IBS, Diverticular disease & Harmorrhoids Flashcards
What is IBS (3)
- Irritable Bowel Syndrome
- An abnormally sensitive condition characterised by a set of associated symptoms
- Abnormally high sensitivity to natural stimuli: Foods/stress leading to symptoms
What are the main symptoms of IBS (7)
- Abdominal pain/discomfort
- Bloating
- Changes in bowel habit - Diarrhoea or constipation
- mucous in stool
- incomplete evacuation
- Episodes may last days to weeks
- Recur over a long period of time
What risk factors may sensitise the gut (3)
- Gastroenteritis
- Traumatic/upsetting event
- Antibiotics
what can sensitisation of the gut lead to (3)
- Stimulation of gut immune system
- Mild inflammation
- Dysbiosis (depletion of colonic bacteria)
what are the triggers of an IBS flare-up (6)
- Familial link, may be genetic or environment = similar gut bacteria
- Diet and stress most common triggers for a flare up
- Not linked to any serious disease development
- Not linked to any excess death
- 10-20% prevalence
- female to male ratio = ~2.5:1
What are the red flag symptoms of IBS (4)
- Bleeding - Regular rectal bleeding not from Haemorrhoids
- Weight loss - more than 1/2 stone (3 kg) for no reason
- Persistent Fever
- Bowel change - Ongoing change for no reason - Particularly if over 50y/o- bowel cancer risk
What tests are there for IBS (5)
- FBC
- erythrocyte sedimentation rate (ESR)
- C-RP
- antibody for coeliac
- GP diagnosis would rule out bowel cancer, coeliac and IBD leading to cause being IBS
What is the NICE criteria for abdominal discomfort (5)
- Relieved by defaecation OR Associated with altered bowel movements or stool form
And at least two of:
- Altered stool passage
- Abdominal bloating
- Symptoms worse after eating
- Passage of mucus
What is the Rome criteria for abdominal discomfort (5)
- Recurrent abdominal discomfort at least 3 days a month in past 3 months
with two of:
- Relieved by defaecation
- Altered bowel movements
- Altered stool form
- Affected for at least 6 months
How is diet considered with IBS management (4)
- Food allergy rare, must be ruled out (<3%)
- Food intolerance, common, work them out → food/symptom diary
- NICE dietary recommendations
- If NICE fails & under dietician can use FODMAP diet
what are the common IBS flare-up foods (7)
- Coffee
- fizzy drinks
- alcohol
- dairy - particularly cheese
- refined grains (not whole grains)
- high protein diets
- processed foods (e.g. crisps, chips and biscuits)
What are the NICE dietary recommendations for IBS (9)
- Have regular meals and take time to eat
- Drink at least 8cups of fluid per day, ↑ water ↓caffeinated drinks
- Restrict tea and coffee to 3 cups per day
- Reduce intake of alcohol and fizzy drinks
- Limit intake of high‑fibre food
- Reduce intake of digestion ‘resistant starch’ (reaches the colon intact), which is often found in processed or re‑cooked foods
- Limit fresh fruit to 3 portions per day (a portion should be approximately 80g)
- Diarrhoea → Avoid sorbitol (artificial sweetener found in sugar‑free sweets)
- Wind and bloating → eat oats (such as oat‑based breakfast cereal or porridge) and linseeds (up to 1tablespoon per day)
what is FODMAP (8)
- Fermentable
- Oligosaccharides
- Disaccharides
- Monosaccharides
- And
- Polyols
- Poorly absorbed simple and complex sugars (carbohydrates) that reach the colon.
- When in colon: Osmotically draw water in & rapidly fermented by bacteria, releasing gas leading to Bloating, abdominal pain and diarrhoea
What foods are suitable on the low FODMAP diet (5)
- fruit (banana, berries, grapes, oranges, etc…)
- Vegetables (carrot, celery, ginger, green beans, etc..)
- grain foods
- lactose-free milk, hard cheese, brie, ice-cream substitutes
- tofu, sweeteners not ending in ol, honey substitutes
What foods are unsuitable for the low FODMAP diet (5)
- Apple, mango, pear, tinned fruit in natural juice, watermelon, fructose, honey
- milk, cheeses (products containing lactose)
- vegetables containing fructans (asparagus, beetroot, Brussels), cereals
- legumes containing galactan (baked beans, chickpeas, kidney beans)
- apples, apricots, avocado, mushrooms, sweetcorn, sweeteners
How is IBS abdominal pain pharmacologically managed (3)
- Mebeverine - 135 mg TDS, 20 minutes before food
- Hyoscine BUTYLbromide (Buscopan) - 10 mg TDS
- Peppermint oil Colpermin - 1-2 capsules TDS (swallow whole)
How is IBS constipation pharmacologically managed (3)
- Senna (S laxative) - 7.5-15 mg ON
- Movicol (O laxative) - 1 sachet up to three times a day
- Ispaghula husk (BF laxative) - 1 sachet BD
How is IBS diarrhoea pharmacologically managed
Loperamide - 4-8 mg in divided doses (max 16 mg/24hours)
What is the second line pharmacological management of IBS (5)
- if antispasmodics/ laxatives/antidiarrhoeals failed:
- 1st line: Tricyclic antidepressants (TCAs) e.g. Amitriptyline 5-10mg ON and increase to 30mg ON
- 2nd line: Selective serotonin reuptake inhibitors (SSRIs) e.g. Citalopram, Fluoxetine, paroxetine
- Finally try cognitive behavioural therapy (CBT) or/ & hypnotherapy for people with IBS who do not respond to pharmacological treatments after 12months and who develop a continuing symptom profile
- those who wish to purchase and try probiotics need to do so for a minimum of 4/52 (4 weeks)
What is Diverticular disease (3)
- Small bulges or pockets (diverticula) develop in the lining of the large intestine
- 80% with disease asymptomatic → diverticulosis
- Common symptoms of the disease are abdo pain and bloating
What are the pre-disposing factors of diverticular disease (3)
- Age 50-70 y/o (intestine becomes weaker with age, pressure of hard stools causes the bulges to form
- Low fibre diet
- Westernised countries
what is diverticulitis (4)
- pockets become infected, known as diverticulitis.
Then serious symptoms
- pyrexia
- severe abdo pain
- diarrhoea
How is Diverticular disease diagnosed (2)
- Often made based on symptoms
- gold standard – colonoscopy or CT scan
What is the differential diagnosis of diverticular disease (what else could it be?) (3)
- IBD
- IBS
- bowel cancer
What are the preventative measures/pharmacist input of diverticular disease (4)
- keep stools soft and moving
- High fibre diet
- Stool softeners (laxatives)
- Adequate liquid intake
How is diverticular disease managed (5)
- Diet and fluids
- Antibiotics
- Iron replacement (if self-limiting bleed)
- Severe (hosp.): NBM, IV fluids, IV Abx, Analgesics
- Severe (rare) surgery - Resection, Hartmann’s procedure
what are haemorrhoids (4)
- a.k.a. Piles.
- Ball-shaped prolapsed anal cushion filled with enlarged blood vessels.
- Not varicose veins
- Anal cushions: vascularised areas aiding opening/closing
what are the different types of haemorrhoids (2)
- Internal - Start above the dentate line, Painless unless prolapse through the anus. 4 classifications
- External - Start below the dentate line, More often painful due to thrombosis, Do not “reduce” into the rectum as for internal
what are the different types of internal haemorrhoids (4)
1st degree - Remains in rectum
2nd degree - Prolapse through anus on defecation- spontaneously reduce
3rd degree - As for 2nd degree but requires digital reduction (pushing in)
4th degree - Persistently prolapsed
what contributes to the development of haemorrhoids (7)
- Age-related degeneration
- Hard stools/straining at defecation
- Will be experienced by around ½ of all people
- Can occur at any age, but rare <20
- More common as age
- Men=women
- Common in pregnancy
what are the signs and symptoms of haemorrhoids (8)
- Bright red blood on toilet paper often simply haemorrhoids but blood = referral if unsure of cause
- An itchy anus
- Urge to “go” even after defecation
- Mucous in underwear and/or when wiping
- Lumps around anus
- Pain around anus
- Dull ache, often worse when defecating (delay can lead to constipation)
- Often intermittent symptoms lasting a few days – few weeks
What questions are asked when suspecting haemorrhoids (7)
- Duration. If over 3 weeks → refer to GP
- Pain. Usually dull and worse of defecation. If “sharp” or “stabbing” → refer to GP as may suggest anal tear or fissure
- Other symptoms. Should be local (itching, pain), any systemic involvement (nausea, vomiting, low appetite, constipation, diarrhoea) → refer to GP
- Diet. Make sure they are having enough fibre and fluids
- Happy it’s haemorrhoids - offer 7 days treatment (next slide)
- Over 7 days and no better? refer to GP - rule out other causes or future treatment (e.g. ligation, surgery…)
- Under 20- consider other diagnoses (constipation or threadworm) or refer
what are the warning signs of haemorrhoids (6)
- Persistent change in bowel habits >40 yo - potentially cancer
- Unexplained rectal bleeding - potentially cancer
- Have to “reduce” manually - OTC won’t help
- Severe or sharp pain - tear/fissure
- Blood mixed into stool - IBD or GI bleed
- Fever - IBD or GI bleed
What are patients advised to do to manage haemorrhoids (8)
- ↑ fluid and fibre
- Use damp toilet wipes
- Take paracetamol if needed
- Warm bath to ease itching/pain
- Ice pack in towel for pain
- Gently push a pile back inside
- Keep bottom clean and dry
- Reduce caffeine (constipation)
What are patients advised NOT to do to manage haemorrhoids (6)
- Wipe too hard
- Ignore the urge to poo (can lead to constipation)
- Push to hard when pooing
- Take any opiate painkillers
- Take ibuprofen if piles are bleeding
- Linger on the toilet
What pharmacological intervention is there for haemorrhoids (4)
- Lidocaine, benzocaine and cinchocaine - Germoloids (cream, ointment, suppository) - Apply at least twice a day, ideally after a bowel movement
- Bismuth, zinc, allantoin, peru balsam - Anusol (cream, ointment, suppository) - Apply morning and night and after each bowel movement
- Hydrocortisone - Anusol Plus HC (ointment or suppository) - Apply morning and night and after each bowel movement (max. QDS)
Not in pregnancy/breastfeeding - Shark liver oil, lauromacrogol, yeast cell extract. No evidence for their use but may be in other combination products
