15. IBS, IBD and gastroenteritis Flashcards
In a patient who presents with abdo pain ad diarrhoea what red flags would warrant an urgent referral
aged over 60 rectal bleeding anaemia weight loss family history of colorectal cancer abdo/rectal mass raised CRP/ESR or faecal calprotectin
in women over 50 with persistent bloating what is mandatory to rule out ovarian cancer
USS of ovaries
Ca125 levels
What is IBS
it is a functional bowel disorder (FBD)
this means that there is no identifiable organic disease underlying the symptom
‘diagnosis of exclusion’ is the old term
how common is IBS
very common and occurs in 20% of the population
affects women more than men
more common in younger adults
what are the symptoms of IBS
- Diarrhoea
- Constipation
- Fluctuating bowel habit (diarrhoea, constipation or alternating)
- Abdominal pain
- Bloating or distention
- Worse after eating
- Improved by opening bowels
NICE guidelines: criteria for diagnosis
other pathology should be excluded. Which tests do you need to carry out to exclude other pathology
- Normal FBC, ESR and CRP blood tests
- Faecal calprotectin negative to exclude inflammatory bowel disease
- Negative coeliac disease serology (anti-TTG antibodies)
- Cancer is not suspected or excluded if suspected
NICE guidelines: what are the symptoms that suggest IBS
abdo pain/discomfort that is relived on opening bowels or associated with a change in bowel habit AND 2 of; abnormal stool passage bloating worse symptoms after eating PR mucus
what general advice can you give after a diagnosis of IBS
General healthy diet and exercise advice:
• Adequate fluid intake
• Regular small meals
• Reduced processed foods
• Limit caffeine and alcohol
• Low “FODMAP” diet (ideally with dietician guidance)
• Trial of probiotic supplements for 4 weeks
what is a FODMAO diet
stands for fermentable oligo-, di-, mono-saccharides and polyols)
Oligosaccharides: Wheat, rye, legumes and various fruits and vegetables, such as garlic and onions.
Disaccharides: Milk, yogurt and soft cheese. Lactose is the main carb.
Monosaccharides: Various fruit including figs and mangoes, and sweeteners such as honey and agave nectar. Fructose is the main carb.
Polyols: Certain fruits and vegetables including blackberries and lychee, as well as some low-calorie sweeteners like those in sugar-free gum.
what is the first line medications used for IBS
- Loperamide for diarrhoea
- Laxatives for constipation. Avoid lactulose as it can cause bloating. Linaclotide is a specialist laxative for patients with IBS not responding to first-line laxatives
- Antispasmodics for cramps e.g. hyoscine butylbromide (Buscopan)
why do you avoid lactulose in patients with IBS
can cause bloating
what is the second line medication for IBS
tricyclic antidepressants eg amitriptyline 5-10mg at night
what is the third line medication for IBS
SSRI antidepressants
important to tell the patient that this is not to treat the brain but used for the gut at a much lower dose
name some extra intestinal manifestations associated with IBS
o Nausea o Thigh pain o Backache o Lethargy o Urinary symptoms o Gynaecological symptoms (dyspareunia- pain during sexual intercourse)
What is the main issue with an IBS amongst society
stigmatised
inadequacies of treatment
hopelessness and suicide
Give some examples of antispasmodics that are anticholinergic
o Dicycloverine (merbentyl) o Hyoscine (buscopan) o Propantheline (probanthine)
give some examples of antispasmodics that are anti-smooth muscle
o Mebeverine (colofac) o Alverine (spasmonal) o Peppermint (colpermin)
Give some examples of antidiarrhoeals
o Loperamide – the best one
It improves anal tone, regular use low dose is safe and can take inn combination with antispasmodics
apart from medication, what else can be advised to see if it helps with IBS
CBT, hypnotherapy, acupuncture and probiotics
What are the benefits of probiotics in IBS
o Enhances host anti-inflammatory and immune response
o Stimultate anti-inflammatory cytokines
o Restore the balance between pro and anti-inflammatory cytokines
o Improves epithelial cell barrier
o Epithelial adhesion
What advice can you give to patients about IBS
too long winded answer, look at page 2 of your notes
What is IBD and what is it split into
Inflammatory bowel disease is the umbrella term for two main diseases causing inflammation of the GI tract: Ulcerative Colitis and Crohn’s disease. They both involve inflammation of the walls of the GI tract and are associated with periods of remission and exacerbation.
What are the key differentiating factors with chrons
Chrons- think crows NESTS
N – No blood or mucus (less common)
E – Entire GI tract
S – “Skip lesions” on endoscopy
T – Terminal ileum most affected and Transmural (full thickness) inflammation
S – Smoking is a risk factor (don’t set the nest on fire)
what are the key differentiating factors with ulcerative colitis- remember U C CLOSEUP
C – Continuous inflammation L – Limited to colon and rectum O – Only superficial mucosa affected S – Smoking is protective E – Excrete blood and mucus U – Use aminosalicylates P – Primary Sclerosing Cholangitis
how does IBD usually present
- Diarrhoea
- Abdominal pain
- Passing blood
- Weight loss
what tests would you perform when investigating IBD
- Routine bloods for anaemia, infection, thyroid, kidney and liver function
- CRP indicates inflammation and active disease
- Faecal calprotectin (released by the intestines when inflamed) is a useful screening test (> 90% sensitive and specific to IBD in adults)
- Endoscopy (OGD and colonoscopy) with biopsy is diagnostic
- Imaging with ultrasound, CT and MRI can be used to look for complications such as fistulas, abscesses and strictures.
what is diagnostic for IBD
endoscopy with biopsy.
What drugs are used for inducing remission in Chrons
• First line: Steroids (e.g. oral prednisolone or IV hydrocortisone)
do not use steroids to maintain remission
which class of drugs can be used to induce remission if steroids are not sufficient and also used to maintain remission
thiopurines (azathioprine, mercaptopurine) or methotrexate (second-line)
which class of immunosuppressive drugs increases your risk of non-melanoma skin cancer
theopurines
give some alternative Biologic therapy drugs that can be used if the conventional therapy for chrons isn’t effective
anti-tumour necrosis factor alpha monoclonal antibody agents infliximab and adalimumab
What is the treatment for inducing remission of ulcerative colitis
- First line: aminosalicylate (e.g. mesalazine oral or rectal)
- Second line: corticosteroids (e.g. prednisolone
what is the treatment for inducing remission of ulcerative colitis in severe disease
- First line: IV corticosteroids (e.g. hydrocortisone)
* Second line: IV ciclosporin
what is the main treatment for maintaining remission in ulcerative colitis
- Aminosalicylate (e.g. mesalazine oral or rectal)
- Azathioprine
- Mercaptopurine
what is the main area that ulcerative colitis affects
40-50% of people have proctitis
what is the main area affected in chrons
the Ileum/ileoclonic 40%
30-40% have skip lesions in the small intestine
for the next set of questions decide if the answer is ulcerative colitis or chrons;
smoking and appendectomy are protective
ulcerative colitis
for the next set of questions decide if the answer is ulcerative colitis or chrons
-affects mainly the distal colon
ulcerative colitis
for the next set of questions decide if the answer is ulcerative colitis or chrons
-affects the distal ileum and caecum
chrons
for the next set of questions decide if the answer is ulcerative colitis or chrons
- patchy gut inflammation with skip lesions
chrons
for the next set of questions decide if the answer is ulcerative colitis or chrons
-superfical inflammation
ulcerative colitis
for the next set of questions decide if the answer is ulcerative colitis or chrons
- complications include severe bleeding, toxic megacolon, rupture of bowel and colon cancer
ulcerative colitis
for the next set of questions decide if the answer is ulcerative colitis or chrons
- complications include stenosis, abscess formation, fistulas, colon cancer
chrons
what is carnets signs (not that this is not done in actual practice very often at all)
determines whether the pain originates from the viscera or myofascia/abdo wall
test is positive if this manoeuvre exacerbations pain, which indicates an abdo wall pain origin
what are the reasons for a DRE
o Suspected appendicitis o PR bleed o Change in bowel habits o As part of abdo exam o Genitourinary problems o Pelvic or spinal trauma
when doing a DRE what are you looking for in he perianal area
Haemorrhoids
Fistulae
Lesions
Warts
what kind of diarrhoea tends to have a sudden onset
infectious diarrhoea
when exploring diarrhoea what questions do you want to ask about regarding the stools
frequency, consistency, presence of blood, presence of mucus
what are the key risk factors for someone having suspected c difficult infection
antibiotic exposure, advanced age, hospitalisation or residence in a nursing home and a history of C.diff disease
what is the most important advise in regards to infective diaarhoea
• Most important advice is on fluid management, including oral rehydration such as dioralyte or simple oral rehydration solution aka ORS
how do you define diarrhoea
production of more than 2 unformed stools per day
at what point in time does diaarhoea change from being acute to chronic
4 weeks
What are the main bacteria causative agents of infective diarrhoea
Campylobacter, shigella, salmonella, c.difficle
what are the main viral causes of infective diaarhoea
Norovirus, rotavirus
what is dysentry and what are the symptoms
diarrhoea with visible blood in the stools
symptoms are fever, tenesmus and blood/pus in the stools
what are some of the main risk factors for having infectious diaarhoea
- Travel
- Employment (food-handler, caregiver)
- Consumption of unsafe foods
- Swimming in/drinking untreated fresh surface water
- Animal contact
- Contact with other ill persons
- Recent medication (antibiotics, antacids, antimotility agents)
- Underlying HIV, immunosuppression, gastrectomy, extremes of age
- Receptive anal intercourse or oral-anal sexual contact
If you suspect someone has community acquired or travellers diarrhoea what cultures would you test for
salmonella shigella campylobacter E.coli 0157:H7 C. difficult toxins
if patient has nosocomial diarrhoea ie onset if after more than 3 days in hospital then what is the most important culture to test for
c difficle
consider discontinuing antimicrobials and consider metronidazole if illness worsens for persists
what are hte indications for stool culture after 3 days in hospital
older than 645
cormorbid disease
neutropenia
HIV infection
note that most gastroenteritis is self limiting;
treatment of Coli H7:O157 enteritis may increase the risk of developing which diseases
HUS- haemolytic ureic syndrome
TTP - thrombotic thrombocytopenia purapura
what kind of antibiotics are good at treating campylobacter
macrolide such as
azithromycin
clarithromycin
erythromycin
Why do you not give codeine to someone with infective diarrhoea
codeine reduces peristalsis
Give some examples of invasive bacteria
- Shigella
- E coli
- Salmonella
- Campylobacter
- Yersinia
- C.difficile
- Entamoeba histolytica
name some common complications with severe campylobacter infection
• Can cause toxic megacolon, pancreatitis, cholecystitis, peritonitis, arthritis ( HLA-B27)
Go over the rest of the infective bacteria from your notes page 14
go over the rest of infective bacteria from your notes page 14
Why do persons with IBS often suffer from Iatrogenesis (medical treatment/intervention worsens the disease)
- Increasingly invasive investigations
- Unnecessary surgery
- Opiates
name some causes of constiaption
o IBS o Drug induced o Slow transit o Dysinergic defecation o Enterocele o Rectocele o Normal transit
The chronic pain pain use neuropathic pain drugs to substitute narcotic bowel syndrome. Name the 4R principle
Recognition
relationship
replacement
reduction
what medications can be used to replace opioids
TCA, A2D ligands, SSRI
linaclotide
mu opioid antagonists
psychological therapies
what condition does IBS overlap with Rheumatoid arthritis . Colorectal cancer . Fibromyalgia . Crohns disease . Porphyria
Fibromyalgia
which of the following is not a red flag for cancer Rectal bleeding . Age over 50 . Raised CRP . Weight loss . Family history of colorectal cancer
age over 50
