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IBS Flashcards

1
Q

Whats the pathophysiology of IBS?

A

No structural aetiology so its known as a functional bowel disease

Possible mechanisms include: visceral hypersensitivity, abnormal GI immune function, changes in gut microbiome, abnormal autonomic activity, abnormal central pain processing of afferent gut signals, abnormal gastrointestinal motility

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2
Q

Whats the incidence of IBS?

A

10-20% of all adolescents and adults in the west

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3
Q

Which gender does IBS affect more?

A

Women

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4
Q

What are the symptoms of IBS?

A

Abdominal discomfort or pain - often improves with defecation
Changes in bowel habit
Bloating
Disordered defecation
Abdominal tenderness on examination
Mucoid stools
Urgency to defecate
Straining
Tenesmus
Referred pain to LLQ

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5
Q

How is IBS diagnosed in primary care?

A

exclusion of structural or metabolic abnormalities

if abdominal pain/discomfort has been present for at least 6 months and:
Is either…relieved by defecation or associated with altered bowel frequency/stool form
and is accompanied by at least two of the following symptoms:
1. Altered stool passage (straining, urgency, incomplete evacuation).
2. Abdominal bloating, distension, tension or hardness.
3. Made worse by eating.
4. Passage of mucus.

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6
Q

What are the subtypes of IBS?

A

IBS with constipation (IBS-C)
IBS with diarrhoea (IBS-D)
Mixed IBS (IBS-M)
Unsubtyped IBS

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7
Q

What causes the abdominal pain in IBS?

A

Visceral hypersensitivity -> sensory nerve endings a have an abnormally strong response to stimuli e.g. stretching after a meal

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8
Q

What causes the abdominal bowel motility in IBS?

A

Eating foods that have short-chain carbohydrates e.g. lactose and fructose -> aren’t absorbed and act as solutes that draw water across into the lumen -> smooth muscles lining intestines to spasm -> diarrhoea
The unabsorbed short chain carbohydrates are metabolised by GI bacterial flora which produces gas -> causing more bloating, spasm and pain

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9
Q

What are the risk factors for IBS?

A

Infectious diarrhoea - precedes onset of IBS symptoms in 7-30% of cases
Genetics - person with a first degree relative with IBS had an odds ratio of 2.75 of developing it. (Maybe to do with shared childhood experiences/environmental exposures)
GI inflammation
Dietary factors
Stress
Female sex
Pre-existing adverse life events
High hypochondriacal anxiety
Neurotic scores
Drugs e.g. antibiotics

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10
Q

What disorders does IBS coexist with?

A

Chronic fatigue syndrome
Fibromyalgia
Chronic pelvic pain syndrome
Premenstrual syndrome
Sexual dysfunction
Temperomandubular joint dysfunction

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11
Q

What factors can trigger the onset of IBS?

A

Affective disorder
Psychological stress and trauma
GI infection
Antibiotic therapy
Abuse - sexual physical or verbal
Pelvic surgery
EDs

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12
Q

What is IBS-C?

A

IBS with constipation
Hardy lympy stools >25% and loss or watery stools <25%

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13
Q

What is IBS-D?

A

Loose or watery stools >25% and hard/lumpy stools <25% of bowel movements

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14
Q

What is IBS-M?

A

Mixed IBS
Hard or lumpy stools >25% and loose or water stools >25% of bowel movements

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15
Q

What is unsubtyped IBS?

A

When there is insufficient abnormality of stool consistency to meet criteria for IBS-C,D,M

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16
Q

Whats the most common subtype of IBS?

A

Diarrhoea predominant

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17
Q

Whats the criteria used to subtype IBS?

A

Rome IV criteria

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18
Q

What proportion of those with IBS report that food triggers their symptoms?

A

Up to 90%

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19
Q

What age does IBS most commonly affect?

A

Crohns 15-25
UC 15-25 and 55-65

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20
Q

Whats the prognosis of IBS?

A

Symptoms may fluctuate over years
Up to 20% will have worsening IBS sympotms
Up to 50% will have symptoms which remain unchanged
Up to 40% will have improvement of symptoms

Symptoms resolve spontaneously in about 50% of affected people within 6–8 years

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21
Q

What factors are associated with a poorer prognosis?

A

Longer duration of sympotms
Previous history of surgery
Higher somatic scores
Co-morbid anxiety and depression

22
Q

When should you suspect IBS?

A

In the absence of alarming symptoms/signs
If abdominal pain, bloating, change in bowel habit has been present for at least 6 months

23
Q

What are the extra-intestinal features of IBS?

A

Lethargy
Nausea
Back pain
Headache
Gynaecological symptoms
Bladder symptoms

24
Q

How is IBS diagnosed in secondary care?

A

Using the more restrictive ROME IV criteria

Recurrent abdominal pain, on average, at least 1 day per week in the last 3 months (with symptom onset at least 6 months prior to diagnosis) which is associated with two or more or the following:
1. Related to defaecation;
2. Change in frequency of stool;
3. Change in stool form.

25
What are common dietary triggers of IBS?
Alcohol Caffeine Spicy foods Fatty foods Milk Foods high in fructose Carbonated beverages Gluten
26
What examination should you do for IBS?
Check weight and calculate BMI to assess for weight loss Palpate abdomen for signs of tenderness or masses Perform a rectal examination to exclude perianal or rectal pathologu
27
What investigations should you do for IBS?
FBC - look for anaemia and raised Plt ESR and CRP - check for active inflammation or infection Coeliac serology Faecal cal protection - exclude IBD (esp in those <45)
28
What diet is suggested for IBS and IBD and why?
Low FODMAP diet As its suggested that fermentable oligo-, di- and monosaccharides and polyols enter the bowel are fermentated and converted into small chain fatty acids which leads to increased symptoms
29
What type of pain is associated with IBS?
Cramping But acute episodes of sharp pain can occur
30
What are red flags to look out for when considering IBS?
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
31
What stool chart is used? Explain it
Bristol stool chart 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
32
What are differential diagnoses of IBS?
IBD Colorectal cancer Microscopic colitis Diverticular disease Small intestinal bacterial overgrowth Coeliac disease Chronic pancreatitis Neurological disorders (e.g. Parkinson’s) Medications
33
Why is faecal calprotectin so important when diagnosing IBS?
Because its a diagnosis of exclusion and FCP can differentiate between IBS and IBD
34
What can be used for managing predominant symptoms of diarrhoea and or bloating?
Reduce intake of insoluble fibre - whole meal, high fibre flour and breads, cereals high in bran, whole grains e.g. brown rice Consider reducing foods that may exacerbate symptoms e.g. caffeine, alcohol, carbonated drinks and gas-producing foods
35
What can be used for managing predominant symptoms of constipation?
Gradually increase fibre intake to minimize flatulance and bloating - may be several weeks before beneficial effects are seen - Soluble fibre supplements - Foods high in soluble fibre - oats and linseed
36
What are examples of soluble fibre supplements?
Isphalga husk
37
What is isphalga husk?
A bulk forming laxative It consists of 85% water-soluble fibre It forms a bulky hydrated mass in the gut lumen with promotes peristalsis and improves faecal consistency
38
When should you follow up a pt with a new diagnosis of IBS
Within 2 months
39
How should you manage a pt with new IBS when first line diary advice is ineffective?
Low FODMAP diet If the symptoms of constipation are persisting then consider a bulk-forming laxative If symptoms of diarrhoea persist - consider an anti motility drug e.g. loperamide If there are ongoing symptoms
40
How should you manage a pt with new IBS when constipation is persisting after first line dietary advice?
consider a bulk-forming laxative
41
How should you manage a pt with new IBS when diarrhoea is persisting after first line dietary advice?
consider an anti motility drug e.g. loperamide hydrochloride is first line
42
How should you manage a pt with new IBS when abdominal pain is persisting after first line dietary advice?
Antispasmodic drug - mebeverine hydrochloride, alverine citrate, peppermint oil If not effective consider a trial of low-dose TCA e.g. amitriptyline (or SSRI if not possible)
43
What dietary advice is given for IBS?
Fresh fruit consumption no more than 3 times a day Increase dietary fibre using isphahula husk or foods high in soluble fibre like oats insoluble fibre and resistant starch should be avoided Fluid intake - water at least 8 cups a day. Reduce intake of caffeine, alcohol and fizzy drinks Avoid sorbitol (artificial sweetener) in those with diarrhoea Probiotics
44
What laxative is not advised in IBS/
Lactulose - can cause bloating
45
In pt who have not responded to laxatives from the different classes and who have had constipation for at least 12 months… what can you treat them with?
Linaclotide
46
If there are persistent or refractory symptoms following all trials of drug treatments possible for IBS, what should you do?
Consider an alternative diagnosis and ever to a gastroenterologist You could also refer to mental health services for psychological support/intervention
47
What is functional diarrhoea?
When symptoms occur in the absence of abdominal pain
48
What are the common features of functional diarrhoea?
• the passage of several stools in rapid succession, usually first thing in the morning; no further bowel action may occur that day, or defecation takes place only after meals • a first stool of the day that is usually formed, the later ones being mushy, looser or watery • urgency of defecation • anxiety, and uncertainty about bowel function with restriction of movement (e.g. travelling) • exhaustion after defecation.
49
What is treatment for functional diarrhoea?
Loperamide, often combined with a TCA at night
50
What is purgative abuse?
This is most commonly seen in females who surreptitiously take high-dose purgatives and are often extensively investigated for chronic diarrhoea. The diarrhoea is usually of high volume (>1 L daily) and patients may have a low serum potassium. Often need psychiatric help as often associated with EDs
51
How can ovarian cancer present in elderly women?
Bloating, pain in pelvis, no appetite, early satiety, urgent need to pee, constipation and diarrhoea, fatigue, weight loss, PV bleeding after menopause, indigestion
52
Can your menstrual cycle affect your IBS?
Menses is also associated with a significant worsening of IBS symptomatology - bloating, diarrhoea and abdo pain can all worsen

GI AND SURGERY (31 decks)

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