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GI Week 3 > ICL 15.2: IBS and Constipation > Flashcards

ICL 15.2: IBS and Constipation Flashcards

1
Q

what are functional gastrointestinal disorders?

A

FGIDS are disorders, not a disease!!

they’re functional disorder so there’s not structural or biochemical abnormalities which means there will be normal x-rays, blood tests and endoscopies

they can affect any part of the GI tract

considered a disorder of the mind gut axis

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2
Q

what are the most common functional gastrointestinal disorders?

A
  1. irritable bowel syndrome

altered bowel habits combined with abdominal pain/bloating that’s usually relieved with BM

  1. functional dyspepsia

ulcer-like symptoms with upper-GI pain/indigestion/discomfort/fullness +/- nausea, soon after eating

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3
Q

who is affected by IBS?

A

affect 5-20% of population

females > males (1.5-2:1)

younger > Older (50% <35 y/o)

affects lower socioeconomic groups more

PCP: 12%, GI practices : 28% - 50%

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4
Q

how do you diagnose iBS?

A

Rome criteria

recurrent abdominal pain, on average of at least 1 day per week in the last 3 months, associated with two or more of the following:

  1. pain with defecation
  2. onset associated with a change in frequency of stool
  3. onset associated with a change in form of stool

criteria needs to be fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

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5
Q

what is the pathophysiology of IBS?

A

PSYCHOSOCIAL FACTORS
1. life stress

  1. psychologic state
  2. coping ability
  3. social support

PHYSIOLOGY
1. motility

  1. sensation

EARLY LIFE
1. genetics

  1. environment

FGID
1. sypmptom experience

  1. behavior

patients have more sleep issues and somatic pain which all leads to a decreased quality of life and they’re hard to manage because there’s so many different components to try to have to manage because you have to manage the whole brain-gut axis

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6
Q

how are IBS patients hypersensitive?

A

if you post a balloon in their colon they’ll be more uncomfortable but the same happens when you put their hand in an ice bucket so they’re just really hypersensitive

also if you put the balloon in different parts of the colon, they have referred pain in larger areas of their abdomen in comparison to normal people

so they’re just really hypersensitive to pain so they report pain more often than normal patients with the balloon insertions

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7
Q

what are the subtypes of iBS?

A

they’re based on stool consistency

IBS-C = constipation predominant IBS

IBS-D = diarrhea predominant IBS

IBS-M = mixed-IBS with both diarrhea and constipation

IBS-U = unclassified IBS

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8
Q

what are the different types of stool consistency?

A

type 1 = separate hard lumps = severe constipation

type 2 = lumpy and sausage like = mild constipation

type 3 = sausage shape with cracks in the surface = normal

type 4 = smooth, soft sauce or snake = normal

type 5 = soft blobs with clear cut edges = lacking fibre

type 6 = mushy consistency with ragged edges = mild diarrhea

type 7 = liquid consistency with no solid pieces = severe diarrhea

IBS-D has types 5-7 more than 25% of the time and IBS-C has types 1 and 2 and IBS-M it has both

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9
Q

what is the clinical presentation of IBS?

A
  1. chronic abdominal pain
  2. bloating
  3. altered bowel habits

in the absence of red flags***

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10
Q

what are the red flags that would make something not IBS?

A
  1. unintended weight loss
  2. blood in the stools not caused by hemorrhoid or anal fissures
  3. abnormal labs = anemia, hypoalbuminemia, liver tests, elevated CRP or ESR
  4. fever
  5. family history of GI cancer, IBD or celiac disease
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11
Q

how do you workup someone who you think has IBS if there aren’t alarm signs?

A
  1. PE
  2. complete blood count
  3. stool for occult blood
  4. routine colorectal cancer screening if over 50
  5. blood tests
  6. fecal calprotectin
  7. check stool of C/S, ova and parasites if they’re having diarrhea
  8. diagnostic colonoscopy if poor response to treatment

CT scans should not be routinely performed in iBS patients unless they have alarm features

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12
Q

what characteristics of a patient presentation would suggest that they don’t have IBS?

A
  1. onset in old age
  2. steady progressive course
  3. frequent awakening by pain
  4. weight loss not attributed to depression
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13
Q

what do you need to do to diagnose IBS-D?

A
  1. stool cultures: little role in chronic diarrhea (except for Giardia).
  2. celiac disease: screening with serum TTG IgA
  3. 24 hour stool collection: if osmotic, secretory or malabsorptive diarrhea is suspected
  4. colonoscopy or flexible sigmoidoscopy & biopsy: rule out microscopic colitis
  5. radiography: a plain film of the abdomen can detect retained stool, (constipation)
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14
Q

which diseases mimic IBS-D?

A

I = intolerances, especially carbohydrates

B = bacterial overgrowth/dysbiosis

S = sprue and maybe gluten sensitivity

D = drugs, alcohol and laxative

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15
Q

what is post-infectious IBS?

A

20% of IBS patients describe acute infectious prodrome

occurs in 5-25% after bacterial enteritis and is mostly diarrhea predominant

can occur after most after most enteric pathogens (bacterial & viral) and after antibiotic treatment

more common in females

long duration of diarrhea (eventual resolution not certain but more likely than in non-PI-IBS)

occurs in subjects with anxiety, depression

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16
Q

what does CIC stand for?

A

chronic idiopathic constipation

no reliable radiologic, endoscopic, biomarkers abnormalities…

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17
Q

what is chronic idiopathic constipation?

A

infrequent or difficult evacuation of stool

normal stool frequency is three times weekly to as frequently as twice daily so infrequency is two or fewer times a week

difficult evacuation, less clearly defined but encompasses inability to initiate or complete evacuation, excess straining, or feeling of incomplete evacuation

hard stool definition varies and is subjective… but it’s stool that’s physically hard or hard to pass

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18
Q

how is stool formed?

A

approximately 1L fluid daily reaches the cecum:

derived of water, insoluble fiber and salts

during the next 24-30hrs 90% of water and salts are reabsorbed

fiber is fermented into gas

yield is 80-120g/24hrs feces

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19
Q

how does the gut move?

A

phasic contractions and background contractility

there are high amplitude propagated contractions contribute to mass movements

parasympathetic (+)

sympathetic (-)

external Sphincter is voluntary

ascending and transverse colon act as depot for stool

transit ~12 hours/segment

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20
Q

what is the pathophysiology of CIC?

A

it’s due to altered signalizing in the GI tract!!
1. defects in mucosal serotonin/ACh

  1. altered numbers of EC cells
  2. altered levels of serotonin transporters

this all leads to altered GI physiology like altered motility, altered sensitivity, and altered secretion which can result in chronic constipation or IBS-C

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21
Q

what populations are moe likely to have constipation?

A
  1. females
  2. older subjects (increases with age)
  3. lower socioeconomic status.
  4. linked to impaired quality of life
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22
Q

what are the 2 posible categories of constipation?

A

IDIOPATHIC
1. slow transit constipation

  1. functional outlet
  2. obstruction
    obscure

SECONDARY
1. metabolic

  1. endocrine
  2. smooth muscle isorders
  3. CNS Disorders
  4. peripheral nervous
    system Disorder
  5. stenosis/obstruction
  6. painful anal lesions

RULE OUT THE SECONDARY CAUSES FIRST!!

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23
Q

what are the endocrine causes of constipation?

A
  1. hypothyroidism

2. DM

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24
Q

what are the metabolic causes of constipation?

A
  1. hypercalcemia

2. hypokalemia

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25
Q

what are the neurologic causes of constipation?

A
  1. Parkinson’s
  2. multiple sclerosis
  3. spinal cord lesions
  4. cerebrovascular accident
  5. muscular dystrophy
  6. autonomic myopathy
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26
Q

what are the rheumatologist causes of constipation?

A
  1. systemic sclerosis
27
Q

what are the psychosocial causes of constipation?

A
  1. depression

2. eating disorders

28
Q

what are the medication causes of constipation?

A
  1. narcotics
  2. anticholinergenics
  3. antipsychotics
  4. calcium channel blockers
  5. anti-Parkinson’s therapy
  6. anticonvulsants
  7. tricyclic antidepressants
  8. iron
  9. calcium
  10. aluminum antacids
  11. sucralfate
29
Q

what is the ROME0IV diagnostic criteria for chronic idiopathic constipation?

A

presence of difficult stool passage with symptoms for 3 months with onset more than 6 months ago

during at least 25% of their defections, there must be 2+ of the following:
1. straining

  1. lumpy or hard stools
  2. sensation of incomplete evacuation
  3. sensation of anorectal obstruction/blockage
  4. manual maneuvers to facilitate defecation
  5. less than 3 delectations per week
30
Q

how do you dignase CIC?

A

if they meet the ROME-IV criteria then you look for an abnormal balloon expulsion test or abnormal anorectal manometry or anal surface EMG.

31
Q

what is the ROME clinical friendly definition for IBS and CIC?

A

IBS : abdominal discomfort/pain associated with altered bowel habits

CIC: unsatisfactory defecation that is characterized by infrequent stools, difficult stool passage, or both

32
Q

how can you differentiate CIC and IBS-C?

A

CIC
must include 2+:
1. hard or lumpy stool

  1. straining
  2. incomplete evacuation
  3. sensation of anorectal obstruction/blockage
  4. manual maneuvers
  5. < 3 defecations/week
  6. pain not usually present

IBS-C
recurrent abdominal pain/discomfort with:
1. change in pain with defecation

  1. onset associated with change in frequency of stool
  2. onset associated with change in form (appearance) of stool
33
Q

what are the different diagnostic tests you can do for IBS or CIC?

A
  1. anorectal manomety
  2. balloon-expulsion
  3. colonic-transit study
  4. defecography
34
Q

what is anorectal manometry and what is it used for?

A

a pressure-sensitive catheter is inserted into the anus to measure resting and squeeze pressures of the sphincter

normally there is an increased pressure in the rectum and decrease in the anal canal as stool moves out but with anorectal dyssynergia there’s no increased pressure in the rectum and the anal canal pressure remains elevated

assesses the internal and external anal sphincters, pelvic floor, and associated nerves

35
Q

what is a balloon-expulsion test and what is it used for?

A

a balloon with 50 ml of water or air is inserted into the rectum and then the patient is asked to expel the balloon –> if they expel within 1 minute that’s normal and more than 2 minutes is abnormal

helps detects defecatory disorders and is a simple, office-based screening test

sensitivity 88%, specificity 89%, PPV 67% and NPV 97%

36
Q

what is a colonic-transit study and what is it used for?

A

the patient swallows a capsule filled with radiopaque markers and then serial abdominal radiographs are taken 120 hours later

ingesting 24 plastic markers with xrays on day 1 & day 6 (120 hours) <20% should be present at day 6

it measures rate at which fecal residue moves through colon

37
Q

what is a defecography and what is it used for?

A

thickened barium is instilled into the rectum and then radiographic films are taken during defecation

it detects structural abnormalities of the rectum –> provides useful evaluation of prolapse

38
Q

what is the finger test?

A

put your finger in someones rectum and feel for something abnormal which means you probably need to do a more invasive modality

39
Q

how do you generally manage iBS?

A
  1. avoid narcotics!! they cause constipation
  2. patient education about exercise and stress reduction
  3. fiber supplements
  4. diet
  5. anticholinergic medications
  6. avoid antidepressants
  7. antibiotics
  8. serotonergic tangents and prosecretory agents
40
Q

what are the dietary interventions for iBS?

A
  1. gluten free
  2. FODMAP
  3. lactose free diet
  4. exclusion of gas producing foods = beans, onions, celery, car
41
Q

what is a FODMAP?

A

fermentable oligo-di- and monosaccharides and polyps

huge change in IBS symptoms just by trying a low FODMAP diet!

the theory is that there is impaired absorption of the FODMAPS that leads to intestinal fermentation of the carbohydrates by gut bacteria which leads to symptoms and increased intestinal permaeability

people who do a low FODMAP diet have improved pain, bloating, passing of satisfaction with stool consistency

42
Q

what is non-celiac gluten sensitivity?

A

gut and other symptoms that respond to a gluten-free diet; wheat allergies are excluded

they do not fulfill criteria for Celiac disease

there’s no real way of determining that gluten is inducing the symptoms because there’s no biomarkers so it’s all symptom based and a lot of people feel better when they’re put on a gluten free diet

up to 13% of the population has some gluten sensitivity! but 20% of these people actually have Celiac

43
Q

what medication do you treat IBS-C with?

A

Prosecratory:

  1. linactolide
  2. plecanatide
  3. lubiprostone
44
Q

what medication do you treat IBS-D with?

A
  1. rifaximin 550mg tid x 2 weeks
  2. ntidepressants:
    TCAs
    SSRIs
  3. eluxadoline (ópiod derivative)
  4. alosetron
45
Q

what medication can you treat any type of IBS with?

A

antispasmodics:

  1. otilonium
  2. pineverium
  3. hyocine Bromide
  4. cimetroprium bromide
  5. drotaverine
  6. dicyclomine hydrochloride
  7. peppermint oil
46
Q

how do you treat CIC?

A
  1. fiber supplements
  2. osmotic laxatives
  3. stimulate laxatives
  4. PEG
  5. prosecretory: lubiprostone linaclotide prucalopride
47
Q

what classes of laxatives are there?

A
  1. bulk agents
  2. non absorbed substances
  3. diphenylmethanes
  4. anthraquinone
  5. secretory drugs
48
Q

what non absorbed laxatives are there?

A
  1. PEG (polyethylene glycol)

2. lactulose

49
Q

what bulk agent laxatives are there?

A
  1. psyllium
  2. methylcellulose
  3. calcium polycarbophil
  4. wheat dextrin
50
Q

what anthraquinone laxatives are there?

A

senna

51
Q

what secretory drug laxatives are there?

A
  1. lubiprostone
  2. linaclotide
  3. plecanatide
52
Q

what are the benefits of using PEG?

A

polyethylene glycol improves stool frequency only in CIC

may not alleviate abdominal pain

53
Q

what are the benefits of using lubiprostone? what are the side effects and MOA?

A

selectiveC-2 chloride channel activators so it releases a bunch of Cl into the glut which is then followed by water which drives stool motility

relief of IBS symptoms in female IBS-C patients

may cause nausea, diarrhea, abdominal pain, and headache, teratogenic risks

54
Q

what are the benefits of using linaclotide? what are the side effects and MOA?

A

guanylate cyclase agonists which drives HCO3 excretion which is also followed by water –> on the nonluminal side it induces NO which relaxes the nerve and helps with IBS-C pain!

relief symptoms of IBS-C

long-term risks are unknown, severe uncontrolled diarrhea

55
Q

what are the benefits of using prucalopride? what are the side effects and MOA?

A

5-HT4 receptor agonist

relief of symptoms of CIC

suicidal ideation, nausea and diarrhea

56
Q

how do you treat long term CIC?

A

subtotal colectomy for colonic intertia

this is only for patients with severe intractable and disabling symptoms

they can’t have evidence of intestinal pseudo-obstruction and must have anorectal function

57
Q

how do you workup refractory constipation?

A

when you start a patient on treatment for CIC, start with fibers and laxatives first

then you do anorectal manometry and balloon expulsion test and if both are normal you look at clonic transit – if it’s slow you see if you can medically manage it or if you need a partial colectomy but if they’re normal then it’s IBS-C –> if they’re abnormal then you refer to biofeedback which teaches the pelvic floor how to respond properly which usually helps a lot of people –> if the two tests don’t match do defecography to figure out specifically where is messed up

58
Q

what is biofeedback treatment for CIC?

A

for pelvic floor dysfunction (dyssynergia).

biofeedback, performed by a trained and skilled therapist

59
Q

how do you medically and dietary treat IBS-D?

A

DIETARY

  1. gluten free
  2. low FODMAP

MEDICATION

  1. tricyclics
  2. rifaximin
  3. eluxadoline
60
Q

what is eluxadoline?

A

Mu and Kappa agonist, delta antagonist so it acts like an opioid without giving the high

good for treating IBS-D

contraindication: patients at risk for pancreatitis or have had their gallbladder removed

61
Q

if someone has chronic constipation what is the differential and how would you treat each?

A
  1. slow transit/functional constipation –> treat with linaclotide, lobiprostone, prucalopride, PEG, or laxatives
  2. IBS-C normal transit –> treat with llinaclotide, lobiprostone, SSRI, or laxatives
  3. dyssynergic defecation –> biofeedback therapy
62
Q

what drugs are used for iBS-C treatment?

A
  1. linaclotide*
  2. lubiprostone*
  3. CBT/hypnotherapy
  4. diet modification
  5. SSRIs
  6. probiotics
  7. elobixibat
63
Q

what drugs do you use to treat IBS-D?

A
  1. CBT/hypnotherapy
  2. diet
  3. rifaximin*
  4. TCAs
  5. enterra-GAM*
  6. eluxadoline*
  7. alosetron*
  8. probiotics
  9. IBgard

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