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GI 1 > Clin Med IBS & Constipation > Flashcards

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
Q

What symptoms is urgency seen with in IBS

A
  • BOTH diarrhea and constipation
26
Q

How is IBS diff from functional constipation or functional diarrhea

A
  • IBS has alternation of the two, bloating, and pain!
27
Q

IBS: clinical hx

A
  • hallmark: abd pain, esp lower abdomen
  • altered bowel habits
  • unpredictable pattern
  • sx of bloat +/- distention
28
Q

IBS: PE

A
  • tenderness on palpation of lower abdomen

- rectal exam to r/o rectal disease, check stool for blood if indicated

29
Q

IBS ddx

A
  • celiac dz
  • IBD
  • microscopic colitis
  • bile acid diarrhea
  • dyssynergic defecation / pelvic floor dysfunction
30
Q

True false: there are no clear diagnostic markers for IBS

A

true!! it is a clinical dx

Use stool markers/blood tests to r/o other things on ddx

31
Q

Lab studies in IBS

A
  • CBC
  • CRP
  • Thyroid
  • stool analysis for infection if diarrhea
  • stool calprotectin and/or lactoferrin which are inflammation markers
32
Q

IBS: when is colonoscopy approrpaite

A
  • ALARM sx
  • fam hx colon ca
  • persistent diarrhea
33
Q

ALARM sx big three

A
  • person/fam hx of colorectal ca, intestinal polyposis, IBD, celiac
  • new onset of sx after age 50
  • recent change in bowel movement habit
34
Q

ALARM sx - additional

A
  • nocturnal sx
  • fever
  • anemia
  • weight loss
  • fecal blood
  • severe abd pain
  • palpable mass
  • occult stool +
35
Q

IBS Treatment overview

A
  • relationship is key! assure them they won’t die and let them know you care
  • direct tx towards dominant sx
36
Q

IBS Treatment - lifestyle

A
  • avoid food precipitants (food diary)
  • ask about artificial sweeteners
  • increase soluble fiber
  • gluten restriction
  • FODMAP restriction
    • make sure explain why all these changes
37
Q

What does FODMAP stand for

A 
Fermentable
Oligosaccharides
Disaccharides
Monosaccharides
and
Polyhydric alcohols
38
Q

IBS Fiber tx

A

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
Q

IBS and Probiotics

A
  • proven to be slightly helpful with pain/bloating
  • no help with bowel regularity
  • bifidobacterium breve, b. longum, lactobacillus acidophilus
40
Q

IBS and prebiotics

A
  • promote proliferation of bifidobacteria

- not proven useful for IBS

41
Q

IBS - common medication

A
  • Rifaximin (Xifaxin)
  • non-absorbable abx
  • IBS-D and IBS_M
  • modest improvements, mostly to bloat
  • sx tent to return over time
42
Q

IBS - psych interventions

A
  • 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
Q

IBS Treatment - Anti-depressant meds

A
  • tricyclic anti-depressants
  • SSRI
  • SNRI
44
Q

IBS tx with tricyclic anti-depressants

A
  • slow jejunal transit, delay gut transit time
  • may alter visceral hypersensitivity
  • lower dose
  • anticholinergic side effects that help diarrhea
  • best with IBS-D
45
Q

IBS tx with SSRI

A
  • paroxetine accelerates transit time, better for IBS-C

- efficacy needs more study

46
Q

Treatment of IBS-D

A
  • Mu Opioid receptor agonist (Imodium and Lomotil)
  • bile acid sequestrants (Cholestyramine, Colesevelam, Colestipol)
  • 5-HT3 receptor antagonists (Lotronex)
47
Q

what medication is sometimes used but has no FDA approval to treat IBS-D

A

Ondansetron

48
Q

Three additional potential future IBS-D treatments

A
  • Mast cell stabilizers
  • muscarinic type 3 receptor antagonists
  • glutamine
49
Q

IBS-C treatment first line

A

soluble fiber

50
Q

IBS-C treatment after soluble fiber

A
  • Osmotic laxatives (don’t help pain)

- Intestinal Secretagogues (Lubiprostone, Linaclotide, Pecanatide)

51
Q

IBS Pain tx

A
  • Anti-cholinergic drugs (PRN): dicyclomine, hyoscyamine, don natal, clidinium bromide, peppermint oil
  • Gas pain: gas-x, beans, lactaid
52
Q

Chronic Idiopathic Constipation (CIC)

- Dx

A
  • must rule out all other organic causes before idiopathic label
  • usually requires specialist
  • some will have intractable constipation
53
Q

Common meds that can cause constipation

A
  • opioids
  • antiemetics
  • antipsychotics
  • antihypertensives (CCB, atenolol, furosemide, clonidine)
  • ibuprofen
  • ca and iron supplements

** also ask about laxative use/abuse: rebound constipation can occur

54
Q

Chronic Idiopathic Constipation (CIC) ddx

A

SO MANY, big list on the lecture

55
Q

Chronic Idiopathic Constipation (CIC)

- tests

A
  • 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
Q

Chronic Idiopathic Constipation (CIC)

- non-pharm tx

A
  • toileting habits, positioning (squatty potty)
  • exercise
  • hydration
  • dc meds that cause
  • soluble fiber (usually doesn’t work though)
57
Q

Chronic Idiopathic Constipation (CIC)

- pharm tx

A
  • 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
Q

When might biofeedback therapy for Chronic Idiopathic Constipation (CIC) be needed?

A
  • anorectal motility issue
  • difficulty evacuating rectum
  • manual extraction is required
59
Q

When is surgery required for Chronic Idiopathic Constipation (CIC)

A
  • rarely required, only if true colonic inertia

- subtotal colectomy

GI 1 (16 decks)

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