IBS Diarrhea Constipation Flashcards
(97 cards)
1
Q
Red flags of bowel issues
A
iron deficiency anemia
weight less
severe/progressive worsening
2
Q
what is IBS?
A
functional bowel disorder characterized by recurrent abdominal pain AND altered bowel habits
3
Q
subtypes of IBS
A
C- constipation
D- diarrhea
M- mixed
U- unclassified
4
Q
Epidemiology of IBS
A
20-39 YO
F>M
~4 years to diagnose
5
Q
Etiology of IBS
A
physiological - abnormal motility, visceral hypersensitivity
psych - abuse, anxiety, depression, phobia
environmental - diet, post-infectious, gut microbiome
6
Q
Presentation of IBS
A
chronic/recurrent abdominal pain/discomofort – cramping; diffuse (variable, periodic)
altered bowel habits - D, C, M, U
+/- dyspepsia, atypical CP, vomiting (rare)
+/- extra-intestinal: sexual dysfunction, dysmennorhea, irritative voiding, fibromyalgia sx, somatic/psych complaints
7
Q
Red flags/alarm features
A
sx onset after 50 YO severe/progressively worsening nocturnal diarrhea fevers/vomiting unexplained weight loss melena, hematochezia, + occult blood personal or FH of colon CA, IBD, celiac disease Unexplained Fe def anemia
8
Q
PE for IBS
A
usually normal
normal VS
abdominal exam: may be TTP
perianal/DRE (Crohn’s can present as perianal disease)
9
Q
Dx of IBS
A
Rome IV Criteria:
- recurrent ab pain at least 1 day/week in last 3 months, a w/ two or more of the following:
- related to defecation
- associated w/ change in stool frequency
- change in stool form (appearance)
10
Q
Describing stool
A
Bristol stool form scale
11
Q
Diagnostic tools for IBS
A
often not necessary for non-alarming
+/- CBC (anemia), CMP, TSH, ESR/CRP (elevated in IBD), celiac serologies, stool studies
12
Q
Alarming sx work-up
A
lab/stool study
cross-sectional/small bowel imaging
endoscopy/colonoscopy w/ bx
13
Q
Types of tx for IBS
A
relieve sx and improve QOL
- diet/lifestyle
- psychosocial support
- pharm
- therapeutic clinician-pt relationship
14
Q
Diet for IBS
A
food diary fiber (20-35 g/day) - start low and increase FODMAP diet *** probiotics? exercise
15
Q
Tx for abdominal pain
A
Antispasmodics:
- Levsin (hyoscyamine)
- Bentyl (dicyclomine)
- caution anticholinergic effects
16
Q
Tx for constipation
A
Psyllium fiber Miralax (polyethylene glycol) Amitiza Linzess Trulance
17
Q
Tx for diarrhea
A
Imodium
Rifaximin (abx that only works in gut)
Alosetron (women-only-risk management program)
Viberzi
18
Q
Tx of psychosocial tx for IBS
A
TCAs, off-label
* caution AEs
19
Q
Which meds exacerbate constipation?
A
Antipsychotics*
Iron*
Opioids*
Anticholinergics
Antacids (calcium, aluminum)
CCB
20
Q
Epidemiology of constipation
A
most common digestive complain
F>M
21
Q
Risk factors for constipation
A
improper diet/inadequate fluid intake
sedentary lifestyle
polypharmacy
age
22
Q
Etiology of constipation
A
functional - chronic idiopathic constipation (constipation), IBS-C (constipation + pain) meds slow transit - colonic inertia obstruction metabolic/systemic disease Other: IBD, Volvulus
23
Q
Systemic diseases that cause constipation
A
hypercalcemia hyperparathyroidism hypothyroidism DM, pregnancy, Hirschprung MS, Parkinson Spinal cord injury
24
Q
Hx questions for constipation
A
acute/chronic normal bowel pattern frequency, consistency laxative use? need for digital evacuation? previous colonoscopy red flag sx contributing causes - reconcile meds, review PMH
25
What is considered constipation
25% of defecations w/:
- <3 spontaneous BM/week
- lumpy/hard stool
- straining
- manual maneuvers to facilitate
- anorectal obstruction/blocakge
- sense of incomplete evacuation
26
Presentation of constipation
above constipation sx
| +/- ab pain, bloating, pain on defecation, rectal bleeding, tenesmus
27
tenesmus
feeling of being unable to completely empty bowel
28
Red flag sx for constipation
```
acute onset
sx onset after 50 YO
fever/vomiting
unexplain weight loss
melena, hematochezia, occult blood
family hx of colon CA, IBD, celiac disease
Fe deficiency anemia
```
29
PE for constipation
usually normal
ab ex -- distention, mass?
DRE - fissures, hemorrhoids, tenderness, mass, stool, anal stricture, sphincter tone, perineal descent, dyssynergic defecation
Pelvic exam (rectocele)
30
Dx of constipation
limited labs: +/- CBC, CMP, TSH
alarm features: imaging, colonoscopy or Flex sig/BE (lesions that narrow/occlude bowel)
Refractory:
- colonic transit (radipague marker) study- evaluates rate of residue moving through colon
- defecography- anatomical/functional changes
- anorectal manometry- measures anal sphincter pressure/function
31
Diet/lifestyle for constipation
increase fluid/fiber
increase activity/exercise
bowel habit training
biofeedback helpful w/ defecatory dyfunction
32
meds for constipation
fiber supplements
stool softener
osmotic/stimulant laxative
Rx agents
33
SE of fiber supplement
flatulence
bloating
distention
34
SE of stool softener
GI cramping
35
Osmotic laxative SE (pulls water in)
GI discomort
bloating
Caution: Mg-containing laxative and hypermagnesemia in pts wiht renal insufficiency
36
Stimulant laxative
q 3 days
Cramping, rarely lyte disturbance
melanosis coli- color change in colon
37
Rx agents for constipation SE
diarrhea
38
Fiber supplements
Psyllium (Metamucil) Methylcellulose (Citrucel) Polycarbophil (Fiber Con) Benefiber
39
Stool softener
Docusate
40
Osmotic laxative
Polyethylene glycol (Miralax), Milk of magnesia, Mag citrate, Lactulose
41
Stimulant laxatives
Bisacodyl
| Senna
42
Rx agents
* Lubiprostone (Amitiza)
• Linaclotide (Linzess)
• Plecanatide (Trulance)
43
Complications of constipation
hemorrhoid/anal fissure
fluid and lyte abnormalities from laxative abuse
fecal impaction --> bowel obstruction
44
high risk for bowel obstruction
dimentia
neuro disease
immobile
on hypomotility meds
45
Sx of fecal impaction
N/V
ab pain
distention
paradoxical "diarrhea"
46
Tx for fecal impaction
disimpaction followed by maintenance bowel prep as appropriate
47
Most likely associated w/ acute diarrhea
Norovirus
48
What is diarrhea
passage of >3 unformed stools/day
49
Timing for diarrhea
acute: <14 days
Persistent: >14-30 days
Chronic: >30 days
50
Etiology of acute diarrhea
```
infections- most likely viral; bacterial, protozoal
meds
paradoxical diarrhea
food intolerance
radiation/ischemic colitis
appendicits
diverticulitis
intussusception
emotional stress
IBD, Celiac disease
```
51
Warning sx for diarrhea
* Fever
* Unexplained weight loss
* Melena, hematochezia, + occult blood
* Persistent/progressive/nocturnal symptoms
* Immunocompromised
* Personal or FH of Colon cancer, IBD, Celiac disease
* Fe deficiency anemia •Signs of volume depletion
52
Exposure to acute diarrhea questions
```
recent hospitalization/abx use
travel
ingestion of improperly stored/prepped foods
sick person exposure
pet/animal
new meds/dose changes
public health risk
```
53
Presentation of non-inflammatory diarrhea
watery nonbloody diarrhea
n/v cramps, bloating/flatulence
+/- low grade fever
54
Etiology of noninflammatory acute diarrhea
viral: norovirus*, rotavirus
Bacterial: v. cholera, C. perfringens, s. aureus, bacillus cereus
Protozoa: Giardia*, crypto, cyclcospora
55
Presentation of inflammatory diarrhea
fever
bloody diarrhea
severe abdominal pain
56
Etiology of Acute inflammatory diarrhea
Viral: CMV
Bacterial: Salmonella, Campylobacter, Shigella, Enterohemorrhagic E. coli 0157:H7, Clostridioides (formerly Clostridium) difficile Vibrio parahemolyticus (rare), Yersinia (rare)
protozoal: entamoeba histolytica
57
PE for diarrhea
focus on volume status and complications
- vitals
- skin turgor
- oral mucous membrane
- HR
- ab: distention, BS, tenderness, peritoneal signs, mass
- rectal: tenderness, stool guaic, perianal disease
- neuro: mental status
58
Dx for diarrhea
not routine
| +/- CBC, CMP, CRP; stool culture, imaging, culture for E.coli, Giardia, O&P, C.diff, hemoccult
59
Stool culture includes
salmonella
shigella
campylobacter
60
Acute diarrhea needing prompt eval
•Signs of inflammatory diarrhea (Fever ≥ 101.3°F, leukocytosis, bloody diarrhea, severe abdominal pain
•Intractable vomiting
•Profuse watery diarrhea and dehydration •AKI/Lyte abnormalities
•Elderly or nursing home residents
• Immunocompromised
•Hospital-acquired diarrhea, exposure to
antibiotics
61
Management of diarrhea
```
supportive/symptomatic
- oral rehydration
-lactose free diet
- probiotics
+/- antidiarrheal (never w/ blood)
```
62
SE of bismuth subsalicylate (pepto-bismol)
black stool
63
Antidiarrheal agents
```
Loperamide (imodium)
bismuth subsalicylate (pepto-bismol)
```
safe and effective in those w/o dysentery
64
Norovirus
older children, adults
food, cruise ship, camp, etc.
duration: abrupt onset, resolves 24-72 hrs
tx: supportive
65
Rotavirus
6mo-2YO
fecal contaminated food/water
sick contact (daycare)
duration: self-limited
Tx: supportive
66
"rice-water"
vibrio cholerae
67
V. cholera
rice water stool
unsanitary conditions, food/water, travel hx
tx: supportive; +/- Doxy, macrolide, Tetracycline, FLQ
68
C. perfringens (entertoxin)
food born; home-canned goods (poutry, gravy, meat)
supportive
69
S. aureus (entertoxin)
VOMITING!
food born: creamy foods, egg/potoato salad, dairy, processed meat
illness w/i hours of exposure
supportive
70
Bacillus cereus (entertoxin)
VOMITING
food born (GRAINS-rice!)
illness w/i hours
supportive
71
rice
B. cereus
72
vomiting
s. aureus
| b. cereus
73
Giardia lamblia source
Waterborne, foodborne, fecal-oral transmission (camping, lakes, streams, ponds, daycares, pools)
74
Tx for giardia
metronidazole (tinidazole, albendazole)
75
Cryptosporidium (self limited, serious in AIDS)
recreational water outbreaks
daycares
supportive; tx if immunocompromised
76
Cyclospora source
imported foods (fruits/veggies)
77
Tx for cyclospora
TMP-SMX
78
Salmonella source/tx
poultry/livestock; reptiles
supportive; abx in some
79
Campylobacter jejuni linked to
Guillain-Barre
80
Source of campylobacter
undercook poultry
| unpasteurized milk
81
Tx for campylobacter
supportive
| severe: macrolide or FLQ
82
"classic dysentery"
shigella
83
Source of shigella
fecal contamination of food/water (daycares, crowded living)
84
Tx of shigella
supportive
| abx shorten course (FLQ, macrolide, bactrim)
85
severe afebrile blood diarrhea
E.coli
86
Source of e.coli
undercooked ground beef or unpasteurized products
87
Tx of e.coli
supportive
NO ANTIDIARRHEAL
NO ABX- RISK OF HUS
88
RISK OF HUS
e. coli
89
C. diff source
Recent hospitalization /antibiotic use, community acquired
| Fluoroquinolones, clindamycin, cephalosporins
90
meds associated w/ c. diff
FLQ
Clindamycin
Cephalosporin
91
Tx for c. diff
dicontinue abx
Vancomycin*
Fidazomicin*
Metronidzaole*
92
Vibrio parahemolyticus source
raw seafood/shellfish*
| travel
93
Tx for v. parahemolyticus
supportive
| FLQ, Doxy if severe
94
Mimics appendicitis
Yersinia enterocolitica
95
Source of Yersinia
Undercooked pork, unpasteurized milk, fecally contaminated water
supportive
96
E. histolytica (intraluminal and disseminated disease)
fecal contaminated food/water
travel
Metronidazole + iodoquinol
97
inflammatory protozoa
e. histolytica
