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PMY3304 > IBS > Flashcards

IBS Flashcards

1
Q

What is IBS

A

Chronic, relapsing and often debilitating disorder of gut-brain interaction

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2
Q

What are possible Mechanisms

A
  • Visceral hypersensitivity.
  • Abnormal GI immune function.
  • Changes in gut microbiome
  • Abnormal autonomic activity.
  • Abnormal central pain processing of afferent gut signals (altered ‘brain-gut interactions’).
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3
Q

Risk and contributing factors

A
  • Co-morbidities
    - GI infection
    - GI inflammation, e.g. due to infection, IBD
  • Drugs, e.g. antibiotics
  • Diet, e.g. alcohol, caffeine, spicy foods, fatty foods
  • Psychological factors, e.g. stress, anxiety, depression
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4
Q

Diagnosis - no alarm symptoms and present for at least 6 months

A
  • Abdominal pain or discomfort
  • Bloating (more common in women)
  • Change in bowel habit
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5
Q

3 criteria required for diagnosis

A
  1. Abdominal pain or discomfort for at least 6 months
  2. Is either relieved by defecation of associated with altered bowel frequency (increased / decreased), or stool form (hard, lumpy, loose, watery)
  3. Is accompanied by 2 or more of:
    - Altered stool passage (e.g. straining, urgency, incomplete evacuation)
    - Abdominal bloating, distension, tension or hardness
    - Made worse by eating
    - Passage of mucus
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6
Q

Diagnosis - classification

A
  • IBS-C: Constipation-predominant IBS >25% hard stools, <25% loose stools
  • IBS-D: Diarrhoea-predominant IBS (most common) > 25% loose < 25% hard
  • IBS-M: Mixed, fluctuating between diarrhoea and constipation > 25% hard and loose
  • IBS-U: Unclassified; symptoms meet criteria for IBS but don’t fall into one of the 3 subgroups
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7
Q

Bristol stool chart

A

Type 1-2 indicate constipation
Type 3-4 are ideal stools as they are easier to pass
Type 5-7 may indicate diarrhoea and urgency

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8
Q

Clinical assessment - Clinical History

A

Symptoms – onset, duration, type, severity (use Bristol chart)
Impact of symptoms on daily functioning (home, work, social, etc.)
Lifestyle
Diet (including fibre intake), nutrition, and any known food triggers
Physical activity
Alcohol intake
Smoking status
Psychosocial Hx. - Any recent stresses, anxiety, or depression
Medical Hx. – e.g. GI, psychological or previous surgery
Medication Hx. – e.g. those contributing to diarrhea / constipation
Signs of alternative diagnosis, especially alarm signs

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9
Q

Clinical assessment - Physical examination and investigation

A

Weight, BMI (check for unintended weight loss)
Palpate the abdomen for signs of tenderness or masses (abdominal examination)
Rectal examination to exclude perianal or rectal pathology
Full blood count (FBC) to exclude Anaemia or Raised platelet count
C-reactive protein (CRP) and / or Erythrocyte sedimentation rate (ESR)
to exclude Active inflammation, e.g. IBD, infection
Coeliac serology to exclude Coeliac disease
Faecal calprotectin to exclude IBD

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10
Q

Drugs causing diarrhoea

A

Magnesium-containing medicines, e.g. antacids
Antibiotics
PPIs / H2RAs
ACE-Inhibitors, e.g. lisinopril
Metformin
Levothyroxine
NSAIDs
Chemotherapy
Laxatives (inappropriate or prolonged use)
Iron

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11
Q

Drugs causing constipation

A

Opioids, e.g. morphine, codeine
Anticholinergics, e.g. tolterodine, hyoscine
Amitriptyline (TCA)
Verapamil / diltiazem
Beta-blockers, e.g bisoprolol
Aluminium-containing antacids
Iron

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12
Q

Non-GI symptoms

A
  • Psychological
  • Rheumatological
  • uro- gynaecological
  • neurological
  • pulmonary
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13
Q

Lower GI – Alarm features!!

A

Unintentional and unexplained weight loss
Unexplained or uninvestigated rectal bleeding
Positive faecal immunochemical (FIT) test
Rectal or abdominal mass
Aged >60 with any of; change in bowel habit, raised faecal calprotectin, iron deficiency anaemia, abdominal pain
Persistent or frequent bloating in females (especially over 50)

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14
Q

Management Provide Information and support

A

Explaining diagnosis in context of the gut-brain axis and explaining that IBS is a chronic, relapsing condition which can be triggered by stress, intercurrent illness, medications, eating
Reassurance, e.g. not associated with increases risk cancer or mortality
Aim of management is to improve symptoms and quality of life
Signpost to sources of information and support,

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15
Q
  1. Management Diet and lifestyle
A

General dietary advice (personalised to individual):
–Regular meals, healthy balanced diet - take time to eat
–Avoid missing meals, long gaps, eating late at night
–Drink > 8 cups of fluid/day (water and non-caffeinated drinks)
–Restrict tea/coffee to 3 cups/day
–Reduce alcohol and fizzy drinks
–Reduce intake of ‘resistant starch’
–Limit fresh fruit to 3 portions/day (portion = 80g)
–Avoid sorbitol if diarrhoea
–Eating oats may help wind and bloating

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16
Q
  1. Diet and lifestyle
A

Review fibre intake
Alter gradually while monitoring symptoms
Diarrhoea – reduce insoluble fibre
If constipated – increase soluble fibre
If advising an increase in dietary fibre, this should be soluble fibre, such as ispaghula (see bulk-forming laxatives), or foods high in soluble fibre such as oats and fruit (not skin

17
Q
  1. Diet and lifestyle cont.
A

If this initial diet modification fails, the following should be considered:
Probiotics
Patients should not be discouraged from trying specific probiotic products (e.g. Lactobacillus and Bifidobacterium). NICE recommend 12-week trial then stop if no benefit

Consider single food avoidance and exclusion diets - more specialist, expert only per NICE, e.g. dietician-led)
Such as a a low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) diet
Foods with high levels of FODMAPs include:
some fruits (apples, cherries, peaches, nectarines)
artificial sweeteners
most lactose-containing foods (milk, ice-cream, cream cheeses, chocolate and sour cream)
many green vegetables (broccoli, Brussels sprouts, cabbage, peas)

18
Q

Diet and lifestyle cont.

A

Regular exercise
Improves IBS symptom severity, e.g. 30 mins moderate physical activity 5 days per week
Weight management
If overweight / obese
Relaxation
Reduce stress, manage co-existing anxiety, depression, including referral to MH services as needed

19
Q
  1. Pharmacological treatment
A

If symptoms persist despite dietary/ lifestyle advice
Most recommendations are guideline based and consensus opinions
Management should be individualised to the person’s symptoms and psychosocial situation
Choice of medicine(s) is determined by the predominate symptom

20
Q
  1. Pharmacological treatment: Abdominal pain 1st line: antispasmodics
A

Mechanism: relax smooth gut muscle, relieve spasm
Anticholinergics:
e.g. mebeverine 135mg TID is generally well tolerated and can be used on an as required basis (before meals). Hyoscine or alverine as alternative
Cautions/ CI: include glaucoma (CI), prostate problems, CVD
Side-effects: dry mouth, blurred vision, palpitations, constipation, contribute to anticholinergic burden
Alternative: peppermint oil (heartburn SE)

Aim for PRN use, r/v 3/12, discontinue if no benefit

21
Q
  1. Pharmacological treatment: Abdominal pain second line treatment
A

2nd line: Antidepressants (off-label)
Mechanism: ?potentiate analgesics and may alter pain perception and normalise GI transit (affects gut-brain axis)

TCAs (tricyclic antidepressant)
e.g. low dose amitriptyline (start 5-10mg nocte; max 30-50mg nocte)
Side-effects: constipation, dry mouth, drowsiness, fatigue, contribute to ACB

SSRIs (selective serotonin reuptake inhibitor)
If TCAs not tolerated, ineffective, CI, e.g. citalopram 20mg OD

Trial for 4/52, increase dose gradually if tolerating / needed. Continue at least 6/12 if effective & review every 6/12

22
Q

Pharmacological treatment: Diarrhoea

A

Anti-motility medication: loperamide

Usage: Stat dose (4mg initially then 2mg with each loose motion up to max 16mg daily) or can be used on more regular or PRN basis aiming to produce regular, soft, well-formed stool (e.g. 4-8mg daily in divided dose; up to max 16mg daily)

Benefits: doesn’t cause confusion or other anticholinergic side effects

Trial, review after 3/12; stop if no benefit

23
Q
  1. Pharmacological treatment: Constipation (IBS-C)
    first line
A

1st line: Bulk-forming laxatives (e.g. Ispaghula husk – Fybogel)

Mechanism: Contains soluble fibre
Retains liquid within stool
Increases faecal mass
Stimulates peristalsis
Stool softening properties

Correct use:
Adequate fluid intake important to prevent intestinal obstruction
Adjust dose according to response, aim for comfortable, regular, soft, well-formed stool
2-3 days to take effect, can be longer

R/v 3/12. stop if no benefit

24
Q
  1. Pharmacological treatment: Constipation (IBS-C)
    second line
A

2nd line: Osmotic laxatives
No strong evidence for use
May worsen bloating (NICE discourage lactulose for this reason, macragols, e..g. Laxido preferred)

25
Q
  1. Pharmacological treatment: Constipation (IBS-C)
    third line
A

3rd line newer therapies for IBS-C (normally specialist-intitated)
Linaclotide (Constella)
Is a first-in-class, once-daily guanylate cyclase-C receptor agonist that also increases intestinal fluid secretion
When to use: NICE recommend if optimal / max doses of laxatives from different classes ineffective and they have had constipation for at least 12 months
Review after 12 weeks, stop if no benefit

Prucalopride (Resolor)
5HT4 serotonin receptor agonist stimulating peristalsis, intestinal secretions, GI motility
Not currently in NICE guidance but use increasing – no RCTs in IBS-C

26
Q

Psychological Therapies

A

Cognitive behavioural therapy

Psychodamic interpersonal therapy

Hypnotherapy

Increasing evidence for significant role in management

27
Q
A

PMY3304 (11 decks)

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