IBS & Perianal Disorders Flashcards by Rory McNally

IBS-D

IBS Diarrhoea

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IBS-C

IBS constipation

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IBS-M

IBS mixed

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IBS common presentation

Change in bowel habit

Abdo pain

Bloating

Chronic, relapsing condition

Urgency

Sensation of incomplete emptying

Mucous PR

Aggravated by stress

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What are the criteria for IBS?

Pain/discomfort for at least 3 days per month for 3 months

Improvement with defecation

Change of stool habit with onset

Change of stool form

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What is IBS associated with (diseases)

Fibroyalgia
Chronic fatigue syndrome
TMJ dysfunction
Chronic pelvic pain

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IBS - psychology

Many are depressed/anxious/hypochondriacs

Many have anxiety

Stressed –> more IBS –> MORE stress –> IBS and so on.

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IBS history

Bowel habit change

What do they eat? - something may be triggering it

Bloating

Nocturia

Changed your diet?

Triggers?

Opiate use?

Psychological - stress, anxiety

Underlying fears

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Alarm features

Age > 50

Short duration of symptoms / sudden onset

Woken from sleep by altered bowel habit

Rectal bleeding

Weight loss

Anaemia

FHx of colorectal cancer

Recent Abx

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Investigations for IBS

FBC
ESR
CRP
TTG (coeliac)
Lower GI tests if aged > 50 
Endoscopy (if alarm symptoms)

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Management of IBS

Diet
Regular meal times
Fibre
FODMAP/GFD (gluten free diet)

Eat more vegetables

Stop opiate analgesia (reliance)

Antidiarrhoeal

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What drug do you NOT use?

Lactulose

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Anti-diarrhoeal - loperamide 1ST LINE

Opiate analogue

Inhibits peristalsis, gut secretions

Benefits diarrhoea

Works quickly

No dependency

PRN use

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IBS - antidepressants

Amitryptyline

Reduce diarrhoea
Reduce afferent signals from gut
Help restore sleep pattern

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IBS psychological treatment

Severe anxiety/depression

Relaxation therapy
Hypnosis

Probiotic yoghurts

If it helps, it’s worth doing.

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Amitryptyline

Anti-depressant

Good therapy for IBS

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What kind of stool consistency are you aiming for?

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Soft well formed (bristol type 4)

Below the dentate line =

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PAINFUL

Perianal conditions - key questiosn

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How long have you had symptoms for?

First episode?

Bleeding - fresh? Dark? mixed with stool? dripping in the toilet or just on the paper?

Pain - sharp, dull, how long

Anything protruding?

Any discharge

Haemorrhoids

what are they

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Enlarged vascular cushions in the lower rectum and anal canal

Haemorrhoids - presentaiton

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Painless bleeding

Fresh, bright red blood, not mixed with stool

Usually on the paper

Perianal itchiness

No change in bowel habit, no weight loss or other associated symptoms

Haemorrhoids - clincial

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Obvious haemorrhoids if 3rd degree piles are present

Maceration of peri-anal skin

Must use proctoscope to properly see

Unless they are very large they are difficult to see.

Classic positions of haemorrhoids?

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3, 7 and 11 o’clock

in lithotomy position

Investigations - haemorrhoids

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PR exam
Rigid sigmoidoscopy
Proctoscopy

Flexible sigmoidoscopy in patients above the age of 50 (cancer)

Management - Haemorrhoids

Symptomatic Sclerosation therapy Rubber band ligation Open haemorrhoidectomy Stapled haemorrhoidectomy HALO/THD procedure (haemorrhoids artery ligation)

Above dentate line?

Painless

Rectal prolapse - partial - complete

Partial (anterior mucosal prolapse) - more common Complete (full thickness)

Rectal Prolapse - presentation

Protruding mass from anus (esp during defectation) May reduce spontaneously Bleeding and passing mucous PR Poor anal tone

COMPLETE prolapse - management

Many patients are too frail Bulking agent and education on manual reduction Surgery Biological mesh (pig skin) used

Partial prolapse - management Children Adults

Children - dietary advice & treatments for constipation Adults - treatment similar to haemorrhoids (suturing and pushing back)

Anal Fissure

Tear in anal margin due to passage of constipated stool Usually in midline, posteriorly but may anterior Multiple fissures - Crohn's? Below dentate line so are painful

Anal fissure - presentation

Acute onset of severe anal pain Following constipation "Passing glass" pain lasts after defecation

Vicious cycle of anal fissures?

They hold on to their poo because they are afraid of the pain Become more constipated When they finally go it is very painful

What could multiple anal fissures indicate?

Crohn's disease

Anal fissure - treatment

Dietary advice Stool softeners Lateral sphyncterotomy Botox injection

Why would a paralytic drug be good for anal fissures?

The blood vessels are spasming because the muscle is spasming (due to pain) tissue will not heal properly If you relax the sphincters blood can get to it and allow it to heal

Fistula in ano

Abnormal comm between two epithelial surfaces internal opening in anal canal and one or more external openings on the peri-anal skin crohn's, TB, carcinoma

Fistula in ano - presentation

Majority arise from delay in treatment Crohn's TB

Multiple fistulae could be due to?

Crohn's

Fistula in ano - Ix

EUA of anorectum (exam under anaesthetic) Rigid sigmoidoscopy Proctoscopy Flexible sigmoidoscopy MRI

Fistula - management

Laying open Insertion of seton (draining, cutting) LIFT procedure Glue/permacol Let it heal

Fistula - complications

``` Pain Bleeding Incontinence of flatus/stool Recurrence Further surgery ```

IBS & Perianal Disorders Flashcards

(42 cards)