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X Clin Med III Exam I > IBS, Diarrhea and Constipation > Flashcards

IBS, Diarrhea and Constipation Flashcards

1
Q

What is IBS?

A

Functional bowel disorder (in absence of organic cause) characterized by recurrent abdominal pain and altered bowel habits

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2
Q

Classifications of IBS

A 
*based on predominant bowel habit
IBS-C (constipation predominant)
IBS-D (diarrhea predominant)
IBS-M (mixed)
IBS-U (unclassified)
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3
Q

Etiology of IBS

A

Multifactorial:
Physiological (abnormal motility or visceral hypersensitivity)
Psychosocial (early life stressors, anxiety, depression)
Environmental (diet, post-infectious etc)

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4
Q

What might be an alleviating factor of IBS?

A

Having a bowel movement

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5
Q

Associated sxs of IBS

A

Bloating and gas

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6
Q

How would a pt describe the IBS pain?

A

Cramping and diffuse through the lower abdomen (variable intensity with maybe periodic exacerbations)

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7
Q

Presentation of IBS-C

A 
Difficult, painful, infrequent defecation
Hard, lumpy stools
Prolonged time on toilet
Excessive straining during defecation
Sense incomplete evacuation
Abdominal bloating/distension
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8
Q

Presentation of IBS-D

A 
Frequent, loose BMs
Fecal urgency
Sense incomplete evacuation
Incontinence
Mucus discharge
Usually in the morning and after meals!
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9
Q

Other parts of general presentation of IBS

A 
GI sxs (dyspepsia, atypical CP, rare vomiting)
Extra-intestinal sxs
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10
Q

Extra intestinal sxs associated with IBS

A 
Sexual dysfunction
Dysmenorrhea
Irritative voiding sxs
Fibromyalgia sxs
Somatic or psychological complaints
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11
Q

Red flag sxs and alarm features of IBS***

A 
Must do prompt eval and GI referral/work up with them:
Sxs onset after 50
Severe or progressively worsening sxs
Nocturnal diarrhea
Fevers/vomiting
Unexplained weight loss
Melena, hematochezia, occult blood
Personal or FH of colon CA, IBD or Celiac
Unexplained IDA
(FUSSPUMN)
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12
Q

How might a PE look with IBS?

A

Generally normal with normal vitals
Abdomen might be TTP (no peritoneal signs)
Should do perianal/DRE

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13
Q

Rome IV diagnostic criteria for IBS

A

Recurrent abdominal pain on avg at least 1xwk in last 3 mos and with 2+ of the following:
Related to defecation
Associated with change in stool frequency
Associated with change in stool appearance

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14
Q

What does the work-up look like for IBS?

A

Normal history and no alarm features usually means no lab, x-rays or endoscopic tests are recommended
May do some screening tests when needed (CBC, CMP, TSH, ESR/CRP, Celiac serologies, stool studies)

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15
Q

What to do when you suspect IBS but atypical history, alarm features or refractory to tx?

A

Additional work up:
Lab/stool studies
Cross-sectional/small bowel imaging
Endoscopy/colonoscopy with biopsie

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16
Q

Approach to tx of IBS

A

Relieve sxs and improve QOL

Clinician-pt relationship!

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17
Q

Components of IBS tx

A

Dietary/lifestyle
Psychosocial support
Pharm

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18
Q

Considerations for dietary measures with IBS

A

Food diary/symptomatology
Dietary fiber (20-35 g/day)- start low and go slow
FODMAP diet (eliminate foods that contain sugars and fibers that cause pain and bloating)
Probiotics
Exercise

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19
Q

Considerations for psychosocial support with IBS

A

Cognitive behavioral therapy
Relaxation/stress management
Maybe refer to behavioral health

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20
Q

Pharmacologic therapy for IBS with abdominal pain

A

Levsin
Bentyl
*caution anti-cholinergic effects of constipation b/c these are anti-spasmotics

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21
Q

Pharmacologic therapy for IBS with constipation

A 
Psyllium fiber
Miralax
Amitiza
Linzess
Trulance
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22
Q

Pharmacologic therapy for IBS with diarrhea

A

Imodium
Rifaximim (abx)
Alosetron (women only-risk management)
Viberzi

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23
Q

Pharmacologic therapy for IBS with psychosocial problems

A

TCAs

Off label meds

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24
Q

Most common digestive complaint in general population

A

Constipation

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25
Risk factors of constipation
Improper diet and inadequate fluids Sedentary lifestyle Polypharmacy Age
26
Categories for the etiology of constipation
``` Functional Medication Induced Slow transit Defecation/ obstructive disorders Metabolic/systemic disease Others (IBD, volvulus) ```
27
Functional causes of constipation
Chronic idiopathic constipation | IBS-C (constipation and pain predominant)
28
Mediation causes of constipation
``` Opioids Anticholinergics Antipsychotics Iron Antacids (Ca, Al) CCBs ```
29
Slow transit cause of constipation
Colonic inertia (does not propel well)
30
Defecation/obstructive disorders associated with constipation
``` Pelvic floor dysfunction Anorectal disease Rectal prolapse or rectocele Colon cancer Polyp Stricture/stenosis Fecal impaction/obstruction ```
31
Metabolic/systemic causes of constipation
``` Hypercalcemia and hyperparathyroidism Hypothyroidism DM Pregnancy Hirschsprung MS Parkinsons Spinal cord injuries ```
32
Important questions not to be missed when taking history for constipation
``` Laxative use (chronic makes colon flaccid) Need for digital evacuation Previous colonoscopy Ref flag sxs/ alarm features *reconcile meds, review PMH ```
33
How do we define constipation?
``` 1/4 of defecations are associated with: <3 spontaneous DMs/ wk Lumpy or hard stools Straining Manual maneuvers Sensation of anorectal obstruction/blockage Sense incomplete evacuation ```
34
Presentation of constipation
Maybe GI sxs (abdominal pain/bloating, pain on defecation, rectal bleeding, tenesmus- anal quivering)
35
Alarm sxs/red flags associated with constipation
``` Acute onset Sxs onset after 50 Fevers/vomiting Unexplained weight loss Melena, hematochezia, occult blood Personal or FH of colon CA, IBD or Celiac Unexplained IDA ```
36
PE for constipation
Usually benign Abd exam (look for distension or masses) DRE looking for fissures, hemorrhoids, masses, tenderness, stool, strictures, tone, perianal descent, dyssynergic defecation PE to r/o rectocele
37
Workup when someone presents with constipation and alarm sxs
Imaging | Colonoscopy of flex sig/BE (ID lesions that narrow or occlude bowel)
38
Management of constipation
Treat secondary causes (reconcile meds etc) Dietary, lifestyle, behavior Med therapies
39
Lifestyle modifications for constipation
Increase fluid and fiber intake Increase activity and exercise Bowel habit training Biofeedback help with defecatory dysfunction
40
Med therapy for constipation
Fiber supplements Stool softeners Osmotic and stimulant laxatives Rx agents
41
Adverse effects of fiber supplements
Flatulence, bloating and distension | Psyllium, Methylcellulose, Polycarbophil, Benefiber
42
Adverse effects of stool softeners
GI cramping | Docusate
43
Adverse effects of osmotic laxatives
GI discomfort and bloating | *Caution with Mg-containing laxatives and hypermagnesemia with renal insufficient pts
44
Adverse effects of stimulant laxatives
Cramping, lyte distubances, melanosis coli (pigmentation) | Bisacodyl, Senna
45
Adverse effects of rx agents for constipation
Diarrhea | Lubiprostone, linaclotide, plecanatide
46
Complications of constipation
Hemorrhoids/anal fissures Fluid and electrolyte abnormalities from laxatives Fecal impaction leading to bowel obstruction
47
Pts at high risk for fecal impaction
Pts with dementia, neurologic disease, immobile or on hypomotility meds
48
Signs of fecal impaction/bowel obstruction
N/v, abd pain, distension, paradoxical diarrhea
49
What is diarrhea?
Pass >3 unformed stools/day
50
Timing classification of diarrhea
Acute is <14 days Persistent is 14-30 days Chronic is >30 days
51
Most common etiology of acute diarrhea
Viral infectious
52
Can't miss questions in history of diarrhea
Normal pattern Previous colonoscopy Red flag sxs Exposures!
53
Alarm sxs/ red flags for diarrhea
``` Sxs onset after 50? Persistent, progressive, nocturnal sxs Immunocompromised Fevers Unexplained weight loss Melena, hematochezia, occult blood Personal or FH of colon CA, IBD or Celiac Unexplained IDA Signs of vol depletion ```
54
What might be considered an exposure in acute diarrhea?
``` Recent hospitalization or abx use Travel history Ingestion of improperly stored or prepared food Sick contacts or community exposure Pets/animals New meds or dose changes Public health (healthcare, day care) ```
55
Presentation of non-inflammatory diarrhea
Watery, nonbloody diarrhea with n/v Mild, diffuse abd cramps and bloating/flatulence Maybe low grade fever
56
Common etiologies of noninflammatory diarrhea
Norovirus | Giardia
57
Presentation of inflammatory diarrhea
Fever, bloody diarrhea, severe abd pain
58
Common etiologies of inflammatory diarrhea
Bacterial!! (salmonella, campylobacter, shigella, E coli, C diff)
59
What to focus on with PE of diarrhea
Volume status and complications
60
Diagnostics for diarrhea?
Not for most pts | Some as needed (CMC/CMP, stool studies, imaging)
61
Who needs a prompt evaluation of acute diarrhea?
``` Signs of inflammatory diarrhea (Fever >101.3, leukocytosis, bloody diarrhea, severe abd pain) Intractable vomiting Profuse watery diarrhea and dehydration AKI/lyte abnorms Elderly or nursing home Immuncompromised Hospital acquired ```
62
Management for acute diarrhea
Mostly supportive care and sx relief: Oral rehydration, trial of lactose free, probiotics maybe or antidiarrheal agents (loperamide, bismuth subsalicylate--not for pt with dysentery)
63
Adverse effect of peptobismol
(Bismuth subsalicylate) | Black stool
64
Antibiotic therapy for acute diarrhea
Usually not b/c most are self-limited | Some need specific abx but can used empiric abx (FLQ for 5 days or azitrho)
65
Diarrhea associated with vibrio cholerae
Rice water stools
66
Food borne sources of non-inflammatory diarrhea
C. perfringens S. aureus B. cereus
67
Source of giardia exposure
Camping, lakes, streams, ponds, daycares, pools (fecal-oral)
68
Source of salmonella exposure
Poultry and livestock, reptiles
69
What can campylobacter infection be associated with?
Guillain-barre syndrome
70
What is shigella associated with?
Classic dysentery
71
Presentation of e. coli infection
Severe afebrile bloody diarrhea
72
Why can you not give abx to e coli infection?
Risk of HUS
73
Source and tx of C dif infection
Recent hospitalization or abx use (can be community acquired) Vanco, fidaxomicin, metronidazole
74
Source of vibrio parahemolyticus exposure
Raw seafood or shellfish
75
Presentation of versinia enterocolitica infection
Mimics appendicitis
76
Clue for ZES
Diarrhea unrelieved with fasting

X Clin Med III Exam I (5 decks)

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