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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
Q

What can cause constipation

A

Slow transit: slow movement from proximal to distal colon
Pelvic floor dysfunction: can’t evacuate rectal contents
Medications

26
Q

DDx for constipation should be

A 
obstruction 
impaction 
neoplasms 
volvolus 
intussusception 
IBD/IBS 
Endocrine abnormalities 
Hemorrhoids 
fissures 
strictures 
drugs 
celiac disease
27
Q

What PE should you do for constipation

A

Anal reflex
DRE
Evaluate for rectocele and evidence of pelvic floor dysfunction

28
Q

What diagnostics should you get for constipation

A

CBC, CMP, Thyroid function
If high risk, colonoscopy
Give trial of fiber and close follow up

29
Q

If patients are refractory to treatment of constipation, try

A 
Colonic transit study (rate of radiopaque marker) 
Anorectal manometry (sphincter pressure)
30
Q

How do you manage constipation

A 
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
Q

What are the available laxatives

A 
Osmotic laxatives 
Milk of magnesium (caution in renal failure) 
Colace 
Senokot 
Peri-colace
32
Q

Complications of constipation are

A

Fecal impaction, LBO (esp.. if confined to bed, dementia, depression, disability, etc.)
Associated anorexia, nausea, vomiting, abdominal pain

33
Q

How do you manage fecal impaction

A

manual removal of stool, enema

34
Q

How does length of Sx change diarrhea dx

A

Acute: 14 or less days
Persistent: >14, <30 days
Chronic: >30 days

35
Q

DDx for diarrhea should include

A 
IBS
meds 
IBD 
Microscopic colitis (NSAID use) 
Malabsorption syndrome 
Chronic infection 
HIV
36
Q

Diarrhea is MCC by

A

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
Q

When acute diarrhea presents, rule out

A 
Infection 
Drug reaction 
IBD
Fecal impaction (loos stool seeps out) 
Laxative abuse 
Radiation colitis 
Emotional stress
38
Q

How does non-inflammatory acute diarrhea present

A

Diffuse, watery* diarrhea with abdominal cramping
N/V
fever
-Think Giardia!

39
Q

How does inflammatory acute diarrhea present

A

Fever
Bloody diarrhea
LLQ pain
Tenesmus (feel like you have to have a BM)
-think salmonella, shigella, campylobacter, E. coli, C diff

40
Q

What can Rotavirus cause in kids <2

A 
viral gastroenteritis (but can also infect adults)
Sx last < 1 week: vomiting, diarrhea, fever- leads to dehydration and can be fatal
41
Q

How do you manage acute diarrhea

A

HYDRATION!!

42
Q

Associate clues with causes of acute diarrhea

A

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
Q

What is LGV

A

Lymphogranuloma venereum, an STI caused by a strain of chlamydia
Common in MSM

44
Q

What is enterohemorrhagic E. Coli (EHEC) associated with

A

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
Q

What is C. diff associated with

A

Hospitalization

Recent abx use

46
Q

What is Giardia associated with

A

Contaminated water, camping

Diarrhea > 7 days, fatty stools

47
Q

What microbiologic testing is available for acute diarrhea

A

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
Q

Other tests to consider for acute diarrhea are

A

UA: dehydration (high specific gravity)
CBC: infection
BMP/CMP: electrolytes

49
Q

How do you approach a patient abut acute diarrhea

A

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
Q

When should you test for a pathogen in diarrhea

A

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
Q

How do you manage acute diarrhea

A

*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
Q

Sx Tx for diarrhea includes

A 
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
Q

Who should NEVER take antidiarrheals (loperamide and bismuth subsalicylate)

A

Kids!
Imodium can cause hemolytic uremic syndrome
Pepto can trigger Reye’s syndrome

54
Q

When can you consider using empiric antibiotics in acute diarrhea

A

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
Q

What antibiotics are used for empiric therapy in acute diarrhea

A

Cipro or Azithromycin

Or specific pathogen identified

56
Q

Take home points for acute diarrhea

A 
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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