11. Functional Bowel disorders Flashcards
Compare structural and functional GI diseases.
Structural: Detectable pathology (Macroscopic e.g. a Cancer; Microscopic e.g. Colitis). Prognosis depends on pathology
Functional: No detectable pathology, Related to gut function, “Software faults”, Long-term prognosis good
Large group of GI disorders termed ‘functional’ because symptoms occur in the absence of any demonstrable abnormalities in the digestion and absorption of nutrients, fluid and electrolytes, and no structural abnormality can be identified in the GI tract, although there may be discernible abnormalities in neuromuscular function, e.g. dysmotility and visceral hypersensitivity, which are not routinely investigated.
Name some functional GI disorders.
Oesophageal spasm Non-Ulcer Dyspepsia (NUD) Biliary Dyskinesia Irritable Bowel syndrome Slow Transit Constipation Drug Related Effects
Non-ulcer dyspepsia:
- What are the symptoms?
- T/F: ulcer present on endoscopy.
- T/F: H. pylori status varies
- What other diseases may be associated with?
- Dyspeptic type pain
- False. No ulcer present on endoscopy.
- True
- Probably not a single disease:
- Reflux
- Low grade duodenal ulceration
- Delayed Gastric emptying
- Irritable bowel syndrome
How would you diagnose non-ulcer dyspepsia?
- Careful History and Examination: Family History
- Gastric Cancer rare in those < 45 years
- H. pylori status
- Alarm symptoms
- If all negative: Treat symptomatically
- If H. pylori positive: Eradication therapy
- If Doubt: Endoscopy
Define:
- Nausea
- Retching
- Vomiting
- Nausea: The sensation of feeling sick
- Retching: Dry heaves. Antrum contracts, glottis closed
- Vomiting: Contents expelled
What kind of questions would you ask during history from patient with vomiting and what does it indicate in terms of cause?
How long after food did vomiting start?
- Immediate? Psychogenic
- 1 hour or more? Pyloric obstruction or Motility disorders (Diabetes, Post gastrectomy)
- 12 hours: Obstruction etc
What are the functional causes of vomiting?
- Drugs
- Pregnancy
- Migraine
- Cyclical Vomiting Syndrome: Onset often in childhood. Characterized by typical bouts of intense vomiting lasting for hours to days, separated by periods with no symptoms.
- Alcohol
Psychogenic vomiting:
- Which gender does it affect more?
- T/F: may have no preceding nausea.
- T/F: maybe self induced (overlap with bulimia)
- Is the appetite affected?
- When does it stop?
- Often young women
- True
- True
- Appetite usually not disturbed but may lose weight
- Often go on for years. Often stops shortly after admission
Name Functional Disease of Lower GI tract.
Irritable Bowel Syndrome
Slow Transit Constipation
What kind of questions would you ask when investigating patient’s bowel habits?
Consider changes in Gut Function:
- “What is normal for you?”
- Change in frequency, consistency?
- Blood?
- Mucus?
Take a careful history:
- What does the patient mean?
- Duration: From birth? Recent onset?
- Soiling?
- Drugs
What kind of physical examination would you perform on a patient complaining of lower GI symptoms?
- Look for systemic disease
- Careful abdominal examination
- Rectal examination
- Faecal occult blood (FOB): test detects small amounts of blood in your faeces
What kind of investigations would you perform on a patient complaining of lower GI symptoms?
- FBC
- Blood glucose
- U + E, etc.
- Thyroid status
- Coeliac serology
- FIT (Faecal immunochemical test) testing: uses antibodies that specifically recognise human haemoglobin (Hb). Screening test for colon cancer.
- Sigmoidoscopy
- Colonoscopy
What is the aetiology of constipation?
- Systemic: Diabetes, Hypothyroidism, Hypercalcaemia
- Neurogenic: Autonomic neuropathies, Parkinson’s disease, Strokes, Multiple sclerosis, Spina bifida
- Organic: Strictures, Tumours, Diverticular disease, Proctitis, Anal fissure
- Functional: Megacolon, Idiopathic constipation, Depression, Psychosis, Institutionalised patients
Case: 26yr female, No family history, 4 year history of irregular bowel habit (Alternating constipation and loose stool), Colicky pain relieved by defecation, No blood, No weight loss.
On examination Normal Physical and rectal examination. FIT and calprotectin negative. Blood tests normal.
What is the diagnosis?
Irritable bowel syndrome
What are the clinical features of irritable bowel syndrome?
Symptoms of IBS usually occur in chronic relapsing, remitting manner.
- Abdominal pain
- Altered bowel habit
- Abdominal bloating
- Belching wind and flatus
- Mucus
Abdominal Pain:
- How do patients describe the pain?
- Where does it radiate to?
- What other symptoms it may be associated with?
- If pain can be replicated by balloon inflation then what does it suggest its due to?
- T/F: often altered by bowel action.
- T/F: always occurs during the night.
- Burning, sharp
- Occasionally radiates, often to lower back
- Bloating
- Pain can be replicated by balloon inflation suggesting it may be due to bowel distension
- True
- False. Rarely occurs at night
Name types of irritable bowel syndrome.
- IBS-C: is when the digestive system contracts slowly, delaying transit time for products of digestion, resulting in hard, difficult to pass, infrequent stools (constipation).
- IBS-D: is when the digestive system contracts quickly, transiting products of digestion rapidly through the digestive tract, resulting in frequent, watery bowel movements (diarrhoea).
- IBS-M: is when the transit time throughout the digestive tract fluctuates, causing patients to experience a mix of both diarrhea and constipation, often alternating between the two. These extreme stool consistencies can sometimes even occur within the same bowel movement.
Bloating:
- What symptoms might patients get?
- T/F: mucus may be present in stools.
- T/F: Abdominal muscles are relaxed.
- Wind and flatulence. Upper and other GI symptoms.
- True
- True
How is irritable bowel syndrome diagnosed?
A compatible history
Normal physical examination
Rome and NICE guidelines
What investigations would you perform to diagnose irritable bowel syndrome?
- Blood analysis: FBC, U & E, LFTs, Ca, CRP, Thyroid function tests, Coeliac serology
- Stool Culture
- Calprotectin (released by inflamed gut mucosa. Used for differentiating IBS from IBD and for monitoring IBD.
- FIT testing
- Rectal Examination
- ?Colonoscopy
How is irritable bowel syndrome treated?
- A firm diagnosis
- Education and reassurance
- Dietetic review:
- Tea, coffee, alcohol, sweetener
- Lactose, gluten exclusion trial
- low FODMAP (Fermentable Oligo-, Di- and Mono-Saccharides and Polyols) diet for bloating. - Drugs
- Psychological interventions
List pharmacological treatment of irritable bowel syndrome.
Pain: antispasmodics. Linaclotide (for IBS-C).
- Antidepressants: tricyclic group (TCAs) for IBS-D. SSRI, e.g. paroxetine for IBS-C.
Bloating: probiotics. Linaclotide (IBS-C). Avoid bulking agents/fibre.
Constipation: Bulking agents/fibre (episodic), softeners (adjuvants), stimulants (occasional), osmotics (regular). Linaclotide. Avoid TCAs and FODMAP
Diarrhoea: Antimotility agents, FODMAP. Avoid SSRIs. Insufficient evidence = rifaximin.
Name some psychological interventions for irritable bowel syndrome patients.
Relaxation training e.g. meditation: effective in patients with diarrhoea and psychological comorbidity
Hypnotherapy: Helps to manage pain, constipation, flatulence, anxiety in refractory patients.
CBT: effective for abdominal pain, bloating, flatulence. Not effective for depression or when patients believe in physical cause of their symptoms.
Psychodynamic interpersonal therapy: effective in patients with history of abuse. Not really effective for constant pain, constipation or depression.
What causes irritable bowel syndrome?
Altered Motility: In IBS-D, muscular contractions may be stronger and more frequent than normal. In IBS-C, contractions may be reduced
Visceral Hypersensitivity
Stress, Anxiety, Depression
T/F: Gut response to triggers may be altered in IBS.
True. Contractions can be triggered by waking and eating. In IBS-D, the response to these normal triggers may be stronger than normal. In IBS-C, the response may be reduced.
T/F: The brain hears the gut too loudly in IBS.
True. The brain is able to hear messages from the gut such as hunger or the urge to go to the toilet. In IBS the brain hears these messages too loudly.
T/F: Heightened gut awareness in IBS.
True. The gut works all day, every day, but most people do not feel it
People with IBS often have an excessive awareness of normal digestive processes.
T/F: The stress response may be chronic in IBS
True. We all get butterflies and diarrhoea in response to stress. In IBS, the gut is more sensitive to stress, and this response can become chronic.
Case: 36yr female. 8 year history of abdominal pain, bloating. Bowels open every 2-3 days with tenesmus. Occasional diarrhoea and urgency with incontinence. Occasional fresh blood on wiping. Weight stable. No upper GI symptoms/mouth ulceration. Normal examination including PR. Routine bloods normal. Calprotectin 12. FIT negative.
Name suspected diagnosis and how you would manage it?
Suspected diagnosis: IBS-C with overflow diarrhoea and haemorrhoids.
Management:
- Clear explanation and discussion of alarm symptoms
- Optimise laxatives: Laxido titrated upwards
- Regular peppermint (Colpermin) (has antispasmodic effects and temporarily causes pain-sensing fibres in the gut to becomes less sensitive.
- Dietetic referral for FODMAP
- Trial of linaclotide if above unsuccessful
