E1: IBS, Constipation, Diarrhea Flashcards
What is IBS?
A functional bowel disorder characterized by recurrent abdominal pain AND altered bowel habits
What are the red flag symptoms associated with IBS?
- Severe onset after age 50
- severe or progessively worsening symptoms
- nocturnal symptoms
- fevers/vomiting
- unexplained weight loss
- melena, hematochezia, and occult blood
- Unexplained Fe deficiency anemia
What are the Co morbid conditions often seen with IBS?
Fibromyalgia, interstitial cystitis,dyspareunia, and dyspepsia
Patient presents with chronic, recurrent abdominal pain of variable intensities. Patient complains of altered bowel habits. What are you concerned about?
IBS
What is the Rome criteria for IBS?
- Recurrent abdominal pain on average at least one day per week in the last 3 months associated with two or more of the following criteria
1) related to defecation
2) associated with change in stool frequency
3) Associated with a change in stool form
What is the scale that is used to determine the classification of IBS according to the patients predominant symptoms?
The Bristol stool scale
How is IBS diagnosed in a patient with typical history and no alarm features?
- Limited lab screening
- CBC, CMP, TSH, ESR/CRP, H pylori testing
How is IBS diagnosed in a patient with atypical history and alarm features?
- Lab and stool studies
- cross sectional/small bowel imaging
- endoscopy and colonoscopy with biopsies
What is the initial management in IBS?
-Dietary, lifestyle, and behavioral modifications
What are the dietary/lifestyle/and behavioral modifications that can be used to treat IBS?
- Food diary, symptomatology log to ID trigger foods
- High fiber
- adequate hydration
- reconcile offending medications
- Low FODMAP diet
What are the pharmacologic options are used to treat the abdominal pain associated with IBS?
- Antispasmodics (dicyclomine, hyocyamine, and peppermint oil)
- Antidepressants (TCA and SSRI)
What are the pharmacologic treatments of constipation associated with IBS?
- Fiber (Psyllium)
- Stool softeners
- osmotic and stimulant laxatives
- polyethylene glycol
- prosecretory agents
- 5HT4 agonist
What are the pharmacologic treatments of diarrhea associated with IBS?
- OTC anti-diarrhea (loperamide)
- Bile acid sequestrants
- rifaximin
- eluxadoline
- 5-HT3 antagonist
What is the most common digestive complain in the general population?
Constipation
What conditions are functional constipation?
Chronic idiopathic constipation and IBS-C
What medications may induce constipation?
Opioids, anticholinergics, antipsychotics, iron, antacids
What are the defecation and obstructive disorders that may cause constipation?
Pelvic floor dysfunction, rectal prolapse, rectocele, colon cancer, and polyps
What are the metabolic syndromes that may cause constipation?
Hypercalcemia, hyperparathyroidism, hypothyroidism, DM, pregnancy, MS, Parkinson’s
What is the clinical presentation of constipation?
-25% of defecations are associated with <3 spontaneous BMs/week. Lumpy or hard stools, straining, manual maneuvers, sensation of anorectal obstruction, and sense of incomplete evacuation
What is dyssnergic defecation?
When there is paradoxical contraction of the external anal sphincter which impedes defecation
What tests can be performed for patients with refractory constipation?
- Sitz marker study
- Defecography
- Anorectal manometry
What is a sitz marker study?
evaluates colonic transmit, measures movement of radiopaque markers through the colon via a series of X-rays
What is a defecography?
- Radiological imaging to assess the mechanics of defecation using fluoroscopy
- assesses the anatomy and function of anorectum and pelvic floor
What is anorectal manometry?
Measures the anal sphincter pressure/function
What is the first step in treating constipation?
- treat secondary and contributing cause of constipation
- reconcile offending meds
What are are the lifestyle modifications that can help treat constipation?
- Increase fiber and fluid intake
- increase activity and exercise
- bowel habit training
What are the pharmacologic options for treating constipation?
- Fiber supplements
- stool softeners
- osmotic laxatives
- stimulant laxatives
What are the prescription only agents used to treat constipation?
Lubiprostone, Linaclotide, and Plecanatide
What are the adverse effects of fiber supplements?
Flatulence, bloating, and distention
What are the adverse effects of stool softeners?
GI cramping
What are the adverse effects of osmotic laxatives?
GI discomfort, bloating, caution with Mg containing laxatives and hypermagnesemia in patients with renal insufficiency
What are the adverse effects of stimulant laxatives?
GI cramping, rarely lyte disturbances, and Melanosis coli
What are some complications that can arise from constipation?
- hemorrhoids/anal fissures
- fluid and electrolyte abnormalities from laxative abuse
- Fecal impaction and bowel obstruction
What constitutes diarrhea?
Passage of ≥3 unformed stools/day
What is the most common cause of diarrhea?
Infectious, particularly viral
What are the red flag symptoms associated with diarrhea?
- Fever
- unexplained weight loss
- melena, hematochezia
- persistent/progressive/nocturnal symptoms
- immunocompromised
- Signs of volume depletion
- IDA
What is the clinical presentation of non-inflammatory diarrhea?
- watery, non-bloody diarrhea, nausea and vomiting
- mild diffuse abdominal cramping, bloating, and flatulence
What are the most common causes of non inflammatory diarrhea?
Norovirus and giardia
What is the clinical presentation of inflammatory diarrhea?
- Fever
- bloody diarrhea
- severe abdominal pain
What are common etiologies of inflammatory diarrhea?
-CMV, salmonella, campylobacter, shigella, E. coli, C diff
What symptoms associated with diarrhea warrants prompt evaluation?
- Signs of inflammatory diarrhea (fever ≥ 101.3, leukocytosis, bloody diarrhea, and severe abdominal pain)
- intractable vomiting
- profuse watery diarrhea and dehydration
- AKI
- immunocompromised
What is the management of diarrhea?
- oral rehydration therapy
- trial of lactose free diet
- possible anti diarrhea agents
What are the antidiarrheal agents that may be used for diarrhea?
- Loperamide (Imodium)
- Bismuth Subsalicylate (peptobismol)(adverse effect is black stool)
