Abdominal pain- IBS Flashcards
IBS: who gets it
Presents in young adults 20-30s
Females more then males
Runs in families
IBS- mechanism and risk factors
Mechanism- Hypersensitive viscera, abnormalities to the GI immune function, colonic microbiota, autonomic activity and GI motility
Risk factors- Genetic, previous inflammation/infection of the gut, dietary factors, medication, psychological factors
Symptoms of IBS
Abdominal pain/bloating or changes in bowel habit- tend to have the symptoms for over 6 months
Associated symptoms: altered stool passage, abdominal bloating, distension, hardness, symptoms worsened by eating, passage of rectal mucus
Diagnosis of IBS
Normally a diagnosis of exclusion, you will find nothing on examination but distension of the abdomen and generalised tenderness
Red flags for IBS symptoms
Unexplained weight loss, new onset of symptoms over 50, bleeding per rectum, fevers, night sweats, localised tenderness/rigidity
Investigating IBS
Bedside examinations- digital rectal examination, body mass index
Other tests- FBC, inflammatory markers i.e. CRP/ESR, stool sample id suspect infection, coeliac screening
Management of IBS
May be useful to keep a food diary to identify triggers. Avoid short-chain fermentable carbohydrates (see FODMAP diet), eat regular balanced meals, limit alcohol, coffee, foods high in insoluble fibre, and sugar-free products.
Medications- if constipation is the main symptoms then take soluble fibre supplements i.e. ispaghula husk or anti-spasmodic agents like mebevarine or buscopan. Tricyclic antidepressants and SSRI can also be considered
Management of Crohns- inducing remission
First line: steroids i.e. oral prednisiolone or IV hydrocortisione
Second line: Azathioprine, Mercaptopurine, Methotrexate, Infliximab, Adalimumab
Management of Crohns- maintaining remission
First line: Azatthioprine, Mercaptopurine
Second line: Methotrexate, Infliximab, Adalimumab
Crohns surgery
When the disease only affects the distal ileum it is possible to surgically resect this area and prevent further flares of the disease. Crohns typically involves the entire GI tract
Surgery can also be used to treat strictures and fistulas secondary to Crohns disease.
Management of UC- inducing remission
Mild to moderate disease
First line: aminosalicylate (e.g. mesalazine oral or rectal)
Second line: corticosteroids (e.g. prednisolone)
Severe disease
First line: IV corticosteroids (e.g. hydrocortisone)
Second line: IV ciclosporin
Management of UC: maintaining remission
Aminosalicylate (e.g. mesalazine oral or rectal)
Azathioprine
Mercaptopurine
Management of UC- surgery
Ulcerative colitis typically only affects the colon and rectum. Therefore, removing the colon and rectum (panproctocolectomy) will remove the disease. The patient is then left with either a permanent ileostomy or something called an ileo-anal anastomosis (J-pouch). This is where the ileum is folded back in itself and fashioned into a larger pouch that functions a bit like a rectum. This “J-pouch” which is then attached to the anus and collects stools prior to the person passing the motion.
Biliary colic
Is caused by an impacted stone at the neck of the gallbladder and typically presents with crampy abdominal pain in the absence of infective features (e.g. fever/raised inflammatory markers). Biliary colic is typically triggered by the consumption of fatty foods.
Cholecystitis
Typically presents with constant RUQ pain, fever and raised inflammatory markers. However, jaundice is absent in most cases as there is no associated biliary obstruction (except if the gallbladder is compressing the common bile duct, as in Mirizzi syndrome). Inflammation of the gallbladder, usually due to a gallstone blocking the cystic duct
Macroscopic and Microscopic changes with Ulcerative colitis
Macroscopic findings:
Continuous, uniformly inflamed mucosa
Erythematous, friable mucosa
Abnormal vascular pattern
Ulceration
Inflammatory polyps (‘pseudopolyps’)
Microscopic findings (biopsy):
Crypt abscesses
Decreased goblet cell abundance
UC summary
UC is the most common type of inflammatory bowel disease and has a relapsing-remitting course.
Common symptoms of UC include episodic diarrhoea with urgency, rectal bleeding and abdominal pain.
Extra-intestinal manifestations include; erythema nodosum, uveitis and joint pain.
Topical and oral aminosalicylates are the mainstay therapies used in UC.
Surgical intervention should not be delayed for urgent indications and usually involves partial or complete resection of the colon.
UC increases the lifetime risk of colorectal cancer and thromboembolic events.
General examination findings for uc
Features of anaemia (e.g. pallor, fatigue)
Joint pain
Clubbing
Erythema nodosum
Pyoderma gangrenosum
Uveitis
Episcleritis
UC: classification
Proctitis: rectum
Proctosigmoiditis: rectum and sigmoid colon
Left-sided colitis: rectum, sigmoid colon and descending colon
Extensive colitis: rectum, sigmoid colon, descending colon and transverse colon
Pancolitis: rectum and entire colon
Diabetic ketoacidosis
- Associated with type 1 diabetes mellitus
- Ketone bodies are generated in excess of clearance. Ketone bodies are produced when there is scarcity of glucose
Appearance of diabetic ketoacidosis
Acute deterioration – abdominal pain, nausea, vomiting
Examination – Hypotension, Tachycardia, fever, reduced GCS
Causes: Missed insulin dose(s), Sepsis, Myocardial Ischaemia, Alcohol
Investigations into diabetic ketoacidosis
Blood glucose (>11 mmol/L)
Blood Ketones (>3 mol/L) or Urine Ketones (2+)
Arterial or Venous blood gas – Metabolic Acidosis (pH < 7.3, HCO3 <15 mmol/L)
Other tests – raised inflammatory markers, Urea and Electrolytes, ECG, septic screen
