider lactose free
exclude gas-producing foods
consider food allergies
\+/- fiber foods
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32
Q

physical activity and IBS

A

increases peristalsis in sm and lg intestines

20-60 minutes 3-5x week

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33
Q

medication therapy in IBS

A

don’t do it if you don’t have to (be reluctant to use long term), there isn’t evidence that it helps long term which doesn’t make the side effects worth it

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34
Q

diarrhea predominant IBS

A

antispasmotic agents

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35
Q

antispasmotic agent MOA

A

directly affects intestinal smooth muscle relaxion (anticholinergics > more constipation)

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36
Q

specific antispasmotic for IBS

A

dicyclomine (Bentyl)
hyoscyamine (levsin)
if no relief in 2 weeks, stop

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37
Q

side effects for dicyclomine and hyoscyamine

A

dry mouth, dizziness, blurred vission

38
Q

when don’t you use antidepressants to treat IBS

A

constipation predominant

39
Q

How do antidepressants help IBS

A

analgesic properties to work on neurotransmitters all over the body

endogenous endorphine release > block norepinephrine reuptake so inhibits pain pathway

slows intestinal transit time bc anticholinergics

40
Q

the only antidiarrheal agent sufficiently investigated for use in IBS that results in a reduction in stool frequency and improvement in consistency

does not reduce pain, bloating, global symptoms of IBS

A

Loperimide (immodium)

41
Q

first step of medication therapy for constipation predominant IBS

A

Lubiprostone (amitiza)

42
Q

Lubiprostone MOA

A

chloride channel activator resulting in increased salt and water in intestinal lumen

43
Q

what medicaion is approved for IBS in women >18

A

Lubiprostone (amitiza)

44
Q

what must be monitored while on Lubiprostone

A

electrolytes (keep up on labs)

45
Q

drug whose MOA is binding to guanylate cyclase-C (GC-C) to relieve constipation in IBS to release secretion of Chloride and bicarb into intestinal lumen

A

Linaclotide (Linzess)

46
Q

percentages with constipation for both genders over 65

A

26% men

34% women

47
Q

how much spent yearly on laxatives

A

$800mil

48
Q

is constipation benign?

A 
no. complications include
perforation
hemmorhoids
anal fissures
fecal impaction
overflow diarrhea
49
Q

rome II criteria for constipation

A

atleast 12 weeks (not necessarily consecutive) in the past year including 2+ of
straining in >25% attempts
lumpy/hard stools >25%
sensation of incomplete evacuation >25%
sensation of anorectal obstruction >25%
<3 stools per month

50
Q

some complications for the elderly population contributing to constipation

A

not enough dietary fiber

poor denture fitting

51
Q

which drugs provoke constipation?

A

those that affect smooth muscle, nerve conduction, or the CNS

52
Q

specific drugs that cause constipation

A

opioids: inhibit gastric emptying and propulsive motor activity by depressing excitability of neurons in GI tract
(S.E. does not lessen as tolerance of opiods increase)

anticholinergics: benadryl, OTC cough and cold, anti-nausea (zofran)

vitamins (iron, calcium, antacids)

heart medicines (CCB and diuretics)

53
Q

metabolic causes of constipation

A

hypothyroidism
hypokalemia
hypo and hypercalcemia

54
Q

neurologic causes of constipation

A

spinal cord injury: neurogenic bowel and bladder disruption, ANS component loss
parkinson’s: disease itself of meds to treat it
stroke: affects central bowel and bladder control

55
Q

tumor causes of constipation

A

rectal and sigmoid tumors

56
Q

pregnacy causing constipation

A

high progesterone levels > constipation

57
Q

Normal colonic transit time idiopathic chronic constipation

A 
normal colonic transit time
no relief from laxatives or fiber
misperception of bowel freq
stressed about BM
abnormal anorectal sensory/motor function that makes sensory and perception of defecation similar to someone with a slow transit
58
Q

slow transit idiopatic chronic constipation

A

visualized with radiopaque marker
resting colonic motility is normal
little or no increase in motility with stimulus or laxative
problem is likely to be enteric nerve plexus

59
Q

outlet delay IBS

A

radiopaque markers move through colon normally but stop at rectum
could be from pelvic floor dys-synergy

60
Q

pertinent history questions to ask for iBS

A 
2 week diary
what do they think is normal?
new meds?
underlying illness?
associated symptoms?
sudden change in calliber or freq, insidious onset (cancer)
61
Q

physical exam findings for constipation

A

abd exam: hard masses
rectal exam: impaction, rectal tone, ROBT, hemorrhoids
voluntary holding of stool
concern of chancer

62
Q

when would you observe labs for constipation

A

when you think they have a metabolic cause

63
Q

when does hyperkalemia occur leading to constipation

A

patients with CHF who are on lasix
renal failure
history of hypothyroidism
mew med change

64
Q

when do you use imaging for constipation

A

you don’t unless you’re concerned about impaction or cancer

65
Q

gastrocolic reflex

A

reflex to defecate 15 minutes - 90 minutes after meal start time

66
Q

diet modification for constipation

A

consume 20-35g fiber daily

absorbs water and increases stool bulk

67
Q

bulk forming laxatives

A

psyllium (metamusil)
methylcellulose (citrucel)
polycarbophil (fibercon)

make sure to drink enough water to make this effective

68
Q

best in class of bulk forming laxatives

A

metamucil

69
Q

stool softeners (how do they work)

A

decrease the surface tension on the surface of the bowel to allow more water to enter

70
Q

what are stool softeners ineffective for?

A

chronic constipation

71
Q

what are stool softeners very effective for?

A

anal fissures or hemorrhoids

72
Q

examples of stool softeners

A 
docusate sodium (colace) -maintains soft stools
mineral oil -do not ingest, use enema to soften and lubricate recutm before manual disimpaction
73
Q

stimulate laxatives (how they work?)

A

increase bowel motility by stimulating the colon

74
Q

examples of stimulant laxatives

A

sennakot

bisacodyl (dulcolax)

75
Q

what are stimulant laxatives very effective at?

A

preventing and treating opiod induced constipation

76
Q

can you use stimulant laxatives long term?

A

NO, cause hypokalemia

77
Q

what precaution do you take with stimulant laxatives

A

anorexic and bulimic disorders

78
Q

how osmotic laxatives work

A

substances are hypertonic osmotically active particles > draw water into the colon due to osmotic gradient

79
Q

when should you use osmotic laxatives

A

LAST RESORT

80
Q

types of osmotic laxatives

A

milk of magnesia
polyethylene glycol (miralax)
magnesium citrate (colonscopy bowel prep)
lactulose (enulose)

81
Q

describe lactulose

A 
nondigestible sugar 
very effective
prescription only
very sweet!
broken down by gut flora
can cause a lot of gas
82
Q

disimpaction

A

removal of bulk of stool in rectum blocking the exit

83
Q

enemas

A

sodium phosphate enema (Fleets)
soap suds in tap water
glycerine suppository

84
Q

when are enemas best used

A

if you’re concerned about impaction
help clear the path before aggressively soften and stimulate with PO meds

if you stimulate with PO meds to increase contractions it can be very painful or perforation can occur

85
Q

what should you do prior to prescribing an enema

A

do a DRE

86
Q

acute mesenteric ischemia

A

ischemic bowel caused by a reduction in intestinal blood flow

87
Q

vasospasm

A

vessels feeding part of the intestines, spasm, cut off blood supply

88
Q

hypoperfusion

A

bowel becomes dehydrated, low flow

89
Q

occlusion

A

a clot, atrial fibrillation

90
Q

what is the serious risk of an ischemic bowel

A

sepsis
bowel infarction
death

91
Q

risk factors of acute mesenteric ischemia

A 
advanced age
atherosclerosis
low cardiac output states
cardiac arrhythmias (A FIB!)
severe card

CMPP (17 decks)

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