IBS/constipation/colon polyps

Question 1

What are the general characteristics of IBS?

Answer 1

1. Functional disorder without known pathology
2. Most common cause of chronic or recurrent abd pain in US
3. Intermittent, lifelong problem
4. F > M

Question 2

What is the pathophys of IBS?

Answer 2

1. Altered motility
2. Hypersensitivity to intestinal distention
3. Psychological distress

Question 3

What are the sxs of IBS?

Answer 3

1. Abd pain
A. Hypogastrium
B. LLQ
2. Pain worsened w/ food & relieved w/ defecation
3. Postprandial urgency
4. Bowel distention
A. Accumulation of gas
5. Constipation, diarrhea or both
6. PE usually normal

Question 4

What is the ddx for IBS?

Answer 4

1. Lactose intolerance
2. Cholecystitis
3. Chronic pancreatitis
4. Intestinal obstruction
5. Pancreatic CA
6. Stomach cancer
7. Celiac disease

Question 5

What dx studies are used for IBS?

Answer 5

1. Dx of exclusion
2. Stool for O&P, fecal WBC’s, blood, culture
   A. R/O infection
3. CT w/contrast/Ba enema
   A. R/O obstructing mass, pancreatic cancer
4. Endoscopy
   A. R/O celiac disease, stomach cancer
5. Lactase breath test
   A. R/O lactose intolerance

Question 6

What are the non medical options for treatment of IBS?

Answer 6

1. Reassurance
2. Strong provider-patient relationship
3. Avoidance of known triggers
4. High fiber diet

Question 7

What bulking agents can be used to treat IBS?

Answer 7

1. Psyllium / Metamucil
2. Methylcellulose / Citrucel
3. Calcium Polycarbophil /FiberCon

Question 8

What antispasmodic meds can be used in IBS?

Answer 8

1. Blocks parasympathetic stimulation of gut and reduces GI tone & motility
   A. Dicyclomine HCl (Bentyl)
   B. Hyoscyamine sulfate (Levsin)
   C. Phenobarb/hyoscyamine/atropine/scopolamine (Donnatal)

Question 9

What anti-diarrheal meds can be used for IBS?

Answer 9

1. Opioid Agonists
   A. Activate opioid receptors in GI smooth muscle -> inhibits AcH release -> inhibits peristalsis
2. Includes:
   A. Loperamide (Immodium) – opioid analogue
   B. Diphenoxylate (Lomotil)

Question 10

What anti-constipation meds can be used for IBS?

Answer 10

1. Increase intestinal fluid secretion & motility
   A. Lubiprostone (Amitiza)
   B. Linaclotide (Linzess)

Question 11

What prokinetic meds can be used for IBS?

Answer 11

1. Stimulates motility of upper GI tract w/out stimulating gastric, biliary or pancreatic secretions
2. Metochlopramide (Reglan) 10 mg po 30 min ac & hs

Question 12

What are the antidepressants/antidiarrheal drugs used for females with IBS?

Answer 12

1. Used in severe cases only, restricted use
2. Serotonin (5HT3) receptor agonist
3. Slows down GI motility
4. Alosetron (Lotronex)

Question 13

What are the general characteristics of constipation?

Answer 13

1. Normal bowel function ranges from 3 stools/day to 3 stools/week
2. Decrease in stool volume & increase in stool firmness accompanied by straining

Question 14

Who should be checked for colon cancer?

Answer 14

Patients > 50 yr with new onset constipation should be evaluated for colon cancer

Question 15

What is the etiology of primary constipation?

Answer 15

1. Anal stricture
2. Rectocele
3. Rectal prolapse

Question 16

What is the etiology of secondary constipation?

Answer 16

1. Systemic disease
A. Hypothyroidism, DM, hypercalcemia
2. Medications
A. Opioids, diuretics, anticholinergics, Ca & Fe supplements
3. Obstructing colonic lesions

Question 17

What dx studies need to be performed for constipation?

Answer 17

1. Complete Hx & PE is essential, including:
A. DRE
B. Stool guaiac
C. CBC
D. Electrolytes
E. Ca, glucose
F. TSH
G. Colonoscopy

Question 18

What is the rx for constipation?

Answer 18

1. Increase fiber 
A. 10-20 gm daily
2. Increase fluid intake
A. 1.5 – 2 L / day
3. Increase activity
4. If constipation lasts > 2 weeks or if constipation refractory to above measures, further investigation to detect etiology

Question 19

What are colon polyps?

Answer 19

1. Colon polyps are discrete mass lesions that protrude into intestinal lumen
   A. Can be benign or malignant

Question 20

What are risk factors for colon cancer?

Answer 20

1. Removal of colon polyps can reduce occurrence of colon cancer
2. Familial polyposis syndrome is a genetic predisposition to multiple colon polyps
   A. High risk colon cancer

Question 21

What are mucosal neoplastic (adenomatous) polyps?

Answer 21

1. Most common type

2. 95% adenocarcinoma of colon arise from these polyps

Question 22

What are mucosal non-neoplastic (hyperplastic) colon polyps?

Answer 22

Non-malignant

Question 23

What are submucosal colon polyps?

Answer 23

1. Lipomas

2. Lymphoid aggregates

Question 24

What preventative measures may reduce the risk of colon polyps?

Answer 24

1. Diet high in fruits, vegetables & fiber
2. Low fat diet
3. Limit ETOH intake
4. Avoid tobacco
5. Anti-oxidant vitamins
   A. A, C, E, beta carotene

Question 25

When is ASA recommended as a preventative treatment for colon polyps?

Answer 25

1. Due to risks asst w/long term use, ASA not recommended in pts w/polyps unless there are other medical indications 2. Reduces number of recurrent adenomas at 1-3 yr A. Low dose ASA 81 mg PO qd B. Celecoxib (Celebrex) 400 mg PO bid

Question 26

What are the risk factors for colon polyps?

Answer 26

1. Diet rich in fats and red meats 2. (+) FH 3. IBS 4. Age

Question 27

What are the sxs of colon polyps?

Answer 27

1. Polyps generally asymptomatic | 2. May be asst with rectal bleeding & iron deficiency anemia

Question 28

What are the dx studies for colon polyps?

Answer 28

1. Guaiac (+) stool common 2. Imaging studies: A. Barium enema: Not used much today B. Colonoscopy: Diagnostic study of choice for localizing & identifying (Bx) polyps -Histologic evaluation of polyps C. Virtual colonoscopy/ pill camera

Question 29

When should a pt w/ FH of familial polyposis be evaluated?

Answer 29

Family members of pts w/ familial polyposis should be evaluated q 1-2 yr beginning at 10-12 yr of age

Question 30

What is the rx for colon polyps?

Answer 30

Colonoscopic polypectomy

Question 31

What is recommended post-polypectomy surveillance?

Answer 31

1. Colonoscopy w/in 3-5 yr after initial exam A. Adenomas found in 30-40% of pt after initial (+) exam B. Colonoscopy in 5-10 yr after first normal post-polypectomy exam 2. Patients with 3-10 adenomatous polyps or polyp > 1 cm A. Colonoscopy in 3 yr

Question 32

What is familial adenomatous polyposis?

Answer 32

Inherited condition characterized by early development of hundreds to thousands of colonic adenomatous polyps & adenocarcinoma

Question 33

What genetic testing is available for FAP?

Answer 33

1. Genetic testing confirms mutation of: A. APC gene (90%) B. MYH gene (8%)

Question 34

What is the recomneded preventative treatment for FAP?

Answer 34

1. Prophylactic colectomy recommended to prevent otherwise inevitable colon cancer A. Usually before age 20 yr

Question 35

Who needs colonoscopies every 3 years?

Answer 35

1. baseline colonoscopy with Low risk adenoma, then high risk adenoma on first surveillance 2. baseline colonoscopy with high risk adenoma, then high risk adenoma on first surveillance

Question 36

Who needs colonoscopies every 5 years?

Answer 36

1. baseline colonoscopy with Low risk adenoma, then low risk adenoma on first surveillance 2. baseline colonoscopy with high risk adenoma, then low risk adenoma on first surveillance 3. baseline colonoscopy with high risk adenoma, then no adenoma on first surveillance

Question 37

Who needs colonoscopies every 10 years?

Answer 37

1. baseline colonoscopy with Low risk adenoma, then no adenoma on first surveillance