IBS Flashcards
Is iron def anemia assoc with IBS
no
Is weight loss assoc with IBS
no
IBS: _______ bowel disorder characterized by what?
function
recurrent abdominal pain AND altered bowel habits
4 subclassifications of IBS
Constipation predom
Diarrhea predom
Mixed
Unclassified
ages IBS affects
20-39
M or F predominance with IBS
F
Average time to dx IBS
about 4 yrs
etiology of IBS
physiological
psychosocial
environmental
2 physiological reasons for IBS
abnormal motility
visceral hypersensitivity
psychosocial reasons for IBS
early life stressors (like abuse)
anxiety, depression, phobias
environmental reasons for IBS
diet, post-infectious, gut microbiome
two components needed for IBS
** chronic/recurrent abdominal pain/discomfort
** altered bowel habits (constipation/diarrhea)
when does diarrhea happen with IBS
in AM and post-prandially
IBS clinical presentation
chronic/recurrent abdominal pain and discomfort
altered bowel habits
+/- dyspepsia, atypical CP, vomiting
extra-intestinal symptoms assoc with IBS
sexual dysfunction
dysmenorrhea
irritative voiding symptoms
fibromyalgia
somatic or psyc complaints
alarm features of IBS
symptom onset after 50
severe or progressively worsening symptoms
nocturnal diarrhea
fevers/vomiting
unexplained weight loss
melena, hematochezia + occult blood
personal or FH of colon cancer, IBD, or celiac disease
unexplained iron def anemia
IBS physical exam
usually normal
tenderness upon palpation on abdominal exam
do perianal and DRE
dx criteria for IBS (name of the criteria NOT criteria)
Rome IV
Rome IV criteria (what is it?)
recurrent abdominal pain at least one day/week for the last 3 months w/ 2+ criteria:
related to defecation
assoc with change in stool freq
assoc with change in stool form (appearance)
IBS dx: typical hx and no alarm features
lab, radiographic, endoscopic tests not routinely recommended
IBS dx: if not typical hx or an alarm feature or refractory to tx
CBC, CMP, TSH, ESR/CRP, Celiac serologies, stool studies
cross-sectional/small bowel imaging
endoscopy/colonoscopy with biopsies
goal of IBS tx
relieve symptoms and improve quality of life + therapeutic clinician-pt relationship**
dietary/lifestyle measures
psychosocial support
pharm therapy
some dietary/lifestyle measures
food diary/symptomatology
dietary fiber (20-35 g/day)
FODMAP diet
Probiotics
Exercise
IBS psychosocial support
CBT
Relaxation/stress mgmt
behavioral health referral
abdominal pain IBS meds
group of side effects
levsin
bentyl
**anticholinergic effects
IBS-C medications
fiber
miralax
amitiza
linzess
trulance
IBS-D meds
imodium
rifaximin
viberzi
psychosocial IBS meds
TCAs (off label)
- crazy side effects
3 classes of meds that make constipation worse
antipsychotics
iron
opioids
most common digestive complaint in gen pop
constipation
males or females complain of constipation more
females
4 risk factors of constipation
improper diet and inadequate fluid intake
sedentary lifestyle
polypharm
increased age
6 etiology categories of constipation
functional
med-induced
slow transit
defecation/obstruction
metabolic/systemic disease
other
key history questions for constipation
laxatives?
need for digital evacuation?
previous colonoscopy
red flag symptoms/alarm features
reconcile meds/review PMH if needed for secondary/contributing causes of constipation
dx criteria for constipation
25% of defecations are:
less than 3 spontaneous BM/week
lumpy or hard stools
straining
manual maneuvers
anorectal obstruction sensation
incomplete evacuation
common GI symptoms assoc with constipation
abdominal pain and bloating
pain on defecation
rectal bleeding
tenesmus (anal quivering)
red flag symptoms in constipation
acute onset
50+
fevers/vomiting
weight loss
melena/hematochezia
personal or FH of colon cancer, IBD, celiac’s
iron def anemia
what should you do for refractory pts with constipation
colonic transit (radiopaque marker)
defecography
anorectal manometry
adverse effects of fiber
flatulence, bloating, distention
adverse effects of osmotic laxatives
GI discomfort, bloating
who should you NOT give osmotic laxatives containing Mg to
those with renal insufficiency
4 categories of constipation medications
fiber supplements
stool softeners
osmotic laxatives
stimulant laxatives
complications of constipation
hemorrhoids/anal fissures
fluid and electrolyte abnormalities from laxative abuse
fecal impacting and bowel obstruction (high risk in those with dementia, neurologic disease, immobile, hypomotility meds)
disimpaction followed by maintenance bowel prep as appropriate
symptoms of fecal impaction
N/V, abdominal pain, distention, paradoxical diarrhea
what are some secondary/contributing causes of constipation
med-induced
slow transit
defecation/obstructive disorders
metabolic/systemic dx
most likely assoc with acute diarrhea
norovirus
acute diarrhea length of time + definition of diarrhea
less than 14 days
more than 3 unformed stools/day
most common etiology of acute diarrhea
viral
3 key history questions regarding acute diarrhea
prev colonoscopy
red flag symptoms
exposures
red flags of diarrhea
fever
unexplained weight loss
melena, hematochezia
persistent/progressive/nocturnal symptoms
immunocompromised
personal or FH of colon canccer, IBD, celiacs
iron def anemia
SIGNS OF VOLUME DEPLETION**
exposures that can cause acute diarrhea
recent hospitalization or antibx use
travel hx
ingestion of improperly stored or prepared food
sick contact exposure
pets/animal exposure
new meds or dose changes
healthcare workers, daycare workers, food handlers
inflammatory or noninflammatory:
watery nonbloody diarrhea, nausea/vomiting
mild diffuse abdominal cramps, bloating/flatulence
+/- low grade fever
noninflammatory
viral causes of acute noninflammatory diarrhea
norovirus
protozoal cause of acute noninflammatory diarrhea
giardia
inflammatory or noninflammatory acute diarrhea
fever
bloody diarrhea
severe abdominal pain
inflammatory
bacterial causes of inflammatory acute diarrhea
salmonella
campylobacter
shigella
e. coli 0157:H7
c. diff
what should we focus on with acute diarrhea
volume status and complications:
look at vitals, skin turgor, mucus membranes, heart rate, abdominal stuff, rectal tenderness, stool guaiac, perianal disease, mental status
normal pts with acute diarrhea dx
clinical
what are signs that accompany acute diarrhea that require prompt evaluation
101.3F
leukocytosis
bloody diarrhea
severe abdominal pain
intractable vomiting
watery diarrhea and dehydration
AKI/lyte abnormalities
elderly or nursing home residents
immunocompromised
hospital-acquired diarrhea
acute diarrhea mgmt
supportive care and symptomatic relief
oral rehydration tx
lactose free diet
probiotics
imodium
pepto-bismol
do you need antibx for acute diarrhea
not usually - generally self limiting
rice water diarrhea assoc with what
vibrio cholerae
where do you pick up giardia lamblia
camping, lakes, streams, ponds, daycares, pools
picked up from poultry and livestock, reptiles
salmonella
what organism can be linked to guillain-barre syndrome
campylobacter jejuni
classic dysentery AKA
shigella
severe afebrile bloody diarrhea - what pathogen
E. Coli 0157:H7
tx of E. Coli 0157:H7
no antidiarrheal
no antibx DUE TO RISK OF HUS
what bug has a risk of HUS
E. coli 0157:H7
what bug is assoc with recent hospitalization/antibiotic use
c. diff
tx of c.diff
vanco (DOFC)
fidaxomicin
metro
what bug is assoc with raw seafood/shellfish
vibrio parahemolyticus
what mimics appendicits and how
yersinia entercolitica (RLQ pain)
