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GI AND SURGERY > IBS > Flashcards

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
Q

What are common dietary triggers of IBS?

A

Alcohol
Caffeine
Spicy foods
Fatty foods
Milk
Foods high in fructose
Carbonated beverages
Gluten

26
Q

What examination should you do for IBS?

A

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
Q

What investigations should you do for IBS?

A

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
Q

What diet is suggested for IBS and IBD and why?

A

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
Q

What type of pain is associated with IBS?

A

Cramping
But acute episodes of sharp pain can occur

30
Q

What are red flags to look out for when considering IBS?

A

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
Q

What stool chart is used? Explain it

A

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
Q

What are differential diagnoses of IBS?

A

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

33
Q

Why is faecal calprotectin so important when diagnosing IBS?

A

Because its a diagnosis of exclusion and FCP can differentiate between IBS and IBD

34
Q

What can be used for managing predominant symptoms of diarrhoea and or bloating?

A

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
Q

What can be used for managing predominant symptoms of constipation?

A

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
Q

What are examples of soluble fibre supplements?

A

Isphalga husk

37
Q

What is isphalga husk?

A

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
Q

When should you follow up a pt with a new diagnosis of IBS

A

Within 2 months

39
Q

How should you manage a pt with new IBS when first line diary advice is ineffective?

A

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
Q

How should you manage a pt with new IBS when constipation is persisting after first line dietary advice?

A

consider a bulk-forming laxative

41
Q

How should you manage a pt with new IBS when diarrhoea is persisting after first line dietary advice?

A

consider an anti motility drug e.g. loperamide hydrochloride is first line

42
Q

How should you manage a pt with new IBS when abdominal pain is persisting after first line dietary advice?

A

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
Q

What dietary advice is given for IBS?

A

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
Q

What laxative is not advised in IBS/

A

Lactulose - can cause bloating

45
Q

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?

A

Linaclotide

46
Q

If there are persistent or refractory symptoms following all trials of drug treatments possible for IBS, what should you do?

A

Consider an alternative diagnosis and ever to a gastroenterologist
You could also refer to mental health services for psychological support/intervention

47
Q

What is functional diarrhoea?

A

When symptoms occur in the absence of abdominal pain

48
Q

What are the common features of functional diarrhoea?

A

• 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
Q

What is treatment for functional diarrhoea?

A

Loperamide, often combined with a TCA at night

50
Q

What is purgative abuse?

A

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
Q

How can ovarian cancer present in elderly women?

A

Bloating, pain in pelvis, no appetite, early satiety, urgent need to pee, constipation and diarrhoea, fatigue, weight loss, PV bleeding after menopause, indigestion

52
Q

Can your menstrual cycle affect your IBS?

A

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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