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1. Clin Med III > 1- IBS, Diarrhea, Constipation > Flashcards

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)

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2
Q

How is IBS defined?

A

Functional bowel disorder characterized by recurrent abd pain AND altered bowel habits

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3
Q

How is IBS subclassified?

A

By predominant stool pattern (constipation, diarrhea, mixed, unclassified)

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4
Q

What is the pathophysiology of IBS?

A

Multifactorial (no single unifying etiology)

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5
Q

Is a pt that has red flag symptoms, concerning for IBS?

A

No. They should not have any red flag sx

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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

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7
Q

Bowel movements of diarrhea predominant IBS typically occur when?

A

In the morning and postprandially

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8
Q

Will vital signs & PE for IBS pt have any specific findings?

A

No (generally normal)

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9
Q

What additional exam should be performed for pt w/ suspected IBS?

A

DRE/perianal exam

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10
Q

What is the diagnostic criteria for IBS?

A

Rome IV criteria

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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)

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12
Q

What scale is used to idenity stool patterns and provides diagnostic criteria for IBS substypes?

A

Bristol Stool Scale

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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

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14
Q

Is the Bristol scale alone diagnostic for IBS?

A

No! Pain criteria must also be met

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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

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16
Q

What Bristol scale stool patterns fall under IBS-C?

A

Bristol types 1 & 2

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17
Q

What Bristol scale stool patterns fall under IBS-M?

A

Bristol types 1 & 6

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18
Q

What Bristol scale stool patterns fall under IBS-D?

A

Bristol types 6 & 7

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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)

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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)

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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

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22
Q

What is the goal of IBS tx?

A

Relieve sx and improve QOL

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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

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24
Q

A high fiber diet for a pt with IBS should be encouraged under what guidelines?

A

Start low and increase slowly

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25
Q

What is a low FODMAP diet?

A

Eliminates foods that contain sugar and fibers that cause pain and bloating

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26
Q

What are the “stages” of the FODMAP diet?

A

Eliminate foods (4-8wks) → reintroduce foods → personalize diet (dietitian)

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27
Q

What is the target of psychosocial support as a part of IBS tx?

A

Target visceral hypersensitvitiy & coping skills offered in pt friendly manner (outcomes are Pt/Pr dependent)

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28
Q

Pharmacologic therapies for IBS are tailored to what?

A

Predominant symptomatology and risk benefit profile (abd pain/ discomfort, constipation, or diarrhea)

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29
Q

If pt with IBS has predominantly sxs of abd pain/ discomfort, what are the pharmacologic tx options?

A

Antispasmodics, antidepressants

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30
Q

What is the caution with antispasmodics in treating IBS?

A

Anticholinergic SEs

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31
Q

If pt with IBS has predominantly sxs of constipation, what are the pharmacologic tx options?

A

Fiber, stool softeners, laxatives, prosecretory agents

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32
Q

If pt with IBS has predominantly sxs of diarrhea, what are the pharmacologic tx options?

A

Anti-diarrheal, bile acid sequestrants

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33
Q

What meds can exacerbate constipation?

A

Antipsychotics, iron, opioids

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34
Q

What is the most common digestive complaint in the general population?

A

Constipation

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35
Q

What are the RFs for constipation?

A

Improper diet/ inadequate fluid, sedentary lifestyle, polypharmacy, age (motility decreases w age)

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36
Q

Is acute or chronic constipation more concerning?

A

Acute

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37
Q

Aside from general hx questions, what is important to ask a pt w/ CC of constipation?

A

Laxative use, hx for digital evacuation, previous colonoscopy, red flag sxs, & review meds

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38
Q

How is constipation defined?

A

25% of BMs a/w infrequent defication (< 3 per week) (also a/w other “constipation” sxs)

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39
Q

The following GI sxs might be a/w with what? Abd pain/ bloating, pain on defecation, rectal bleeding, tenesmus (recurrent inclination to evacuate bowels)

A

Constipation

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40
Q

What is the most important thing to eval for on DRE of PE for constipation?

A

Fissures (also hemorrhoids, tenderness, masses, stool, anal stricture tone, perineal descent, dyssynergic defecation)

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41
Q

Pt with dyssynergic defecation will have what on DRE?

A

Abnormal relaxation of external anal sphincter (pulls finger inward and does not relax)

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42
Q

Alarm features for a pt presenting with constipation requires further eval with what diagnostic studies? (as clinically appropriate)

A

Imaging, colonoscopy, flex sig/ BE (identifies lesions that narrow or occlude the bowel)

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43
Q

What are the functional causes of constipation?

A

Chronic idiopathic constipation & IBS-C

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44
Q

Is chronic idiopathic constipation constipation or constipation + pain predominent?

A

Constripation predominant

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45
Q

Is IBS-C constipation or constipation + pain predominent?

A

Constipation + pain predominant

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46
Q

Opion, anticholinergics, antipsychotics, iron, antacids (Ca & Al), CCBs, and TCAs can all cause what?

A

Medication induced constipation

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47
Q

Pelvic floor dysfunction, rectal prolapse, rectocele, colon CA, polyps, stricture/stenosis, and fecal impaction can all cause what?

A

Constipation due to defication/obstuctive disorders

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48
Q

IBD and volvulus can cause what?

A

Constipation

49
Q

Hypercalcemia, hyperparathyroidism, hypothyroidism, DM, pregnancy, hischsprung, MS, parksinsons, and spinal cord injuries can all lead to what?

A

Metabolic/systemic disease induced constipation

50
Q

What is the first step in the management of constipation?

A

Treat secondary/ contributing causes of constipation and reconcile offending meds (also dietary/ lifestyle/ behavioral mod, and pharm)

51
Q

What are the dietary, lifestyle, and behavioral modifications for a pt with constipation?

A

Increase fluid/ fiber, increase activity, bowel habit training, biofeedback (defecatory dysfunction)

52
Q

What OTC med classes might be used in the management of constipation?

A

Fiber supplements, stool softeners, osmotic/ stimulant laxatives (also can use rx agents)

53
Q

What are the SEs of fiber supplements used in the tx of constipation?

A

Flatulence, bloating, distention (initally)

54
Q

What is the SE of Docusate (stool softener) used in the tx of constipation?

A

GI cramping

55
Q

What are the SEs of osmotic laxatives used in the tx of constipation?

A

GI discomfort, bloating

56
Q

What are the SEs of stimulant laxatives used in the tx of constipation?

A

GI cramping, electrolyte disturbances (rare), melanosis coli

57
Q

In what populations should you be cautious with the use of Mg-containing laxatives and hypermagnesemia in the tx of constipation?

A

Renal insufficiency

58
Q

What rx agents are used in the tx of constipation?

A

Amitiza, Linzess, Trulance

59
Q

What are the SEs of rx agents used in the tx of constipation?

A

Diarrhea

60
Q

Med induced, slow transit, defication/obstructive disorders, and metabolic/systemic dx can all cause what?

A

Constipation (secondary/contributing causes)

61
Q

What are complications of constipation?

A

Hemorrhoids, anal fissures, fluid & e-ltye abnormalities if chronic laxative use, fecal impaction, bowel obstruction

62
Q

Fecal impaction due to constipation can lead to what?

A

Bowel obstruction

63
Q

The following are sx of what? N/V/ abd pain, distention, paradoxical diarrhea

A

Bowel obstruction

64
Q

Pt w/ dementia, neuro disease, immobile or on hypomotility meds are at higher risk for what?

A

Constipation

65
Q

What is the most common etiology of acutre diarrhea?

A

Infectious (viral > bacterial, protozoal) EX: Norovirus

66
Q

How is diarrhea defined?

A

Passage of ≥ 3 unformed stools/ day

67
Q

What is the duration for acute diarrhea?

A

< 14 days duration

68
Q

What is the duration for persistent diarrhea?

A

> 14-30 days duration

69
Q

What is the duration for chronic diarrhea?

A

> 30 days duration

70
Q

What are key history questions when evaluating acute diarrhea?

A

Previous colonoscopy, red flag sx/alarm features, risk exposures

71
Q

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?

A

Acute diarrhea

72
Q

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

A

Acute diarrhea

73
Q

What is most common cause of viral acute noninflammatory diarrhea?

A

Norovirus > Rotovirus

74
Q

What is the most common cause of protozoal acute Non inflammatory diarrhea?

A

Giardia > cryptosporidium, cyclospora

75
Q

What are the sx of acute noninflammatory diarrhea?

A

watery, nonbloody, diarrhea, mild diffuse abdominal cramps, bloating/flatulence, +/- fever

76
Q

What are the most common infectious etiologies of acute non inflammatory diarrhea?

A

Viral and protozoal > bacterial

77
Q

Fever, bloody diarrhea, and severe abdominal pain are concerning for what?

A

Acute inflammatory diarrhea

78
Q

What is the most common infectious etiology of acute inflammatory diarrhea?

A

Bacterial > viral, protozoal

79
Q

What are the common bacterial etiologies of acute inflammatory diarrhea?

A

Salmonella, campylobacter, Shigella, E. coli, C. diff

80
Q

When evaluating a pt w/ acutre diarrhea, what should be the focus of your exam?

A

Focus on volume status & complications

81
Q

Is diagnostic eval typically warranted for a pt w/ acute diarrhea?

A

No (most infectious, viral, self-limited)

82
Q

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?

A

Prompt evaluation (red flag sx)

83
Q

What is the overall management for acute diarrhea?

A

Supportive care/ sxs relief

84
Q

If pepto-bismol (antidiarrheal agent) is used in the tx of acute diarrhea, what is a possible adverse effect?

A

Black stool

85
Q

Are abx typically indicated in the management of acute diarrhea?

A

No (most are self-limited, some causative organisms, if empiric abx- Fluoroquinolone x 3-5 days/ alternative- Azithro)

86
Q

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?

A

Norovirus, supportive care (self limited disease)

87
Q

6 mo-2 yo pt in daycare presents w/ diarrhea. What is the suspected causitive agent and tx?

A

Rotavirus, supportive care (self limited)

88
Q

What is the concern w/ rotavirus induced diarrhea?

A

Can progress to dehydration

89
Q

Pt presents with rice-water diarrhea after traveling to unsanitary conditions. What is the likely causitive agent and tx?

A

Vibrio chloerae, supportive care, if severe then ABX (doxy, macrolide, tetracyline, FLQ)

90
Q

Pt presents with diarrhea after eating reheated food and home-canned bean. What is the likely causitive agent and tx?

A

Clostridium perfringens (enterotoxin), supportive care

91
Q

Pt presents w/ vomiting 2 hrs after eating creamy egg and potatoe salad. What is the likely causitive agent and tx?

A

S. aureus (enterotoxin), supportive care

92
Q

Pt presents with vomiting 2 hrs after eating rice. What is the likely causitive agent and tx?

A

Bacillus cereus (enterotoxin), supportive care

93
Q

Pt with cc of diarrhea and hx of camping/ exposure to outdoor water sources. What causative agent should be concerned for?

A

Giardia lamblia

94
Q

What is the treatment of diarrhea w/ causative agent Giardia lamblia?

A

Metronidazole

95
Q

What is the concern with a pt infected w/ Giardia lamblia?

A

Chronic giardiasis can lead to profound weight loss

96
Q

Diarrhea w/ causative agent of Cryptosporidium is typically self limited and tx is supportive except in which population?

A

AIDS/ IMC (source = rec water, daycares)

97
Q

What is the source of Cyclospora and what is the tx? (causative agent of diarrhea)

A

Imported foods (fresh fruits/ veggies), tx with Bactrim

98
Q

What are the 3 non-inflammatory protozoal etiologies of diarrhea?

A

Giardia lamblia, cryptosporidium, cyclospora

99
Q

What are the 4 non-inflammatory bacterial etiologies of diarrhea?

A

Vibrio chloerae, Clostridium perfringens, Staph aureus, Bacillus cereus

100
Q

What are the 2 non-inflammatory viral etiologies of diarrhea?

A

Norovirus, rotavirus

101
Q

What is the inflammatory protozoal etiology of diarrhea?

A

E. histolytica

102
Q

What diarrhea causing bacteria is associated w/ poultry/livestock and reptiles?

A

Salmonella

103
Q

What is the tx for salmonella?

A

supportive, +/- abx

104
Q

What diarrhea causing bacteria is linked to Guillain-Barre syndrome and caused by consuming undercook poultry or unpasteurized milk?

A

Campylobacter jejuni

105
Q

What is the tx for Campylobacter jejuni?

A

Supportive, macrolide or FLQ if severe

106
Q

What pathogen is responsible for you “classic dysentery” sx usually aquired by fecal contaminated w/ food or water?

A

Shigella

107
Q

What is the tx for shigella?

A

Supportive, ABX will shorten course (FLQ, macrolide, bactrim)

108
Q

What bacteria can cause severe afebrile bloody diarrhea after consuming undercooked beef/unpasteurized products?

A

Enterohemorrhagic E. coli O157:H7

109
Q

What is the tx for Enterohemorrhagic E. coli

A

Supportive/monitoring.

110
Q

Why are antidiarrheal and ABX not used to tx Enterohemorrhagic E. coli ?

A

Risk of HUS

111
Q

Pt with cc of diarrhea and hx of recent hospitalization/ abx use. What is suspected causative agent and what is the tx?

A

C. diff (community acquired), tx w/ discontinuation of inciting abx and tx w/ vanco, fidaxomicin, metronidazole

112
Q

Pt with cc of diarrhea and hx of eating raw seafood/ shellfish. What is suspected causative agent and what is the tx?

A

Vibrio parahemolyticus, tx= supportive, if severe then FLQ, doxy

113
Q

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?

A

Yersinia enterocolitica, tx= supportive but tx if severe

114
Q

What is the concern with infection with Yersinia enterocolitica?

A

Mimics appendicitis

115
Q

Pt presents with cc of diarrhea. You suspect E. histolytica as the causative agent. What is the likely source/ appropriate therapy?

A

Fecally contaminated food/water, travel, tx w/ metro + iodoquinol

116
Q

What is the concern with E. histolytica?

A

Intraluminal and disseminated disease

117
Q

What is the first stepin the evaluation fo diarrhea?

A

Identify duration (acute vs chronic)

118
Q

What is the 2nd step in classifying diarrhea

A

Identify noninflammatory vs inflammatory

119
Q

Are lab/stool studies and ABX indicated for acute diarrhea?

A

No (rarely indicated, only as clinically appropriate)

1. Clin Med III (29 decks)

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