Chronic Abdo Pain Flashcards
1
Q
Abdominal Pain is primarily due to which of the following;
- Structural disorder
- Functional disorder
- Biochemical disorder
A
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
2
Q
What is the ROME classification/criteria?
A
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
3
Q
What test on stool can be done to differentiate between IBS and IBD?
A
Faecal Calprotectin Test
- Faecal calprotectin ↑↑ (up to 10 times) in inflammatory bowel disease
- Faecal calprotectin = normal in IBS
4
Q
How does the Faecal Calprotectin Test work?
A
- 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)
5
Q
Define Irritable Bowel Syndrome
A
IBS = a syndrome comprising of;
-
Abdominal pain
- Pain is often colicky + relieved by bowel movements
- Bloating
- Change in bowel habit
6
Q
What 2 factors can cause exacerbation of IBS?
A
- Diet
- Stress
7
Q
IBS can be sub-classified by dominance of certain symptoms - what sub-classifcations are these?
A
- Diarrhoea dominant
- Consipationd dominant
8
Q
Answer the following regarding IBS:
- Prevalence?
- Age of onset?
- Women:men?
- Curative or treated?
A
- ~ 1 in 5 adults (20%)
- Age of onset ~ <40yrs
- Women : Men = 2:1
- IBS is treated via mangement of symptoms
9
Q
What symptoms might a patient with IBS exhibit?
A
- 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
10
Q
What 7 red flags should be considered alongside a potential new diagnosis of IBS?
A
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
11
Q
A female patient > 50yrs presenting with; persistent bloating , feeling full quickly, lower abdominal pain or urinary urgency/frequency - what 2 tests should be ordered?
A
- US of ovaries
- CA-125 (cancer antigen 125)
These are done to rule out ovarian cancer
12
Q
What are the diagnostic criteria for IBS?
A
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
13
Q
What test might you order in a patient with suspected IBS?
A
-
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
14
Q
What Lifestyle changes are involved in treatment of IBS?
A
- 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
15
Q
What 4 classes of drugs are 1st line Pharmacological Treatment for IBS?
A
- 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
16
Q
What are 3 common Antispasmodics (antimuscarinics) for IBS?
A
Antispasmodics (anti-muscarinics):
- Dicycloverine (Merbentyl) = used as GI antispasmodic and in urinary incontinence (10-20mg 3 times daily)
- Hyoscine (Buscopan)
- Propantheline (Probanthine)
17
Q
What are 3 common Anti-Smooth muscle (SM relaxants) used in IBS?
A
Anti-Smooth muscle (SM relaxants):
- Mebeverine (Colofac) = anti-cholinergic with unknown mechanism (200mg twice daily for IBS)
- Alverine (Spamonal)
- Peppermint (Colpermin)
18
Q
What are the 3 classes of Laxatives and name a common example for each?
A
Laxatives:
-
Stimulant laxative
- Senna = oral tablet (7.5-15mg, max = 30mg daily) taken at bedtime
-
Osmotic laxatives –> pull water back into colon to soften stool
- Polyethylene glycol
- Lactulose (avoid in IBS due to ↑wind which IBS patients have anyway)
-
Softeners
- Docusate
19
Q
Name 2 common Anti-diarrheals for IBS treatment?
A
Anti-diarrheals:
-
Loperamide (first choice) = anti-motility agent for diarrhoea - stimulates µ-opioid receptors in the myenteric plexus –> ↓myenteric activity and gut motility
- Improves anal tone
- Regular use + low dose
- No effect on pain
- Codeine phosphate (has central effects so not favoured)
20
Q
What drugs are used as 2nd line in treatment of IBS?
A
-
Tricyclic antidepressants (TCAs)
- Consider TCAs for IBS if; laxatives, loperamide (anti-diarrheal) or antispasmodics haven’t helped
- Used at much lower dose than when used for depression
-
Serotonin-reuptake inhibitors (SSRIs)
- Use for IBS only if TCAs are ineffective
- Used at much lower dose than when used for depression
-
Serotonin (5-HT)
- 70-80% of the bodies serotonin is in the GI tract
- 5-HT acts in the gut to; increase motility, secretion and visceral sensitivity
- 5-HT concentration is reduced in IBS!! Thus:
- For diarrhoea dominant IBS we want to ↓ 5-HT
- For constipation dominant IBS we want to ↑ 5-HT
- Prucalopride = 5-HT4 agonist = ONLY serotinin IBS medication that has been produced with an ‘acceptable’ side-effect profile
-
Probiotics
- Enhance host anti-inflammatory and immune response –> to restore balance between pro- and anti- inflammatory cytokines
- Preparations contain live organisms which exert different potential health benefits depending on the organism
21
Q
Define Inflammatory Bowel Disease
A
Define:
- Group of conditions involving inflammation of GI tract – 2 most common forms = Crohn’s disease and ulcerative colitis (UC)
22
Q
Both Crohn’s Disease and Ulcerative Colitis are described as following a ‘relapsing-remitting’ course, what does this mean?
A
Refers to the presentation of disease symptoms that become worse over time (relapsing), followed by period of less severe symptoms that do not completely cease (remitting)
23
Q
Biostatistics of IBD:
- Which is more common UC or Crohn’s?
- Which populations are more/less likely to suffer from IBD?
- Which is more common in children vs adults (Crohn’s or UC)?
A
-
UC is more common
- UC incidence = 10-20 per 100 000
- Crohn’s incidence = 5-10 per 100 000
- Both are more common in Caucasians vs african-caribbean or Asian
- Most common in Jewish people of european origin
-
Crohn’s is more common in children / UC is more common in adults
- UC peak has 2 peaks in incidence; 15-25yrs and 55-65yrs
24
Q
What features are common to both UC and Crohn’s, including so called extra-intestinal symptoms?
A
- Fever
- Malaise
- Weight loss
- Arthralgia / arthritis in large joints (most common extra-instestinal features of both UC and Crohn’s)
- Ulcers in mouth and vagina - (more common in Crohn’s)
- Iritis - inflammation of iris (worse than conjunctivitis)
- Skin:
- Erythema Nodosum - painful itchy raised round lumps (1-5cm), commonly on legs (more common in UC)
- Pyoderma gangrenosum - dead black pus necrotic tissue, commonly on legs or around stoma
- Primary sclerosing cholangitis (more common in UC)
25
What are the key features of Ulcerative Colitis?
**Define:**
* UC is a relapsing-remitting disease characterised by;
* **Colon inflammation** (lead-pipe appearance on barium enema)
* **Rectal bleeding**
* **Ulcers** interspersed with preserved mucosa **--\>** producing **pseudo-polyps**
**Physiology of Inflammation:**
* Inflammation is worse/starts distally in the rectum and can progress proximally BUT rarely passes ileocecal valve
* **No inflammation beyond submucosa** (confined to mucosa + submucosa)
* Neutrophils migrate into glandular lumens forming '**crypt abscesses'**
* **40-50%** **Proctitis** = inflammation of anus/rectum (only first 6 inches of rectum)
* Proctosigmoiditis = inflammation of rectum + sigmoid colon
* **30-40%** **Left-sided colitis** = Inflammation can spread in proximal direction i.e. from rectum/sigmoid backwards through descending colon
* **20% extensive colitis** = Inflammation can spread further proximally to involve transverse colon
* Pancolitis = inflammation of entire colon
**Signs/Symptoms:**
* **Bloody diarrhoea**
* **Mucus** in stool
* **Tenesmus** - feeling of incomplete defecation
* Feacal urgency
* **Abdominal pain** (particularly **LLQ**)
* Extra-intestinal features
**Prognosis:**
* NO ↓ in mortality, 10-30% need colectomy (within 10yrs post onset)
26
Flares of Ulcerative Colitis can be classified as; Mild, moderate and severe - what are the features of each?
* **Mild:**
* \< 4 stools / day (with/without blood)
* No systemic disturbance
* Normal ESR + CRP
* **Moderate:**
* 4-6 stools / day (with/without blood)
* Minimal systemic disturbance
* **Severe:**
* \> 6 stools / day - contains blood
* Evidence of systemic disturbances e.g.
* Fever
* ↑ HR (tachy)
* ↑ ESR
* Abdo pain, distension or reduced bowel sounds
* Anaemia
* Hypoalbuminaemia
27
What tests might you want to do in a patient with UC?
**Beside**:
* General Obs - ↑ temp, ↑ HR, ↑ RR in severe flare of UC
* Abdominal exam - LLQ pain, clubbing, erythema nodosum, pyoderma gangrenosum, iritis
* PR exam - may show blood on glove
* Stool sample - ↑ WBCs suggestive of infective cause
**Bloods**: - in flare
* FBC:
* ↑ WCC
* ↑ platelets
* ↓ Hb (iron-deficient anaemia)
* ↑ ESR
* ↑ CRP
* pANCA - may be positive in UC (usually negative in Crohn's)
Other tests:
* **Flexible sigmoidoscopy** - often shows inflammation, ulceration and bleeding mucosa (is rare rectum/sigmoid are clear in UC)
* AXR - may show air in colon + colonic dilation
* **Barium Enema**: - in UC:
* Loss of haustrations
* Superficial ulceration
* Long standing UC: shortened + narrow colon 'leadpipe'
* Colonoscopy:
* Should not be used during actue attacks of IBD
* Can be used during remission to assess; extent of IBD, perform biopsies to rule out malignancy
28
What are 4 potential complications associated with UC?
1. Bleeding
2. Perforation
3. **Toxic megacolon**
4. Colorectal cancer
29
What drugs are used to induce remission of UC and which are used for maintiaining remission?
**Induce Remission:**
* Acute Severe:
* 1st line = IV steroids e.g. hydrocortisone
* 2nd line = Ciclosporin (immunosuppresant) or Infliximab (monoclonal antibody - not advised due to lack of evidence but is more effective in Crohn's)
* 3rd line = surgery (colectomy)
* Acute moderate:
* Topical (suppository or enema) **mesalazine** (aminosalicylate anti-inflammatory) + oral prednisolone
* Acute mild:
* 1st line = Topical (suppository or enema) mesalazine
* 2nd line = Topical (suppository or enema) mesalazine + oral prednisolone
**Maintaining Remission:**
* **Oral aminosalicylates** e.g. **Mesalazine**
* **Thiopurines** e.g. **azathipurine** or **mercatopurine** (immunosuppresants)
30
What are the key features of Crohn's Disease?
**Define:**
* **Relapsing**-**remitting** disease
* Can affect any part of GI tract (mouth-anus) often present as ‘**skip lesions**’ = areas of pathology with gaps of healthy GI tract in-between
* Often involves **all layers of bowel** + pattern of inflammation gives **cobblestone** appearances
* Rectum is rarely affected BUT anus often is (fistulae + perianal abscesses)
**Physiology of Inflammation:**
* **40% ileocecal area** (ileum + cecum)
* 30-40% small intestine - inflammation appears in segments (skip lesions)
* 20% Crohn’s Colitis = skip lesions in colon (large intestine)
* \<10% Perianal inflammation
**Signs/symptoms:**
* **Diarrhoea** (usually non-bloody)
* Can cause constipation if blockage forms e.g. stricture
* **Weight loss** - crohn's often affects small intestine (failure to thrive in children)
* **Abdominal pain** (can mimic appendicitis i.e. umbilical --\> LRQ)
* **Right iliac fossa mass** - 70% of Crohn's affects the terminal ileum - can produce an abscess
* **Fistulae** + **Abscesses** - results from full thickness ulceration of GI tract
* **Perianal disease** - e.g. skin tags or ulcers
* **Gallstones + renal stones** - more common in Crohn's secondary to reduced bile acid reabsorption (Crohn's affects small intestine)
* **Fat wrapping** - mesentery becomes thickened and wraps around bowel to anti-mesenteric border
* Extra-intestinal symptoms
**Prognosis:**
* Slight ↓ mortality
* ~50% need surgery (within 10yrs post diagnosis)
31
What are the 4 main complications of Crohn's Disease?
1. **Stricture** - can cause obstruction, presents as 'acute abdomen' can mimic appendicitis
2. **Fistulas** = abnormal connnection between 2 organs e.g. bladder-bowel
3. **Adhesions**
4. **GI cancer** - commonly adenocarcinomas of terminal ilieum
32
What test might you do for a patient with Crohn's Disease?
**Bedside:**
* Abdominal exam - acute abdomen, LRQ pain/mass, clubbing, erythema nodosum, pyoderma gangrenosum, mouth ulcers, iritis
* PR exam - may have blood on glove, identify perianal abscess / skin tags
* Stool samples - to exclude infective diarrhoea (↑ WBCs)
**Bloods**:
* FBC:
* ↑ WCC (if disease active)
* ↓ Hb (anaemia)
* Serum Iron + B12 if anaemic on FBC - ↓ B12 anaemia
* ↑ CRP
* ↑ ESR
* LFTs - may be deranged if gallstones are present
* U+Es - may be deranged if renalstones are present
Other tests:
* **Faecal calprotectin test**
* CT - can show fistuals, fistulas and bowel wall changes
* **Barium swallow** - shows; strictures, mucosal changes and fistulas and picture of skip lesions
33
How is smoking advice potentially different in UC vs Crohn's?
* Potentially don't stop smoking in UC --\> protective in UC, stopping smoking ↑ risk of relapse
* Stop smoking in Crohn's --\> it can be enough to maintain remission
34
How is Crohn's Disease managed?
Crohn's is NOT treated if asymptomatic (unlike UC)!!
**Lifestyle:**
* If small intestine is affected paraenteral nutrition may be required as fat soluable vitamins e.g. A, D, E and K may be under-absorbed
* Low residue diet is advised in those with stricture
**Pharmacological:**
* Acute flares:
* 1st line = Glucocorticoids
* 2nd line = aminosalicylates (5-ASA drugs) e.g. Mesalazine
* Adjunct: Thiopurines e.g. azathipurine or mercatopurine (immunosuppresants) or Methotrexate
* Last line prior to surgery: Infliximab (monoclonal antibody)
* Surgery
* Maintaining remission:
* Stop smoking!!
* Azathipurine or mercatopurine
35
If you were to draw the colon and small intestine to demonstrate affected areas in UC vs Crohn's how would each look?
36
Clostridium Difficle is an organism which is part of normal gut flora. Abx can make it more predominate by killing competing organisms. This can present with what symptoms? And what complications?
Symptoms of C.Diff infection:
* Diarrhoea
* Fever
* Nausea
* Abdominal pain
* ↑ WCC
Complications:
1. C.Diff colitis
2. **Toxic megacolon**
* Acute form of colonic distension/dilation, which is often accompanied by paralysis of peristalsis, which can lead to accumulation of faeces in the immotile segment. Also characterised by
* Very distended colon
* Abdo pain
* Fever
* Bloating
3. Colon **perforation**
4. **Sepsis**
37
How do you manage a C.Diff patient?
1. **Discontinue** offending Abx
2. Oral **vancomycin** or **fidaxomicin** or **metronidazole**
3. Isolate pt in side-room
4. Gown + glove interaction with patient
5. Fluid support if dehydrated due to diarrhoea
38
What are the 5 main negative consequences of using opiates in gastro pathologies?
1. ↓ gut motility
2. ↑ cannula infections when giving parenteral nutrition ( opiates impair immune function)
3. Cognitive-behavioural effects e.g. mental fog, drug-seeking behaviour
4. Opiate induced hyperalgesia (↑ sensitivity to pain)
5. Narcotic bowel syndrome - follows the cycle of;
* Opioids --\> ↓ GI motility --\> constipation --\> distention (accumulation of faeces) --\> nausea + vomiting --\> ↑ intestinal pain/spasms --\> ↑ requirement for pain-relief --\> prescribe ↑ opioids
39
Which of the following is not a suitable treatment for IBS?
1. Morphine
2. Low FODMAP diet
3. Hypnotherapy
4. Mebeverine
5. Linaclotide
Morphine
40
Which of the following are not “red flags” for cancer?
1. Age over 50
2. Raised CRP
3. Family Hx of colorectal cancer
4. Weight loss
5. Rectal bleeding
Age over 50 (it's age over 60)
41
What scoring system would you use to assess a patient's risk of malnutrition?
**MUST** score
Involves the following to calcualte risk of malnutrition and appropriate action:
* BMI score
* Weight loss score
* Acute disease effect score
