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Medicine Y3 TCD 13-24 > 15. IBS, IBD and gastroenteritis > Flashcards

15. IBS, IBD and gastroenteritis Flashcards

1
Q

In a patient who presents with abdo pain ad diarrhoea what red flags would warrant an urgent referral

A 
aged over 60
rectal bleeding 
anaemia 
weight loss
family history of colorectal cancer 
abdo/rectal mass 
raised CRP/ESR or faecal calprotectin
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2
Q

in women over 50 with persistent bloating what is mandatory to rule out ovarian cancer

A

USS of ovaries

Ca125 levels

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3
Q

What is IBS

A

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

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4
Q

how common is IBS

A

very common and occurs in 20% of the population
affects women more than men
more common in younger adults

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5
Q

what are the symptoms of IBS

A
  • Diarrhoea
  • Constipation
  • Fluctuating bowel habit (diarrhoea, constipation or alternating)
  • Abdominal pain
  • Bloating or distention
  • Worse after eating
  • Improved by opening bowels
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6
Q

NICE guidelines: criteria for diagnosis

other pathology should be excluded. Which tests do you need to carry out to exclude other pathology

A
  • 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
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7
Q

NICE guidelines: what are the symptoms that suggest IBS

A 
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
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8
Q

what general advice can you give after a diagnosis of IBS

A

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

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9
Q

what is a FODMAO diet

A

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.

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10
Q

what is the first line medications used for IBS

A
  • 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)
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11
Q

why do you avoid lactulose in patients with IBS

A

can cause bloating

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12
Q

what is the second line medication for IBS

A

tricyclic antidepressants eg amitriptyline 5-10mg at night

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13
Q

what is the third line medication for IBS

A

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

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14
Q

name some extra intestinal manifestations associated with IBS

A 
o	Nausea
o	Thigh pain 
o	Backache 
o	Lethargy 
o	Urinary symptoms 
o	Gynaecological symptoms (dyspareunia- pain during sexual intercourse)
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15
Q

What is the main issue with an IBS amongst society

A

stigmatised
inadequacies of treatment
hopelessness and suicide

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16
Q

Give some examples of antispasmodics that are anticholinergic

A 
o	Dicycloverine (merbentyl)
o	Hyoscine (buscopan) 
o	Propantheline (probanthine)
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17
Q

give some examples of antispasmodics that are anti-smooth muscle

A 
o	Mebeverine (colofac)
o	Alverine (spasmonal) 
o	Peppermint (colpermin)
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18
Q

Give some examples of antidiarrhoeals

A

o Loperamide – the best one

 It improves anal tone, regular use low dose is safe and can take inn combination with antispasmodics

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19
Q

apart from medication, what else can be advised to see if it helps with IBS

A

CBT, hypnotherapy, acupuncture and probiotics

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20
Q

What are the benefits of probiotics in IBS

A

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

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21
Q

What advice can you give to patients about IBS

A

too long winded answer, look at page 2 of your notes

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22
Q

What is IBD and what is it split into

A

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.

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23
Q

What are the key differentiating factors with chrons

Chrons- think crows NESTS

A

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)

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24
Q

what are the key differentiating factors with ulcerative colitis- remember U C CLOSEUP

A 
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
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25
Q

how does IBD usually present

A
  • Diarrhoea
  • Abdominal pain
  • Passing blood
  • Weight loss
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26
Q

what tests would you perform when investigating IBD

A
  • 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.
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27
Q

what is diagnostic for IBD

A

endoscopy with biopsy.

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28
Q

What drugs are used for inducing remission in Chrons

A

• First line: Steroids (e.g. oral prednisolone or IV hydrocortisone)
do not use steroids to maintain remission

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29
Q

which class of drugs can be used to induce remission if steroids are not sufficient and also used to maintain remission

A

thiopurines (azathioprine, mercaptopurine) or methotrexate (second-line)

30
Q

which class of immunosuppressive drugs increases your risk of non-melanoma skin cancer

A

theopurines

31
Q

give some alternative Biologic therapy drugs that can be used if the conventional therapy for chrons isn’t effective

A

anti-tumour necrosis factor alpha monoclonal antibody agents infliximab and adalimumab

32
Q

What is the treatment for inducing remission of ulcerative colitis

A
  • First line: aminosalicylate (e.g. mesalazine oral or rectal)
  • Second line: corticosteroids (e.g. prednisolone
33
Q

what is the treatment for inducing remission of ulcerative colitis in severe disease

A
  • First line: IV corticosteroids (e.g. hydrocortisone)

* Second line: IV ciclosporin

34
Q

what is the main treatment for maintaining remission in ulcerative colitis

A
  • Aminosalicylate (e.g. mesalazine oral or rectal)
  • Azathioprine
  • Mercaptopurine
35
Q

what is the main area that ulcerative colitis affects

A

40-50% of people have proctitis

36
Q

what is the main area affected in chrons

A

the Ileum/ileoclonic 40%

30-40% have skip lesions in the small intestine

37
Q

for the next set of questions decide if the answer is ulcerative colitis or chrons;
smoking and appendectomy are protective

A

ulcerative colitis

38
Q

for the next set of questions decide if the answer is ulcerative colitis or chrons

-affects mainly the distal colon

A

ulcerative colitis

39
Q

for the next set of questions decide if the answer is ulcerative colitis or chrons

-affects the distal ileum and caecum

A

chrons

40
Q

for the next set of questions decide if the answer is ulcerative colitis or chrons

  • patchy gut inflammation with skip lesions
A

chrons

41
Q

for the next set of questions decide if the answer is ulcerative colitis or chrons

-superfical inflammation

A

ulcerative colitis

42
Q

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
A

ulcerative colitis

43
Q

for the next set of questions decide if the answer is ulcerative colitis or chrons

  • complications include stenosis, abscess formation, fistulas, colon cancer
A

chrons

44
Q

what is carnets signs (not that this is not done in actual practice very often at all)

A

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

45
Q

what are the reasons for a DRE

A 
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
46
Q

when doing a DRE what are you looking for in he perianal area

A

 Haemorrhoids
 Fistulae
 Lesions
 Warts

47
Q

what kind of diarrhoea tends to have a sudden onset

A

infectious diarrhoea

48
Q

when exploring diarrhoea what questions do you want to ask about regarding the stools

A

frequency, consistency, presence of blood, presence of mucus

49
Q

what are the key risk factors for someone having suspected c difficult infection

A

antibiotic exposure, advanced age, hospitalisation or residence in a nursing home and a history of C.diff disease

50
Q

what is the most important advise in regards to infective diaarhoea

A

• Most important advice is on fluid management, including oral rehydration such as dioralyte or simple oral rehydration solution aka ORS

51
Q

how do you define diarrhoea

A

production of more than 2 unformed stools per day

52
Q

at what point in time does diaarhoea change from being acute to chronic

A

4 weeks

53
Q

What are the main bacteria causative agents of infective diarrhoea

A

Campylobacter, shigella, salmonella, c.difficle

54
Q

what are the main viral causes of infective diaarhoea

A

Norovirus, rotavirus

55
Q

what is dysentry and what are the symptoms

A

diarrhoea with visible blood in the stools

symptoms are fever, tenesmus and blood/pus in the stools

56
Q

what are some of the main risk factors for having infectious diaarhoea

A
  • 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
57
Q

If you suspect someone has community acquired or travellers diarrhoea what cultures would you test for

A 
salmonella 
shigella
campylobacter
E.coli 0157:H7 
C. difficult toxins
58
Q

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

A

c difficle

consider discontinuing antimicrobials and consider metronidazole if illness worsens for persists

59
Q

what are hte indications for stool culture after 3 days in hospital

A

older than 645
cormorbid disease
neutropenia
HIV infection

60
Q

note that most gastroenteritis is self limiting;

treatment of Coli H7:O157 enteritis may increase the risk of developing which diseases

A

HUS- haemolytic ureic syndrome

TTP - thrombotic thrombocytopenia purapura

61
Q

what kind of antibiotics are good at treating campylobacter

A

macrolide such as
azithromycin
clarithromycin
erythromycin

62
Q

Why do you not give codeine to someone with infective diarrhoea

A

codeine reduces peristalsis

63
Q

Give some examples of invasive bacteria

A
  • Shigella
  • E coli
  • Salmonella
  • Campylobacter
  • Yersinia
  • C.difficile
  • Entamoeba histolytica
64
Q

name some common complications with severe campylobacter infection

A

• Can cause toxic megacolon, pancreatitis, cholecystitis, peritonitis, arthritis ( HLA-B27)

65
Q

Go over the rest of the infective bacteria from your notes page 14

A

go over the rest of infective bacteria from your notes page 14

66
Q

Why do persons with IBS often suffer from Iatrogenesis (medical treatment/intervention worsens the disease)

A
  • Increasingly invasive investigations
  • Unnecessary surgery
  • Opiates
67
Q

name some causes of constiaption

A 
o	IBS
o	Drug induced 
o	Slow transit 
o	Dysinergic defecation 
o	Enterocele 
o	Rectocele 
o	Normal transit
68
Q

The chronic pain pain use neuropathic pain drugs to substitute narcotic bowel syndrome. Name the 4R principle

A

Recognition
relationship
replacement
reduction

69
Q

what medications can be used to replace opioids

A

TCA, A2D ligands, SSRI
linaclotide
mu opioid antagonists
psychological therapies

70
Q 
what condition does IBS overlap with 
Rheumatoid arthritis .
Colorectal cancer .
Fibromyalgia .
Crohns disease .
Porphyria
A

Fibromyalgia

71
Q 
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
A

age over 50

Medicine Y3 TCD 13-24 (32 decks)

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