IBS & Perianal Disorders Flashcards
IBS-D
IBS Diarrhoea
IBS-C
IBS constipation
IBS-M
IBS mixed
IBS common presentation
Change in bowel habit
Abdo pain
Bloating
Chronic, relapsing condition
Urgency
Sensation of incomplete emptying
Mucous PR
Aggravated by stress
What are the criteria for IBS?
Pain/discomfort for at least 3 days per month for 3 months
Improvement with defecation
Change of stool habit with onset
Change of stool form
What is IBS associated with (diseases)
Fibroyalgia
Chronic fatigue syndrome
TMJ dysfunction
Chronic pelvic pain
IBS - psychology
Many are depressed/anxious/hypochondriacs
Many have anxiety
Stressed –> more IBS –> MORE stress –> IBS and so on.
IBS history
Bowel habit change
What do they eat? - something may be triggering it
Bloating
Nocturia
Changed your diet?
Triggers?
Opiate use?
Psychological - stress, anxiety
Underlying fears
Alarm features
Age > 50
Short duration of symptoms / sudden onset
Woken from sleep by altered bowel habit
Rectal bleeding
Weight loss
Anaemia
FHx of colorectal cancer
Recent Abx
Investigations for IBS
FBC ESR CRP TTG (coeliac) Lower GI tests if aged > 50 Endoscopy (if alarm symptoms)
Management of IBS
Diet
Regular meal times
Fibre
FODMAP/GFD (gluten free diet)
Eat more vegetables
Stop opiate analgesia (reliance)
Antidiarrhoeal
What drug do you NOT use?
Lactulose
Anti-diarrhoeal - loperamide 1ST LINE
Opiate analogue
Inhibits peristalsis, gut secretions
Benefits diarrhoea
Works quickly
No dependency
PRN use
IBS - antidepressants
Amitryptyline
Reduce diarrhoea
Reduce afferent signals from gut
Help restore sleep pattern
IBS psychological treatment
Severe anxiety/depression
Relaxation therapy
Hypnosis
Probiotic yoghurts
If it helps, it’s worth doing.
Amitryptyline
Anti-depressant
Good therapy for IBS
What kind of stool consistency are you aiming for?
Soft well formed (bristol type 4)
Below the dentate line =
PAINFUL
Perianal conditions - key questiosn
How long have you had symptoms for?
First episode?
Bleeding - fresh? Dark? mixed with stool? dripping in the toilet or just on the paper?
Pain - sharp, dull, how long
Anything protruding?
Any discharge
Haemorrhoids
what are they
Enlarged vascular cushions in the lower rectum and anal canal
Haemorrhoids - presentaiton
Painless bleeding
Fresh, bright red blood, not mixed with stool
Usually on the paper
Perianal itchiness
No change in bowel habit, no weight loss or other associated symptoms
Haemorrhoids - clincial
Obvious haemorrhoids if 3rd degree piles are present
Maceration of peri-anal skin
Must use proctoscope to properly see
Unless they are very large they are difficult to see.
Classic positions of haemorrhoids?
3, 7 and 11 o’clock
in lithotomy position
Investigations - haemorrhoids
PR exam
Rigid sigmoidoscopy
Proctoscopy
Flexible sigmoidoscopy in patients above the age of 50 (cancer)
Management - Haemorrhoids
Symptomatic
Sclerosation therapy
Rubber band ligation
Open haemorrhoidectomy
Stapled haemorrhoidectomy
HALO/THD procedure (haemorrhoids artery ligation)
Above dentate line?
Painless
Rectal prolapse
- partial
- complete
Partial (anterior mucosal prolapse) - more common
Complete (full thickness)
Rectal Prolapse - presentation
Protruding mass from anus (esp during defectation)
May reduce spontaneously
Bleeding and passing mucous PR
Poor anal tone
COMPLETE prolapse - management
Many patients are too frail
Bulking agent and education on manual reduction
Surgery
Biological mesh (pig skin) used
Partial prolapse - management
Children
Adults
Children - dietary advice & treatments for constipation
Adults - treatment similar to haemorrhoids (suturing and pushing back)
Anal Fissure
Tear in anal margin due to passage of constipated stool
Usually in midline, posteriorly but may anterior
Multiple fissures - Crohn’s?
Below dentate line so are painful
Anal fissure - presentation
Acute onset of severe anal pain
Following constipation
“Passing glass”
pain lasts after defecation
Vicious cycle of anal fissures?
They hold on to their poo because they are afraid of the pain
Become more constipated
When they finally go it is very painful
What could multiple anal fissures indicate?
Crohn’s disease
Anal fissure - treatment
Dietary advice
Stool softeners
Lateral sphyncterotomy
Botox injection
Why would a paralytic drug be good for anal fissures?
The blood vessels are spasming because the muscle is spasming (due to pain)
tissue will not heal properly
If you relax the sphincters blood can get to it and allow it to heal
Fistula in ano
Abnormal comm between two epithelial surfaces
internal opening in anal canal and one or more external openings on the peri-anal skin
crohn’s, TB, carcinoma
Fistula in ano - presentation
Majority arise from delay in treatment
Crohn’s
TB
Multiple fistulae could be due to?
Crohn’s
Fistula in ano - Ix
EUA of anorectum (exam under anaesthetic)
Rigid sigmoidoscopy
Proctoscopy
Flexible sigmoidoscopy
MRI
Fistula - management
Laying open
Insertion of seton (draining, cutting)
LIFT procedure
Glue/permacol
Let it heal
Fistula - complications
Pain Bleeding Incontinence of flatus/stool Recurrence Further surgery
