IBS diarrhea Flashcards
What is the MC GI diagnosis
IBS- affects 18-34 y/o MC
What is IBS
Combination of disturbance of GI motility, visceral hypersensitivity, and psychopathology
What should you screen for in an individual with IBS
Depression and suicidal ideation
What is the Rome IV criteria
IBS diagnosis tool that is most widely used
IBS is defined by the Rome IV as
Recurrent abdominal pain
at least 1x week
for at least 3 consecutive months
Associated with 2 of the following: Defecation, change in stool frequency, and change in stool appearance/form
What tool can be used to assess stool appearance
Bristol stool form scale
Type 1 is separate hard lumps
Type 7 is watery, no solid pieces
What are the types of IBS
- predominant constipation. BM are bristol T1&2
- predominant diarrhea. BM are T6&7
- mixed bowel habits (diarrhea and constipation)
- unclassified. pt meets criteria for IBS but it can’t be classified into any 3 subtypes
DDx for IBS are
Celiac disease (differentiate by doing IGA TTG or celiac panel, then 2 week GF diet trial) IBD Anxiety Colitis Drug withdrawal, OD, or interaction Parasite infx Colon or pancreas neoplasm
What does a PE for IBS usually look like
normal!
Some may have abd ttp but vitals are normal, no pallor, no rash
How do you diagnose IBS
No specific test! it is a diagnosis of exclusion
Get a CBC (WBC and H&H), celiac panel, and CRP (esp if w/ diarrhea)
Screen for colon cancer if age appropriate
Can do radiographs supine if IBS-C
What are red flags/alarm features for IBS
Age onset >50, or >35 per Coplan Rectal bleeding or melena Nocturnal diarrhea Progressive abdominal pain unexplained weight loss Lab abnormalities (elevated CRP, anemia) FHx of IBD or colon cancer Recent abx or travel
In patients with alarm features how do diagnostics change
CBC, celiac, and CRP are usually sufficient to r/o organic disease
Guide other Dx based on Sx!
Rectal bleeding? colonoscopy or flex sig
Recent abx? stool sample for C diff
45 y/o at onset? colonoscopy
How do you manage IBS if with mild and intermittent Sx
Lifestyle and diet modification
IBS diet: regular mealtime, avoid large meals, reduce fat, insoluble fiber, caffeine, and gas producing food intake
Exclude FODMAPs (diet low in fermentable, oligo, di, and monosaccharide and polyols)
Consider lactose/gluten avoidance
Consider fiber/psyllium
Exercise 20-60min mod-vigorous activity 3-5 days a week
How do you manage IBS with more severe Sx
Lifestyle and diet modification
Adjunct meds
What meds can you give for IBS-C
Osmotic laxatives: psyllium, Miralax (polyethylene)
Lubiprostone: Cl channel activator, enhances Cl rich intestinal fluid secretion. for women 18+ only. ADE nausea, try miralax first
Linactolide (Linzess): reduce colonic sensory neurons
What meds can you give for IBS-D
Antidiarrheals: Loperamide (imodium)
Bile acid sequestrants: cholestyramine
Rifaximin: reduce colonic bacteria overgrowth
What meds can you give to manage abdominal pain and bloating
Antispasmodics prn: Dicyclomine and Hyoscyamine
Who do you NEVER give an anticholinergic/antispasmodic to
Someone with an unstable heart rhythm
When all meds fail, what are your options for managing IBS
Antidepressants: Zoloft (SSRI) for IBS-C. TCA for IBS-D
Antibiotics: Rifaximin if w/o constipation but with significant bloating
Probiotics
If refractory, refer to GI
What highly improves patient outcome with IBS
positive patient-provider relationship
DDx for constipation must include
colon cancer hypothyroidism proctitis obstruction diabetes spinal cord lesion parkinson's IBS-C (looks the exact same but NO abdominal pain**)
What is a big challenge with chronic constipation
the definition is variable between patient and provider!
use Rome IV criteria for provider, but patient criteria is different
What is Rome IV criteria for constipation
E+ of the following for at least 3 months: Straining Lumpy, hard stools Sensation of incomplete evacuation Sensation of anorectal blockage Manual maneuvers to facilitate <3 spontaneous BM per week
Patient criteria for constipation is
Straining stools are hard unproductive urges Infrequency Feeling of incomplete evacuation
What can cause constipation
Slow transit: slow movement from proximal to distal colon
Pelvic floor dysfunction: can’t evacuate rectal contents
Medications
DDx for constipation should be
obstruction impaction neoplasms volvolus intussusception IBD/IBS Endocrine abnormalities Hemorrhoids fissures strictures drugs celiac disease
What PE should you do for constipation
Anal reflex
DRE
Evaluate for rectocele and evidence of pelvic floor dysfunction
What diagnostics should you get for constipation
CBC, CMP, Thyroid function
If high risk, colonoscopy
Give trial of fiber and close follow up
If patients are refractory to treatment of constipation, try
Colonic transit study (rate of radiopaque marker) Anorectal manometry (sphincter pressure)
How do you manage constipation
Adjust causative meds Correct metabolic abnormalities Push fluids Increase activity Increase fiber to 20-30g/d Minimize laxative use- and if you do use one, use miralax
What are the available laxatives
Osmotic laxatives Milk of magnesium (caution in renal failure) Colace Senokot Peri-colace
Complications of constipation are
Fecal impaction, LBO (esp.. if confined to bed, dementia, depression, disability, etc.)
Associated anorexia, nausea, vomiting, abdominal pain
How do you manage fecal impaction
manual removal of stool, enema
How does length of Sx change diarrhea dx
Acute: 14 or less days
Persistent: >14, <30 days
Chronic: >30 days
DDx for diarrhea should include
IBS meds IBD Microscopic colitis (NSAID use) Malabsorption syndrome Chronic infection HIV
Diarrhea is MCC by
Viruses! Rotavirus, Adenovirus, Norwalk virus
Bacterial causes are more severe and cause inflammatory diarrhea (campylobacter, salmonella, shigella, E. coli O157:H7)
Can also be 2/2 protozoa (cryptosporidium in HIV, Giardia)
Major cause of death worldwide
When acute diarrhea presents, rule out
Infection Drug reaction IBD Fecal impaction (loos stool seeps out) Laxative abuse Radiation colitis Emotional stress
How does non-inflammatory acute diarrhea present
Diffuse, watery* diarrhea with abdominal cramping
N/V
fever
-Think Giardia!
How does inflammatory acute diarrhea present
Fever
Bloody diarrhea
LLQ pain
Tenesmus (feel like you have to have a BM)
-think salmonella, shigella, campylobacter, E. coli, C diff
What can Rotavirus cause in kids <2
viral gastroenteritis (but can also infect adults) Sx last < 1 week: vomiting, diarrhea, fever- leads to dehydration and can be fatal
How do you manage acute diarrhea
HYDRATION!!
Associate clues with causes of acute diarrhea
Bloody diarrhea: E. coli
non-inflammatory diarrhea w/ vomiting: viral enteritis
Recent abx: C diff
HIV or STD: AIDS associated diarrhea
Proctitis and rectal discharge: gonorrhea, LGV
What is LGV
Lymphogranuloma venereum, an STI caused by a strain of chlamydia
Common in MSM
What is enterohemorrhagic E. Coli (EHEC) associated with
Shiga toxin! O157:H7 is the MC serotype in the US
Associated with hemolytic uremic syndrome; hemolytic anemia (elevated unconjugated bili and reticulocytes), Renal failure (BUN:Cr), Thrombocytopenia (CBC)
No fever + Bloody stool + Abdominal tenderness
What is C. diff associated with
Hospitalization
Recent abx use
What is Giardia associated with
Contaminated water, camping
Diarrhea > 7 days, fatty stools
What microbiologic testing is available for acute diarrhea
Routine stool culture: shigella, salmonella, campylobacter, EHEC
EHEC: culture E. coli o157:H7 and shiga toxin stool test
C. diff: specific toxin
Giardia: specific antigen
Ova and parasites (rare)
Inflammatory diarrhea: stool occult blood , WBC, or lactoferrin
Other tests to consider for acute diarrhea are
UA: dehydration (high specific gravity)
CBC: infection
BMP/CMP: electrolytes
How do you approach a patient abut acute diarrhea
How bad is the diarrhea? duration, frequency, characteristics, Sx suggesting inflammatory diarrhea (fever, tenesmus, blood)
How sick are you? RF for complications, dehydration Sx
Assess clues to etiology
When should you test for a pathogen in diarrhea
when you suspect one!
If moderate-severe or pt is pretty ill consider testing
If inflammatory is suspected, consider a stool culture for o157:h7 or shiga toxin, or stool occult
How do you manage acute diarrhea
*Rehydration!! Pedialyte preferred
1/2 tsp salt, 1/2 tsp baking soda, 4 tbsp sugar, 1L water
If vomiting, start with small sips; BRAT diet, NO milk
Gatorade only for mild illness, it’s not that great
Sx Tx for diarrhea includes
Loperamide (imodium): inhibits peristalsis and secretions Bismuth subsalicylate (pepto bismol): reduce stool output, relieve n/v and abd pain (turns tongue and stool black)
Who should NEVER take antidiarrheals (loperamide and bismuth subsalicylate)
Kids!
Imodium can cause hemolytic uremic syndrome
Pepto can trigger Reye’s syndrome
When can you consider using empiric antibiotics in acute diarrhea
Benefit>risk
Pt at risk for complications (immunocompromised)
Pt has moderate-severe diarrhea BUT EHEC and C. Diff are not suspected (>6 stools/d, dehydrated, stool + for occult blood, Sx > 1wk)
What antibiotics are used for empiric therapy in acute diarrhea
Cipro or Azithromycin
Or specific pathogen identified
Take home points for acute diarrhea
MC self limited Use caution if w/ fever, significant abdominal ttp, or bloody diarrhea (Fever? no imodium. Blood? no imodium or abx) Management is hydration No antidiarrheals in kids Prevention: Hand washing!!
