L5: IBS, C/D Flashcards
1
Q
IBS age epidemiology
A
F>M
20-39 years
2
Q
3 etiologies of IBS
A
Physiological
Psychosocial
Environmental
3
Q
IBS presentation
A
Chronic/recurrent abdominal pain/discomfort
Cramping, diffuse lower abdominal pain→ variable intensity, periodic exacerbations
+/- dyspepsia, atypical chest pain, vomiting (rare)
4
Q
IBS categories:
A
Constipation predominant
Diarrhea predominant
Mixed
Unclassified
5
Q
Extraintestinal symptoms of IBS
A
Sexual dysfunction dysmenorrhea Irritative voiding symptoms Fibromyalgia somatic or psychological complaints
6
Q
Rome IV criteria for IBS
A
Recurrent abdominal pain 1 or more days/week in last 3 months + 2 or more:
- Related to defecation
- Change in stool frequency
- Change in stool form
7
Q
IBS, C/D alarm symptoms
A
Onset >50 years Severe/progressively worsening Nocturnal diarrhea Fevers/vomiting Unexplained weight loss Melena, hematochezia, (+) occult blood Personal or family history of colon cancer, IBD, Celiac Iron deficiency anemia
8
Q
Labs for IBS
A
Not usually indicated \+/- CBC, CMP, TSH ESR/CRP Celiac serologies stool studies
9
Q
Further workup for IBS is indicated in cases of…
A
Atypical history
alarm features
refractory
10
Q
Further workup for concerning IBS cases includes
A
Laboratory/stool studies
Cross sectional/small bowel imaging
Endoscopy/colonoscopy with biopsies
11
Q
How much fiber should an IBS patient be taking?
A
20-35 g daily→ start low, increase slowly
12
Q
Diet for IBS
A
FODMAP diet:
Eliminate sugars and fibers that cause pain and bloating
Eliminate x 4-8 weeks→ gradually reintroduce 1-2 foods at a time→ assess tolerance
Trained dietician to avoid unnecessary over-restriction, may not be appropriate for everyone
13
Q
Levsin
A
anticholinergic for abdominal pain
14
Q
Bentyl
A
anticholinergic for abdominal pain
15
Q
Side effects of anticholinergic meds
A
Dry eyes
Dry mouth
Constipation
16
Q
Miralax
A
Constipation medication
17
Q
Amitiza
A
Constipation medication
18
Q
Linzess
A
Constipation medication
19
Q
Psyllium fiber
A
Constipation medication
20
Q
Trulance
A
Constipation medication
21
Q
Rifaximin
A
Diarrhea meds
22
Q
Imodium
A
Diarrhea meds
23
Q
Alosetron
A
Diarrhea meds
24
Q
Viberzi
A
Diarrhea meds
25
Which diarrhea med can only be prescribed to women and needs a risk management program?
Alosetron
26
Psychosocial meds for IBS
TCAs
27
Increased risk of constipation
```
Improper diet
Inadequate fluid intake
Sedentary lifestyle
Polypharmacy
Age
F>M
```
28
Most common digestive complaint
Constipation
29
Functional constipation is
Chronic idiopathic constipation
| IBS-C (pain)
30
Medication induced constipation
```
opioids
anticholinergics
antipsychotics
iron
antacids (calcium, aluminum)
CCBs
```
31
Slow transit constipation
Colonic inertia
32
Constipation caused by defecation/obstructive disorders
```
pelvic floor dysfunction
anorectal disease
rectal prolapse
rectocele
colon cancer
polyp
stricture/stenosis, fecal impaction/obstruction
```
33
Other causes of constipation
IBD
| Volvulus
34
Metabolic/systemic causes of constipation
```
hypercalcemia
hyperparathyroidism
hypothyroidism
DM
pregnancy
Hirschsprung
Multiple Sclerosis
Parkinson
Spinal cord injuries
```
35
Further workup for constipation patients with alarm features or refractory to medical therapy
Imaging studies
| Colonoscopy or Flex sig/BE→ identify lesions than narrow or occluded bowel
36
Constipation labs
+/- CBC, CMP, TSH
37
Constipation definition
25% of defecations associated with
<3 spontaneous bowel movements/week
Lumpy or hard stools
Straining
Manual maneuvers to facilitate defecation (digital evacuation, support of pelvic floor)
Sensation of anorectal obstruction/blockage
Sense of incomplete evacuation
38
Possible GI symptoms of constipation
Abdominal pain/bloating
Pain on defecation
Rectal bleeding
Tenesmus
39
Evaluate for ____ on abdominal exam for constipation
Distention
| Mass
40
Evaluate for _____ on DRE for constipation
```
evaluate for fissures
hemorrhoids
tenderness,
masses
stool
anal stricture
anal sphincter tone
perineal descent
dysynergic defecation
```
41
Evaluate for _____ on pelvic exam for constipation
Rectocele
42
Lifestyle modifications for constipation
Increase fluid/fiber intake
Increase activity/exercise
Bowel habit training
Biofeedback helpful with defecatory dysfunction
43
Methylcellulose
Fiber supplement for constipation
44
Psyllium
Fiber supplement for constipation
45
Benefiber
Fiber supplement for constipation
46
Polycarbophil
Fiber supplement for constipation
47
Docusate
stool softener
48
Fiber supplements side effects
```
***
Flatulence
bloating
distention
***
```
49
Docusate side effect
GI cramping
50
Osmotic laxatives side effects
GI discomfort, bloating
***
Caution: Mg→ hypermagnesemia in patients with renal insufficiency
***
51
Polyethylene glycol (Miralax)
Osmotic laxative
52
Lactulose
Osmotic laxative
53
Milk of magnesia
Osmotic laxative
54
Mag citrate
Osmotic laxative
55
Bisacodyl
Stimulant laxative
56
Senna
Stimulant laxative
57
Stimulant laxative side effects
GI cramping
Electrolyte disturbances (rarely)
Melanosis coli
58
Rx agents for constipation side effects
Diarrhea
59
Lubiprostone
Rx agent for constipation
60
Linaclotide
Rx agent for constipation
61
Plecanatide
Rx agent for constipation
62
Complications of constipation
Hemorrhoids/anal fissures
Laxative abuse→ fluid and electrolyte abnormalities
Fecal impaction→ bowel obstruction
63
More at risk for fecal impaction
dementia
neurologic disease
immobile
hypomotility meds
64
Fecal impaction symptoms
N/V
abdominal pain
distention
paradoxical “diarrhea” (only fluid passes)
65
Fecal impaction management
disimpaction then maintenance bowel prep
66
Diarrhea
Passage of >3 unformed stools/day
67
Diarrhea is most commonly
infectious
viral
self-limiting
68
Acute diarrhea
<14 days
69
Persistent diarrhea
14-30 days
70
Chronic diarrhea
>30 days
71
Red flag for diarrhea (but not IBS or constipation)
Signs of volume depletion
72
Exposures that could cause diarrhea
Recent hospitalization or abx
Travel
Ingestion of improperly stored/prepared food
Sick contact exposure, community outbreaks
Pets/animals
New meds or dose changes
73
Public health risk
healthcare worker
daycare worker
food-handlers
74
Physical exam for diarrhea
***Volume status + complications***
Temp, HR, orthostatic BP
Skin turgor, mucous membranes
Abdominal distention, bowel sounds, tenderness, peritoneal signs, masses
Rectal tenderness, stool guaiac, perianal disease
Mental status
75
Noniflammatory diarrhea symptoms
```
Watery nonbloody diarrhea
N/V
Mild diffuse abdominal cramps
bloating/flatulence
+/- Low grade fever
```
76
Inflammatory diarrhea symptoms
Fever
bloody diarrhea
severe abdominal pain
77
Viral causes of NONinflammatory diarrhea
*Norovirus*
| Rotavirus
78
Viral causes of inflammatory diarrhea
Cytomegalovirus
79
Bacterial causes of NONinflammatory diarrhea
Vibrio cholera
Clostridium perfringens
Staph aureus
Bacillus cereus
80
Bacterial causes of inflammatory diarrhea
```
***Salmonella
Campylobacter
Shigella, Enterohemorrhagic E coli 0157:H7
Clostridioides difficile***
Vibrio parahaemolyticus
Yersinia
```
81
Protozoal causes of NONinflammatory diarrhea
***Giardia***
Cryptosporidium
Cyclospora
82
Protozoal causes of inflammatory diarrhea
Entamoeba histolytica
83
Diarrhea diagnostics
```
*Not routinely warranted for most patients*
+/- CBC, CMP, CRP
Stool cultures→ Salmonella, Shigella, Campylobacter
E coli 0157:H7 culture
Ovum + Parasites (
Giardia, C diff
Hemoccult
Imaging
```
84
Diarrhea patients who need prompt evaluation
Signs of inflammatory diarrhea: Fever >101.3 F, leukocytosis, bloody diarrhea, severe abdominal pain
```
Intractable vomiting
Profuse watery diarrhea + dehydration
AKI/Lyte abnormalities
Elderly or nursing home residents
Immunocompromised
Hospital-acquired diarrhea, exposure to abx
```
85
Supportive care for acute diarrhea
Oral rehydration therapy
Trial of lactose free diet
Probiotics
+/- Antidiarrheal agents→ safe + effective for patients without dysentery
86
Loperamide
Antidiarrheal agen
87
Bismuth subsalicylate
Antidiarrheal agen
88
Bismuth subsalicylate side effect
black stool
89
Antibiotic treatment for acute diarrhea
generally not indicated as most cases are self-limited
Some organisms require specific antibiotics→ Reference Sanford Guide
Empiric abx→ Fluoroquinolone or Azithromycin x3-5 days
90
Vibrio cholerae
Non-inflammatory bacterial diarrhea
| Causes "rice-water" diarrhea
91
Norovirus
Non-inflammatory viral diarrhea
92
Giardia lamblia
Non-inflammatory protozoal diarrhea found in camping, lakes, streams, ponds, daycares, and pools
93
Clostridiodides difficile
Inflammatory bacterial diarrhea
Causes: recent abx use or community acquired
Tx: discontinue inciting abx.
Vancomycin
Fidaxomicin
Metronidazole
94
Yersinia enterocolitica
Inflammatory bacterial diarrhea that can mimic appendicitis
