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