Chronic Abdo Pain Flashcards
Abdominal Pain is primarily due to which of the following;
- Structural disorder
- Functional disorder
- Biochemical disorder
Functional Disorder
- I.e. refers to a disorder/disease in which the primary abnormality is altered physiological function, rather than identifiable structural or biochemical abnormality
What is the ROME classification/criteria?
A set of criteria used by clinicians to classify a diagnosis of a patient with an functional gastrointestinal disorder
Classifcations include: - within each class are criteria for diagnosis of conditions
- Oesophageal disorders
- Gastroduodenal disorders
- Bowel disorders
- Centrally mediated disorders of GI pain
- Gallblader and Sphincter of Oddi disorders
- Anorectal disorders
What test on stool can be done to differentiate between IBS and IBD?
Faecal Calprotectin Test
- Faecal calprotectin ↑↑ (up to 10 times) in inflammatory bowel disease
- Faecal calprotectin = normal in IBS
How does the Faecal Calprotectin Test work?
- Colprotectin = complex of proteins, which in the presence of Ca2+ can sequester metals; iron, manganese and zinc –> this gives antimicrobial properties
- Calprotectin comprises up to 60% of soluble content of cytosol of neutrophils –> which secrete it during inflammation
- IBD –> causes migration of neutrophils into intestinal mucosa –> which secrete calprotectin, which moves into the intestinal lumen = faecal calprotectin –> thus faecal calprotectin is ↑ inflammatory bowel diseases (UC and Crohn’s can have 10x ↑ in faecal calprotectin)
Define Irritable Bowel Syndrome
IBS = a syndrome comprising of;
-
Abdominal pain
- Pain is often colicky + relieved by bowel movements
- Bloating
- Change in bowel habit
What 2 factors can cause exacerbation of IBS?
- Diet
- Stress
IBS can be sub-classified by dominance of certain symptoms - what sub-classifcations are these?
- Diarrhoea dominant
- Consipationd dominant
Answer the following regarding IBS:
- Prevalence?
- Age of onset?
- Women:men?
- Curative or treated?
- ~ 1 in 5 adults (20%)
- Age of onset ~ <40yrs
- Women : Men = 2:1
- IBS is treated via mangement of symptoms
What symptoms might a patient with IBS exhibit?
- Abdominal pain (colicky / relieved on defecation)
- Abdominal bloating (may have to go up a clothing size)
-
Change in bowel habit
- Diarrhoea
- Constipation
- Alternation between the two
- Exaggerated gastro-colonic reflex (want to defecate when or just after eating)
- Extra-intestinal symptoms:
- Nausea
- Thigh / back pain
- Lethargy
- ↑ incidence of suicidal ideation due to low QoL (but aren’t depressed, pts are hopeless)
- UTI
- Dysnpareunia = pain on intercourse
What 7 red flags should be considered alongside a potential new diagnosis of IBS?
Presence of any of the following Red Flags for potential cancer:
- Age > 60yrs / change in bowel habit in pt > 60yrs
- Rectal bleeding
- Anaemia
- Weight loss
- Family history of colorectal cancer
- Abdo/rectal mass
- Raised inflammatory markers e.g. ↑ CRP/ESR or faecal calprotectin
A female patient > 50yrs presenting with; persistent bloating , feeling full quickly, lower abdominal pain or urinary urgency/frequency - what 2 tests should be ordered?
- US of ovaries
- CA-125 (cancer antigen 125)
These are done to rule out ovarian cancer
What are the diagnostic criteria for IBS?
IBS diagnosis should only be considered if there is abdominal pain/discomfort that is;
- Relieved by defecation OR
- Associated with altered bowel frequency or stool form
+ at least 2 of the following:
- Altered stool passage (straining, urgency, incomplete evacuation)
- Abdominal bloating (more common in women), distension, tension or hardness
- Symptoms made worse by eating
- Passage of mucus
Other symptoms may include:
- Lethargy, nausea, backache and bladder symptoms
What test might you order in a patient with suspected IBS?
-
Faeceal calprotectin test:
- If raised –> excludes IBS, IBD more likely
-
Stool analysis:
- ↑ WBCs or presence of parasites –> suggests not IBS
-
FBC:
- Anaemia can cause the lethargy seen in IBS
- ↑ WCC –> suggests infection, IBS unlikely
-
CRP:
- ↑ CRP = inflammatory marker –> suggests not IBS
-
ESR:
- ↑ ESR = inflammatory marker –> suggests not IBS
-
Serological testing:
- Anti tTG antibodies - positive in Coeliac disease (high sensitivity + specificity)
- Anti-endomysial antibodies (EMA) - positive in Coeliac disease
-
Flexible sigmoidoscopy / Colonoscopy:
- Can be considered if cancer or IBD are potential differentials
What Lifestyle changes are involved in treatment of IBS?
- Avoid high fibre foods
-
Avoid carbohydrates i.e. ‘FODMAPS’ food (fermentable oligo- di- mono- and poly- saccharides) e.g. fructose, lactose, fructans, galactans etc. (present in fruit and veg)
- Veg = high fibre + FODMAPS food –> avoid
- Limit fresh fruit to 3 portions per day
- Food + symptom diary –> aids identification of main exacerbation culprits – best done by changing one element of diet at a time
- ↓ alcohol (not > 2 units per day + 2 alcohol free days p/w)
- Eat 3 regular meals a day
- Don’t skip any meals or eat late at night
- ↓ caffeine e.g. not >2 mugs p/d)
- ↓ fizzy drinks
- Drink at least 8 cups of water/herbal tea p/d
- ↓ rich or fatty foods
What 4 classes of drugs are 1st line Pharmacological Treatment for IBS?
- Antispasmodics (taken as required) = anti-cholinergic (antimuscarinic)
- Anti-smooth muscle (SM relaxants) drugs
- Laxatives for constipation – no evidence that laxatives damage the bowel
- Anti-doarrhoeals
What are 3 common Antispasmodics (antimuscarinics) for IBS?
Antispasmodics (anti-muscarinics):
- Dicycloverine (Merbentyl) = used as GI antispasmodic and in urinary incontinence (10-20mg 3 times daily)
- Hyoscine (Buscopan)
- Propantheline (Probanthine)