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Summer FDTN Exam 5 > IBS diarrhea > Flashcards

IBS diarrhea Flashcards

1
Q

What is the MC GI diagnosis

A

IBS- affects 18-34 y/o MC

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2
Q

What is IBS

A

Combination of disturbance of GI motility, visceral hypersensitivity, and psychopathology

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3
Q

What should you screen for in an individual with IBS

A

Depression and suicidal ideation

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4
Q

What is the Rome IV criteria

A

IBS diagnosis tool that is most widely used

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5
Q

IBS is defined by the Rome IV as

A

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

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6
Q

What tool can be used to assess stool appearance

A

Bristol stool form scale
Type 1 is separate hard lumps
Type 7 is watery, no solid pieces

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7
Q

What are the types of IBS

A
  • 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
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8
Q

DDx for IBS are

A 
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
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9
Q

What does a PE for IBS usually look like

A

normal!

Some may have abd ttp but vitals are normal, no pallor, no rash

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10
Q

How do you diagnose IBS

A

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

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11
Q

What are red flags/alarm features for IBS

A 
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
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12
Q

In patients with alarm features how do diagnostics change

A

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

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13
Q

How do you manage IBS if with mild and intermittent Sx

A

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

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14
Q

How do you manage IBS with more severe Sx

A

Lifestyle and diet modification

Adjunct meds

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15
Q

What meds can you give for IBS-C

A

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

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16
Q

What meds can you give for IBS-D

A

Antidiarrheals: Loperamide (imodium)
Bile acid sequestrants: cholestyramine
Rifaximin: reduce colonic bacteria overgrowth

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17
Q

What meds can you give to manage abdominal pain and bloating

A

Antispasmodics prn: Dicyclomine and Hyoscyamine

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18
Q

Who do you NEVER give an anticholinergic/antispasmodic to

A

Someone with an unstable heart rhythm

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19
Q

When all meds fail, what are your options for managing IBS

A

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

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20
Q

What highly improves patient outcome with IBS

A

positive patient-provider relationship

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21
Q

DDx for constipation must include

A 
colon cancer 
hypothyroidism 
proctitis 
obstruction 
diabetes 
spinal cord lesion 
parkinson's 
IBS-C (looks the exact same but NO abdominal pain**)
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22
Q

What is a big challenge with chronic constipation

A

the definition is variable between patient and provider!

use Rome IV criteria for provider, but patient criteria is different

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23
Q

What is Rome IV criteria for constipation

A 
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
24
Q

Patient criteria for constipation is

A 
Straining 
stools are hard 
unproductive urges 
Infrequency 
Feeling of incomplete evacuation
25
What can cause constipation
Slow transit: slow movement from proximal to distal colon Pelvic floor dysfunction: can't evacuate rectal contents Medications
26
DDx for constipation should be
``` obstruction impaction neoplasms volvolus intussusception IBD/IBS Endocrine abnormalities Hemorrhoids fissures strictures drugs celiac disease ```
27
What PE should you do for constipation
Anal reflex DRE Evaluate for rectocele and evidence of pelvic floor dysfunction
28
What diagnostics should you get for constipation
CBC, CMP, Thyroid function If high risk, colonoscopy Give trial of fiber and close follow up
29
If patients are refractory to treatment of constipation, try
``` Colonic transit study (rate of radiopaque marker) Anorectal manometry (sphincter pressure) ```
30
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 ```
31
What are the available laxatives
``` Osmotic laxatives Milk of magnesium (caution in renal failure) Colace Senokot Peri-colace ```
32
Complications of constipation are
Fecal impaction, LBO (esp.. if confined to bed, dementia, depression, disability, etc.) Associated anorexia, nausea, vomiting, abdominal pain
33
How do you manage fecal impaction
manual removal of stool, enema
34
How does length of Sx change diarrhea dx
Acute: 14 or less days Persistent: >14, <30 days Chronic: >30 days
35
DDx for diarrhea should include
``` IBS meds IBD Microscopic colitis (NSAID use) Malabsorption syndrome Chronic infection HIV ```
36
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
37
When acute diarrhea presents, rule out
``` Infection Drug reaction IBD Fecal impaction (loos stool seeps out) Laxative abuse Radiation colitis Emotional stress ```
38
How does non-inflammatory acute diarrhea present
Diffuse, watery* diarrhea with abdominal cramping N/V fever -Think Giardia!
39
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
40
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 ```
41
How do you manage acute diarrhea
HYDRATION!!
42
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
43
What is LGV
Lymphogranuloma venereum, an STI caused by a strain of chlamydia Common in MSM
44
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*
45
What is C. diff associated with
Hospitalization | Recent abx use
46
What is Giardia associated with
Contaminated water, camping | *Diarrhea > 7 days, fatty stools*
47
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
48
Other tests to consider for acute diarrhea are
UA: dehydration (high specific gravity) CBC: infection BMP/CMP: electrolytes
49
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
50
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
51
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
52
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) ```
53
Who should NEVER take antidiarrheals (loperamide and bismuth subsalicylate)
Kids! Imodium can cause hemolytic uremic syndrome Pepto can trigger Reye's syndrome
54
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)
55
What antibiotics are used for empiric therapy in acute diarrhea
Cipro or Azithromycin | Or specific pathogen identified
56
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!! ```

Summer FDTN Exam 5 (12 decks)

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