IBS and IBD

Question 1

irritable bowel syndrome

Answer 1

• Disease of altered intestinal function
• Not structural or biochemical explanation – theres no test to prove it
• Clinical Diagnosis
• Prevalence:
• 10-15% of US; ¼ worldwide
• Second highest cause of work absenteeism
• Epidemiology:
• F>M, onset at menarche common

Question 2

possible causes and pathology of IBS

Answer 2

• Motility – motor abnormality detectable in some IBS patients including: changes in contraction frequency, prolonged transit time (constipation predominant), enhanced motor response to hormonal or physical stimuli (diarrhea predominant); Prolonged transit time = more time to move through the gut, We classify IB pts as constipation predominant or diarrhea predominant;
• Visceral hypersensitivity/hperalgesia – increased sensitivity to/perception of distension or bloating; The pt may not actually have extra bloating or distension, but they are more sensitive to it
• Inflammation – Increased lymphocytes demonstrated, studies also correlate pain increases to mast cell increases;
• Weaker associations: post-infectious, changes in fecal microflora, food sensitivity, psychosocial dysfunction (CRF release).
• Its probably a combination of two or more of these things
• Don’t write this off as an anxiety disorder or a stress related illness (We know now that there are physical and biological basis for the sxs that IBS pts experience)

Question 3

presentation of IBS

Answer 3

• episodic, sporadic, cramping, abdominal pain
• Chronic abdominal pain (relieved or intensified by defecation) - “cramping” pain of varying intensity with exacerbations, Pain related to defecation, Stressful situations and meals may exacerbate)
• Alteration in bowel habits (Diarrhea predominant, constipation predominant and mixed forms – most have normal periods and symptoms in exacerbations)
• Absent organic causes
• Symptoms do not wake from sleep

Question 4

differential of IBS

Answer 4

o	Parasites!
o	Celiac
o	IBD
o	Bacterial alterations
o	Abuse of motility agents
o	Medication effects
o	Dietary alterations

Question 5

ROME IV vriteria

Answer 5

• To be used in ABSENCE of a biological marker of disease
• Recurrent abdominal pain (1d/week in last 3 months average) associated with 2 of: A) Related to defecation, B) Associated with change in stool frequency, C) Associated with change in stool form or appearance

Question 6

Workup, labs for IBS

Answer 6

• there’s no confirmatory test, you make this dx when you exclude everything else
• A thorough history is your best friend
• Diary can be useful if you are uncertain
• No confirmatory labs, only done to rule out other causes
• Alarm Symptoms: Onset > 50 yo – IBS is a YOUNG person’s disease! Bleeding or melena – theres no part of IBS that causes bleeding, Nocturnal diarrhea – wakes them from sleep, Progressive abd pain – it just keeps getting worse – IBS is very stable (doesn’t change in character), Unexplained wt loss, Lab abnormalities, FH of colon CA

Question 7

IBD

Answer 7

• Inflammatory Bowel Disease
• Refers only to Ulcerative Colitis (UC) and Crohn Disease
• Prevalence:
• 396/10,000 world wide
• 238 (ulcerative colitis) and 201 (Crohn) per 100,000 in US
• Prevalence rising in developing world
• More common among Jews than non-Jews
• Males have higher incidence of UC and younger age associated with Crohn
• High prevalence in Northern latitudes in US and Europe and peaks in spring (weak association) noted

Question 8

IBD and smoking

Answer 8

• Current and former smokers more likely to develop CD than non-smokers
• Current smoking not associated with AND POSSIBLY PROTECTIVE from UC – in a larger study former smokers had greater risk than non-smokers
• Smoking cessation in UC patients associated with increased incidence of exacerbation and hospitalization

Question 9

other associations

Answer 9

• Food sensitivity – unclear
• Physical activity – lowers risk of CD
• Obesity – unclear
• Gut biome – implications, unclear
• Infections – some evidence supports connection with CD
• Breast feeding – possibly protective
• Isotretinoin – implicated
• NSAIDS – possibly small increased risk of IBD
• OCP - possible increased risk, unclear

Question 10

UC and Crohns

Answer 10

• Common features: Bowel Inflammation, No causative agent, Familial, Accompanied by systemic manifestation
• Distinguishing features: UC confined to anus and rectum and continuous/CD mouth to anus with skip lesions (ULCERATIVE COLITIS = COLON, Lesions in Crohns can happen anywhere in the alimentary canal from mouth to anus), UC mucosal/CD submucosal (deeper), Rectal bleeding in CD, rare in UC, Fistulas strictures and abscesses common in CD, rare in UC, Cancer common in UC, rare in CD

Question 11

work up of IBD

Answer 11

• All about history and presentation
• UC (Chronicity, Diarrhea, possibly with blood, Gradual and progressive onset, Possible systemic symptoms (fever, fatigue, wt loss, anemia))

Question 12

UC - assess severity (montreal)

Answer 12

• Mild: <4/day, +/- blood, no systemic signs, normal ESR. Mildly crampy, tenesmus/constipation common - Tenesmus = feeling the need to defecate without really defecating
• Moderate: >4 loose/bloody stools per day, mild anemia, minimal systemic signs, abd pain, no weight loss
• Severe: >6 loose/bloody stools per day, severe cramps and systemic toxicity

Question 13

UC - complications

Answer 13

• Severe bleeds (up to 10% of pts)
• Fulminant colitis and toxic megacolon (>10 stools and continuous bleeding with fever and anorexia)
• Perforation: Most commonly with megacolon
• Outside GI: Arthritis, uveitis, erythema nodosum, increased coagulation

Question 14

Labs for UC

Answer 14

• CBC (anemia)
• ESR
• Albumin (low)
• Electrolyte abnormalities
• Endoscopy with inflammation confirms disease in pt with weeks of D

Question 15

Crohns

Answer 15

• More variable clinical presentation than UC
• 1/3 have perianal disease (including perianal abscesses)
• 5-15% have involvement of mouth or gastroduodenal area
• Hallmarks include weight loss, fatigue and fever

Question 16

signs and symptoms of Crohns

Answer 16

• Most report episodes of D over long time
• Crampy abdominal pain
• Extraintestinal inflammatory signs (joints, eyes, skin, etc)
• Obstruction common
• D fluctuates over time
• Gross blood less frequent than UC

Question 17

differential of Crohns

Answer 17

• Lactose intolerance
• Appendicitis
• Diverticulitis
• Ischemic colitis
• Lymphoma
• Endometriosis
• Obstruction d/t other causes including CA

Question 18

diagnosis of Crohns

Answer 18

• Need endoscopy and biopsy demonstrating inflammation!!!
• Usually skip lesions are present – if they are there, then its Crohns
• Lesions throughout alimentary canal

Question 19

Treatment of Crohns

Answer 19

• For both-
• Symptomatic treatments
• Dietary control
• Mesalamine (sulfasalazine) – thought to modulate inflammation through leukotrienes
• Immunomodulators (newer and more expensive)