Functional dyspepsia & irritable bowel syndrome (IBS) Flashcards

1
Q

Define irritable bowel syndrome.

A

IBS is a functional bowel disorder defined as recurrent episodes (in the absence of organic pathology) of abdominal pain and discomfort for >6months of the previous year, associated with two of the following:

  • altered stool passage
  • abdominal bloating
  • symptoms made worse by eating
  • passage of mucous
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2
Q

What is the aetiology of IBS?

A

The cause is not known; an organic trigger, such as bacterial gastroenteritis, is seen in some patients however there is undoubtedly a psychological component.

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3
Q

What is the pathophysiology of IBS?

A

Dysfunction of motor and sensory aspects of the GI tract

Altered gut reactivity (motility and secretion) in response to stimuli which may be..

  • environmental - personal life stresses or abuse
  • luminal - certain foods, bacterial overgrowth or toxins, gut distension or inflammation

… and this altered reactivity can lead to constipation/diarrhoea.

People with IBS may also have a lower threshold for pain (lower pressures cause pain) compared to people without IBS.

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4
Q

How common is IBS?

A

10-20% prevalence

More common in females (2:1)

Onset usually <40yrs

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5
Q

What is the typical presentation of IBS?

A
  • >6 months of abdominal pain (often colicky, in lower abdomen, relieved by defecation or flatus)
  • Altered bowel frequency - >3 bowel montions daily or <3 weekly
  • Abdominal bloating
  • Change in stool consistency
  • Passage with urgency or straining
  • Tenesmus - inclination to evacuate bowels

Screen for red flag alarm symptoms: weight loss, anaemia, PR bleeding, late onset (>60 years) = presence of any require referral to exclude colonic malignancy

IBS coexists with chronic fatigue syndrome, fibromyalgia, temporomandibular joint dysfunction.

Non GI features: gynae (dysmenorrhoea, dyspareunia), urinary (frequency, urgency, nocturia, incomplete bladder emptying), other (joint hypermobility, back pain, headache, bad breath, unpleasant taste in mouth, poor sleep)

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6
Q

What are the risk factors for IBS?

A
  • Affective disorders e.g. depression, anxiety
  • Psychological stress/trauma
  • Age <50 years
  • Female sex
  • GI infection (30%)
  • Abx therapy
  • Sexual, physical, verbal abuse
  • Pelvis surgery
  • Eating disorders
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7
Q

What are the signs of IBS on examination?

A
  • Abdominal tenderness - in RLQ or LLQ or normal.
  • Distension
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8
Q

What investigations would you do for IBS?

A

Mainly diagnosis from history but may be vital to exclude organic pathology:

  • FBC
  • ESR/CRP
  • EMA or TTG to exclude coeliac disease

Other:.

Bloods:

  • LFT, ESR, CRP, TFT - should all be normal. CRP <0.5 mg/L makes IBD unlikely (and IBS more likely)
  • Stool studies - MS&C for parasites, cysts and infection; faecal calprotectin <40 micrograms/g makes IBD unlikely (and IBS more likely).

Imaging

  • AXR - normal, may show obstruction

Invasive:

  • Flexible sigmoidoscopy and colonoscopy- abnormal mucosa suggest inflammatory bowel disease
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9
Q

How do you subtype IBS?

A
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10
Q

What is the management of IBS?

A

Conservative:

  • Lifestyle and dietary modification - food (eliminate triggers like caffeine, lactose, or fructose, add fibre), low FODMAP diet, reduce stress. gradually increase fibre as it has been shown to be beneficial in IBS
  • +/- Dietitian referral if no improvement
  • Psychological therapies - e.g. CBT, relaxation and psychotherapy

Medical:

  • Antispasmodics - cause colonic relaxation by anticholinergic action - e.g. mebeverine, metoclopramide
  • Prokinetic agents - e.g. domperidone, metoclopramide
  • Anti-diarrhoeals - e.g. loperamide
  • Laxatives - e.g. conventional laxatives then linaclotide
  • Low-dose TCA - may reduce visceral awareness
  • Peppermint oil 30min before meals may reduce colonic spasm and bloating

‘Do not encourage use of acupuncture or reflexology for the treatment of IBS

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11
Q

What are the complications of IBS?

A
  • Damage to family and work relationships
  • Increased incidence of colonic diverticulosis
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12
Q

What is the prognosis with IBS?

A

75% of patients are helped by explanation and symptomatic relief.

Chronic relapsing and remitting course, often exacerbated by psychosocial stresses

But if no long term complications of the disease then normal life expectancy

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13
Q

What may need to be avoided in the diet to avoid diarrhoea?

A

Reducing fructose will help reduce diarrhoea predominant symptoms. If not well absorbed by the bowel, fructose can contribute to osmotic diarrhoea and increased flatulence.

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14
Q

Which of these is not a recommended treatment for IBS?

  • CBT
  • Hypnotherapy
  • Antispasmodic agents
  • Loperamide for diarrhoea
  • Tricyclic antidepressant
  • Acupuncture
A

Acupuncture

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15
Q

Name 2 anti-diarrhoeals.

A

Loperamide - no peripheral absorption; acts on miu opioid receptors to reduce gastric motility

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16
Q

What are the phases of a low-FODMAP diet?

A

3 phases:

1) restriction (lasting no more than 4-6 weeks),
2) reintroduction of FODMAP foods, and
3) personalization based on results from reintroduction

17
Q

What are important diagnoses to exclude in those with IBS?

A
  • colorectal cancer
  • gynaecological pathology
  • hiatus hernia
  • diverticular disease
  • gallbladder disease
  • ischaemic bowel
18
Q

Which laxative should be avoided in IBS?

A

Lactulose

19
Q

What general dietary advice can be offered in IBS?

A
  • regular meals, take time to eat
  • avoid missing meals or having big gaps
  • drink a lot of water, avoid caffeine
  • restrict tea and coffee to 3 cups/day
  • reduce alcohol and fizzy drinks
  • limit intake of high fibre food
  • reduce ‘resistant starch’ found in processed foods
  • avoid sorbitol for diarrhoea
  • increase oats and linseeds if bloated
20
Q

What criteria may be used to diagnose IBS?

A

Rome II - NB: this differs from NICE as they only require symptoms to be present for 6 weeks