GI: Functional GI disease and IBS

Question 1

What chronic GI symptoms are suggestive of a functional GI disorder?

Answer 1

• Nausea alone
• Vomiting alone
• Belching
• Chest pain unrelated to exercise
• Postprandial fullness
• Abdominal bloating
• Abdo discomfort/pain
• Passage of mucus per rectum
• Frequent bowel movements with urgency first thing in the morning

Question 2

What is globus?

Answer 2

Presistent intermittent sensation of a lump/foreign body in the throat

Question 3

What is functional dyspepsia?

Answer 3

This is the second most common functional gastrointestinal disorder (after irritable bowel syndrome).

Patients can present with a spectrum of symptoms including upper abdominal pain/discomfort, fullness, early satiety, bloating and nausea.

Question 4

Causes of functional dyspepsia

Answer 4

Diet

Acid

Duodenal sensitivity

Brain pain modulating circuits

Anxiety/depression

Question 5

Differential dyspepsia

Answer 5

Reflux/GORD

Low grade duodenal ulcer

Delayed gastric emptying

IBS

Gastric/oesophageal cancer

Question 6

What are the two subgroups of functional dyspepsia?

Answer 6

• Epigastric pain syndrome
• Post-prandial distress syndrome

Question 7

What investigations would you want to consider doing in someone with features of functional dyspepsia?

Answer 7

Tests to exclude H. pylori

Endoscopy if ALARM symptoms

Question 8

How would you manage functional dyspepsia?

Answer 8

• Placebo therapy
• Psychotherapy
• Dietary advice - reduce fat, caffeine, alcohol, cigarette smoking
• Consider SSRI’s
• Management of symtpoms
  
  • ​PPI
  • Prokinetics
  • Eradiation therapy

Question 9

Consider differentials for nausea and vomiting

Answer 9

Immediate - psychogenic

>1 hour - pyloric obstruction, motility disorder

12 hours - obstruction

Aetiology:

• Drugs
• Alcohol
• Pregnancy
• Migraines
• Cyclical vomiting syndrome

Question 10

Whats psychogenic vomiting

Answer 10

• Often occurs in young women
• Often for years
• May have no preceding nausea
• Appetite not usually disturbed but may lose weight
• Self-induce bulimia

Question 11

What is IBS?

Answer 11

A mixed group of abdominal symptoms for which no orgnaic cause can be found. Most are probably due to disorders of intestinal motility, enhanced visceral perception or microbial dysbiosis

“Disorders of enhanced visceral perception (bowel symptoms for which no organic cause can be found)

Question 12

What is the average age of onset of IBS?

Answer 12

<40 yrs

Question 13

Which sex is IBS most common in?

Answer 13

Females

Question 14

What are the different subtypes of IBS based on stool pattern?

Answer 14

• IBS with constipation
• IBS with diarrhoea
• Mixed IBS
• Unsubtyped

Question 15

What type of diagnosis is IBS?

Answer 15

Diagnosis of exclusion

Question 16

What are features of IBS?

Answer 16

Chronic, recurrent abdominal discomfort associated with at least 2 of:

• Relief by defecation
• Altered stool form
• Altered bowel frequency
• Urgency
• Incomplete evacuation
• Abdominal bloating
• Mucus PR
• Worsening symptoms after food

Question 17

What is the ROME criteria?

Answer 17

Used for diagnosis of IBS.

Positive diagnosis if:

3months of abdopain that is releived by defication, associated with change inf requency, cahnge in consistency

+

2 or more of: altered frequency, altered stool form, passage of mucus, bloating

Question 18

What can symptoms of IBS be exacerbated by?

Answer 18

• Stress - incl depression, anxiety, other pscyhological problems and adverse life events​​
• Menstruation
• Gastroenteritis - and other post infectious
• Diet - alcohol, fizzy drinks, chocolate, caffeine drinks, fatty foods

Question 19

What are signs may be present in someone with IBS?

Answer 19

Examination often normal, but may have

• Abdo tenderness
• Insufflation with air during endoscopy may ilicit symptoms
• Change in bowel habit

Question 20

What would be red flag symptoms in someone with suspected IBS?

Answer 20

• Age > 60
• History <6 months
• Anorexia
• DEcreased weight
• Waking at night with pain/diarrhoea
• Mouth ulcers
• Abnormal CRP/ESR

Question 21

Investigations in an IBS like presentation

Answer 21

FBC

TFT

Coeliac antibodies

Inflammatory markers (ESR)

Malabsorption screen

Stool culture

Colonscopy if >60 years

Question 22

What is important to exclude as a diagnosis in females presenting with features of IBS?

Answer 22

• Ovarian cancer - serum CA-125
• Endometriosis

Question 23

What are the genera approaches to management of IBS?

Answer 23

• Lifestyle modification
• Symptom management
• Cognitive therapy

Question 24

How would you manage someone with constipation dominant IBS?

Answer 24

• Ensure adequate water and fibre intake
• Promote physical activity
• Simple laxatives
  
  • ​osmotic - lactulose, movicol
  • stimulant - senna, bisacodyl

Question 25

How would you manage Diarrhoea predominant IBS?

Answer 25

• Avoid sorbitol sweetners, alcohol and caffeine
• Reduce dietary fibre
• Encourage to identify trigger foods
• Consider bulking agents +/- loperamide

Question 26

How would you manage Colic/bloating symptoms in IBS?

Answer 26

• Oral anti-spasmodics - mebeverine/hyoscine butylbromide
• FODMAP diet

Question 27

What is the fodmap diet?

Answer 27

Elimination diet used to try to elminate fermentable oligo-, di-, mono-saccharides and polyols from the diet which are thought to cause IBS symptoms

Question 28

How would you manage the psychological side to IBS?

Answer 28

• Consider CBT, hypnosis
• Consider SSRIs - amitryptilline