IBD / IBS

Question 1

what is irritable bowel syndrome?

Answer 1

functional bowel disorder - no identifiable disease underlying symptoms

just abnormal functioning

Question 2

what are the symptoms of IBS

Answer 2

Diarrhoea (may have urgency or incontinence)
Constipation
Fluctuating bowel habit
Abdominal pain 
Bloating 

Worse after eating (exaggerated gastro-colonic reflex)

Improved by opening bowels

Other effects:

Sexual function is interfered with
Nausea
Thigh and back pain
Lethargy 
Urinary and gynae symptoms (pain on intercourse)

Criteria for Diagnosis (NICE guidelines)

Question 3

what is the exclusion criteria for diagnosis

Answer 3

exclude other pathology with normal FBC, CRP, ESR, stool culture, FAECAL CALPROTECTIN EXCLUDED

Question 4

what other diagnostic criteria is needed for IBS?

Answer 4

o Abdominal pain/discomfort:
Relieved on opening bowels
Or associated with a change in bowel habitat

AND 2 of:

Abnormal stool passage
Bloating
Worse symptoms after eating
PR mucus

Question 5

what is the management of IBS?

Answer 5

reassurance, stress management, altered diet

loperamide for diarrhoea, laxatives for constipation

linaclotide: specialist laxative

anti-spasmodics like buscopine for cramps

Question 6

what sort of diet should people with IBS be eating?

Answer 6

small meals and regular, reduced processed foods, reduced fatty and rich, limit fruit intake to 3 portions, limit coffee and alcohol

probiotic supplement

Question 7

what are the red flags when someone presents with abdominal/bowel symptoms

Answer 7

age >60
rectal bleeding
anaemia
weight loss
FH of colorectal cancer
mass in abdomen or rectum 
raised CRP

Question 8

what is the red flag in a woman >50

Answer 8

persistent bloating = an USS of ovaries and Ca125 for ovarian cancer

Question 9

what is faecal calprotectin

Answer 9

activated by phagocytes such as monocytes and granulocytes and reflects local ongoing inflammation rather than systemic inflammatory response (like CRP)

Question 10

what is carnett’s sign

Answer 10

abdo pain, determine whether pain originates from myofasical or abdo wall

= patient should lie down and raise head or leg against gentre resistance from the doctor
• Test is positive if this exacerbates the pain, indicating an abdominal wall, as opposed to visceral, pain origin

Question 11

what is IBD

Answer 11

ulcerative and crohn’s disease

involve inflammation of walls of GI tract and associated with periods of remission and exacerbation

Question 12

crohn’s NEST?

Answer 12

o N – no blood or mucus (less common)
o E – entire GI tract
o S – “skip lesions” on endoscopy
o T – terminal ileum most affected and Transmural (full thickness) inflammation
o S – smoking is a risk factor
• Crohn’s disease is also associated with weight loss, strictures and fistulas
• 40% of crohn’s cases involve ileo-caecal area

Question 13

CLOSE-UP for ulcerative colitis?

Answer 13

o	C – continuous inflammation
o	L – limited to colon and rectum
o	O – only superficial mucosa affected 
o	S – smoking is protective 
o	E – excrete blood and mucus 
o	U – use aminosalicylates
o	P – primary sclerosing cholangitis 
•	Main areas: rectal = termed proctitis
•	However, inflammation can spread from sigmoid area upwards and can even reach transverse colitis = extensive
•	Spreads distal to proximal colon

Question 14

what are the signs and symptoms of crohn’s and UC?

Answer 14

• Diarrhoea
• Abdominal
• Passing blood
• Weight loss
• Fever
• Vomiting
• Cramps
• Muscle spasms

Question 15

what are the complications of UC?

Answer 15

severe bleeding, toxic megacolon, rupture of bowel, colon cancer

Question 16

complications of CD

Answer 16

stenosis, abscess formation, fistulas, perforation, colon cancer

Question 17

what investigations would you do for IBD?

Answer 17

bloods for anaemia, infection, thyroid etc

CRP
FCP
endoscopy: diagnostic 
imaging for complications
histoloogy 
small bowel enema

Question 18

how do you manage crohn’s disease?

Answer 18

inducing remission: steroid eg prednisolone or steroids + immunosuppressant eg axathioprine, mercaptopurine

maintaining: azathioprine or mercaptopurine

Question 19

what is the surgery for crohn’s?

Answer 19

o When disease only affects distal ileum; can surgically resect this area
o Prevents further flares of disease, but crohn’s typically involves the entire GI tract

Question 20

what is the specific investigations for UC?

Answer 20

enema = loss of haustrations

Question 21

how do you stage UC?

Answer 21

o Mild < 4 stools/ day, only a small amount of blood
o Moderate: 4-6 stools / day, varying amounts of blood, no systemic upset
o Severe: >6 bloody stools per day and features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)

Question 22

how do you manage UC?

Answer 22

• Inducing remission:

Mild to moderate disease (and for proctitis)
 First line: aminosalicylate (mesazaline oral or rectal)
 Second line: corticosteroids (prednisolone)

o Severe disease:
 First line: IV corticosteroids (eg hydrocortisone)
 Second line: IV ciclosporin
• Maintaining remission:

o	Aminosalicylate (eg mesalazine oral or rectal) alone, or with a topical AS daily or intermittent 
o	Azathioprine and Mercaptopurine can be used following a severe relapse or for >2 exacerbations in the past year

Question 23

what is the surgery for UC?

Answer 23

since typically affects colon and rectum, removal of this = ileostomy or ileo-anal anastomosis permanently

Question 24

what is c difficile?

Answer 24

Infection of the colon caused by c diff bacteria, characterised by inflammation of the colon

Question 25

what causes c diff?

Answer 25

recent use of antibiotics

Question 26

how do patients with c diff present?

Answer 26

diarrhoea, abdo pain and leucocytosis, other common symptoms include fever, abdo tenderness and distension

Question 27

what investigations do you do for c diff?

Answer 27

fbc, faecal occult, stool pCR, stool immunoassay for glutamate dehydrogenase

Question 28

how do you treat c diff?

Answer 28

oral vancomycin