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Clin Med IBS & Constipation Flashcards

1
Q

IBS

- define

A
  • recurrent abd pain associated with disordered bowel habits
  • no structural abnormalities
  • bloating and distention are typical
  • disorder of gut-brain axis
  • most frequently dx GI condition
  • “central sensitivity syndrome”
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2
Q

Common comorbidities seen with IBS

A
  • functional somatic syndromes (fibromyalgia, chronic fatigue syndrome, chronic pelvic pain, TJM, chronic back pain)
  • other GI (GERD, dyspepsia)
  • psych (major depression, generalized anxiety disorder, somatization, panic disorder, PTSD)
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3
Q

Symptom patterns IBS

A
  • intermittent
  • duration of episodes vary
  • 67% have functional dyspepsia
  • diarrhea, constipation or alternating between
  • bloating
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4
Q

what is often the most bothersome symptom in IBS

A

bloating

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5
Q

7 contributing factors to IBS

A
  1. family/env
  2. psych disorders
  3. genetic predisposition
  4. prior infectious gastroenteritis
  5. alterations in gut microbiome
  6. bile salt overproduction
  7. diet
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6
Q

IBS Pathophys: major abnormalities (4)

A
  • colon stimulation causes motor abnormalities
  • increased rectosigmoid motor activity after meals
  • increased contraction amplitude in colon
  • rectal balloon inflation causes prolonged contractile activity
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7
Q

IBS Pathophys: visceral hypersensitivity

A
  • not well understood
  • exaggerated response to visceral stimulation (lower threshold for visceral pain)
  • pain is perceived when food bolus enters cecum (exaggerated response to stimuli that are not normally pain-producing)
  • up-regulated connectivity in emotional arousal circuitry = increased sympathetic arousal, anxiety, vigilance
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8
Q

What eating situation improves IBS, what type of food makes it worse

A
  • fasting improves

- lipids make it worse

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9
Q

How is colorectal distention different in patients with IBS (2)

A
  • activates brain stress response

- deactivates brain areas that modulate stress response

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10
Q

IBS Pathophys: Central neural dysregulation (2)

A
  • greater activation of mid-cingulate cortex after colonic stimulation = subjective unpleasantness of pain
  • activation of prefrontal lobe = increased alertness, possibly increased perception of pain
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11
Q

IBS Pathophys: Abnormal psych features (5)

A
  • mood disorders
  • anxiety disorders
  • somatization
  • hypervigilance
  • catastrophizing
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12
Q

IBS Pathophys: Postinfectious

A
  • may be induced by gastroenteritis

- campylobacter, salmonella, shigella were studied, all toxin producers

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13
Q

IBS Pathophys: immune activation/mucosal inflammation

A
  • activated lymphocytes, mast cells, increased cytokines = inflammation
    Cycle:
    stress - cytokines - mucosal inflammation enhanced expression sensory neurons in gut - visceral hypersensitivity - chronic abd pain
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14
Q

IBS Pathophys: altered gut flora

A

differences of fecal microbiota are speculated to contribute

- unsure if causal, consequential, or result of IBS

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15
Q

IBS Pathophys: abnormal serotonin pathways

A
  • 5-HT receptors for serotonin play role in GI motility and visceral perception
  • Increased enterochromaffin cells with 5-HT receptors are seen in IBS-D and UC
  • abnormal serotonin reuptake and variations in gene that encodes serotonin reuptake transport system are found in IBS
  • likely polymorphism of 5-HT2A receptor gene may be associated with IBS
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16
Q

IBS Pathophys: Brain-Gut Axis

A
  • homeostatic info sent to brain via afferent neural and humoral “gut-brain” pathways
  • most signals not consciously perceived under normal conditions
  • strong gut-brain signaling, triggered by noxious stimuli warns of potential treats to homeostasis that require a response
  • in IBS, problems with top down modulation of pain sensation
  • stress contributes to dysfunction
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17
Q

IBS

  • sx onset age
  • male vs. female
  • cardinal sx
A
  • onset before 45
  • women 2-3x men
  • always pain
  • usually bloating
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18
Q

IBS

  • nutrient deficiencies and weight change
  • pertinent negatives
  • major contributors to sx
A
  • no nutrient deficiencies, no weight loss despite diarrhea
  • no nocturnal sx
  • no bleeding (except from hemorrhoids potentially)
  • aggravated by stress or eating
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19
Q

IBS altered bowel habits

A
  • painful defectation
  • small stools
  • frequent or infrequent stools
  • urgency
  • inconsistant/alternating
  • diarrhea: small volume
  • narrow stool shape
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20
Q

IBS abdominal pain

A
  • usually diffuse
  • LLQ most common
  • worse with meals
  • gas pain
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21
Q

IBS other common sx

A
  • dyspepsia
  • heartburn
  • n/v
  • sexual dysfunction :(
  • urinary freq.
  • fibromyalgia
  • fatigue
  • perimenstrual exacerbation
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22
Q

What is name for IBS criteria

A

Rome IV (2016 update)

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23
Q

Rome IV sx criteria

A

Recurrent abd pain => 1 day/week in last 3 months associated with two or more of:

  • defecation
  • assoc. with change in stool frequency
  • assoc. with change in stool form
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24
Q

Rome IV IBS diagnosis time requirements

A

must be active for last 3 months with symptoms over at least the last 6 months total (chronicity)

25
What symptoms is urgency seen with in IBS
- BOTH diarrhea and constipation
26
How is IBS diff from functional constipation or functional diarrhea
- IBS has alternation of the two, bloating, and pain!
27
IBS: clinical hx
- hallmark: abd pain, esp lower abdomen - altered bowel habits - unpredictable pattern - sx of bloat +/- distention
28
IBS: PE
- tenderness on palpation of lower abdomen | - rectal exam to r/o rectal disease, check stool for blood if indicated
29
IBS ddx
- celiac dz - IBD - microscopic colitis - bile acid diarrhea - dyssynergic defecation / pelvic floor dysfunction
30
True false: there are no clear diagnostic markers for IBS
true!! it is a clinical dx Use stool markers/blood tests to r/o other things on ddx
31
Lab studies in IBS
- CBC - CRP - Thyroid - stool analysis for infection if diarrhea - stool calprotectin and/or lactoferrin which are inflammation markers
32
IBS: when is colonoscopy approrpaite
- ALARM sx - fam hx colon ca - persistent diarrhea
33
ALARM sx big three
- person/fam hx of colorectal ca, intestinal polyposis, IBD, celiac - new onset of sx after age 50 - recent change in bowel movement habit
34
ALARM sx - additional
- nocturnal sx - fever - anemia - weight loss - fecal blood - severe abd pain - palpable mass - occult stool +
35
IBS Treatment overview
- relationship is key! assure them they won't die and let them know you care - direct tx towards dominant sx
36
IBS Treatment - lifestyle
- avoid food precipitants (food diary) - ask about artificial sweeteners - increase soluble fiber - gluten restriction - FODMAP restriction * * make sure explain why all these changes
37
What does FODMAP stand for
``` Fermentable Oligosaccharides Disaccharides Monosaccharides and Polyhydric alcohols ```
38
IBS Fiber tx
SOLUBLE ONLY - bulks stool - constipated: speeds colonic transit time - diarrhea: absorbs water, delays colon transit time - reduces perception rectal distention - better results IBC-C - psyllium is best option - start low, titrate up to goal 20-30 grams/day
39
IBS and Probiotics
- proven to be slightly helpful with pain/bloating - no help with bowel regularity - bifidobacterium breve, b. longum, lactobacillus acidophilus
40
IBS and prebiotics
- promote proliferation of bifidobacteria | - not proven useful for IBS
41
IBS - common medication
- Rifaximin (Xifaxin) - non-absorbable abx - IBS-D and IBS_M - modest improvements, mostly to bloat - sx tent to return over time
42
IBS - psych interventions
- ID triggers and feelings (self monitoring) - cognitive strategies: modify thinking errors - problem solving to manage and cope with stress - relaxation techniques - hypnosis - exposure therapy
43
IBS Treatment - Anti-depressant meds
- tricyclic anti-depressants - SSRI - SNRI
44
IBS tx with tricyclic anti-depressants
- slow jejunal transit, delay gut transit time - may alter visceral hypersensitivity - lower dose - anticholinergic side effects that help diarrhea - best with IBS-D
45
IBS tx with SSRI
- paroxetine accelerates transit time, better for IBS-C | - efficacy needs more study
46
Treatment of IBS-D
- Mu Opioid receptor agonist (Imodium and Lomotil) - bile acid sequestrants (Cholestyramine, Colesevelam, Colestipol) - 5-HT3 receptor antagonists (Lotronex)
47
what medication is sometimes used but has no FDA approval to treat IBS-D
Ondansetron
48
Three additional potential future IBS-D treatments
- Mast cell stabilizers - muscarinic type 3 receptor antagonists - glutamine
49
IBS-C treatment first line
soluble fiber
50
IBS-C treatment after soluble fiber
- Osmotic laxatives (don't help pain) | - Intestinal Secretagogues (Lubiprostone, Linaclotide, Pecanatide)
51
IBS Pain tx
- Anti-cholinergic drugs (PRN): dicyclomine, hyoscyamine, don natal, clidinium bromide, peppermint oil - Gas pain: gas-x, beans, lactaid
52
Chronic Idiopathic Constipation (CIC) | - Dx
- must rule out all other organic causes before idiopathic label - usually requires specialist - some will have intractable constipation
53
Common meds that can cause constipation
- opioids - antiemetics - antipsychotics - antihypertensives (CCB, atenolol, furosemide, clonidine) - ibuprofen - ca and iron supplements ** also ask about laxative use/abuse: rebound constipation can occur
54
Chronic Idiopathic Constipation (CIC) ddx
SO MANY, big list on the lecture
55
Chronic Idiopathic Constipation (CIC) | - tests
- plain abd film - Sitz Marker study for colonic transit time - SmartPill to measure overall GI transit time - Anorectal motility testing to determine if evacuation problem exists - colonoscopy if >50, fam hx, alarm sx
56
Chronic Idiopathic Constipation (CIC) | - non-pharm tx
- toileting habits, positioning (squatty potty) - exercise - hydration - dc meds that cause - soluble fiber (usually doesn't work though)
57
Chronic Idiopathic Constipation (CIC) | - pharm tx
- Osmotic laxatives (Miralax, lactulose, magnesium salts) - Stimulant laxatives (Cascara, Senna/ex-lax/perdiem, Bisacodyl) - Intestinal secretagogues - Enema/suppository (Fleet, glycerine support, mineral oil enema, milk of molasses enema)
58
When might biofeedback therapy for Chronic Idiopathic Constipation (CIC) be needed?
- anorectal motility issue - difficulty evacuating rectum - manual extraction is required
59
When is surgery required for Chronic Idiopathic Constipation (CIC)
- rarely required, only if true colonic inertia | - subtotal colectomy

GI 1 (16 decks)

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