Case 15 - IBS and IBD Flashcards
What is IBS?
A functional gut disorder
Psychogenic elements alongside PNS and SNS
Combination of bloating, altered bowel habits and abdominal pain
Can present with constipation/diarrhoea predominant, or as a mixture of both
What could be some of the causes of IBS?
Central sensitisation - overall the patient is more sensitive to pain
Collagen fibres in these patients appear to be more bendy
Dietary factors
Gut microbiome
Can be the result of an infection
What are the signs and symptoms of IBS?
Bloating Increased frequency of stools Urgency/incontinence Abdo pain Constipation/Diarrhoea Allodynia in abdomen Sitophobia (fear of eating) Fatigue Headache Joint pain Muscle pain
How severe can IBS be?
When food enters the mouth there is a reflex to initiate digestion - gastro-colonic reflex
This reflex can be so strong, that some IBS patients are afraid to eat as they know they will need the toilet
In those who suffer from constipation - can not go for 1-2 weeks
How do you diagnose IBS?
Should consider if a patient has abdo pain relieved by defecating, or associated with bowel frequency/stool form alongside two of:
-Straining/urgency/incomplete evacuation
-Abdo bloating/distention/hardness
-Sx made worse by eating
Should exclude other potential causes for the altered bowel habit
What investigations should you do for IBS?
FBC Faecal calprotectin Coeliac serology - tissue transglutaminase CRP Stool culture
What are RFs for IBS?
Abused Psychological stress Female <50y Previous enteric infection
In which 4 ways can you treat IBS?
Diet
Psychological
Holistic
Drugs
How can you modify diet to treat IBS?
Should avoid too much fruit Improve hydration Have regular meals, eating slowly Reduce caffeine Limit fibre and starch
If these don’t work, exclusion diets e.g. FODMAP
Gradually start including foods until the patient can pin down which foods trigger their symptoms
Keep food diary
How can drugs treat IBS?
Anti-spasmodics = Mebeverine/buscopan
Laxatives (not lactulose) - movicol (osmotic), senna (stimulant), docusate (softener)
Loperamide - for anti-motility for diarrhoea
TCAs
SSRIs
Lubiprostone/linaclotide for constipation
Probiotics may be helpful
How can you treat IBS psychologically?
Should have pain management course to change the way the patient views pain and understands the link between physical pain and the brain
By changing the way the patient understands pain, they can actually end up experiencing less pain
What is holistic treatment of IBS?
Self-management and support groups
Stress management
Increased exercise
Chronic pain team
What are the complications of IBS?
Iatrogenesis
Narcotic bowel syndrome
What is IBS iatrogenesis?
These patients are very vulnerable within the healthcare system
Under-diagnosed and take a long time to be eventually diagnosed too
IBS patients often undergo extensive invasive testing and imaging to come to the diagnosis of IBS
Due to the pain they are feeling they can present as though they have appendicitis etc., and end up having completely unnecessary surgery which doesn’t come free of risks
Treatments or investigations done to find the cause of the pain can they themselves cause harm
Opiate use leads to:
- Worse gut motility
- Increased cannula infections
- Hyperalgesia
What is narcotic bowel syndrome?
IBS patients can be in a lot of pain and be prescribed opioids for the pain
Opioids cause constipation anyway, and make the constipation in these patients worse
Can cause distention
Leads to N and V
Increased pain
Prescribed more opioids
What is IBD?
The collective name for UC and Crohn’s disease
Inflammatory condition with a relapsing-remitting course
What are common symptoms of IBD?
Abdominal pain Change in bowel habit - usually diarrhoea Blood in stool Fever Vomiting Muscle spasms Weight loss Tenesmus
How does gender, onset, smoking, anatomical location, pathology and histology differ between Crohn’s and UC?
UC- Both genders equally affected 15-40y onset Smoking is protective for UC Affects the distal colon Superficial inflammation Continuous progressive ulceration of the colon beginning at the rectum and moving proximally
Crohn’s- Affects females more
Onset 15-40y
Smoking is a aggrevator
Anywhere in the GI tract from mouth to anus - most commonly distal ileum and caecum
Transmural inflammation
Will see skip lesions between areas of inflammation
What is Crohn’s?
Inflammatory disease that can affect anywhere in the GI tract from mouth to anus
Has characteristic skip lesions
Signs and symptoms of Crohn’s?
Vomiting Change in bowel habit - diarrhoea or constipation Blood/mucus in stool Mouth ulcers Skin rashes Fistulae Steatorrhea Eye problems Clubbing Anaemia
RFs for Crohn’s?
FHx Caucasion Smoker OCP 15-40y NSAID use
Investigations for IBD
Bloods:
- FBC - Hb for anaemia, platelets
- CRP
- U and E for dehydration
- LFT as drugs baseline
- Coeliac serology
- Vitamins and ferritin to check for malabsorption
Stool sample - faecal calprotectin, microscopy and culture for C. Diff
Imaging that confirms an IBD diagnosis
Colonoscopy/sigmoidoscopy - may only need to do a sigmoidoscopy if UC is suspected, as may not have progressed further than the sigmoid colon
Crohn’s = cobblestone
UC = loss of vascular markings
Can do OGD if Crohn’s is presenting with upper GI symptoms
MRI = can see lead pipe colon in UC
Capsule endoscopy = marks flow through SI, contraindicated if there’s strictures
CT = skin lesions in Crohn’s, abscess and fistulae
In UC, see bowel wall and haustral thickening
Drug treatments for Crohn’s disease
1) GCCs or mesalazine (5-ASA)
2) Azothioprine if 2+ exacerbations in a year or can’t taper off steroids (do TPMT testing first, if low, give methotrexate instead)
3) Biologicals - inflixumab
Surgery for Crohn’s
If Crohn’s is limited to distal ileum
Take into account risks and benefits and chance of recurrence
Monitoring in Crohn’s
Azothioprine can cause neutropenia, so monitor
Monitor for osteoperosis due to malabsorption
Colonoscopy after 10y to check for CRC
What is UC?
A disease progressively working proximally to inflame and ulcerate the colon from the rectum
Protitis = rectum
Pancolitis = beyond the L colon
SIgns and symtpoms of UC
Diarrhoea Urgency Nocturnal bowel opening Pre-defecation pain, relieved on bowel opening Blood in stool
RFs of UC
Non/Ex-smoker
FHx of IBD
Infection
NSAIDs
How do you score the severity of UC?
Using the Truelove-Witts severity scale
Mild - <4 stools a day, low blood in stool, ESR<30 Moderate - 4-6 stools a day, some blood in stool, ESR<30 Severe - 6+, visible blood. One of: fever anaemia HR>90 ESR>30
Complications of Crohn’s
Fistulae Abscesses CRC Stenosis Granulomas
Drug treatment for acute UC
1) Mesalazine and Steroids
2) Oral prednisolone
3) Tacrolimus
4) Inflixumab
When should you assess the need for surgery in UC?
Colonic dilatation on X-ray
More than 8 stools a day
Tachycardia
Low albumin/Hb or high platelets/CRP
LT management of UC?
Mesalazine
Azothioprine if 2+ exacerbations in a year
Complications of UC
CRC
Toxic megacolon
Severe bleeding
Ruptured bowel
