5 IBS, Constipation, Diarrhea Flashcards
Which features are NOT associated with IBS?
Iron deficiency anemia
Weight loss
Severe or progressively worsening symptoms
All should prompt further investigation and referral to gastroenterologist
What is the definition of IBS?
FUNCTIONAL bowel disorder (absence of biochemical cause) characterized by RECURRENT ABDOMINAL PAIN AND ALTERED BOWEL HABITS (need both elements)
What are the different subclassifications of IBS?
IBS-C (Constipation predominant)
IBS-D (Diarrhea predominant)
IBS-M (Mixed)
IBS-U (Unclassified)
IBS typically affects patients ______ y.o. and ______
20-39yo and F>M
Etiology of IBS is likely…
Multifactorial
Physiological - abnormal motility, visceral hypersensitivity
Psychosocial - early life stressors (abuse), anxiety, depression, phobias
Environmental - diet, post-infectious (gastroenteritis), gut microbiome
Main clinical presentation of IBS
Chronic/Recurrent abdominal pain/discomfort
• Cramping, diffuse (lower abdomen)
• Variable intensity
• Periodic exacerbation
Altered bowel habits
• Constipation vs. Diarrhea vs. Mixed vs. Unclassified
If IBS presents with GI symptoms as well, you might see…
Dyspepsia
Atypical CP
Vomiting (rare)
Extra-intestinal Sx of IBS
Sexual dysfunction Dysmenorrhea Irritative voiding symptoms Fibromyalgia symptoms Somatic or psychological complaints
What are the RED FLAG SYMPTOMS for IBS?
KNOW THESE*
Symptom onset after age 50 Severe or progressively worsening symptoms Nocturnal diarrhea Fevers/vomiting Unexplained weight loss Melena, hematochezia, occult blood Personal or FH of colon cancer, IBD, or celiac disease Unexplained iron deficiency anemia
Why do you need to do a perianal/DRE when working up IBS?
To rule out Crohn’s or fissure
More common DDx for IBS
Lactose intolerance Celiac disease Drug induced GI infection IBD Colon cancer
Less common DDx for IBS
Colitis Pancreatic insufficiency Small intestinal bacterial overgrowth Diabetes/thyroid disease Psychiatric disease
What is the diagnostic criteria for IBS?
Rome IV criteria
Recurrent abdominal pain on average at least ONE DAY PER WEEK in the LAST THREE MONTHS, and with two or more of the following:
• Related to defecation
• Associated with a change in stool frequency
• Associated with a change in stool form (appearance)
Most IBS-C patients have Bristol stool types _______, while IBS-D patients have types ______
IBS-C = Bristol types 1 and 2
IBS-D = Bristol types 6 and 7
How to diagnose IBS
If typical hx and no alarm features - laboratory, radiographic, and endoscopic tests not routine
+/- limited screening studies as clinically appropriate (ie CBC, CMP, TSH, ESR/CRP, Celiac serological, stool studies)
If atypical hx, alarm features, or refractory to tx - lab/stool studies, cross-sectional/small bowel imaging, and endoscopy/colonoscopy with biopsies
Goal of IBS treatment is…
To relieve symptoms and improve QOL
Achieved through dietary/lifestyle mods, psychosocial support, and pharmacological therapy
Therapeutic clinician-patient relation is important (continuity of care)
What dietary/lifestyle mods should be suggested to IBS patients?
Food diary/symptom log helpful to ID triggers
Add dietary fiber (20-35g/day) - start low and increase slowly to reduce bloating/gas
FODMAP diet
+/- probiotics
Exercise
What is the FODMAP diet?
Focuses on eliminating foods that contain sugars and fibers that cause pain and bloating
Eliminate x 4-8 weeks then gradually reintroduce 1-2 foods at a time and assess tolerance
Trained dietitian helpful to avoid unnecessary dietary over restriction
May not be appropriate for everyone
What type of psychosocial support is necessary for IBS patients?
Cognitive-behavioral therapy
Relaxation/stress management
+/- behavioral health referral
What drugs can be used by IBS patients to alleviate abdominal pain?
Levsin (Hyoscyamine) and Bentyl (Dicyclomine)
Both are antispasmodic
CAUTION - anticholinergic effects**
What drugs can be used to relieve Sx in IBS-C?
Psyllium fiber
Miralax (polyethylene glycol)
Amitiza (Lubiprostone)
Linzess (Linaclotide)
Trulance (Plecanatide)
What drugs can be used to relieve Sx in IBS-D?
Imodium (Loperamide)
Rifaximin (abx that just works in the gut)
Alosteron (women only)
Viberzi (Eluxadoline)
What drugs are used off-label in IBS for their psychosocial benefit?
TCAs
Caution - AEs **
Name three broad etiologies of IBS
Physiological
Psychosocial
Environmental
NO SINGLE UNIFYING ETIOLOGY
What meds can exacerbate constipation?
Antipsychotics Anticholinergics Iron Antacids (esp Calcium, aluminum) Opioids CCBs
Most common digestive complaint in general population
Constipation
But most do not have serious disease
Risk factors for constipation
Improper diet and inadequate fluid intake
Sedentary lifestyle
Polypharmacy
Age
What is Colonic Inertia?
Constipation caused by slow transit —> bowel movement only once every 7-10 days
Defecation/obstructive disorders that can cause constipation
Pelvic floor dysfunction Anorectal disease Rectal prolapse Rectocele Colon cancer Polyp Stricture/stenosis Fecal impaction/obstruction
Metabolic/systemic diseases that can cause constipation
Hypercalcemia Hyperparathyroidism Hypothyroidism DM Pregnancy Hirschprung MS Parkinson Spinal cord injuries
Key history questions to ask when working up constipation
Acute or chronic Normal bowel pattern Frequency, consistency of stool Laxative use**** Need for digital evacuation**** Previous colonoscopy**** Red flag symptoms/alarm features**** Any secondary/contributing cases (reconcile meds, review PMH)
What do we mean by constipation?
<3 spontaneous BM/week
Lumpy or hard stools
Straining
Manuel maneuvers to facilitate defection (digital evacuation, support of the pelvic floor)
Sensation or anorectal obstruction/blockage
Sense of imcomplete evacuation
