Case 15 - Chronic Abdominal Pain

Question 1

What are the red flags regarding abdominal pain?

Answer 1

Aged over 60
Rectal bleeding 
Anaemia 
Weight loss
Family history of colorectal cancer 
Abdominal/rectal mass felt 
Raised CRP/ESR or faecal calprotectin

Question 2

What are the typical symptoms of IBS?

Answer 2

Abdominal pain - associated with bowel movements
Bloating
Altered bowel habit

Question 3

What causes IBS? (Theories)

Answer 3

Visceral hypersensitivity- nerve endings in the bowl have abnormally strong response to stimuli which cause stretching
Genetic - condition seems to run in families
Diet - certain gas containing foods can cause bowel to spasm

Question 4

What lifestyle changes can people with IBS make to help manage their condition?

Answer 4

Eat three regular meals a day (smaller portions also)
Try not to eat late at night
Limit alcohol intake (2 units per day with 2 free alcohol days a week)
Reduce caffeine intake (no more than 2 mugs a day)
Reduce fizzy drink intake
Cut down on fatty foods
Limit fresh fruit to 3 portions a day

Question 5

What foods should people with IBS avoid?

Answer 5

Fatty foods
Gas containing foods (beans, fruits, broccoli, onions, cabbage)
Carbonated drinks
Caffeine

Question 6

What are the differences between ulcerative colitis and Crohn’s disease?

Answer 6

Ulcerative colitis is only in the colon, whereas crohns can occur anywhere between the mouth and the anus
In crohns there are healthy parts mixed between inflammed areas (skip lesions) whereas colitis is continuous inflammation of the colon
Ulcerative colitis only affects the inner most lining of the colon whereas crohns can occur in all the layers of the bowel walls (transmural)

Question 7

Where does Crohn’s disease usually begin?

Answer 7

Terminal ileum

Question 8

What are the complications of Crohn’s disease?

Answer 8

Fistulas
Abscess
Obstruction

Question 9

What are the complications of ulcerative colitis?

Answer 9

Perforation and Haemorrhage

Toxic megacolon

Question 10

What is carnett’s sign?

Answer 10

Increase of the abdominal pain with tensing of the abdominal wall
The pain will increase when the patient raises their head or legs
This suggests that the pain is coming from the abdominal wall, as opposed to a visceral pain origin

Question 11

What exclusion tests should you do if you suspected someone had IBS?

Answer 11

FBC
ESR 
CRP 
Coeliac serology 
Fecal calprotectin

Question 12

What are the risk factors for developing IBS?

Answer 12

Gastroenteritis- noravirus and rotavirus

Stress

Question 13

What are the main symptoms of crohns disesae?

Answer 13

Abdominal pain - typically in RLQ
Diarrhoea
Malabsorption issues

Question 14

In which IBD can surgery cure and why?

Answer 14

Ulcerative colitis - as you can take out the inflammed area

It cannot cure in crohns as the inflammation can occur anywhere along the GI tract

Question 15

What are the main symptoms of ulcerative colitis?

Answer 15

Abdominal pain - typically in the LLQ
Diarrhoea
Blood in stool

Question 16

What are the main anti inflammatory medications given in ulcerative colitis?

Answer 16

Sulfasalazine

Mesalazine

Question 17

What are the two sub types of IBS?

Answer 17

Diarrhoea predominant

Constipation predominant

Question 18

What is the problem with using opiates as pain killers in patients with gastroenterology issues?

Answer 18

Opiates have a profound slowing effect on the bowel so can lead to worsening GI motility

This constipation can lead to obstruction, nausea and vomiting

This is known as narcotic bowel syndrome

Question 19

What pain killers should opiates be replaced with in narcotic bowel syndrome?

Answer 19

Neuropathic pain drugs:

• amitriptyline
• gabapentin

Question 20

What are the common barium X-Ray findings for crohns and ulcerative colitis?

Answer 20

Crohns - ‘string sign’ on barium AXR

Ulcerative colitis - ‘lead pipe’ colon on barium AXR