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X Clin Med III Exam I > IBS, Diarrhea and Constipation > Flashcards

IBS, Diarrhea and Constipation Flashcards

1
Q

What is IBS?

A

Functional bowel disorder (in absence of organic cause) characterized by recurrent abdominal pain and altered bowel habits

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2
Q

Classifications of IBS

A 
*based on predominant bowel habit
IBS-C (constipation predominant)
IBS-D (diarrhea predominant)
IBS-M (mixed)
IBS-U (unclassified)
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3
Q

Etiology of IBS

A

Multifactorial:
Physiological (abnormal motility or visceral hypersensitivity)
Psychosocial (early life stressors, anxiety, depression)
Environmental (diet, post-infectious etc)

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4
Q

What might be an alleviating factor of IBS?

A

Having a bowel movement

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5
Q

Associated sxs of IBS

A

Bloating and gas

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6
Q

How would a pt describe the IBS pain?

A

Cramping and diffuse through the lower abdomen (variable intensity with maybe periodic exacerbations)

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7
Q

Presentation of IBS-C

A 
Difficult, painful, infrequent defecation
Hard, lumpy stools
Prolonged time on toilet
Excessive straining during defecation
Sense incomplete evacuation
Abdominal bloating/distension
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8
Q

Presentation of IBS-D

A 
Frequent, loose BMs
Fecal urgency
Sense incomplete evacuation
Incontinence
Mucus discharge
Usually in the morning and after meals!
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9
Q

Other parts of general presentation of IBS

A 
GI sxs (dyspepsia, atypical CP, rare vomiting)
Extra-intestinal sxs
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10
Q

Extra intestinal sxs associated with IBS

A 
Sexual dysfunction
Dysmenorrhea
Irritative voiding sxs
Fibromyalgia sxs
Somatic or psychological complaints
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11
Q

Red flag sxs and alarm features of IBS***

A 
Must do prompt eval and GI referral/work up with them:
Sxs onset after 50
Severe or progressively worsening sxs
Nocturnal diarrhea
Fevers/vomiting
Unexplained weight loss
Melena, hematochezia, occult blood
Personal or FH of colon CA, IBD or Celiac
Unexplained IDA
(FUSSPUMN)
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12
Q

How might a PE look with IBS?

A

Generally normal with normal vitals
Abdomen might be TTP (no peritoneal signs)
Should do perianal/DRE

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13
Q

Rome IV diagnostic criteria for IBS

A

Recurrent abdominal pain on avg at least 1xwk in last 3 mos and with 2+ of the following:
Related to defecation
Associated with change in stool frequency
Associated with change in stool appearance

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14
Q

What does the work-up look like for IBS?

A

Normal history and no alarm features usually means no lab, x-rays or endoscopic tests are recommended
May do some screening tests when needed (CBC, CMP, TSH, ESR/CRP, Celiac serologies, stool studies)

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15
Q

What to do when you suspect IBS but atypical history, alarm features or refractory to tx?

A

Additional work up:
Lab/stool studies
Cross-sectional/small bowel imaging
Endoscopy/colonoscopy with biopsie

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16
Q

Approach to tx of IBS

A

Relieve sxs and improve QOL

Clinician-pt relationship!

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17
Q

Components of IBS tx

A

Dietary/lifestyle
Psychosocial support
Pharm

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18
Q

Considerations for dietary measures with IBS

A

Food diary/symptomatology
Dietary fiber (20-35 g/day)- start low and go slow
FODMAP diet (eliminate foods that contain sugars and fibers that cause pain and bloating)
Probiotics
Exercise

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19
Q

Considerations for psychosocial support with IBS

A

Cognitive behavioral therapy
Relaxation/stress management
Maybe refer to behavioral health

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20
Q

Pharmacologic therapy for IBS with abdominal pain

A

Levsin
Bentyl
*caution anti-cholinergic effects of constipation b/c these are anti-spasmotics

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21
Q

Pharmacologic therapy for IBS with constipation

A 
Psyllium fiber
Miralax
Amitiza
Linzess
Trulance
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22
Q

Pharmacologic therapy for IBS with diarrhea

A

Imodium
Rifaximim (abx)
Alosetron (women only-risk management)
Viberzi

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23
Q

Pharmacologic therapy for IBS with psychosocial problems

A

TCAs

Off label meds

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24
Q

Most common digestive complaint in general population

A

Constipation

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25
Q

Risk factors of constipation

A

Improper diet and inadequate fluids
Sedentary lifestyle
Polypharmacy
Age

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26
Q

Categories for the etiology of constipation

A 
Functional
Medication Induced
Slow transit
Defecation/ obstructive disorders
Metabolic/systemic disease
Others (IBD, volvulus)
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27
Q

Functional causes of constipation

A

Chronic idiopathic constipation

IBS-C (constipation and pain predominant)

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28
Q

Mediation causes of constipation

A 
Opioids
Anticholinergics
Antipsychotics
Iron
Antacids (Ca, Al)
CCBs
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29
Q

Slow transit cause of constipation

A

Colonic inertia (does not propel well)

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30
Q

Defecation/obstructive disorders associated with constipation

A 
Pelvic floor dysfunction
Anorectal disease
Rectal prolapse or rectocele
Colon cancer
Polyp
Stricture/stenosis
Fecal impaction/obstruction
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31
Q

Metabolic/systemic causes of constipation

A 
Hypercalcemia and hyperparathyroidism
Hypothyroidism
DM
Pregnancy
Hirschsprung
MS
Parkinsons
Spinal cord injuries
32
Q

Important questions not to be missed when taking history for constipation

A 
Laxative use (chronic makes colon flaccid)
Need for digital evacuation
Previous colonoscopy
Ref flag sxs/ alarm features
*reconcile meds, review PMH
33
Q

How do we define constipation?

A 
1/4 of defecations are associated with:
<3 spontaneous DMs/ wk
Lumpy or hard stools
Straining
Manual maneuvers
Sensation of anorectal obstruction/blockage
Sense incomplete evacuation
34
Q

Presentation of constipation

A

Maybe GI sxs (abdominal pain/bloating, pain on defecation, rectal bleeding, tenesmus- anal quivering)

35
Q

Alarm sxs/red flags associated with constipation

A 
Acute onset
Sxs onset after 50
Fevers/vomiting
Unexplained weight loss
Melena, hematochezia, occult blood
Personal or FH of colon CA, IBD or Celiac
Unexplained IDA
36
Q

PE for constipation

A

Usually benign
Abd exam (look for distension or masses)
DRE looking for fissures, hemorrhoids, masses, tenderness, stool, strictures, tone, perianal descent, dyssynergic defecation
PE to r/o rectocele

37
Q

Workup when someone presents with constipation and alarm sxs

A

Imaging

Colonoscopy of flex sig/BE (ID lesions that narrow or occlude bowel)

38
Q

Management of constipation

A

Treat secondary causes (reconcile meds etc)
Dietary, lifestyle, behavior
Med therapies

39
Q

Lifestyle modifications for constipation

A

Increase fluid and fiber intake
Increase activity and exercise
Bowel habit training
Biofeedback help with defecatory dysfunction

40
Q

Med therapy for constipation

A

Fiber supplements
Stool softeners
Osmotic and stimulant laxatives
Rx agents

41
Q

Adverse effects of fiber supplements

A

Flatulence, bloating and distension

Psyllium, Methylcellulose, Polycarbophil, Benefiber

42
Q

Adverse effects of stool softeners

A

GI cramping

Docusate

43
Q

Adverse effects of osmotic laxatives

A

GI discomfort and bloating

*Caution with Mg-containing laxatives and hypermagnesemia with renal insufficient pts

44
Q

Adverse effects of stimulant laxatives

A

Cramping, lyte distubances, melanosis coli (pigmentation)

Bisacodyl, Senna

45
Q

Adverse effects of rx agents for constipation

A

Diarrhea

Lubiprostone, linaclotide, plecanatide

46
Q

Complications of constipation

A

Hemorrhoids/anal fissures
Fluid and electrolyte abnormalities from laxatives
Fecal impaction leading to bowel obstruction

47
Q

Pts at high risk for fecal impaction

A

Pts with dementia, neurologic disease, immobile or on hypomotility meds

48
Q

Signs of fecal impaction/bowel obstruction

A

N/v, abd pain, distension, paradoxical diarrhea

49
Q

What is diarrhea?

A

Pass >3 unformed stools/day

50
Q

Timing classification of diarrhea

A

Acute is <14 days
Persistent is 14-30 days
Chronic is >30 days

51
Q

Most common etiology of acute diarrhea

A

Viral infectious

52
Q

Can’t miss questions in history of diarrhea

A

Normal pattern
Previous colonoscopy
Red flag sxs
Exposures!

53
Q

Alarm sxs/ red flags for diarrhea

A 
Sxs onset after 50?
Persistent, progressive, nocturnal sxs
Immunocompromised
Fevers
Unexplained weight loss
Melena, hematochezia, occult blood
Personal or FH of colon CA, IBD or Celiac
Unexplained IDA
Signs of vol depletion
54
Q

What might be considered an exposure in acute diarrhea?

A 
Recent hospitalization or abx use
Travel history
Ingestion of improperly stored or prepared food
Sick contacts or community exposure
Pets/animals
New meds or dose changes
Public health (healthcare, day care)
55
Q

Presentation of non-inflammatory diarrhea

A

Watery, nonbloody diarrhea with n/v
Mild, diffuse abd cramps and bloating/flatulence
Maybe low grade fever

56
Q

Common etiologies of noninflammatory diarrhea

A

Norovirus

Giardia

57
Q

Presentation of inflammatory diarrhea

A

Fever, bloody diarrhea, severe abd pain

58
Q

Common etiologies of inflammatory diarrhea

A

Bacterial!! (salmonella, campylobacter, shigella, E coli, C diff)

59
Q

What to focus on with PE of diarrhea

A

Volume status and complications

60
Q

Diagnostics for diarrhea?

A

Not for most pts

Some as needed (CMC/CMP, stool studies, imaging)

61
Q

Who needs a prompt evaluation of acute diarrhea?

A 
Signs of inflammatory diarrhea (Fever >101.3, leukocytosis, bloody diarrhea, severe abd pain)
Intractable vomiting
Profuse watery diarrhea and dehydration
AKI/lyte abnorms
Elderly or nursing home
Immuncompromised
Hospital acquired
62
Q

Management for acute diarrhea

A

Mostly supportive care and sx relief:
Oral rehydration, trial of lactose free, probiotics maybe or antidiarrheal agents (loperamide, bismuth subsalicylate–not for pt with dysentery)

63
Q

Adverse effect of peptobismol

A

(Bismuth subsalicylate)

Black stool

64
Q

Antibiotic therapy for acute diarrhea

A

Usually not b/c most are self-limited

Some need specific abx but can used empiric abx (FLQ for 5 days or azitrho)

65
Q

Diarrhea associated with vibrio cholerae

A

Rice water stools

66
Q

Food borne sources of non-inflammatory diarrhea

A

C. perfringens
S. aureus
B. cereus

67
Q

Source of giardia exposure

A

Camping, lakes, streams, ponds, daycares, pools (fecal-oral)

68
Q

Source of salmonella exposure

A

Poultry and livestock, reptiles

69
Q

What can campylobacter infection be associated with?

A

Guillain-barre syndrome

70
Q

What is shigella associated with?

A

Classic dysentery

71
Q

Presentation of e. coli infection

A

Severe afebrile bloody diarrhea

72
Q

Why can you not give abx to e coli infection?

A

Risk of HUS

73
Q

Source and tx of C dif infection

A

Recent hospitalization or abx use (can be community acquired)
Vanco, fidaxomicin, metronidazole

74
Q

Source of vibrio parahemolyticus exposure

A

Raw seafood or shellfish

75
Q

Presentation of versinia enterocolitica infection

A

Mimics appendicitis

76
Q

Clue for ZES

A

Diarrhea unrelieved with fasting

X Clin Med III Exam I (5 decks)

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