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
