Chronic Abdominal Pain Flashcards
A patient comes in with colicky L sided abdominal pain together with loose and frequent stools for a few weeks. She is also feeling bloated and tired. She is under a lot of stress at work. There has been no rectal bleeding or weight loss and no family history of bowel cancer.
She says her aunt has Crohns disease and she is worried that she has got it as well, so she has come for a GP consultation today.
What tests would you perform at this stage?
- FBC
- CRP
- Stool culture
- Fecal calprotectin
- Celiac serology (tTG, EMA, DGP)
CT and Colonoscopy should be reserved for “red flag” symptoms
What are the red flags indicating urgent referral to secondary care for further investigations?
- Age over 60
- Rectal bleeding
- Anemia
- Weight loss
- Family history of colorectal cancer
- Abdo/rectal mass
- Raised CRP/ESR or fecal calprotectin
Additionally in women over 50 with persistent bloating an USS of the ovaries and Ca125 level is mandated to rule out ovarian cancer.
A patient comes in with colicky L sided abdominal pain together with loose and frequent stools for a few weeks. She is also feeling bloated and tired. She is under a lot of stress at work. There has been no rectal bleeding or weight loss and no family history of bowel cancer.
The test results all come back normal. What is the patient likely to have?
Irritable Bowel Syndrome (diarrhea predominant)
IBS is a syndrome comprising abdominal pain, bloating and altered bowel habit. The pain is colicky and is associated with the bowel movements. It is sub-typed into diarhoea or constipation predominant. It is thought that there may be some different mechanisms underlying diarhoea rather than constipation predominant IBS but also a lot of overlap. In the past IBS was considered a “diagnosis of exclusion” but now we are encouraged to make a positive diagnosis based on the typical symptoms, exclusion of red flags and simple tests.
What is fecal calprotectin?
Faecal calprotectin is a biochemical measurement of the protein calprotectin in the stool. Elevated faecal calprotectin indicates the migration of neutrophils to the intestinal mucosa, which occurs during intestinal inflammation, including inflammation caused by inflammatory bowel disease.
If in normal ranges, suggestive of IBS
What advice would you give someone with IBS?
IBS is a chronic condition for which the mainstay for the majority of patients is guided self-management. From the outset therefore it is important to nurture Mary’s sense of agency.
Dietary factors can be very important. In the first instance encourage Mary to keep a food diary, and look for any obvious food triggers to her symptoms. Give Mary first line dietary advice as to some of the common foods which can worsen symptoms. Stress management can also help, give Mary some simple tips on relaxation.
What are the symptoms of IBS?
- Abdo pain (severe)
- Abdo bloating
- Disordered bowel habit (diarrhea, constipation, alternating; urgency + incontinence)
- Exagerrated gastro-colonic reflux
What are the extra-intestinal manifestations of IBS?
- Nausea
- Thigh pain
- Back pain
- Lethargy
- Urinary symptoms (irritable bladder)
- Gynaecological symptoms (pain on intercourse - dysparenuria)
What is the initial treatment for IBS?
Cereal fibre
- Wheat fibre avoided
- White bread allowed
- Probiotic
- Tried for 3mo and re-check for improvement
What drugs are used for IBS?
- Antispasmotics
- Anticholinergics (Dicycloverine, Hyoscine, Propantheline)
- Anti-smooth muscle (Mebeverine, Alverine, Peppermint) - Anti-Diarrheals
- Loperamide
- Diphenoxylate
- Codeine phosphate - Laxatives
- Osmotic (Polyethylene glycol/movicol, lactulose - avoid in IBS, magnesium salts)
- Stimulant (Sodium picosulfate, Bisacodyl, Senna)
- Softeners (Docusate) - Antidepressants for their effect on gut
- Diarrhea -> tricyclic (too much serotonin)
- Constipation -> tricyclic or SSRI (too little serotonin)
- Serotonin -> Prucalopride - Drugs that promote secretion
- Chloride channel activators (Lubiprostone)
- Guanylate cyclase receptor agonists (Linaclotide) - 2nd line!
- Consider eluxadoline if diarrhea hasn’t improved with above options - 3rd line! - Hypnotherapy
- Helps all symptoms
What are probiotics?
A capsule that contain live organisms that exert benefit to the host
Properties:
- Enhance host anti-inflammatory and immune response
- Stimulate anti-inflammatory cytokines
- Pathogenic bacteria stimulate pro-inflammatory cytokines
- Restore balance between pro and anti-inflammatory cytokines
- Improve epithelial cell barrier
- Epithelial adhesion - exclusion of pathogens
- Inhibit bacterial translocation
- Inhibit growth of pathogens (i.e. salmonella)
- Inhibit adhesion of viruses (i.e. rotavirus)
- Elaborate active proteins and metabolites
- Reduce hyper motility + hypersensitivity
- Reduce anxiety behaviour
What are the main probiotic organisms?
Lactobacillus
Bifidobacterium
- Given in milk
What is IBD?
A chronic inflammatory bowel disease which pursue a protracted, relapsing, and remitting course
- Crohns Disease
- Ulcerative Colitis
What is the main area of bowel affected in Ulcerative Colitis? Crohn’s?
UC: Mainly presents with inflammation of rectum + sigmoid colon (proctitis)
Crohns: Ileocecal area + small intestine (skip lesions) + perianal inflammation
How is UC different from Crohn’s?
UC:
- Both genders affected
- 2-19/100 000 incidence
- Smoking protects
- Onset 15-40yrs
- Affects distal colon
- Continuous inflammatory lesions distal colon -> proximal colon
- Superficial inflammation
- Severe bleeding, toxic megacolon, rupture of bowel, colon cancer = complications
Crohns:
- M
What is Carnett’s Sign?
Carnett’s sign can be tested for to determine whether pain originates from the viscera or myofascia/abdominal wall. To test for Carnett’s sign, the patient should lie down and raise their head or legs against gentle resistance from the physician. The test is positive if this manoeuvre exacerbates pain, which indicates an abdominal wall, as opposed to visceral, pain origin.
What are the reasons for a DRE?
- Suspected appendicitis
- PR bleed
- Change in bowel habits
- GU problems (i.e. urinary retention, prostate enlargement)
- Pelvic or spinal trauma
What are your differentials for a woman who has recurrent IBS symptoms plus fever after treatment?
A. Infectious gastroenteritis – viral or bacterial
B. Inflammatory bowel disease
C. post-infectious IBS
What’s important in the history to distinguish the following 3 differentials?
- Infectious gastroenteritis
- IBD
- Post-infectious IBS
Onset: infectious diarrhoea tends to have a sudden onset
Systemic features: infectious diarrhoea tends to cause other systemic features of infection including fever and general malaise
Specific questions regarding the stool: frequency, consistency, presence of blood, presence of mucus. Blood can be seen in both dysentery and in inflammatory bowel disease. Mucus can be seen in inflammatory bowel disease and irritable bowel syndrome.
Predisposing factors:
Changes to diet, recent takeaways, any travel, any visits to local farms? All these can predispose to infectious causes for diarrhoea.
Anybody else with similar symptoms? Any recent hospital visits? Norovirus (also known as the winter vomiting bug) often occurs in outbreaks and is highly infectious. If an outbreak occurs in a hospital infection control measures are heightened and wards closed to new admissions whilst patients are given supportive treatment.
Any recent antibiotics or medication changes? Diarrhoea can be a side effect of stopping opiates.
Recent antibiotic use can predispose to Clostridium difficile infection. C. difficile can exist in normal gut flora and acts as an opportunistic pathogen that is able to reproduce and become the dominant species in the gut of someone who has had disruption of their gut flora from antimicrobial use. C. difficile is an important pathogen to be aware of as it is associated with health care infections and can have considerable morbidity and mortality. Complications that need to be looked for in a patient with C. difficile diarrhoea include pseudomembranous colitis which can lead to toxic megacolon and colonic perforation. Treatment is with ORAL vancomycin, metronidazole or fidaxomicin.
What complications can occur with a C. Diff infection?
Complications that need to be looked for in a patient with C. difficile diarrhoea include pseudomembranous colitis which can lead to toxic megacolon and colonic perforation.
Treatment is with ORAL vancomycin, metronidazole or fidaxomicin.
What tests would you perform to characterize the possibilities of infectious diarrhea?
Stool cultures are the most important if you are suspecting infectious diarrhoea. Most infectious diarrhoea is self-limiting and does not require antibiotics. The most important advice is on fluid management, including oral rehydration such as dioralyte™ or simple oral rehydration solution also known as ORS. Recipes for this are found freely available online and when travelling in low and middle income countries or in remote places can be a lifesaving recipe to know.
What are important components of an ORS (oral rehydration solution)?
- Sugar
- Potassium
- Sodium
What is diarrhea? Dysentery?
Diarrhea: Production of more than 2 unformed stools per day
Dysentery: Diarrhea with visible blood in the stools
List the causative organisms (bacteria, viruses, parasites) of diarrhea
Bacteria:
- Campylobacter
- Shigella
- Salmonella
- C. difficile
Viruses:
- Norovirus
- Rotavirus
Parasites:
- Giardia
- Cryptosporidium
- Schistosomiasis
What are 5 different mechanisms of acute diarrhea?
- Secretory (i.e. cholera)
- Mixed secretory-osmotic (i.e. rotavirus)
- Mucosal inflammation (i.e. invasive bacteria)
- Motility disturbance
- Osmotic (i.e. Lactose intolerance)
What are important things to ask in a patient history of diarrhea?
- When/how the illness began
- Stool characteristics
- Frequency and relative quantity
- Dysenteric symptoms: fever, tenesmus, blood/pus in stools
- Travel
- Employment (food-handler, caregiver)
- Consumption of unsafe foods
- Swimming in/drinking untreated fresh surface water
- Animal contact
- Contact with other ill persons
- Recent meds (antibiotics, antacids, anti motility agents)
- Underlying HIV, immunosuppression, gastrectomy, extremes of age
- Receptive anal intercourse/oral-anal sexual contact
What is the management of acute diarrhea?
- Initial rehydration: ORS vs IV
- Patient evaluation
- Fecal testing
- Therapeutic considerations
Ensure patients are nursed in a side room (incase of infection)
What are the tests and treatment if suspecting community acquired/traveler’s diarrhea?
Culture/test for:
- Salmonella
- Shigella
- E. Coli O157:H7
- C. difficile toxins A±B (if antibiotics/chemo taken in recent weeks)
Treatment:
- Quinolone (shigellosis)
- Macrolide (campylobacter)
- Avoid antimotility/antimicrobial drugs if suspecting STEC)
What are the tests and treatment if suspecting nosocomial diarrhea (onset after > 3 days in hospital)
Test for C. difficile toxins A±B
Treatment:
- Discontinue antimicrobials
- Consider metronidazole if illness persists/worsens
What are the tests and treatment if suspecting persistent diarrhea > 7d?
Consider parasites:
- Giardia
- Cryptosporidium
- Cyclospora
- Isospora belli
- Inflammatory screen
If HIV positive add:
- Microsporidia (gram-chromotrope)
- M. avian complex + panel A
Treatment:
- Treat per results of tests
What is the 3-day rule for hospitalized patients in terms of stool cultures?
Very low yield from (standard) stool cultures
?Fecal specimens of >3 days hospitalization should not be cultured
What are the indications for stool culture after > 3 days hospitalization?
- Age > 65
- Comorbid disease
- Neutropania
- HIV infection
What is the clinical presentation of someone with campylobacter infection?
Abdo pain, profuse diarrhea, malaise; vomiting is uncommon
Usually mild; severe in 20%
Can cause toxic megacolon, pancreatitis, cholecystitis, peritonitis, arthritis (HLA-B27)
Treatment: Supportive, macrolide if severe
What is the clinical presentation of E. Coli (ETEC) infection?
Watery diarrhea Nausea Cramps Low grade fever Malnutrition in children
What is the presentation of salmonella food poisoning?
Diarrhea
Vomiting
Fever
Salmonella typhi/paratyphi don’t cause dysentery
What is the presentation of enteric fever?
Fever
Abdo pain
Constipation is more common than diarrhea
Diagnosis:
- Culture of blood, stool, urine (and biopsy of liver or bone marrow)
What is the presentation of shigella?
Bloody diarrhea
S. dysenterie may be associated with serious disease: toxic megacolon, hemolytic uremic syndrome
Treatment: supportive, antibiotics if severe
What investigations would you do for a person with watery diarrhea episodes of incontinence and weight loss?
- FBC, U+E, LFT, TSH
- Blood culture
- Malaria film
- HIV test
- Stool culture + microscopy including acid fast staining (and mycobacterial culture)
- Flexible sigmoidoscopy with biopsies
What are causes of chronic diarrhea?
- Colonic neoplasia, UC, Crohn’s disease, microscopic colitis
- Celiac disease, small bowel enteropathies (ie. Whipple’s disease)
- Bile acid malabsorption, SI bacterial overgrowth
- Chronic pancreatitis, pancreatic carcinoma, cystic fibrosis
- Radiation enteritis, lymphoma, giardiasis
- Hyperthyroidism, diabetes, hypoparathyroidism, Addison’s disease
- Hormone secreting tumours (VIPoma, gastrinoma, carcinoid)
- Factitious diarrhea “surgical” causes (small bowel resections, internal fistulae), autonomic neuropathy, IBS
- Drugs, alcohol
What is likely to cause chronic diarrhea in someone who’s HIV positive?
- Cryptosporidium
- Cyclospora
- Isospora belli
- Histoplasma
- MAI
- CMV
- Microsporidium
What is the clinical presentation of amoebiasis: entamoeba histolytica?
Diarrhea
Dysentery
Abscesses
Amoebomas
Treatment:
- Metronidazole
- Luminal cysticide
IBD is an important differential
What is the presentation of schistosomiasis?
Severe disease follows years of mildly symptomatic infections
Intestinal granulomatous reaction results from the host’s immune response to schistosome eggs -> severe active colitis
It seems that Mary’s setback was due to an infective gastroenteritis. Her vomiting has settled as has her temperature. Her IBS is however far worse than it was before and the diet, relaxation and anti-spasmodics are not working. You repeat her stool culture which is negative as is her faecal calprotectin.
Which treatment option would you offer to her next?
Loperamide
These are all possible options, however loperamide is good first line treatment for the diarrhoea component of IBS. The evidence for antibiotics for IBS-D and the role of small intestinal bacterial overgrowth is somewhat controversial. Amitriptyline can help slow diarrhoea and help with abdominal pain and may also blunt the body’s response to stress. It is however a low dose antidepressant and side effects and acceptability can be an issue. More complex dietary interventions, such as the low FODMAP diet, can be helpful but should be overseen by a dietitian. Patients can become very distressed with their symptoms so psychological support is important.
Mary attends A&E because the pain is very bad. The surgeons perform a normal CT scan of her abdomen, a normal colonoscopy and she comes out on a morphine prescription for the pain. Over the next several months she is in and out of hospital with further normal CT scans, abdominal Xrays and barium studies. On one occasion she has her appendix removed but this doesn’t improve things. Her morphine dose is going up and up. She wonders if further operations to remove other parts of her bowel might help and wants to see another surgeon?
What might be going on here?
Mary appears to becoming a victim of “iatrogenesis”. In particular there are 3 types of medical harm she is being subjected to:
A. Increasingly invasive investigations including a lot of radiation and also endsocopies which do carry a perforation risk.
B. Unnecessary surgery – IBS patients have a threefold cholecystectomy rate, double hysterectomy rate and a double appendicectomy rate with an odds ratio of 2.17 for a normal appendix. They also have increased colon resection and increased back surgery (Longstreth G, 2007, Gut)
C. Opiates – The Royal College of Anaesthetists, faculty of pain medicine, have produced an important campaign called “opioids aware” as to the significant iatrogenic effects of opiates in chronic pain - read about this important topic
In gastroenterology, we see at least four negative consequences of opiates: (i) worsening GI motility since opiates have a profound slowing effect (ii) increased cannula infections on parenteral nutrition since opiates impair immune function (iii) cognitive-behavioural effects including mental fogging/narcosis and drug seeking behaviour which is thought to be due to opiate effects on the mesolimbic dopaminergic reward circuits (iv) opiate induced hyperalgesia giving rise to the Narcotic Bowel Syndrome. NBS comprises two vicious circles – a pharmacological vicious circle of opiate induced hyperalgesia and a sociological vicious circle of maladaptive health care interactions.
What is the treatment of narcotic bowel syndrome?
Recognition Relationship Replacement - TCA, a2d ligands, NSRI (SSRI) - Linaclotide? - u-opioid antagonists - psychological therapies Reduction - Rapid? (GA, drug + alcohol team) - Slow controlled patient driven Prevention - TLR4 antagonists
List 7 possible causes of constipation
- Rectocele (weakened tissue; front of rectum bulges against the posterior of the vagina)
- Enterocele (descending of small intestine into lower pelvic cavity)
- Dyssynergic defecation (problem with nerves/muscles in the pelvic floor)
- IBS
- Drug induced
- Slow transit (reduced motility of the large intestine, caused by abnormalities of the enteric nerves)
- Normal transit (constipation due to hardened stools)
What is the treatment for slow transit constipation?
Oral laxatives
Peripheral mu opiate antagonist (if pt on opiates)
Transit study investigation shows markers scattered throughout the colon = slow transit constipation
What is the treatment for defectors outlet obstruction?
Suppositories or biofeedback therapy
Defectory outlet obstruction could be functional due to dysinergic defecation or structural due to a rectocele
Next step = anorectal physiology studies or a defecating proctogram
What is the treatment of a large anterior rectocele?
Surgical treatment
Seen on defecating proctogram
What is the treatment for dysinergic defecation (animus)?
Biofeedback which uses the tracing to retrain patients to relax their anal sphincter
Also helpful for fecal incontinence where the aim is to improve anal sphincter tone
Shown on anorectal manometry where upper trace is (normal) rectal pressure and lower trace is (inappropriate) sphincter contract
IBS overlaps with which condition?
Fibromyalgia
What is a useful first line test in IBS?
Fecal calprotectin
What are the “red flags” for cancer?
- Raised CRP
- Weight loss
- Rectal bleeding
- Family history of colorectal cancer
- Age over 50
What is not a suitable treatment for IBS?
Morphine
What are 4 suitable treatments for IBS?
Mebeverine (antispasmodic)
Hypnotherapy
Low FODMAP diet
Linaclotide
A 19-year-old man presents to his GP complaining of intermittent loose stools and colicky abdominal pain. His symptoms are bad at times when he feels under pressure with his study and examinations. PMH. He has suffered from irritable bowel syndrome for the past three years. He recently saw a gastroenterologist and following tests, the diagnosis was confirmed. DH. His gastroenterologist recommended amitriptyline 20 mg orally to help his abdominal symptoms, but he has not tried this treatment yet. It was supplied In tablet form and he is worried that he may be intolerant to lactose. SH. He is at a local University, studying to gain a degree in biochemistry.
On examination:
- His abdomen is soft and not tender on palpation.
What is the most appropriate management option at this stage?
reassure that lactose content of amitriptyline tablets will not worsen his symptoms and encourage him to try them.
Amitriptyline is available as an oral solution. However, it is expensive and there is no history of previous severe lactose intolerance. The BNF states that the lactose content in most medicines is too small to cause problems in most lactose-intolerant patients. It would be best to discuss his concerns and offer reassurance in the first instance.
Prescribe a regular dose of Movicol sachets for a patient with chronic constipation. He usually takes 1 sachet daily in the morning. NKDA.
Movicol
One Sachet
Oral
What does the celiac disease screen consist of?
- Anti-tissue transglutaminase (tTG)
- Endomysial antibodies (EMA)
- Deamidated gliadin peptide (DGP)
What fecal calprotectin result can present with NSAID use?
Positive
What is the IBD severity scoring criteria called?
Truelove + Witts
What is a sign of a toxic megacolon? How should it be treated?
Transverse colon diameter > 6cm
- Risk of perforation
- IV steroids + daily X-rays
When can flexible sigmoidoscopy be used?
In acute colitis. Colonoscopy is contraindicated b/c of perforation risk
Explain 7 investigations used for GI pathology
- Colonoscopy: Bowel prep, painful
- Pillcam: Poor with strictures, patency = use gelatine that mimics capsule + dissolves
- MR Small Bowel: 3D scan, No radiation, blurred pics, no details
- Barium Follow Thru: 2D scan, Radiation, Distinct details of ulcers seen, no lymph node info
- Double Balloon Enteroscopy: If need to take samples/biopsy, painful, requires sedation
- Yersinia: Infection that can mimic Crohn’s Disease (serology blood test), request if history of travel
- Quantiferon: Test for latent TB, before decreasing immune system with meds
What are the causes of hypoalbuminemia?
- Liver impairment
- Inflammatory proteins synthesis in infection/inflammation (increased CRP/WBC)
- Nephrotic syndrome (check urine)
- Crohn’s (Gut protein loss) -> may have low B12 (low absorption in terminal ileum)
*Not a good sign of nutrition!
What is refeeding syndrome?
- Risk after prolonged starvation
- Electrolyte shift of magnesium, potassium, sodium into cells as a result of increased glucose from eating
- Can also cause thiamine deficiency (vitamin B1)
- Check daily bloods!
