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General, Upper GI, Hepatobiliary + Colorectal/Lower GI Surgery > IBS > Flashcards

IBS Flashcards

1
Q

Irritable bowel syndrome is a chronic, … bowel disorder characterised by abdominal pain and altered … …

A

Irritable bowel syndrome is a chronic, functional bowel disorder characterised by abdominal pain and altered bowel habits.

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2
Q

The term ‘…’ refers to a condition that is not associated with structural or biochemical abnormalities that are detectable with current routine diagnostic tests.

A

The term ‘functional’ refers to a condition that is not associated with structural or biochemical abnormalities that are detectable with current routine diagnostic tests.

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3
Q

IBS is very common and accounts for a significant number of referrals to gastroenterologists. It is estimated to affect …-…% of the general population and can have a significant impact on quality of life (QOL).

A

IBS is very common and accounts for a significant number of referrals to gastroenterologists. It is estimated to affect 5-20% of the general population and can have a significant impact on quality of life (QOL).

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4
Q

Define Functional GI disorders

A

These are disorders of the gut-brain interaction that do not have a detectable structural or biochemical abnormality.

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5
Q

Classification of functional disorders -

A

Unfortunately, there is no single test for functional disorders and diagnosis relies on diagnostic criteria. Rome IV criteria:

Oesophagus (e.g. Functional heartburn, functional dysphagia)
Gastroduodenal (e.g. Functional dyspepsia, belching disorders)
Bowel (e.g. IBS, functional constipation, functional diarrhoea)
Hepatobiliary (e.g. Functional biliary sphincter of Oddi disorder)
Anorectal (e.g. Functional defecation disorders)

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6
Q

Rome IV criteria for functional GI disorders:

… (e.g. Functional heartburn, functional dysphagia)
Gastroduodenal (e.g. Functional dyspepsia, belching disorders)
Bowel (e.g. IBS, functional constipation, functional diarrhoea)
… (e.g. Functional biliary sphincter of Oddi disorder)
… (e.g. Functional defecation disorders)

A

Oesophagus (e.g. Functional heartburn, functional dysphagia)
Gastroduodenal (e.g. Functional dyspepsia, belching disorders)
Bowel (e.g. IBS, functional constipation, functional diarrhoea)
Hepatobiliary (e.g. Functional biliary sphincter of Oddi disorder)
Anorectal (e.g. Functional defecation disorders)

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7
Q

Numerous risk factors have been linked to the development of IBS, what are they? (8)

A 
Female sex
Younger age
Stressful life events
Anxiety and/or depression
Gastrointestinal infection (post-infectious IBS)
Somatic symptoms (e.g. joint pain, migraine)
Endometriosis
Family history of mental illness
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8
Q

Risk factors for IBS:

… sex
… age
… life events
… and/or ..
Gastrointestinal infection (post-infectious IBS)
… symptoms (e.g. joint pain, migraine)
E…
… … mental illness
A 
Female sex
Younger age
Stressful life events
Anxiety and/or depression
Gastrointestinal infection (post-infectious IBS)
Somatic symptoms (e.g. joint pain, migraine)
Endometriosis
Family history of mental illness
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9
Q

IBS is linked with numerous other functional gastrointestinal disorders (e.g. functional dyspepsia), functional non-gastrointestinal disorders and psychiatric conditions (e.g. depression, anxiety). Commonly associated functional non-gastrointestinal disorders include: (6)

A 
Chronic pelvic pain syndrome
Overactive bladder
Premenstural syndrome
Sexual dysfunction
Fibromyalgia
Chronic fatigue syndrome
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10
Q

List 6 functional non-gastrointestinal disorders:

A 
Chronic pelvic pain syndrome
Overactive bladder
Premenstural syndrome
Sexual dysfunction
Fibromyalgia
Chronic fatigue syndrome
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11
Q

The exact cause of IBS is unknown, but it is considered a disorder of …-… interaction.

A

The exact cause of IBS is unknown, but it is considered a disorder of gut-brain interaction.

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12
Q

IBS is heterogeneous disoder characterised by a multiple disrupted mechanisms:

…. problems
Visceral …
Altered mucosal and immune function
Gut … alteration
… sensitivity
… factors
A 
Motility problems
Visceral hypersensitivity
Altered mucosal and immune function
Gut microbiome alteration
Food sensitivity
Psychosocial factors
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13
Q

… refers to how fast digested food is transported through the intestines.

A

Motility refers to how fast digested food is transported through the intestines.

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14
Q

The brain, via the autonomic nervous system, can significantly impact intestinal …

A

The brain, via the autonomic nervous system, can significantly impact intestinal motility.

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15
Q

Visceral hypersensitivity - define

A

This describes a heightened response to a perceived stimuli via nociceptors within the bowel. These receptors transmit signals to the brain for processing, but it is unclear whether the hypersensitivity is predominantly mediated by the enteric nervous system (i.e. local GI nerves), through central brain processing, or a combination of both.

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16
Q

Patients with … are more sensitive to distention of the bowel and there is evidence for higher activation of visceral and somatic pain pathways. It is postulated these affects are mediated by mast cells and enteroendocrine cells through release of histamine and serotonin, respectively.

A

Patients with IBS are more sensitive to distention of the bowel and there is evidence for higher activation of visceral and somatic pain pathways. It is postulated these affects are mediated by mast cells and enteroendocrine cells through release of histamine and serotonin, respectively.

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17
Q

Altered mucosal and immune function has been identified in some patients of IBS, particularly those with diarrhoea predominant symptoms. Two key factors are intestinal … and … activation

A

Increased intestinal permeablity: been identified in patients with IBS. Causes low-grade immune cell infiltration, diarrhoea, and increased pain severity.
Immune system activation: increased activation of immune cells (e.g. mast cells), increased lymphocyte infiltration and elevated inflammatory cytokines in a subset of IBS patients. Up to 10% of patients develop IBS following an episode of gastroenteritis.c

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18
Q

Up to 10% of patients develop IBS following an episode of …

A

Up to 10% of patients develop IBS following an episode of gastroenteritis.

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19
Q

What diet is recommended in IBS and IBD?

A

ne area with growing interest is carbohydrate malabsorption. It is suggested that fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) enter the distal small bowl and colon where they are fermented and converted into small chain fatty acids (SCFAs). This leads to increased symptoms, intestinal permeability and possibly inflammation. This theory has lead to the recommendation of low FODMAP diets in both IBS and inflammatory bowel disease (IBD) patients.

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20
Q

It is well recognised that patients with IBS have more lifetime and daily stressful events, increased mental heath illness including anxiety, depression and phobias, and an association with previous abuse. The link between these factors and IBS has been hypothesised to relate to … releasing factor.

A

It is well recognised that patients with IBS have more lifetime and daily stressful events, increased mental heath illness including anxiety, depression and phobias, and an association with previous abuse. The link between these factors and IBS has been hypothesised to relate to corticotropin releasing factor.

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21
Q

Abdominal pain - IBS (SOCRATES)

A

Site: commonly lower abdomen, but variable and may be diffuse
Origin: chronic pain, at least 1 day per week, but often more frequent
Character: typically cramping, acute episodes of sharp pain may occur
Associated factors: pain is frequently related to defecation. May improve or worsen
Exacerbating factors: food and stress may worsen symptoms

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22
Q

Altered bowel habits - IBS

A

Diarrhoea: frequent, loose stools. Up to 50% report mucous discharge. Generally occurs in waking hours. Tenesmus may be present (sensation of incomplete bowel emptying)
Constipation: infrequent, hard stools. Often described as pellets

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23
Q

Other GI features of IBS

A

Bloating/Distention
Belching
Nausea
Others: IBS may overlap with other functional GI disorders

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24
Q

Red flags - IBS

A

These refer to features that warrant investigation for an alternative cause (e.g. colorectal cancer, IBD). Despite their presence, most patients will ultimately have negative tests.

Onset of symptoms > 50 years
Rectal bleeding or melaena
Unexplained weight loss (> 10% in 3 months)
Palpable abdominal mass
Nocturnal diarrhoea
Significant family history (e.g. colorectal cancer, inflammatory bowel disease or coeliac disease)
Anaemia or raised inflammatory markers

25
Q

The … … chart is a way of describing the shape and type of faeces.

A

The Bristol stool chart is a way of describing the shape and type of faeces.

Type 1 - Separate hard lumps, like pellets
Type 2 - Sausage-shaped but lumpy
Type 3 - Like a sausage but cracks on surface
Type 4 - Like a sausage, smooth and soft
Type 5 - Soft blobs, clear-cut edges
Type 6 - Mushy stool. Fluffy pieces with ragged edges
Type 7 - Watery, no solid pieces

26
Q

The diagnosis of IBS is based on the … … criteria.

A

The diagnosis of IBS is based on the Rome IV criteria.

27
Q

IBS should be a positive clinical diagnosis based on symptoms fulfilling the … … criteria. This should be in conjunction with normal results on a limited numbers of investigations needed to rule out alternative diagnoses with reasonable certainty.

A

IBS should be a positive clinical diagnosis based on symptoms fulfilling the Rome IV criteria. This should be in conjunction with normal results on a limited numbers of investigations needed to rule out alternative diagnoses with reasonable certainty.

28
Q

IBS is defined as recurrent abdominal pain that has occurred, on average, at least … day per week over the last … months and symptoms begin at least … months ago. In addition, pain is associated with ≥2 of the following criteria:

Related to ..
Associated with change in stool …
Associated with change in stool …

A

IBS is defined as recurrent abdominal pain that has occurred, on average, at least one day per week over the last three months and symptoms begin at least six months ago. In addition, pain is associated with ≥2 of the following criteria:

29
Q

Differential diagnosis of IBS (9)

A 
IBD
Colorectal cancer
Microscopic colitis
Diverticular disease
Small intestinal bacterial overgrowth
Coeliac disease
Chronic pancreatitis
Neurological disorders (e.g. Parkinson’s)
Medications
30
Q

IBS is classified into different subtypes - what are they?

A 
IBS with predominant constipation (IBS-C): > 25% of bowel motions are usually constipation (Bristol stool type 1/2)
IBS with predominant diarrhoea (IBS-D): > 25% of bowel motions are usually diarrhoea (Bristol stool type 6/7)
IBS with mixed bowel habits (IBS-M): > 25% of bowel motions are constipation (Bristol stool type 1/2) and > 25% of bowel motions are diarrhoea (Bristol stool type 6/7)
IBS unclassified (IBS-U): cannot accurately classify into one of the three subtypes
31
Q

IBS with predominant constipation (IBS-C): > …% of bowel motions are usually constipation (Bristol stool type 1/2)

A

IBS with predominant constipation (IBS-C): > 25% of bowel motions are usually constipation (Bristol stool type 1/2)

32
Q

IBS with predominant diarrhoea (IBS-D): > …% of bowel motions are usually diarrhoea (Bristol stool type 6/7)

A

IBS with predominant diarrhoea (IBS-D): > 25% of bowel motions are usually diarrhoea (Bristol stool type 6/7)

33
Q

IBS with mixed bowel habits (IBS-M): > …% of bowel motions are constipation (Bristol stool type 1/2) and > …% of bowel motions are diarrhoea (Bristol stool type 6/7)

A

IBS with mixed bowel habits (IBS-M): > 25% of bowel motions are constipation (Bristol stool type 1/2) and > 25% of bowel motions are diarrhoea (Bristol stool type 6/7)

34
Q

IBS unclassified (IBS-U): cannot accurately classify into one of the … subtypes

A

IBS unclassified (IBS-U): cannot accurately classify into one of the three subtypes

35
Q

What is faecal calprotectin?

A

This is a sensitive biomarkers of intestinal inflammation.

36
Q

Faecal calprotectin (FCP) is a sensitive and specific biomarker for intestinal inflammation. It can be used to aid differentiation between …. and …

A

Faecal calprotectin (FCP) is a sensitive and specific biomarker for intestinal inflammation. It can be used to aid differentiation between IBS and IBD.

Due to its high negative predictive value (i.e. a negative test means it is highly likely you don’t have the disease), it can be used as a screening tool in primary care among young patients with chronic diarrhoea to differentiate between IBS and IBD. Assays are variable but generally a value < 100 mcg/g is considered negative and local guidelines should be followed.

37
Q

Faecal calprotectin is useful to differentiate between IBS and IBD - why?

A

Due to its high negative predictive value (i.e. a negative test means it is highly likely you don’t have the disease), it can be used as a screening tool in primary care among young patients with chronic diarrhoea to differentiate between IBS and IBD. Assays are variable but generally a value < 100 mcg/g is considered negative and local guidelines should be followed.

38
Q

FCP …-… mcg/g: grey area (consider gastroenterology opinion)

A

FCP 100-250 mcg/g: grey area (consider gastroenterology opinion)

39
Q

FCP < … mcg/g: negative

A

FCP < 100 mcg/g: negative

40
Q

FCP > … mcg/g: positive (warrants endoscopic assessment)

A

FCP > 250 mcg/g: positive (warrants endoscopic assessment)

41
Q

Basic investigations for IBS in the absence of reg flags include: (4)

A

Basic investigations in the absence of reg flags include:

Full blood count
C-reactive protein
Faecal calprotectin
Coeliac testing

42
Q

There are three key aspects to management of IBS:

A

There are three key aspects to management:

Nutrition
Drug therapy
Psychological therapies

43
Q

Dietary modifications for IBS can include:

A

Exclusion of gas-producing foods: these are food that increase flatulence and bloating (e.g. beans, onion, carrots, bananas, caffeine, alcohol, wheat germ)
Lactose avoidance: some patients with IBS may have co-existent lactose intolerance leading to worsening of symptoms
Low FODMAP diet: these dietary modifications have been confirmed in randomised trials. This includes reducing various quantities of oligosaccharides (e.g. wheat, rye, various fruits), disaccharides (e.g. milk, yoghurt), monosaccharides (e.g. fructose containing food), and polyols (e.g. low calorie sweeteners). Advice of a dietitian should be followed
Gluten avoidance: Non-coeliac gluten sensitivity has been suggested to influence symptoms. Although this may be related to the fructan (carbohydrate) contained within gluten products

44
Q

Medications are generally reserved for patients with moderate to severe IBS symptoms that impair …

A

Medications are generally reserved for patients with moderate to severe IBS symptoms that impair QOL.

45
Q

The use of … are the principle treatment in IBS-C.

A

The use of laxatives are the principle treatment in IBS-C.

46
Q

IBS-C treatment - first line

A

First line: bulk-forming laxative (e.g. ispaghula husk)

47
Q

IBS-C treatment - second line

A

Second line: osmotic laxatives (e.g. movicol). Lactulose is not recommended in IBS-C (leads to bloating)

48
Q

IBS-C treatment - third line

A

consider newer laxative classes such as Chloride channel activators (e.g. Lubiprostone), Guanylate cyclase agonists (e.g. Linaclotide) or 5-hydroxytryptamine 4 receptor agonists (e.g. Prucalopride).

49
Q

IBS-D treatment - first line

A

First line: loperamide is the principle anti-diarrhoeal agent, which is an opioid receptor agonist that slows bowel transit. The initial dose is 2 mg 45 minutes before a meal. Its use should be limited in IBD-M.

50
Q

IBS-D treatment - second line

A

Second line: bile acid sequestrants (e.g. cholestyramine, colesevelam) may be used due to the high prevalence of bile acid malabsorption. Where possible, the diagnosis of bile acid malabsorption should be confirmed with SeHCAT testing before embarking on therapy.

51
Q

IBC-D other options (after first and second line)

A

Other options: serotonin antagonists (e.g. ondansetron) may be prescribed. Ondansetron is a commonly prescribed anti-emetic of which constipation is a common side-effect

52
Q

Anti-… and anti-… can be used to treat abdominal pain in IBS.

A

Anti-spasmodics and anti-depressants can be used to treat abdominal pain in IBS.

53
Q

Anti-spasmodics: … (Hyoscine butylbromide) and … are commonly prescribed on an ‘as-needed’ basis. These provide short-term relief of pain by relaxing smooth muscle. … is an antimuscarinic whereas … works directly on gastrointestinal smooth muscle.

A

Anti-spasmodics: Buscopan (Hyoscine butylbromide) and mebeverine are commonly prescribed on an ‘as-needed’ basis. These provide short-term relief of pain by relaxing smooth muscle. Buscopan is an antimuscarinic whereas mebeverine works directly on gastrointestinal smooth muscle.

54
Q

Anti-depressants: low dose… … are commonly prescribed as neuromodulators in many functional gastrointestinal disorders like IBS. They have analgesic properties independent of their effect on mood and have additional benefit in IBD-D by … transit time. … … … … may be used if depression is a cofactor.

A

Anti-depressants: low dose tricyclic antidepressants are commonly prescribed as neuromodulators in many functional gastrointestinal disorders like IBS. They have analgesic properties independent of their effect on mood and have additional benefit in IBD-D by slowing transit time. Selective serotonin reuptake inhibitors may be used if depression is a cofactor.

55
Q

Abdominal pain - IBS - other options

A

Other options: a trial of antibiotics may be offered to patients with IBS without constipation who have ongoing pain/bloating despite dietary modifications, anti-spasmodics and antidepressants. Rifaximin is often used.

56
Q

Psychological therapies may be used as the primary treatment or as an … in IBS.

A

Psychological therapies may be used as the primary treatment or as an adjunct in IBS.

57
Q

There are several psychological therapies with an evidence-base that can be used in IBS - these are…

A

Cognitive–behavioural therapy (CBT): this has the best evidence in the treatment of IBS. CBT is based on the assumption that IBS symptoms are a response to stressful life events and maladaptive behaviour. CBT attempts to modify this.
Psychodynamic (interpersonal) therapy: this looks at symptoms as a consequence of difficult relationships or conflicts.
Gut-directed hypnosis: this type of therapy addresses the miscommunication between gut and brain.
Mindfulness-based therapy: this is a type of meditation that focuses on strategies for coping with IBS symptoms.

58
Q

IBS is a … gastrointestinal disorder in which symptoms may … over many years.

A

IBS is a chronic gastrointestinal disorder in which symptoms may fluctuate over many years.

59
Q

In patients with …-… IBS that represents a unique cohort of patients, symptoms resolve in up to 50% within 6-8 years.

A

In patients with post-infectious IBS that represents a unique cohort of patients, symptoms resolve in up to 50% within 6-8 years.

General, Upper GI, Hepatobiliary + Colorectal/Lower GI Surgery (39 decks)

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