Exam 1 - IBS, Constipation, Diarrhea Flashcards
What is the definition of IBS?
Function bowel disorder characterized by recurrent abdominal pain AND altered bowel habits.
What are the different sub-classifications of IBS?
- IBS-C (constipation predominant)
- IBS-D (diarrhea predominant)
- IBS-M (mixed)
- IBS-U (unclassified)
What are some red flag symptoms/alarm features that should prompt evaluation/referral to GI for condition other than IBS?
- Symptoms onset after age 50
- Severe or progressively worsening symptoms
- Nocturnal symptoms
- Fevers/vomiting
- Unexplained weight loss
- Melena, hematochezia, + occult blood
- Personal or family hx of colon cancer, IBD, or Celiac disease
- Unexplained iron deficiency anemia
What is the clinical presentation associated with IBS?
- Chronic diffuse and cramping lower abdominal discomfort with periodic exacerbations
- Altered bowel habits
What is the diagnostic criteria for IBS?
Rome IV Criteria:
Recurrent abdominal pain on at least one day per week in the last three months associated with two or more of the following:
- Related to defecation
- Associated with change in stool frequency
- Associated with a change in stool form/appearance
What is the general management outline for IBS?
- Dietary/lifestyle/behavioral modifications (initial)
- Psychosocial support
- Pharmacological therapy
What are some dietary/lifestyle/behavioral modifications for IBS management?
- Reconcile offending medications
- Food diary/symptom log to help identify triggers
- High fiber (20-35 g/day)
- Adequate hydration (8-10, 8oz glasses water daily)
- Low FODMAP diet
- Toileting behavior
- Mindful eating
- Physical activity
What is a low FODMAP diet?
- Focuses on eliminating foods that contain sugars and fibers that cause pain and bloating
- Eliminate x 4-8 weeks than gradually reintroduce 1-2 foods at a time and assess tolerance
What are the different drug classes that may be prescribed to help with abdominal pain/discomfort associated with IBS?
- Antispasmodics
- Antidepressants
What are the different drug classes that may be prescribed to help with constipation associated with IBS?
- Fiber
- Stool softeners
- Laxatives
- Polyethylene glycol (PEG)
- Prosecretory Agents (Lubiprostone, Linaclotide)
- 5-HT4 agonist
What are the different drug classes that may be prescribed to help with diarrhea associated with IBS?
- OTC Anti-diarrheal (Loperamide)
- Bile acid sequestrants
- Rifaximin
- 5-HT3 antagonist
What is the most common digestive complaint in the general population?
Constipation
What are some examples of medications that can exacerbate constipation?
- Antipsychotics
- Iron
- Opioids
- Anticholinergics
- Antacids
- CCBs
- TCAs
What defines constipation?
25% of defecations associated with:
- < 3 spontaneous BMs/week
- Lumpy or hard stools
- Straining
- Manual maneuvers to facility defacation
- Sensation of anorectal obstruction/blockage
- Sense of incomplete evacuation
What are symptoms may accompany constipation?
- Abdominal pain and bloating
- Pain on defecation
- Rectal bleeding
- Tenesmus
What is the general management outline for constipation?
1: Treat secondary/contributing causes of constipation such as reconcile offending meds
- Dietary, lifestyle, behavioral modifications
- Medication therapies
What are some dietary, lifestyle, behavioral modifications that you can recommend to patients suffering from constipation?
- Increase fluid intake (8-10, 8 oz glasses of water per day)
- Increase fiber (20-35 g/day; start slow)
- Bowel habit training
- Biofeedback (for defecatory dysfunction)
What are medication options for constipation?
- Fiber supplements
- Stool softeners
- Osmotic laxatives
- Stimulant laxatives
- Rx agents (Lupiprostone, Linaclotide, Plecanatide)
What are some adverse effects of fiber supplements?
Flatulence, bloating, distention
What are some adverse effects of stool softeners?
GI cramping
What are some adverse effects of osmotic laxatives?
GI discomfort, bloating
Caution with Mg-containing laxatives and hypermagnesemia in patients with renal insufficiency
What are some adverse effects of stimulant laxatives?
GI cramping, rarely lyte disturbances, melanosis coli
What are some adverse effects of Rx agents for constipation?
Diarrhea
What are some possible complications of constipation?
- Hemorrhoids
- Anal fissures
- Fluid and electrolyte abnormalities from laxative abuse
- Fecal impaction which can lead to bowel obstruction
What are some signs/symptoms of a possible fecal impaction/bowel obstruction?
- Nausea and vomiting
- Abdominal pain
- Distention
- Paradoxical “diarrhea”
When performing a DRE, what specific etiology should you test for as a cause of the patient’s constipation?
Dyssynergic defecation
What is the definition of diarrhea?
Passage of 3 or more unformed stools per day
What is the difference between acute diarrhea and chronic diarrhea?
Acute: < 14 days duration
Chronic: > 30 days duration
What is the most common cause of acute diarrhea?
Viral infection
What are red flag symptoms/alarm features of diarrhea?
- Fever
- Unexplained weight loss
- Melena, hematochezia, + occult blood
- Persistent/progressive/nocturnal symptoms
- Immunocompromised
- Personal or family hx of colon cancer, IBD, Celiac disease
- Iron deficiency anemia
- Signs of volume depletion (dry mucus membranes, orthostatic, tachycardia, dark urine, decreased skin turgor)
What are some possible risk exposure for acute diarrhea?
- Recent hospitalization or antibiotic use
- Travel history
- Ingestion of improperly stored or prepared food
- Sick contact exposure/Community outbreaks
- Pets/Animal exposure
- New medication or dose changes
- Public Health Risk: Healthcare worker, Daycare employees, Food-Handlers
What is the clinical presentation associated with acute non-inflammatory diarrhea?
- Watery, non-bloody diarrhea
- Nausea/Vomiting
- Mild diffuse abdominal cramping, bloating/flatulence
- (+/-) low grade fever
What are the most common viral and protozoal causes of acute non-inflammatory diarrhea?
Viral: Norovirus
Protozoal: Giardia
What is the clinical presentation associated with acute inflammatory diarrhea?
- Fever
- Blood diarrhea
- Severe abdominal pain
What are the common bacterial causes of acute inflammatory diarrhea?
- Salmonella
- Campylobacter
- Shigella
- Enterohemorrhagic E. coli
- C. diff
What does the diagnostic evaluation consist of for acute diarrhea?
Other than H and P, diagnostic evaluation is not routinely warranted for most patients as most cases are infectious and self-limiting
With acute diarrhea, what signs warrant a need for prompt evaluation?
- Signs of inflammatory diarrhea (fever 101.3F or greater, leukocytosis, bloody diarrhea, severe abdominal pain)
- Intractable vomiting
- Profuse watery diarrhea and dehydration
- AKI/Lyte abnormalities
- Elderly or nursing home residents
- Immunocompromised
- Hospital-acquired diarrhea, exposure to antibiotics
What is the management for acute diarrhea?
- Oral rehydration/lyte management
- Trial of lactose free diet
- (+/-) Anti-diarrheal agents
Antibiotics are generally not indicated as most cases are self-limited, but for some cases empiric antibiotics are appropriate
- FLQ x 3-5 days or Azithromycin as alternative
What are the anti-diarrheal agents that you may suggest for acute diarrhea?
What is an adverse effect of one of the medications?
- Loperamide (Imodium)
- Pepto-Bismol
Pepto-Bismol can cause black stool
Norovirus:
Source?
Duration?
Therapy?
Source: Prepared foods, sick contacts (Cruise ships, camps, restaurants)
Duration: Abrupt, self-limited, 24-72 hours
Therapy: Supportive, hand washing
Rotovirus:
Population?
Source?
Duration?
Therapy?
Population: 6 months - 2 years old
Source: Fecally contaminated food/water, sick contacts (Daycares)
Duration: Self-limited
Therapy: Supportive, hand washing
Vibrio cholerae (“rice-water” diarrhea):
Source?
Therapy?
Source: Unsanitary conditions, food and waterborne, travel hx
Therapy: Supportive; Doxy, macrolide, tetracycline, FLQ if severe
What is the source/exposure of Clostridium perfringens (enterotoxin)?
Food-borne: inadequately heated/reheated meats; home-canned goods
What is the source/exposure of Staphylococcus aureus (enterotoxin and vomiting predominant)?
Food-borne: creamy foods, egg/potato salad
What is the source/exposure of Bacillus cereus (enterotoxin and vomiting predominant)?
Food-borne: Grains (rice)
Giardia lamblia:
Source?
Therapy?
Source: Waterborne, foodborne, fecal-oral transmission (camping, lakes, streams, ponds, daycares, pools)
Therapy: Metronidazole
What can chronic giardiasis cause?
Profound weight loss
Cryptosporidium:
Source?
Therapy?
Source: Recreational water outbreaks, daycares
Therapy: Supportive; Treat if immunocompromised
While Cryptosporidium is self-limiting, in which population can it lead to serious disease?
Patients with AIDS
Cyclospora:
Source?
Therapy?
Source: Imported foods (fresh fruits/vegetables)
Treatment: TMP-SMX
Salmonella:
Source?
Therapy?
Source: Poultry and livestock; reptiles
Treatment: Supportive; abx in appropriate patietns
What can Campylobacter jejuni be linked to?
Guillain-Barre Syndrome
What is the therapy for Campylobacter jejuni?
Supportive; Macrolide or FLQ if severe
What inflammatory bacterial etiology is known as “classic dysentery”?
Shigella
What inflammatory bacterial etiology causes severe afebrile bloody diarrhea and is only treated with supportive measure due to risk of HUS?
Enterohemorrhagic E. coli
Clostridioides difficile:
Source?
Therapy?
Source: Recent hospitalization/antibiotic use, community acquired
Therapy: Discontinue inciting abx; Vancomycin, Fidaxomicin, Metronidazole
Vibrio parahemolyticus:
Source?
Therapy?
Source: Raw seafood/shellfish
Treatment: Supportive; FLQ or Doxy if severe
Which inflammatory bacterial etiology can mimic appendicitis?
Yersinia enterocolitica
E. histolytica:
Source?
Therapy?
Source: Fecally contaminated food/water, travel
Therapy: Metronidazole + Iodoquinol
What is significant about E. histolytica?
Can lead to intraluminal and disseminated disease
