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CMPP > Intestinal Diseases 2 (part 1) > Flashcards

Intestinal Diseases 2 (part 1) Flashcards

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1
Q

Irritable Bowel Syndrome

A

Chronic abd pain and altered bowel habit without an organic cause identified

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2
Q

IBS prevalence in US

A

10-15%

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3
Q

who does IBS affect?

A

everyone, but mostly
younger patients
women

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4
Q

diagnosis of exclusion

A

consider other things before diagnosing with IBS

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5
Q

what is the second most common cause of absenteeism after the common cold?

A

IBS

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6
Q

what is the predominant pattern of motor activity in IBS?

A

there is none

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7
Q

components of IBS

A

abnormal motor patterns (increased frequency and irregularity of luminal contractions, ^ peristalsis but not effective

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8
Q

in patients with constipation predominant IBS what is altered with their transit time?

A

it is prolonged

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9
Q

what comes of exaggerated motor response to CCK and meal ingestions in IBS

A

diarrhea predominant IBS

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10
Q

visceral hypersensitivity in IBS

A

distension occurs at lower balloon volumes in IBS patients

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11
Q

intestinal inflammation in IBS

A

increased number of lymphocytes in the colon and small intestine
release NO and histamine > activate visceral response
more proinflammatory cytokines (TNF)

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12
Q

psychosocial dysfunction

A

pts have more stressful life style

increased anxiety, depression, phobias, somatization (physical evidence of mentally being stressed)

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13
Q

what is released from the paraventricular nucleus and plays as a major mediatory of the stress response

A

corticotropic releasing factor

higher in IBS patients and causes overactivity in the brain

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14
Q

chronic abdominal pain in IBS

A 
crampy
variable intensity
periodic exacerbation (waxes and wanes)
emotional stress and eating exacerbates pain
defecation may provide relief
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15
Q

abd pain features that DO NOT contribute to IBS

A

pain w/ anorexia, malnutrition, or weight loss
people who can’t eat anything
progressive pain
pain which awakens from sleep

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16
Q

what should you ask about diarrhea predominant IBS

A

stools of small or moderate size
does it occur during waking hours? (unusal to have IBS wake one up at night)
associated with lower abd cramps or urgency prior to BM
tenesmus
mucus in stools

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17
Q

diarrhea symptoms that DO NOT contribute to IBS

A

large volumes
blood
nocturnia diarrhea
greasy

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18
Q

constipation and IBS

A

lasts days to months
could have periods of diarrhea or normal bowel habits
sense of incomplete evacuation (tenesmus)

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19
Q

other vague GI complaints of IBS

A 
GERD
dysphagia
early satiety
intermittent dyspepsia
nausea
non-cardiac chest pain
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20
Q

extraintestinal symptoms of IBS

A 
dysparunia
lack of sexual function
dysmenorrhea
increased urinary frequency or urgency
fibromyalgia
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21
Q

rome III criteria for IBS

A

recurrent abd pain/discomfort for at least 3 days/month
last 3 months associated with 2 of the following
improvement with defecation
onset associated with change in frequency of stool
onset associated with change of consistency of stool

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22
Q

other supportive symptoms of IBS

A 
abnormal stool frequency < or = 3BM/wk or >3BM/day
abnormal stool form
defecation straining
urgency
feeling of incomplete BM
passing mucus
bloating
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23
Q

4 subtypes of IBS

A

IBS with constipation
IBS with diarrhea
Mixed IBS
Untyped IBS

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24
Q

IBS w/ constipation

A

> 25% lumpy stools, <25% loose, watery stools

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25
IBS w/ diarrhea
>25% loose, watery stools, <25% lumpy stools
26
mixed IBS
>25% loose, watery stools, >25% lumpy stools
27
untyped IBS
doesn't meet any of the >/<25% criteria
28
treatment for IBS
relief of symptoms | addressing patients concerns
29
cure for IBS
there is none
30
pt education on IBS
emphasis that this is a chronic illness, but it is benign
31
dietary considerations with IBS diagnosis
``` do a diary of diets consider lactose free exclude gas-producing foods consider food allergies +/- fiber foods ```
32
physical activity and IBS
increases peristalsis in sm and lg intestines | 20-60 minutes 3-5x week
33
medication therapy in IBS
don't do it if you don't have to (be reluctant to use long term), there isn't evidence that it helps long term which doesn't make the side effects worth it
34
diarrhea predominant IBS
antispasmotic agents
35
antispasmotic agent MOA
directly affects intestinal smooth muscle relaxion (anticholinergics > more constipation)
36
specific antispasmotic for IBS
dicyclomine (Bentyl) hyoscyamine (levsin) if no relief in 2 weeks, stop
37
side effects for dicyclomine and hyoscyamine
dry mouth, dizziness, blurred vission
38
when don't you use antidepressants to treat IBS
constipation predominant
39
How do antidepressants help IBS
analgesic properties to work on neurotransmitters all over the body endogenous endorphine release > block norepinephrine reuptake so inhibits pain pathway slows intestinal transit time bc anticholinergics
40
the only antidiarrheal agent sufficiently investigated for use in IBS that results in a reduction in stool frequency and improvement in consistency does not reduce pain, bloating, global symptoms of IBS
Loperimide (immodium)
41
first step of medication therapy for constipation predominant IBS
Lubiprostone (amitiza)
42
Lubiprostone MOA
chloride channel activator resulting in increased salt and water in intestinal lumen
43
what medicaion is approved for IBS in women >18
Lubiprostone (amitiza)
44
what must be monitored while on Lubiprostone
electrolytes (keep up on labs)
45
drug whose MOA is binding to guanylate cyclase-C (GC-C) to relieve constipation in IBS to release secretion of Chloride and bicarb into intestinal lumen
Linaclotide (Linzess)
46
percentages with constipation for both genders over 65
26% men | 34% women
47
how much spent yearly on laxatives
$800mil
48
is constipation benign?
``` no. complications include perforation hemmorhoids anal fissures fecal impaction overflow diarrhea ```
49
rome II criteria for constipation
atleast 12 weeks (not necessarily consecutive) in the past year including 2+ of straining in >25% attempts lumpy/hard stools >25% sensation of incomplete evacuation >25% sensation of anorectal obstruction >25% <3 stools per month
50
some complications for the elderly population contributing to constipation
not enough dietary fiber | poor denture fitting
51
which drugs provoke constipation?
those that affect smooth muscle, nerve conduction, or the CNS
52
specific drugs that cause constipation
opioids: inhibit gastric emptying and propulsive motor activity by depressing excitability of neurons in GI tract (S.E. does not lessen as tolerance of opiods increase) anticholinergics: benadryl, OTC cough and cold, anti-nausea (zofran) vitamins (iron, calcium, antacids) heart medicines (CCB and diuretics)
53
metabolic causes of constipation
hypothyroidism hypokalemia hypo and hypercalcemia
54
neurologic causes of constipation
spinal cord injury: neurogenic bowel and bladder disruption, ANS component loss parkinson's: disease itself of meds to treat it stroke: affects central bowel and bladder control
55
tumor causes of constipation
rectal and sigmoid tumors
56
pregnacy causing constipation
high progesterone levels > constipation
57
Normal colonic transit time idiopathic chronic constipation
``` normal colonic transit time no relief from laxatives or fiber misperception of bowel freq stressed about BM abnormal anorectal sensory/motor function that makes sensory and perception of defecation similar to someone with a slow transit ```
58
slow transit idiopatic chronic constipation
visualized with radiopaque marker resting colonic motility is normal little or no increase in motility with stimulus or laxative problem is likely to be enteric nerve plexus
59
outlet delay IBS
radiopaque markers move through colon normally but stop at rectum could be from pelvic floor dys-synergy
60
pertinent history questions to ask for iBS
``` 2 week diary what do they think is normal? new meds? underlying illness? associated symptoms? sudden change in calliber or freq, insidious onset (cancer) ```
61
physical exam findings for constipation
abd exam: hard masses rectal exam: impaction, rectal tone, ROBT, hemorrhoids voluntary holding of stool concern of chancer
62
when would you observe labs for constipation
when you think they have a metabolic cause
63
when does hyperkalemia occur leading to constipation
patients with CHF who are on lasix renal failure history of hypothyroidism mew med change
64
when do you use imaging for constipation
you don't unless you're concerned about impaction or cancer
65
gastrocolic reflex
reflex to defecate 15 minutes - 90 minutes after meal start time
66
diet modification for constipation
consume 20-35g fiber daily | absorbs water and increases stool bulk
67
bulk forming laxatives
psyllium (metamusil) methylcellulose (citrucel) polycarbophil (fibercon) make sure to drink enough water to make this effective
68
best in class of bulk forming laxatives
metamucil
69
stool softeners (how do they work)
decrease the surface tension on the surface of the bowel to allow more water to enter
70
what are stool softeners ineffective for?
chronic constipation
71
what are stool softeners very effective for?
anal fissures or hemorrhoids
72
examples of stool softeners
``` docusate sodium (colace) -maintains soft stools mineral oil -do not ingest, use enema to soften and lubricate recutm before manual disimpaction ```
73
stimulate laxatives (how they work?)
increase bowel motility by stimulating the colon
74
examples of stimulant laxatives
sennakot | bisacodyl (dulcolax)
75
what are stimulant laxatives very effective at?
preventing and treating opiod induced constipation
76
can you use stimulant laxatives long term?
NO, cause hypokalemia
77
what precaution do you take with stimulant laxatives
anorexic and bulimic disorders
78
how osmotic laxatives work
substances are hypertonic osmotically active particles > draw water into the colon due to osmotic gradient
79
when should you use osmotic laxatives
LAST RESORT
80
types of osmotic laxatives
milk of magnesia polyethylene glycol (miralax) magnesium citrate (colonscopy bowel prep) lactulose (enulose)
81
describe lactulose
``` nondigestible sugar very effective prescription only very sweet! broken down by gut flora can cause a lot of gas ```
82
disimpaction
removal of bulk of stool in rectum blocking the exit
83
enemas
sodium phosphate enema (Fleets) soap suds in tap water glycerine suppository
84
when are enemas best used
if you're concerned about impaction help clear the path before aggressively soften and stimulate with PO meds if you stimulate with PO meds to increase contractions it can be very painful or perforation can occur
85
what should you do prior to prescribing an enema
do a DRE
86
acute mesenteric ischemia
ischemic bowel caused by a reduction in intestinal blood flow
87
vasospasm
vessels feeding part of the intestines, spasm, cut off blood supply
88
hypoperfusion
bowel becomes dehydrated, low flow
89
occlusion
a clot, atrial fibrillation
90
what is the serious risk of an ischemic bowel
sepsis bowel infarction death
91
risk factors of acute mesenteric ischemia
``` advanced age atherosclerosis low cardiac output states cardiac arrhythmias (A FIB!) severe card ```

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