IBD vs IBS Flashcards
Disorders of gut brain interaction
Examples of how it can affect any part of the GI tract
Globus sensation - feel like lump in throat
Functional heartburn - feeling reflux
Rumination - regurgiation of food
Functional dyspepsia - discomfort/bloating in epigastrium
Post-prandial distress
- Worse with meals
Epigastric pain syndrome
- Distinct from meals
Functional vomiting / Cyclical Vomiting Syndrome
IBS
- Associated with altered bowel habit +/-defecation
Functional abdominal pain
Why does multiple areas of GI affected?
-delayed emptying
-impaired accomodation (stomach cant strecth as much)
- Altered motility of stomach
- Visceral hypersensitivity (normal stimuili cause discomfort)
-Changes in the epithelial barrier of the gut
- Mucosal immune dysfunction
- Microbiome disturbance (Abx / GI illness)
- Psychosocial factors
- Stress
-Gut central nervous system neural processing
Microbiome in IBS vs NON-IBS pateitns
Microbiome of IBS patients has an increased abundance of family Enterobacteriaceae
Criteria for IBS:
Recurrent abdominal pain, on average, at least 1 day per week in the last 3 months, associated with 2 or more of the following criteria:
Related to defecation : How does the pain change when you pass a stool?
Associated with a change in frequency of stool : When you have the pain, is there a change in frequency of stool?
Associated with a change in form (appearance) of stool: When you have the pain, does the stool look different?
***Criteria fulfilled for the last 3 months with symptom onset at least 6 months before
Supportive symptoms of IBS that relate to the GI
- Defecation straining, urgency or a feeling of incomplete evacuation
2.Passing mucus - Gas, bloating
- Associated with meals
- Rich in carbohydrates, fat, coffee, alcohol, spicy food
Other symptoms of IBS that arent related to GI
-Headache
- Back pain
-Fatigue
-Myalgia (muscle aches/pains)
-Dyspareunia (painful intercourse)
-Urinary frequency
-Other urinary symptoms
-Dizziness
Alarm features (ie make you think of an alternative DDX)
- Older patient (>40/50 years old) (more likely to have cancer
- Short history (usually go on for a long time)
- Nocturnal symptoms (if functional unusual to be woken at night, less likely to be IBS)
- Rectal bleeding (can be IBS if a fissure from constipation or could be something else)
- Anaemia or iron deficiency
6.Weight loss
7.Vomiting
8.Family history of colon cancer
Typical other diagnosis other than IBS but present very simialry
Hormones (Thyroid)
* Coeliac
*Pregnant?
* Pancreatitis
- Infection
* IBD
- Food intolerance
* SIBO
* Malignancy
* Medication side effect (NSAIDS, PPI, THC,
Fe)
* Endometriosis
IBS Tests
- History
- Alarm features - Physical examination
- Blood tests (often normal)
- Coeliac testing - Stool tests (rule out infective or inflamm cause)
- Possibly endoscopy
- Gastroscopy / Colonoscopy
Management of IBS
- Reassurance
-Be confident
-Explain:
“No evidence of inflammation, cancer – still a lot we can do.
- Sensitive gut, heightened awareness of natural stimuli – stool and gas try to explain mechanisms - Management of expectation:
- What do you expect from treatment.
“What is your biggest concern?”
- If in several weeks you are feeling maybe 25% better, would you be satisfied with this plan?
- Unlikely completely symptom free manage expectations
Lifestyle changes to aid IBS
and Systematic approach for IBS
- Stress
-Sleep - Cognitive behavioral therapy
-Removal of dietary triggers - Hydration
- Exercise – 20 minutes physical activity
- FODMAP diet
- To address Constapation? Diarrhoea? Mixed?
-Fibre: eg Metamucil (May cause bloating)
-Laxatives for constapation (Green kiwifruit / prunes or Osmotic laxatives (Molaxole)
FODMAP diet ( Fermentable Oligo-, Di-, Monosaccharides And Polyols)
reduce certain foods that cause a lot of fermentation when you eat them fermentation creates gas which expands inside the gut and causes stimuli on inside lining of the bowel to cause symptoms in IBS patients
- Fermentable Oligo-, Di-, Monosaccharides And Polyols (carbohydrates)
- Oligosaccharides
-Fructans and galactans – Garlic / Onion - Disaccharides
- Lactose - Milk - Monosaccharides
- Fructose - Honey - Polyols
- Sorbitol, mannitol – Sugar-free gum
Cause for IBD
Mulitfactoral:
1. Environmental factors in genetically susceptible individuals”
2. 200 genes (NOD2
3. First degree relatives: 3-20x more likely to have IBD
Environmental factors causing IBD
Western diet!
- Changes in gut microbiota
- Antibiotics in childhood (causation or correlation?)
-Travel - Pollution / allergen exposure
- SMOKING: Crohn’s (makes alot worse) vs UC (makes it better)
3.Hygiene hypothesis
- Early childhood exposure to allergens establishes immune tolerance.
- Avoidance may result in inadequate immune development.
Clinical features (symptoms) of IBD)
- Diarrhoea
-Frequency
-Urgency
- Plan all the trips, know where the toilets are, stay in the house, don’t go out to eat - Blood in stool
- Abdominal pain
- Tenesmus “incomplete emptying”
Symptoms outside of GI for IBD
Tired, brain fog, weight loss
Eyes: Episcleritis V painful red eyes
Skin: erythema nodosum / mouth ulcers
Joints: Sacro-ileitis (Back pain)/ enthesits (Inflammation of tendons)
IBD: Process of diagnosis and other possible DDx
- History
-Weight loss (clothes any looser?) - Examination
- Rectal examination
Other DDx
- Infection
-Diverticulitis
-Ischemia
-IBS
-Cancer
-Coeliac
What is Ulcerative Colitis
-How widespread in GI
-Location/progression
- visual appearance of GI
- Limited to colon
- Continious
Begins in rectum and
spreads proximally
-Mucosal inflammation
(Diffuse and granular)
-Generally presents with bloody diarrhoea
What is Crohns
Any part of GI tract, commonly ileum and colon
Discontinuous “skip lesions”
Transmural inflammation
- Starts as small ulcers on
mucosa: aphthous ulcers
-Progress to deep penetrating ulcers with fissuring
- Mucosa swollen cobblestone appearance
Clinical signs of IBD (Crohns)
(appearance of GI tract on exam)
- Inflammatory
- Stricturing
- Fistulising
- Perianal (eg abcesses in anus)
IBD Crohns: What is Fistula and examples of some
enterocutaneous fistula
enteroenteric fistula
enterocolic fistula
rectovaginal fistula
Fistula is an abnormal connection/tract between the gut and another organ/vessel
- enterocutaneous fistula = small intestine and skin
-enteroenteric fistula
= small intestine and small
intestine
- enterocolic fistula
=small intestine and colon
-rectovaginal fistula
= rectum and vagina
IBD Crohns: Whats a perianal abscess, fistula, fissure
anal fistula is an abnormal tunnel that develops near the anus, connecting the inside of the rectum to the skin outside
anal fissure is a small tear in the lining of the anus, typically painful during bowel movements
anal abscess is a pus-filled pocket near the anus, which can develop from an infected anal gland and sometimes lead to the formation of a fistula
IBD Crohns: What is stricturing
can can it result in and long term consquences
Recurrent inflammation
Can result in
Abdominal pain and distension
Vomiting
Bowels not opening
Initially inflammatory i.e. due to oedema, over time becomes fibrotic i.e. due to scarring
Pathology Crohns vs UC
Crohns
Fat wrapping: Frequent
Granulomas: Occassionally
Lymphoid aggregates: Frequent
Crypt abscesses: Uncommon
Patchiness:Freuqent
UC
Fat wrapping: Rare
Granulomas :Rare
Lymphoid aggregates :Rare
Crypt abscesses : Frequently
Patchiness :Uncommon
Symptoms Crohns vs Ulcerative
Crohns
Diarrhoea with urgency - Frequently
Rectal Bleeding: Occassionally
Mucous defecation: Ocassionaly
Abdominal pain: Frequently
Abdominal mass: Sometimes in lower quadrant
Fever: Frequently
Fatigue: Frequently
Perianal disease: Yes
UC
Diarrhoea with urgency: Frequently
Rectal Bleeding: Frequently
Mucous defecation: Frequently
Abdominal pain: Occasionally
Abdominal mass: Rare
Fever: Uncommon
Fatigue: Frequently
Perianal disease: No
Tests for IBD crohn and UC
- Blood tests
-FBC
-CRP
-Electrolytes (diarrhoea)
-Thyroid function
-Coeliac - Stool culture for infection
- Faecal calprotectin (looking for inflam cells in stool - Colonoscopy (Gold std)
Treatment IBD
- 5-aminosalicylates (5-ASA)
- Mild anti-inflammatory action - Steroids
- Immunosuppression
-Azathioprine, 6-mercaptopurine - Biologics thorugh vein
- Infliximab, adalimumab
- Vedolizumab / ustekinumab
When do you need surgery?
Failure of medical treatment
- Resect diseased bowel e.g. colectomy, ileal resection
Treatment of complications
- Bowel obstruction
- Perforation
- Fistula
- Abscess
In UC, colectomy is curative. Crohns affects any part so never cured
IBS vs IBD table
IBS
- very common
- unlikely in older adult
- altnerating bowel habit
-no bleeding
- No alarm symptoms (maybe 1)
-Normal blood tests
IBD
- Less Common
- Can be young or old
- Dirrhoea perdominates
- Bleeding can occur
- Alarm symptoms occur
-blood tests abnormal
-perianal disease extraintestinaly symptoms
