IBS/Pilonidal disease Flashcards
Irritable Bowel Syndrome (IBS)
General
Most common cause of chronic or recurrent abdominal pain in the United States
Functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause
♀>♂
Symptoms usually begins in late teens to early 20s
IBS
patho
Proposed pathogenic mechanisms
Abnormal Motility
↑ Frequency of luminal contractions in the intestines
↓ Transit → irritable bowel syndrome (IBS) with constipation
↑ Transit → irritable bowel syndrome (IBS) with diarrhea
Visceral Hypersensitivity (hyperalgesia)
↑ Sensitivity to normal abdominal and rectal distension
↑ Sensitivity to bloating and gas
Intestinal Inflammation
Dietary factors, medications (antibiotics), or infections trigger inflammation
↑ Lymphocytes and mast cells have been noted in the bowel
Psychosocial Abnormalities
> 50% have underlying depression, anxiety, or somatization disorder
Other factors under investigation:
Altered fecal flora, food allergies, malabsorption, genetics
IBS
classifications
IBS is classified based on the clinical presentation
IBS with diarrhea:
Loose or watery stools
Frequent bowel movements (> 3/day)
Fecal urgency +/- incontinence
IBS with constipation:
Hard or lumpy stools
Infrequent bowel movements (< 3/week)
Straining during defecation
IBS with mixed bowel habits:
Presents with both diarrhea and constipation
Unclassified IBS:
Insufficient abnormality in the stool consistency or frequency to meet criteria for the other types
IBS
Clin man
Other signs and symptoms
Short-chain carbohydrates are often triggers
lactose and fructose
Chronic abdominal pain
Intermittent, crampy, and frequently in the lower abdomen
Associated with altered bowel habits
May improve or worsenwith defecation
Abdominal distension or bloating
IBS
Extraintestinal symptoms
Generalized pain (fibromyalgia)
Fatigue
Sleep disturbances
Chronic headache
IBS
Red flags/alarm Sx
Alarm features that suggest an alternative diagnosis and warrant further investigation
Weight loss or anorexia
Fever
Anemia
Rectal bleeding
Nocturnal diarrhea
Severe constipation or diarrhea
Progressive symptoms
Acute onset of disease, or onset in older patients
IBS
Criteria for Diagnosis
Irritable bowel syndrome is a diagnosis of exclusion
Rome IV criteria provides a standardized symptoms-based criteria for diagnosis:
Onset ofabdominal painis ≥ 6 months prior to diagnosis
Recurrent abdominal pain that lasts at least 1 day per week during the previous 3 months
Is associated with 2 of the following 3:
Pain related to defecation
Pain associated with change in stool frequency
Pain associated with change in consistency of stool
IBS
Labs
Obtained to rule out organic causes of disease:
Complete blood count (iron deficiency anemia)
Fecal calprotectin (Inflammatory bowel disease)
Serological markers for celiac disease
Thyroid-stimulating hormone (hyperthyroidism or hypothyroidism)
Stool ova and parasites (Giardia)
Stool culture (other infectious causes)
IBS
Imaging
Abdominal radiograph
Performed in patients with constipation
Determines the severity of constipation
Rules out stool impaction
Colonoscopy with biopsy
All patients should have age-appropriate cancer screening
Use is based on the patient’s presentation (exclude malignancy and IBD)
IBS
general Tx
Education and support for the patient
Daily physical activity
Normal diet
Daily recommended fiber intake
Avoid alcohol and caffeine
Maintain proper hydration
Exclude gas-producing foods (beans, cabbage, and fermentable carbohydrates)
Reduce intake of sweeteners
IBS
Pharm Tx
Selected based on symptoms
IBS-D: antidiarrheal agents (loperamide)
IBS-C: osmotic laxatives (polyethylene glycol)
Antispasmodic agents(dicyclomine)
↓Smooth muscle contraction and visceral hypersensitivity
Tricyclic antidepressants (amitriptyline)
↓ Intestinal transit (use with caution inconstipation)
Pilonidal Disease
general
Spectrum of clinical presentations, ranging from asymptomatic hair and skin debris containing cysts and sinuses to large symptomatic abscesses
Occurs most often at or near the upper part of the gluteal (natal) cleft of the buttocks
Acute or chronic disease
Mean age at presentation:
♀ age 19
♂ age 21
2-3x > in males
Pilonidial disease
RF
Overweight/obesity
Local trauma or irritation
Sedentary lifestyle
Deep gluteal cleft
↑ hair density in the affected region
Family history
Male gender
Characteristics of a person’s hair
Poor personal hygiene
Pilonidial disease
patho
Specific mechanism is unclear
Contributing factors: hair and inflammation in the gluteal cleft
Sitting/bending stretches the skin over the cleft, damaging or breaking hair follicles and opening a pore (pit)
Pore collects debris
Hairs are drawn deeper into the pore and friction with movement causes the hairs to form a sinus and “cyst”
A cyst that becomes infected develops into an acute subcutaneous abscess
pilonidial disease
Acute vs chronic
Acute
Sudden onset of mild-to-severe pain in the intergluteal region with sitting and movement
Tender, fluctuant mass in or near the top of the natal cleft with or without overlying erythema
Fever and malaise are associated with an undrained abscess
Abscess with mucoid, purulent, and/or bloody drainage
Chronic
Recurrent or persistent pain
One or more areas of drainage
pilonidial disease
DDx
Differential Diagnosis
Perianal abscess
Anorectal fistula
Perianal complications of Crohn’s disease
Skin abscess
Furuncle/Carbuncle
Hidradenitis suppurativa
pilonidial disease
Acute abscess Tx
Incision and drainage (I&D) performed over the area of maximal fluctuance
Debridement of all inflammatory debris and visible hair
Wound packed with gauze
Healing by secondary intention
60% successful healing; 40% 2nd procedure to address excess granulation before healing
