GI-Constipation&Diarrhea Flashcards
Mr. Flux has c/c of stomach pain. What are the DDX
a. Dyspepsia/GERD
b. IBS/Chronic Pain
c. Colon Cancer Screening
d. Elevated Liver Enzymes
e. Viral Hepatitis
f. Diarrhea
g. “Gas”- colon distension
h Chronic Liver Disease
i. Constipation/Hemorrhoids
j. Emergency-append, perf, blood
What DDX are emergent?
Acute GI Bleed- cirrhosis, perfs, NSAIDs, Trauma
Acute Abdomen- rigid
Food/FB Children
What is used to determine stool quality?
Bristol stool form scale-IBS
What is most common reason for constipation?
MC-obstruction due to stricture or tumor
2/2: Hypothyroidism -post preg
Opiates-major
lithium-Diarrhea, LTC burn thryoid out
What TX is for children and adults acute constipation?
Fiber and water
Children MC, Adult-drugs, diet, meds
What are cause of chronic constipation?
- Functional constipation- anatomy and neuro
- Hypothyroidism
- DM
- Gut neuropathy
- Obstruction/colon cancer
- IBS
- Meds/drugs- opiods)
The following are neurogenic cause of constipation
Peripheral: DM, ANS neuropathy, Hirsburg dx, Chagas,
IBS
Drug
Central: MS, Spinal cord, Parkinson
The following are NON neurogenic cause of constipation
Hypothyroidism HYPOkalemia- Dirurectics, CHF AN Preg Panhypopitutarism Systemic sclerois Myontonic dystrophy
What is the work up for chronic constipation?
CBC-anemia, TSH LFTs VitD CMP- electrolyte imbalance, renal fx Tox- lithium levels Rectal PE- hemorroids, guaiac, Fistula obstruction-sarcoid, tumor
Should chronic constipation be sent right away to GI?
NO, After trial of stool softner
Fiber
Hydration
Once labs and drug R/O
What is a hemorroid?
Dilated vein from straining. Bleed bc thin valves, small perforation from pressure and stain. Varicose veins of Anus
SX- pain w/ bowel, itching, healing, BRIGHT RED streaks or in toilet
How are Hemorroids TX?
- Treat symptoms w/ topicals:pads, creams, suppositories, etc
- banding or other surgical tx
- annucort/annusol-topical hydrocortisone rectal cream
shrink the inflammation
What are line agent for constipation?
patient education,
dietary change- less red meat
bulk-forming laxatives,
enemas as next line therapy
Avoid stimulant LAX-too much, dependent, crampy
SEVERE
suppositories,
biofeedback,
botulinum toxin injections into the puborectalis muscle
What are the DDX for Diarrhea?
Travel Diarrhea
Acute-Inflammatory-shigella, salmonella, campylobacter, e coli, c diff (bloody, fever)
Non-inflammatory-viral, giardia, parasites, meds, IBD, IBS
Chronic Diarrhea >4wks Infection-Bacteria, parasite Malabsorb-Celiac, Lactose IBD, IBS, Hyperthyroidsim, LIver/Bilary tract AN, Bulemia, METFORMIN
28 yo male c/o intermittent diarrhea x 6 mos. Travel to Central. What is work up?
FMHX,
a. Stool test, culture (ONP)
b. CBC-WBC
c. CMP
d. Guaiac -LAX
e. Giardia antibody
f. tTG-celiac
g. TSH
If labs normal, then think about IBS
35yo F has **recurrent abdominal pain plus **constipation/diarrhea. Some days Diarrhea only. Other
“Gas” Only. Labs are normal.
Irritable Bowel syndrome
What are DDX of NON-IBS
DX is exculsion, r/o this
d. Non-ulcer dyspepsia (NUD)
d. Chronic pain syndrome
d. Psychogenic vomiting
d. Pelvic floor dysfunction
d. IBD,
d. Enteric infection (protozoal or bacterial),
d. celiac sprue,
d. malabsorption,
d. diverticular disease,
d. substance abuse (including Etoh and coffee),
d. idiosynchratic food/additive rxn,
d. eating disorder,
d. true psychogenic disorder, somatization
The following are related to:
- Probably heterogenous
- Older theories: Psychogenic, Primary motility disorder
- diarrheal infection
- History of sexual/physical abuse
Theory to idiopathic IBS
**Currently favored: visceral hypersensitivity
How does stress affect IBS?
Persistent stress= release of cortisol, INC sugars, INC inflam
Dampen inflammation response
INC mast cells
INC bacterial growth-gas
Malabsorbtion of lactose,fructose,sorbitol-sits
Dampen pain perception-sensitive, habituate
Sensitive nerve gut endings-plexus dfx, spasm
Stress levels relate w/ sx. stress hormones, CRF ANS.
Serotonin=INC stress=PNS=INC motility
What condition is 2/2 infection leading to IBS?
Post-Infectious Irritable Bowel Syndrome
- follows bacterial dysentery cases
- 25% of all IBS cases
- indistinguishable from other forms of IBS
What is main difference in IBS vs IBD?
IBS physical lab finding are normal
except sigmoid loop sometimes tender and palpable LLQ
CBC, thyroid, stool, ova and parasite (OP), WBC, TTG normal.
Calprotectin- POS IBD
IBS +/- colonscopy-severe
How is IBS DX?
Relapse remission Stress Somatic complaints 1.3 month Hx of continuous or intermittent abdominal pain/discomfort AND 2 of 3 below: a. Relief with defecation b. change in frequency of stool and form of stool 3. bloating, mucus, incomplete evacuation
What are the RED FLAGS of IBS?
- wakes them up from sleep = BAD
- Recent onset > 40 yo
- Blood or occult blood in stool
- **Anemia
- Fever and vomiting
- **Weight loss or anorexia
- Progressive symptoms
- Localized pain other than LLQ
- Painless diarrhea w/Blood
14you M c/c of diarrhea and gas past 4 months, intermittent every time he goes to school?What is TREATMENT?
Antispasmodic, anti diarrheal drugs Stool bulk Tricyclic#!, SSRI Amitiza Biofeedback, Acupunture Biome
