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Clin Med III Unit I > 5 IBS, Constipation, Diarrhea > Flashcards

5 IBS, Constipation, Diarrhea Flashcards

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1
Q

Which features are NOT associated with IBS?

A

Iron deficiency anemia
Weight loss
Severe or progressively worsening symptoms

All should prompt further investigation and referral to gastroenterologist

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2
Q

What is the definition of IBS?

A

FUNCTIONAL bowel disorder (absence of biochemical cause) characterized by RECURRENT ABDOMINAL PAIN AND ALTERED BOWEL HABITS (need both elements)

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3
Q

What are the different subclassifications of IBS?

A

IBS-C (Constipation predominant)
IBS-D (Diarrhea predominant)
IBS-M (Mixed)
IBS-U (Unclassified)

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4
Q

IBS typically affects patients ______ y.o. and ______

A

20-39yo and F>M

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5
Q

Etiology of IBS is likely…

A

Multifactorial

Physiological - abnormal motility, visceral hypersensitivity

Psychosocial - early life stressors (abuse), anxiety, depression, phobias

Environmental - diet, post-infectious (gastroenteritis), gut microbiome

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6
Q

Main clinical presentation of IBS

A

Chronic/Recurrent abdominal pain/discomfort
• Cramping, diffuse (lower abdomen)
• Variable intensity
• Periodic exacerbation

Altered bowel habits
• Constipation vs. Diarrhea vs. Mixed vs. Unclassified

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7
Q

If IBS presents with GI symptoms as well, you might see…

A

Dyspepsia
Atypical CP
Vomiting (rare)

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8
Q

Extra-intestinal Sx of IBS

A 
Sexual dysfunction
Dysmenorrhea
Irritative voiding symptoms
Fibromyalgia symptoms
Somatic or psychological complaints
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9
Q

What are the RED FLAG SYMPTOMS for IBS?

KNOW THESE*

A 
Symptom onset after age 50
Severe or progressively worsening symptoms
Nocturnal diarrhea
Fevers/vomiting
Unexplained weight loss
Melena, hematochezia, occult blood
Personal or FH of colon cancer, IBD, or celiac disease
Unexplained iron deficiency anemia
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10
Q

Why do you need to do a perianal/DRE when working up IBS?

A

To rule out Crohn’s or fissure

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11
Q

More common DDx for IBS

A 
Lactose intolerance
Celiac disease
Drug induced
GI infection
IBD
Colon cancer
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12
Q

Less common DDx for IBS

A 
Colitis
Pancreatic insufficiency
Small intestinal bacterial overgrowth
Diabetes/thyroid disease
Psychiatric disease
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13
Q

What is the diagnostic criteria for IBS?

A

Rome IV criteria

Recurrent abdominal pain on average at least ONE DAY PER WEEK in the LAST THREE MONTHS, and with two or more of the following:
• Related to defecation
• Associated with a change in stool frequency
• Associated with a change in stool form (appearance)

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14
Q

Most IBS-C patients have Bristol stool types _______, while IBS-D patients have types ______

A

IBS-C = Bristol types 1 and 2

IBS-D = Bristol types 6 and 7

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15
Q

How to diagnose IBS

A

If typical hx and no alarm features - laboratory, radiographic, and endoscopic tests not routine

+/- limited screening studies as clinically appropriate (ie CBC, CMP, TSH, ESR/CRP, Celiac serological, stool studies)

If atypical hx, alarm features, or refractory to tx - lab/stool studies, cross-sectional/small bowel imaging, and endoscopy/colonoscopy with biopsies

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16
Q

Goal of IBS treatment is…

A

To relieve symptoms and improve QOL

Achieved through dietary/lifestyle mods, psychosocial support, and pharmacological therapy

Therapeutic clinician-patient relation is important (continuity of care)

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17
Q

What dietary/lifestyle mods should be suggested to IBS patients?

A

Food diary/symptom log helpful to ID triggers

Add dietary fiber (20-35g/day) - start low and increase slowly to reduce bloating/gas

FODMAP diet

+/- probiotics

Exercise

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18
Q

What is the FODMAP diet?

A

Focuses on eliminating foods that contain sugars and fibers that cause pain and bloating

Eliminate x 4-8 weeks then gradually reintroduce 1-2 foods at a time and assess tolerance

Trained dietitian helpful to avoid unnecessary dietary over restriction

May not be appropriate for everyone

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19
Q

What type of psychosocial support is necessary for IBS patients?

A

Cognitive-behavioral therapy

Relaxation/stress management

+/- behavioral health referral

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20
Q

What drugs can be used by IBS patients to alleviate abdominal pain?

A

Levsin (Hyoscyamine) and Bentyl (Dicyclomine)

Both are antispasmodic

CAUTION - anticholinergic effects**

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21
Q

What drugs can be used to relieve Sx in IBS-C?

A

Psyllium fiber

Miralax (polyethylene glycol)

Amitiza (Lubiprostone)

Linzess (Linaclotide)

Trulance (Plecanatide)

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22
Q

What drugs can be used to relieve Sx in IBS-D?

A

Imodium (Loperamide)

Rifaximin (abx that just works in the gut)

Alosteron (women only)

Viberzi (Eluxadoline)

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23
Q

What drugs are used off-label in IBS for their psychosocial benefit?

A

TCAs

Caution - AEs **

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24
Q

Name three broad etiologies of IBS

A

Physiological
Psychosocial
Environmental

NO SINGLE UNIFYING ETIOLOGY

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25
What meds can exacerbate constipation?
``` Antipsychotics Anticholinergics Iron Antacids (esp Calcium, aluminum) Opioids CCBs ```
26
Most common digestive complaint in general population
Constipation But most do not have serious disease
27
Risk factors for constipation
Improper diet and inadequate fluid intake Sedentary lifestyle Polypharmacy Age
28
What is Colonic Inertia?
Constipation caused by slow transit —> bowel movement only once every 7-10 days
29
Defecation/obstructive disorders that can cause constipation
``` Pelvic floor dysfunction Anorectal disease Rectal prolapse Rectocele Colon cancer Polyp Stricture/stenosis Fecal impaction/obstruction ```
30
Metabolic/systemic diseases that can cause constipation
``` Hypercalcemia Hyperparathyroidism Hypothyroidism DM Pregnancy Hirschprung MS Parkinson Spinal cord injuries ```
31
Key history questions to ask when working up constipation
``` Acute or chronic Normal bowel pattern Frequency, consistency of stool Laxative use**** Need for digital evacuation**** Previous colonoscopy**** Red flag symptoms/alarm features**** Any secondary/contributing cases (reconcile meds, review PMH) ```
32
What do we mean by constipation?
<3 spontaneous BM/week Lumpy or hard stools Straining Manuel maneuvers to facilitate defection (digital evacuation, support of the pelvic floor) Sensation or anorectal obstruction/blockage Sense of imcomplete evacuation
33
Constipation may also present with these GI symptoms...
Abdominal pain and bloating Pain on defection Rectal bleeding TENESMUS
34
Red flag symptoms for constipation
``` Acute onset Symptom onset after age 50 Fevers/vomiting Unexplained weight loss Melena, hematochezia, occult blood Personal or FH of colon cancer, IBD, celiac disease Iron deficiency anemia ```
35
PE components for constipation
(Usually benign) Abdominal exam to evaluate for distention, masses DRE (evaluate for fissures, hemorrhoids, tenderness, masses, stool, anal stricture, anal sphincter tone, perineal descent, dyssynergic defection) Pelvic exam to evaluate for rectocele
36
What is dyssynergic defecation?
Do DRE and ask patient to valsalva —> drowns your finger in (🤮)
37
What diagnostics do you need to do for constipation?
Limited lab eval necessary (+/- CBC, CMP, TSH) Alarm features —> further eval • Imaging studies • Colonoscopy or flex sig to ID lesions that narrow or occlude the bowel
38
How to evaluate refractory constipation patients
Colonic transit (radiopaque marker) study - evaluates rate of residue moving through colon Defecography - assesses for anatomical/functional changes Anorectal manometry - measures anal sphincter pressure/function
39
Dietary/lifestyle mods for constipation
Increase fluid/fiber intake Increase activity/exercise Bowel habit training Biofeedback helpful with defecatory dysfunction
40
What medication therapies are available for constipation?
Fiber supplements Stool softeners Osmotic and stimulant laxatives Ex agents
41
Adverse effects of fiber supplements
Flatulence Bloating Distention
42
Adverse effects of osmotic laxatives
GI discomfort/bloating CAUTION - Mg-containing laxatives and hypermagnesemia in patients with RENAL INSUFFICIENCY
43
Adverse effects of stool softeners
GI cramping
44
Adverse effects of stimulant laxatives
GI cramping Rarely lyte disturbances Melanosis coli (benign)
45
Complications of constipation
Hemorrhoids/anal fissures Fluid and electrolyte abnormalities from laxative abuse Fecal impaction —> bowel obstruction
46
Who are at higher risk of fecal impaction?
Patients with dementia, neurologic disease, immobile, or on hypomotility meds Present with N/V, abdominal pain, distention, paradoxical “diarrhea” (only liquid passing)
47
What is the most likely cause of acute diarrhea?
Viral infection (esp Norovirus)
48
What is the definition of diarrhea?
Passage of ≥ 3 unformed stools/day
49
Diarrhea is considered acute if duration is...
<14 days
50
Diarrhea is considered persistent if duration is ...
14-30 days
51
Diarrhea is considered chronic if duration is ...
>30 days
52
Most common cause of acute diarrhea?
Infectious******* • Viral*** • Bacterial • Protozoal
53
Non-infectious causes of acute diarrhea
``` Meds Fecal impaction Food intolerance Radiation/ischemic colitis Appendicitis Diverticulitis Intussusception Emotional stress IBD Celiac disease ```
54
Red flag symptoms for diarrhea
``` Fever Unexplained weight loss Melena, hematochezia, occult blood Persistent/progressive/nocturnal symptoms Immunocompromised Personal or FH of colon cancer, IBD, celiac Iron deficiency anemia SIGNS OF VOLUME DEPLETION ```
55
Acute diarrhea is considered noninflammatory if...
Watery and nonbloody, +/- N/V Mild diffuse abdominal cramps, bloating/flatulence +/- low grade fever
56
Possible etiologies of noninflammatory acute diarrhea
Viral: Norovirus, rotavirus Bacterial: Vibrio cholera, Clostridium perfringens, Staph aureus, Bacillus cereus Protozoal: Giardia, Cryptosporidium, Cyclospora
57
Acute diarrhea is considered inflammatory if...
Fever Bloody Severe abdominal pain
58
Possible etiologies of inflammatory acute diarrhea
Viral: CMV Bacterial: Salmonella, Campylobacter, Shigella, Enterohemorrhagic E. coli O157:H7, C. difficile, Vibrio parahemolyticus, Yersinia Protozoal: entamoeba histolytica
59
The focus for your PE in diarrhea cases should be...
Volume status and complications Diagnostics not routinely warranted for most patients
60
When should acute diarrhea —> prompt evaluation?
Signs of inflammatory diarrhea (Fever ≥ 101.3, leukocytosis, bloody diarrhea, severe abdominal pain) Intractable vomiting Profuse watery diarrhea and dehydration AKI/electrolyte abnormalities Elderly or nursing home residents Immunocompromised Hospital-acquired diarrhea, exposure to abx
61
Treatment of acute diarrhea is usually...
``` Supportive care and symptomatic relief • Oral rehydration therapy • Trial of lactose free diet • Probiotics? • +/- antidiarrhea agents ```
62
What adverse effect do you need to warn patients about when prescribing bismuth subsalicylate?
Black stool 💩💩💩💩
63
Older children/adults with acute diarrhea, with hx of prepared foods, sick contacts (CRUISE ships, camps, healthcare facilities, schools, daycare)
Norovirus
64
Viral diarrhea typically affecting kids 6 months to 2 years, with hx of sick contacts
Rotavirus
65
Rice-water diarrhea, travel hx to area with unsanitary conditions
Vibrio cholerae Supportive case, MAYBE doxy, macrolide, tetracycline, FLQ
66
C. perfringens, S. aureus, and B. cereus cause diarrhea primarily via...
Enterotoxins, typically food borne
67
Inadequately heated/reheated meats, poultry, gravy, home-canned goods
Clostridium perfringens
68
Food borne diarrhea - creamy foods, egg/potato salad, dairy, processed meat Illness within hours of exposure
Staphylococcus aureus
69
Food borne diarrhea: Grains (esp rice) Illness within hours of exposure
Bacillus cereus
70
Camping, lakes, streams, ponds
Giardia lamblia Treat with metronidazole
71
Diarrhea from cryptosporidium is associated with ...
Recreational water outbreaks, daycares Self-limited except in AIDS patients
72
Cyclospora is associated with
Imported foods (fresh fruits, veggies) Treat with TMP-SMX
73
Inflammatory bacterial diarrhea associated with poultry and lifestock
Salmonella
74
Inflammatory bacterial diarrhea that can be linked to Guillan-Barre syndrome
Campylobacter jejuni Undercooked poultry, unpasteurized milk
75
“Classic dysentery” etiology
Shigella - fecal contamination of food/water (daycares, crowded living)
76
Severe afebrile bloody diarrhea
Enterohemorrhagic E. coli (O157:H7) - shiga toxin producing Associated with undercooked ground beef or unpasteurized products
77
Why don’t we give antidiarrheals or abx to patients with O157:H7 E. coli?
Risk of HUS
78
Recent hospitalization or abx use —> acute inflammatory diarrhea
C. diff Discontinue inciting abx, give vancomycin, fidaxomicin, or metronidazole
79
Inflammatory diarrhea associated with raw seafood/shellfish
Vibrio parahemolyticus
80
Which inflammatory diarrhea etiology mimics appendicitis?
Yersinia enterocolitica - from undercooked pork, unpasteurized milk, or Fe ally contaminated water

Clin Med III Unit I (6 decks)

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