GI - Other conditions e-book

Question 1

The common symptoms of IBS overlap with more serious disorders:

Answer 1

 Diarrhoea or constipation
o May have one that is more prevalent or both
 Abdominal pain (relieved by defecation)
 Bloating/abdominal distension
 Passage of mucus
 Faecal incontinence
 Symptoms may be worsened by eating

Question 2

There are also a number of extra-GI symptoms associated with IBS:

Answer 2

 Lethargy
 Urinary incontinence
 Nausea
 Backache
 Fibromyalgia

Question 3

Diagnosis

Answer 3

For a diagnosis of IBS to be considered, the patient must have had one or more of the following symptoms for at least six months:
 Abdominal Pain or discomfort
 Bloating
 Change in bowel habit

Question 4

They must NOT have any of the following ‘red-flag’ indicators:

Answer 4

 Unintentional weight loss
 Age over 60 with a change in bowel habits for more than 6 weeks with looser and/or more frequent stools.
 Abdominal masses
 Rectal bleeding
 Family history of bowel or ovarian cancer
If any of these are present patients should be referred to secondary care for further investigations.
More serious causes of the patient’s symptoms must be ruled out before arriving at a diagnosis of IBS.
 Check for anaemia
o Rule out malignancy, diverticular disease, peptic ulcer
 ESR/CRP
o Rule out IBD
 Endomysial antibodies/Tissue tranglutaminase
o Rule out coeliac disease

Question 5

Treatment

Answer 5

Treatment of IBS very much depends upon the predominant symptoms. The first line of treatment is dietary advice:
 Have regular meals, and take time to eat
 Avoid missing meals
 Drink 8 cups of fluid/day
 Reduce tea/coffee intake to 3 per day
 Reduce alcohol/fizzy drinks
 Limit fresh fruit to 3 portions/day
 Reduce the amount of fibre in diet
 People with wind and bloating may find it useful to eat oats e.g. porridge.
Patients should be offered antispasmodic agents which should be taken alongside dietary and
lifestyle advice

Question 6

Constipation specific recommendations

Answer 6

Dietary advice that pertains to constipation should be given. Laxatives can be recommended, but these should be bulk forming that contain soluble fibre (e.g. isphagula husk). Lactulose should be avoided due to the sugar based content as this tends to cause bloating more
frequently.
Other treatments
 Domperidone (motilium 10®)
o Useful for bloating or nausea symptoms
 Tricyclic antidepressants
o Recommended 2nd line by NICE
o Used for their analgesic effect
o Low dose (5-10mg amitryptiline per day)
 Cf 50-150mg for depression
o Could use SSRIs if TCAs are shown to be effective
o Be careful of side effects and contra-indications

Question 7

Psychological interventions

Answer 7

Patients who have not responded to pharmacological treatments after 12 months and have refractory IBS can be considered for referral for
 Cognitive Behavioural Therapy
 Hypnotherapy
 Psychological therapy
 Acupuncture/reflexology should be avoided (no evidence for their benefit!)

Question 8

Haemorrhoids

Answer 8

Within the rectum and anus there are cushions of vascular and connective tissue which provide sensory information. It is enlargement or displacement of this tissue that leads to the problem.
Up to half of the UK population will suffer from haemorrhoids at some point in their life and they can occur at any age from the mid-teens onwards. The prevalence of haemorrhoids increases with age and they are very common in pregnancy.

Question 9

Classification of haemorrhoids

Answer 9

Internal haemorrhoids arise above the pectinate (dentate) line whilst external haemorrhoids arise below the dentate line. Internal haemorrhoids are more likely to cause symptoms and also more likely to prolapse

Question 10

Internal haemorrhoids can be classified into four degrees:

Answer 10

 1st degree - project into lumen but don’t prolapse
 2nd degree - prolapse on straining but return spontaneously
 3rd degree - prolapse and have to be manually returned
 4th degree - prolapse and cannot be returned

Question 11

The symptoms of haemorrhoids include:

Answer 11

 Bleeding
o Fresh blood on toilet paper
 Itching and irritation
 Discomfort following defecation
 Mucus associated with stool
 Faecal incontinence (3rd and 4th degree haemorrhoids only)

Question 12

Treatment of haemorrhoids

Answer 12

Creams are more suitable for external haemorrhoids whilst suppositories are more suitable for internal haemorrhoids. However, some creams are available that have an applicator nozzle for internal use. The patient should be counselled to eat a high fibre diet. 3rd or 4th degree haemorrhoids may require surgery.

Question 13

Anal Fissure

Answer 13

An anal fissure is a small tear or ulcer in the anal canal. They occur most commonly posterior to the midline but can occur anteriorly following childbirth. Anal fissures can be extremely painful with the pain being sharp or burning in nature. There may be a small amount of bleeding.
As mentioned above, anal fissures can be a result of child birth, but they are most commonly caused by the passage of hard stool. Other causes include mucosal ischaemia secondary to muscle spasm and local injury to the anus.

Question 14

Anal Fissure treatment

Answer 14

Bulk-forming laxatives will ease stool passage. Pain relief may be required and paracetamol or local anaesthetics (lidocaine 5% ointment) can be useful. Sitz baths (sitting in warm or cold water up to the hips) may provide some relief. GTN or calcium antagonist ointments are used
to improve mucosal blood flow and so aid healing.

Question 15

Preparations for the treatment of haemorrhoids contain combinations of the following five ingredient types:

Answer 15

 Astringents
o Allantoin, bismuth oxide, zinc oxide
 Emollients
o White soft paraffin
 Mild antiseptics
o Balsam peru, zinc oxide, benzoyl benzoate
 Local anaesthetics
o Cinchocaine, lidocaine, benzocaine
 Corticosteroids
o Hydrocortisone, fluocortolone