What is the different between Functional and structural/organic GI disorders?
- No detectable pathology
- Macroscopic or microscopic detectable change in tissue
In what type of GI disorder are psychological effects more important?
Psychological factors are very important in functional disorders, particularly IBS
Name a few functional GI disorders?
Irritable Bowel Syndrome
Slow Transit Constipation
What is non-ulcer Dyspepsia?
Dyspepsia without a visible cause on endoscopy
Dyspepsia is a group of symptoms:
- Abdominal pain
What causes non-ulcer dyspepsia?
- Delayed gastric emptying
- An H. Pylori infection
- Low level duodenal ulceration (i.e. not visible)
How do we diagnose Non-ulcer Dyspepsia?
- Careful history & exam
- ALARMS symptoms
- H Pylori Test
If in doubt about whether its NUD do an endoscopy in case its not
What are the ALARMS symptoms?
Age> 55 yrs Loss of Weight Anorexia/Anaemia Recent Onset Melaena or Haematemesis/Mass Swallowing Difficulty
Also look out for nocturnal symptoms, rectal bleeding, recent med changes (particularly antibiotics) and a family history of bowel or ovarian cancer.
How do we treat NUD?
If H Pylori +ve treat with eradication therapy
If -ve treat the symptoms
Define Vomiting, Nausea and Retching?
Nausea = feeling sick Retching = Dry heaves. The antrum is contracting with closed glottis Vomiting = Contents expelled
What is the chemoreceptor trigger zone?
An area of the medulla oblongata that receives inputs from blood-borne drugs and hormones and communicates with structures in the vomiting center to initiate vomiting
How does time after eating help us determine the cause of vomiting?
Immediate = Psychogenic
1 hour or More = Pyloric OBstruction or a motility disorder (e.g. diabetes)
12 Hours = Intestinal obstruction
Name some functional disorders causing of vomiting?
- Cyclical Vomiting Syndrome
What is cyclical vomiting syndrome?
A rare disorder starting mainly in childhood causing recurrent episodes of vomiting
Between a few a year to a few a month
Often have to be hospitilized till they settle
Who is most at risk of psychogenic vomiting?
What causes psychogenic vomiting?
We dont really know, possibly stress or anxiety.
Sometimes it may be self-induced, there is some overlap with bulimia
What are the symptoms of psychogenic vomiting?
Often just sudden vomiting, sometimes with nausea
Can sometimes lose weight or appetite but not often
Often stops on admission
How do we know whats normal in terms of bowel habits?
We don’t as it varies massively by culture, location, diet and individual
Have to ask the patient whats changed in their frequency, color, consistency.
What investigations should we do for someone with a change in bowel habits?
- Blood Glucose
- Thyroid Status
- Coeliac Serology
Can follow up with endoscopy and colonoscopy as necessary
What are some systemic causes of constipation?
Hypothyroidism - Because without thyroid hormones the natural muscle action of the gut is slowed
Hypercalcaemia - Can lead to polyuria and dehydration and also suppress the nervous system all resulting in constipation
What are some neurogenic causes of constipation?
Autonomic neuropathies Stroke MS Spina Bifida Parkinson's Disease
Name some organic causes of constipation?
Strictures Tumours Diverticular Disease Proctitis (inflammation of anus and rectal lining) Anal Fissure
Functional causes of constipation?
Megacolon Idiopathic Constipation Depression Psychosis Being an institutionalized patient
What are the symptoms of IBS?
- Abdominal pain
- Altered Bowel Habits
- Abdominal Bloating
- Heightened Gut Awareness
Describe the abdominal pain of IBS
Its very variable, rarely occurs at night and is often altered by bowel movements
What are the classes of IBS?
IBS-C = Constipation (May be due to reduced contractions of the bowel tube)
IBS-D = Diarrhoea (Contractions of the bowel may be stronger & faster than normal)
IBS-M = Both
What causes the abdominal bloating of IBS and how do we assess it?
Seems to be due to relaxation of abdominal wall muscles which stretches the mesentery & causes bloatin/discomfort. Rather than excess gas.
Ask them to try and replicate it
What is heightened gut awareness?
IBS sufferers are often excessively aware of normal digestive processes
what are the NICE guidelines for defining IBS?
Abdominal pain relieved by defecation or associated with altered stool frequency/form plus two or more:
- Altered Stool Passage
- Abdominal bloating
- Symptoms worsened by food
- Passing mucous
What tests can we do for IBS?
Bloods = FBC, U&E, LFT, Ca, CRP, TFTs & Coeliac serology
Rectal Exam & Foecal Occult Blood Test
What is Calprotectin?
A protein released by inflamed gut mucosa
Useful for differentiating between IBS and IBD and then for monitoring IBD status
How do we treat IBS?
Educate & Reassure
Psychological Intervention (actually more evidence than drugs)
What is included in an IBS dietetic review?
- Avoiding laxative e.g. cafeine, alcohol and sweeteners.
- Test lactose intolerance
- Gluten Exclusion Trial
- FODMAP Diet
What is the FODMAP diet?
Fermentable Oligo-, Di- & Mono- saccharides and polyols.
Exclude then reintroduce one at a time to find the trigger
What drugs are used to treat IBS?
- Anti Spasmodics
- Anti Depressants
- Some Probiotics can help with infection related IBS
- No bulking agents of fibre
- Temporary Laxatives (Clears out the bowel)
- Antimotility agents
How do anti-depressants help with IBS?
They have a side effect of visceral analgesia
So we use them in small doses for the pain of IBS
What types of psychological interventions are there for IBS?
Relaxation therapy - meditation & muscle relaxation to relieve stress
Cognitive Behavioural Therapy - Identify & learn how to respond to triggers
Psychodynamic Interpersonal Therapy - Helps patients to understand how their emotions affect bowel issues (good for people with abusive childhoods)
All these need an expert psychologist to review, determine and deliver treatment
What cause IBS?
Thought to be a combination of:
Stress, Anxiety and depression
The gut tube contracts in response to certain triggers including waking and eating, in IBS these responses may be increased (IBS-D) or reduced (IBS-C)
How does stress IBS become chronic?
We all get nervous tummy/diarrhoea with stress.
In IBS the gut is more sensitive to stress
Stress -> IBS -> More Stress -> More IBS etc