IBS And Diverticula Flashcards by Nicole Torchia

What is diagnostic criteria for IBS called?

Rome IV

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What are components of Rome IV criteria

Recurrent abdominal pain at least 1 day pew week in the past 3 months with 2 or more of:

Changes with defecation
Associated with change in freq of stool
Associated with change in form or appearance

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IBS in more common in this population

Young people

Females

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Symptoms of IBS

Abdominal pain or discomfort
Constipation/ diarrhea
Bloating /dissension
Non colonic symptoms like dyspepsia, GERD, Nausea

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What are the subtypes of IBS?

IBS-C
IBS-D
IBS-M
IBS-U

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What is the threshold for classifying IBS?

25% of Bowel Movements in a category

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Non-colonic symptoms of IBS

Nausea, dyspepsia, GERD

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How long are IBS going on before diagnosis? What can you rule out?

3 to 6 months

Rule out: pregnancy, food poisoning, dietary indiscretion

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What are diverticula?

Sac-like protrusion owns of the colonic wall

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Diverticulosis vs. diverticulitis

Osis- refers to presence of diverticula

Itis- inflammation of diverticulum

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IBS puts patient at an increased risk for what three surgical procedures?

Cholecystectomy
Appendectomy
Hysterectomy

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Abdominal motility in IBS includes what?

Diarrhea (high amp propulsive contractions, enhanced gastro-colic response, rectal hypersensitivity)

Constipation (decreased HAPC, increased segmental contractions, decreased rectal sensitivity

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IBS hypersensitivity includes what?

Low level distension causes pain
Visceral pain, not somatic
Increased cerebral cortex activity

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Markers of inflammation in IBS

Lymphocytes 
Mast cells (activated next to colonic nerves in abd pain)
Proinflammatory cytokines (elevated interleukin and TNF)

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There is a 5x higher incidence of IBS in which situation?

Post-infection post-inflammatory state

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What kind of food sensitivity is involved in IBS?

Food allergy (food high in IgG)
Carb malabsorption (fermentable FODMAP foods)
Gluten sensitive

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When diagnosis IBS, you should always test for and rule out ______ _______

Celiac disease

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Alarming IBS features

Bloody stool
Fever
Night poops
Weight loss
Family history of other diseases
Onset after 50 yo
Travel to parasitic countries

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What lab tests do you want to order to confirm IBS-D?

Stool culture or O&P r/o infection

Celiac disease panel r/o celiac

Fecal calprotectin or CRP r/o IBD

Colonoscopy r/o microscopic colitis

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What lab tests do you want to order to confirm the diagnosis of IBS-C?

Radiography
Colonoscopy (structural lesions)

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IBS differential- infection

Giardia
Ameba
Bacterial SI overgrowth

IBS differential- IBD

Ulcerative colitis
Crohn’s
Microscopic colitis

IBS differential- malabsorption

Celiac
Pancreatic disease
Post-surgical

IBS differential- Psychological

Anxiety
Pain
Depression
Somatization

IBS differential- dietary factors

``` Lactose Sorbitol Fructose Caffeine Alcohol Fat Gas producing foods ```

IBS diet

Fiber- soluble fiber No lactose Low FODMAP diet

What is in FODMAP? What is low FODMAP diet?

``` Fructans Galatans Lactose Fructose Sorbitol Xylitol Mannitol ``` Diet includes high meat low carb usually

Medications for IBS-D | Indicate first line and second line

First line: opioid agonist like loperamide ppx Second line: bile salt sequestering agents Also try: Mixed opioid agonist/antagonist: eluxadoline 5-HT3 Antagonist: Alosetron (limited in US)

Medications for IBS-C

``` Osmotic laxatives (Miralax)- bloat, pain Stimulant laxatives (Dulcolax)- cramping Lubiprostone (amitiza)- activates Cl channels to draw fluid Linaclotide (if laxatives fail) guanylate Cyclase agonist ```

IBS medications for pain management

Antispasmodics and anticholinergics Smooth muscle relaxants Antidepressants (TCAs and SSRIs)

Why give rifaximin for IBS?

Its non-absorbable, so stays in gut only Improves in the setting of no constipation Improvement in bloating, abdominal pain, altered bowel habits

Peppermint oil can be used in IBS for

Pain, diarrhea, flatulence, distension

IBS bloating | First and second steps?

First: adjust diet, treat constipation Second: probiotic, abx, TCA, SSRI

IBS constipation first and second step?

First: fiber supplement, polyethylene glycol laxative Second: lubiprostone, linaclotide

IBS diarrhea first and second steps for treatment

First: loperamide Second: 5HT3 antagonist (alosetron)

IBS abdominal pain management first and second steps

First: antispasmodic, peppermint oil Second: TCA, SSRI, psych therapy

Diverticula disease prevalence

Higher with increasing age Western nations: left side Asia: right side

Predisposing dietary factors for Diverticulosis

``` Low fiber High fat High red meat Low fruit veggies Obese Sedentary lifestyle ```

Diverticular disease pathophysiology

There is a point of weakness, decrease resistance of the wall to intravascular-luminal pressure, increased pressure causes herniation in the mucosa

In diverticular bleeding, the blood vessel is separated from the bowel ______ by _______. Over time, the vessel wall is exposed to injury, leading to weakness and predisposing _________.

Lumen, mucosa, rupture

Clinical manifestations of diverticulitis

``` LLQ pain Few days, previous episodes N/V Changed bowel habits Urinary symptoms Labs show mild leukocytosis Low grade fever ```

What kind of imaging do you order for Diverticulitis?

CT scan with PO and IV contrast

What do I see on diverticulitis imaging?

Increased soft tissue density in pericolic fat Bowel wall thickening Phlegmon/abscess

What makes diverticulitis complicated?

Perforation Obstruction Fistula Abscess

How do you treat uncomplicated diverticulitis?

7-10 days antibiotics Quinolone + metro Amoxicillin-clavulante Bactrim + metro

How do you treat complicated diverticulitis?

IV antibiotics, then PO for following 10-14 days Amp-sulbactam Pip-tazo Ticarcillin/clavulante Ceftriaxone+metro

I have diverticulitis- what should my diet look like?

NPO Clear liquids High fiber diet after resolution Seeds and nuts are OK

Clinical presentation of a diverticular bleed

Painless rectal bleeding Shock in extreme cases Mild cramps Normal abdominal exam

What is the most common cause of a lower GI bleed?

Diverticulitis

Patient is presenting with bright red stool per rectum. What are my first two steps?

Rule out UGI bleed with EGD then assume it is coming from colon

Diverticula bleed treatment

Resuscitation (IV blood products prn) Endoscopic visualization to localize and clip Most heal on own