1- IBS, Diarrhea, Constipation Flashcards
1
Q
IDA, weight loss, and severe/ progressively worsening sxs are NOT a/w IBS and you should do what?
A
Further investigate and refer to gastroenterologist (other red flag sxs: onset after 50 yo, nocturnal sxs, fevers/ vomiting, melena/ hematochezia/+ occult blood, personal/ family hx of colon CA/ IBD/ celiac disease)
2
Q
How is IBS defined?
A
Functional bowel disorder characterized by recurrent abd pain AND altered bowel habits
3
Q
How is IBS subclassified?
A
By predominant stool pattern (constipation, diarrhea, mixed, unclassified)
4
Q
What is the pathophysiology of IBS?
A
Multifactorial (no single unifying etiology)
5
Q
Is a pt that has red flag symptoms, concerning for IBS?
A
No. They should not have any red flag sx
6
Q
Pt presents with chronic/recurrent abd pain and diffuse lower abd cramping and reports altered bowel habits. What disease should you be concerned about?
A
IBS
7
Q
Bowel movements of diarrhea predominant IBS typically occur when?
A
In the morning and postprandially
8
Q
Will vital signs & PE for IBS pt have any specific findings?
A
No (generally normal)
9
Q
What additional exam should be performed for pt w/ suspected IBS?
A
DRE/perianal exam
10
Q
What is the diagnostic criteria for IBS?
A
Rome IV criteria
11
Q
How is IBS defined according to Rome IV criteria?
A
Recurrent abd pain 1 day/ week in last 3 mos WITH 2+ of: related to defecation, a/w change in stool frequency, a/w change in stool form (appearance)
12
Q
What scale is used to idenity stool patterns and provides diagnostic criteria for IBS substypes?
A
Bristol Stool Scale
13
Q
Chronic IBS is Rome IV criteria fulfilled for the last 3 mos with sx onset when?
A
At least 6 mos prior to dx
14
Q
Is the Bristol scale alone diagnostic for IBS?
A
No! Pain criteria must also be met
15
Q
How is the Bristol scale used to classify stool pattern?
A
> 25% of BM must fall within the treshold for each IBS subtype
16
Q
What Bristol scale stool patterns fall under IBS-C?
A
Bristol types 1 & 2
17
Q
What Bristol scale stool patterns fall under IBS-M?
A
Bristol types 1 & 6
18
Q
What Bristol scale stool patterns fall under IBS-D?
A
Bristol types 6 & 7
19
Q
If pt suspicious for IBS but has typical hx and no alarm features, how do you proceed with diagnostic eval?
A
Limited lab screening, radiographic and endoscopic tests not routinely recommended (other diagnostic tests: CBC, CMP, TSH, tTG IgA, +/- fecal calprotectin vs CRP)
20
Q
If pt suspicious for IBS but has atypical hx, alarm features or is refractory to tx, how do you proceed with diagnostic eval?
A
Additional workup- lab/ stool studies, cross-sectional/ small bowel imaging, endoscopy/ colonoscopy with biopsies (other diagnostic tests: CBC, CMP, TSH, tTG IgA, +/- fecal calprotectin vs CRP)
21
Q
What is included in the tx of IBS?
A
Multimodal approach supported by therapeutic clinician-patient relationship: 1. Dietary/life style/behavior mod 2. Psychosocial support 3. Pharm therapy
22
Q
What is the goal of IBS tx?
A
Relieve sx and improve QOL
23
Q
What is included in dietary/ lifestyle/ behavioral modification for management of IBS?
A
Food diary/ symptomatology log (trigger foods), high fiber, hydration, exercise, toileting behavior, reconcile offending meds, mindful eating
24
Q
A high fiber diet for a pt with IBS should be encouraged under what guidelines?
A
Start low and increase slowly
25
What is a low FODMAP diet?
Eliminates foods that contain sugar and fibers that cause pain and bloating
26
What are the "stages" of the FODMAP diet?
Eliminate foods (4-8wks) → reintroduce foods → personalize diet (dietitian)
27
What is the target of psychosocial support as a part of IBS tx?
Target visceral hypersensitvitiy & coping skills offered in pt friendly manner (outcomes are Pt/Pr dependent)
28
Pharmacologic therapies for IBS are tailored to what?
Predominant symptomatology and risk benefit profile (abd pain/ discomfort, constipation, or diarrhea)
29
If pt with IBS has predominantly sxs of abd pain/ discomfort, what are the pharmacologic tx options?
Antispasmodics, antidepressants
30
What is the caution with antispasmodics in treating IBS?
Anticholinergic SEs
31
If pt with IBS has predominantly sxs of constipation, what are the pharmacologic tx options?
Fiber, stool softeners, laxatives, prosecretory agents
32
If pt with IBS has predominantly sxs of diarrhea, what are the pharmacologic tx options?
Anti-diarrheal, bile acid sequestrants
33
What meds can exacerbate constipation?
Antipsychotics, iron, opioids
34
What is the most common digestive complaint in the general population?
Constipation
35
What are the RFs for constipation?
Improper diet/ inadequate fluid, sedentary lifestyle, polypharmacy, age (motility decreases w age)
36
Is acute or chronic constipation more concerning?
Acute
37
Aside from general hx questions, what is important to ask a pt w/ CC of constipation?
Laxative use, hx for digital evacuation, previous colonoscopy, red flag sxs, & review meds
38
How is constipation defined?
25% of BMs a/w infrequent defication (< 3 per week) (also a/w other "constipation" sxs)
39
The following GI sxs might be a/w with what? Abd pain/ bloating, pain on defecation, rectal bleeding, tenesmus (recurrent inclination to evacuate bowels)
Constipation
40
What is the most important thing to eval for on DRE of PE for constipation?
Fissures (also hemorrhoids, tenderness, masses, stool, anal stricture tone, perineal descent, dyssynergic defecation)
41
Pt with dyssynergic defecation will have what on DRE?
Abnormal relaxation of external anal sphincter (pulls finger inward and does not relax)
42
Alarm features for a pt presenting with constipation requires further eval with what diagnostic studies? (as clinically appropriate)
Imaging, colonoscopy, flex sig/ BE (identifies lesions that narrow or occlude the bowel)
43
What are the functional causes of constipation?
Chronic idiopathic constipation & IBS-C
44
Is chronic idiopathic constipation constipation or constipation + pain predominent?
Constripation predominant
45
Is IBS-C constipation or constipation + pain predominent?
Constipation + pain predominant
46
Opion, anticholinergics, antipsychotics, iron, antacids (Ca & Al), CCBs, and TCAs can all cause what?
Medication induced constipation
47
Pelvic floor dysfunction, rectal prolapse, rectocele, colon CA, polyps, stricture/stenosis, and fecal impaction can all cause what?
Constipation due to defication/obstuctive disorders
48
IBD and volvulus can cause what?
Constipation
49
Hypercalcemia, hyperparathyroidism, hypothyroidism, DM, pregnancy, hischsprung, MS, parksinsons, and spinal cord injuries can all lead to what?
Metabolic/systemic disease induced constipation
50
What is the first step in the management of constipation?
Treat secondary/ contributing causes of constipation and reconcile offending meds (also dietary/ lifestyle/ behavioral mod, and pharm)
51
What are the dietary, lifestyle, and behavioral modifications for a pt with constipation?
Increase fluid/ fiber, increase activity, bowel habit training, biofeedback (defecatory dysfunction)
52
What OTC med classes might be used in the management of constipation?
Fiber supplements, stool softeners, osmotic/ stimulant laxatives (also can use rx agents)
53
What are the SEs of fiber supplements used in the tx of constipation?
Flatulence, bloating, distention (initally)
54
What is the SE of Docusate (stool softener) used in the tx of constipation?
GI cramping
55
What are the SEs of osmotic laxatives used in the tx of constipation?
GI discomfort, bloating
56
What are the SEs of stimulant laxatives used in the tx of constipation?
GI cramping, electrolyte disturbances (rare), melanosis coli
57
In what populations should you be cautious with the use of Mg-containing laxatives and hypermagnesemia in the tx of constipation?
Renal insufficiency
58
What rx agents are used in the tx of constipation?
Amitiza, Linzess, Trulance
59
What are the SEs of rx agents used in the tx of constipation?
Diarrhea
60
Med induced, slow transit, defication/obstructive disorders, and metabolic/systemic dx can all cause what?
Constipation (secondary/contributing causes)
61
What are complications of constipation?
Hemorrhoids, anal fissures, fluid & e-ltye abnormalities if chronic laxative use, fecal impaction, bowel obstruction
62
Fecal impaction due to constipation can lead to what?
Bowel obstruction
63
The following are sx of what? N/V/ abd pain, distention, paradoxical diarrhea
Bowel obstruction
64
Pt w/ dementia, neuro disease, immobile or on hypomotility meds are at higher risk for what?
Constipation
65
What is the most common etiology of acutre diarrhea?
Infectious (viral > bacterial, protozoal) EX: Norovirus
66
How is diarrhea defined?
Passage of ≥ 3 unformed stools/ day
67
What is the duration for acute diarrhea?
< 14 days duration
68
What is the duration for persistent diarrhea?
> 14-30 days duration
69
What is the duration for chronic diarrhea?
> 30 days duration
70
What are key history questions when evaluating acute diarrhea?
Previous colonoscopy, red flag sx/alarm features, risk exposures
71
Signs of volume depletion, fever, unexplained weight loss, melena, hematochezia, occult blood, persistent/progressive/nocturnal sx, IMC, personal or FH of colon CA, IBD, celiac disease, and Fe deficiency anemia are all red flag sx for what disease?
Acute diarrhea
72
The following are risk exposures for what disease? Recent hospitalization or ABX use, travel hx, ingestion of improperly stored/prepped food, sick contact, pet/animal exposure, new meds/dose changes, healthcare or day care worker
Acute diarrhea
73
What is most common cause of viral acute noninflammatory diarrhea?
Norovirus > Rotovirus
74
What is the most common cause of protozoal acute Non inflammatory diarrhea?
Giardia > cryptosporidium, cyclospora
75
What are the sx of acute noninflammatory diarrhea?
watery, nonbloody, diarrhea, mild diffuse abdominal cramps, bloating/flatulence, +/- fever
76
What are the most common infectious etiologies of acute non inflammatory diarrhea?
Viral and protozoal > bacterial
77
Fever, bloody diarrhea, and severe abdominal pain are concerning for what?
Acute inflammatory diarrhea
78
What is the most common infectious etiology of acute inflammatory diarrhea?
Bacterial > viral, protozoal
79
What are the common bacterial etiologies of acute inflammatory diarrhea?
Salmonella, campylobacter, Shigella, E. coli, C. diff
80
When evaluating a pt w/ acutre diarrhea, what should be the focus of your exam?
Focus on volume status & complications
81
Is diagnostic eval typically warranted for a pt w/ acute diarrhea?
No (most infectious, viral, self-limited)
82
What is the course of action for pts presenting w/ acute diarrhea and one of the following: fever > 101.1, intractable vomiting, profuse watery diarrhea/dehyation, lyte abnormalities, elderly, IMC, and hospital aquired diarrhea/recent ABX exposure?
Prompt evaluation (red flag sx)
83
What is the overall management for acute diarrhea?
Supportive care/ sxs relief
84
If pepto-bismol (antidiarrheal agent) is used in the tx of acute diarrhea, what is a possible adverse effect?
Black stool
85
Are abx typically indicated in the management of acute diarrhea?
No (most are self-limited, some causative organisms, if empiric abx- Fluoroquinolone x 3-5 days/ alternative- Azithro)
86
Pt presents w/ abrupt onset of diarrhea after eating at a restaurent/being on a cruise ship? What is the most likely causitive agent and tx?
Norovirus, supportive care (self limited disease)
87
6 mo-2 yo pt in daycare presents w/ diarrhea. What is the suspected causitive agent and tx?
Rotavirus, supportive care (self limited)
88
What is the concern w/ rotavirus induced diarrhea?
Can progress to dehydration
89
Pt presents with rice-water diarrhea after traveling to unsanitary conditions. What is the likely causitive agent and tx?
Vibrio chloerae, supportive care, if severe then ABX (doxy, macrolide, tetracyline, FLQ)
90
Pt presents with diarrhea after eating reheated food and home-canned bean. What is the likely causitive agent and tx?
Clostridium perfringens (enterotoxin), supportive care
91
Pt presents w/ vomiting 2 hrs after eating creamy egg and potatoe salad. What is the likely causitive agent and tx?
S. aureus (enterotoxin), supportive care
92
Pt presents with vomiting 2 hrs after eating rice. What is the likely causitive agent and tx?
Bacillus cereus (enterotoxin), supportive care
93
Pt with cc of diarrhea and hx of camping/ exposure to outdoor water sources. What causative agent should be concerned for?
Giardia lamblia
94
What is the treatment of diarrhea w/ causative agent Giardia lamblia?
Metronidazole
95
What is the concern with a pt infected w/ Giardia lamblia?
Chronic giardiasis can lead to profound weight loss
96
Diarrhea w/ causative agent of Cryptosporidium is typically self limited and tx is supportive except in which population?
AIDS/ IMC (source = rec water, daycares)
97
What is the source of Cyclospora and what is the tx? (causative agent of diarrhea)
Imported foods (fresh fruits/ veggies), tx with Bactrim
98
What are the 3 non-inflammatory protozoal etiologies of diarrhea?
Giardia lamblia, cryptosporidium, cyclospora
99
What are the 4 non-inflammatory bacterial etiologies of diarrhea?
Vibrio chloerae, Clostridium perfringens, Staph aureus, Bacillus cereus
100
What are the 2 non-inflammatory viral etiologies of diarrhea?
Norovirus, rotavirus
101
What is the inflammatory protozoal etiology of diarrhea?
E. histolytica
102
What diarrhea causing bacteria is associated w/ poultry/livestock and reptiles?
Salmonella
103
What is the tx for salmonella?
supportive, +/- abx
104
What diarrhea causing bacteria is linked to Guillain-Barre syndrome and caused by consuming undercook poultry or unpasteurized milk?
Campylobacter jejuni
105
What is the tx for Campylobacter jejuni?
Supportive, macrolide or FLQ if severe
106
What pathogen is responsible for you "classic dysentery" sx usually aquired by fecal contaminated w/ food or water?
Shigella
107
What is the tx for shigella?
Supportive, ABX will shorten course (FLQ, macrolide, bactrim)
108
What bacteria can cause severe afebrile bloody diarrhea after consuming undercooked beef/unpasteurized products?
Enterohemorrhagic E. coli O157:H7
109
What is the tx for Enterohemorrhagic E. coli
Supportive/monitoring.
110
Why are antidiarrheal and ABX not used to tx Enterohemorrhagic E. coli ?
Risk of HUS
111
Pt with cc of diarrhea and hx of recent hospitalization/ abx use. What is suspected causative agent and what is the tx?
C. diff (community acquired), tx w/ discontinuation of inciting abx and tx w/ vanco, fidaxomicin, metronidazole
112
Pt with cc of diarrhea and hx of eating raw seafood/ shellfish. What is suspected causative agent and what is the tx?
Vibrio parahemolyticus, tx= supportive, if severe then FLQ, doxy
113
Pt with cc of diarrhea and hx of eating undercooked pork, unpasteurized milk, or ingestion of fecally contaminated water. What is the suspected causative agent and what is the tx?
Yersinia enterocolitica, tx= supportive but tx if severe
114
What is the concern with infection with Yersinia enterocolitica?
Mimics appendicitis
115
Pt presents with cc of diarrhea. You suspect E. histolytica as the causative agent. What is the likely source/ appropriate therapy?
Fecally contaminated food/water, travel, tx w/ metro + iodoquinol
116
What is the concern with E. histolytica?
Intraluminal and disseminated disease
117
What is the first stepin the evaluation fo diarrhea?
Identify duration (acute vs chronic)
118
What is the 2nd step in classifying diarrhea
Identify noninflammatory vs inflammatory
119
Are lab/stool studies and ABX indicated for acute diarrhea?
No (rarely indicated, only as clinically appropriate)
