Irritable bowel syndrome

Question 1

Rome 4 criteria for diagnosis of irritable bowel syndrome

Answer 1

abdominal pain at least 1 day per week (or >3 days/month) for last 3 months with 2 out of the 3 symptoms:

1. pain related to defecation
2. change in stool frequency
3. change in stool character or form

Question 2

how to diagnose irritable bowel syndrome

Answer 2

needs an evaluation to rule out red flag signs like anemia, wt loss, constitutional symptoms (night sweats or fevers, rectal bleeding)

Need CMP, CBC, ESR, CRP, celiac testing, colonoscopy and 24 stool collection for malabsorption or osmotic secretory diarrhea with giardia testing

Question 3

Treatment of irritable bowel syndrome non pharmacological management is

Answer 3

exercise regimen
low FODMAP diet
trial of avoidance of gluten and gas producing foods, increased fluid intake in pts with constipation

best stool softner is psyllium isphaghula - most efficacy without side effects

if not tolerated then can do polyeythlene glycol as a gentle laxative.

Question 4

Does probiotics play a role in treatment of Irritable bowel syndrome?

Answer 4

no. no benefit.

Question 5

Rome 3 criteria for functional constipation:

Answer 5

symptoms present>6 months with full criteria >3 months.

> 2 present for >25% of the bowel movements:
straining with defecation
lumpy or hard stool
sensation of incomplete evacuation
sensation of anorectal obstruction
manual maneuvers required for defecation (digital evacuation)
<3 bowel movements a week
Loose stools are rare unless laxatives are used
does not meet criteria for IBS

Question 6

slow transient constipation treatment

Answer 6

discontinuation of common offending medications (CCB, anticholinergics, opioids, NSAIDS)
increasing dietary fiber/fluids, engaging in daily exercise

Question 7

If non pharmacological methods don’t work, recommend a

Answer 7

bulking agent methylcellulose or psyllium

Question 8

who should get colonoscopy?

Answer 8

alarm features (gross or occult bleeding, acute onset of constipation or mechanical obstruction unexplained weight loss and change in caliber of stool

symptoms refractory to medical management

features of pelvic floor dysfunction (inability to expel stool due to lack of relaxation of pelvic floor muscles.

Question 9

why are not osmotic laxatives (polyeylene glycol) not first line for slow transit constipation?

Answer 9

if used excessively can cause volume overload and electrolyte abnormalities.

Question 10

why do we avoid phosphate enemas?

Answer 10

avoided in older adults due to potential complications of volume depletion, hypotension, and acute phosphate nephropathy. Avoid in CKD.

if enema is needed prefer tap water enema.

Question 11

colon secretagogues like lubiprostone and linaclotide are

Answer 11

used on severe chronic constipation as failure from other methods.

they stimualte intestinal fluid secretion and decrease colonic transit times.

Question 12

Rome diagnostic criteria for irritabile bowel syndrome?

Answer 12

symptom improvement with BM
change in stool frequency of stool
change in form of stool

recurrent abdominal pain/discomfort for >3 days/month for the past 3 months and 2 of the following:

Question 13

warning signs that bowel changes are from something besides irritable bowel syndrome:

Answer 13

rectal bleeding
nocturnal (awakens from or prevents sleep) or worsens abdominal pain
weight loss
abnormal laboratory findings (anemia, or electrolyte issues)

Question 14

classification of IBS:

Answer 14

IBS with constipation: firm or lumpy stools >25% , loose/fluid stools <25%

IBS with diarrhea: firm/lumpy stool<5%, loose/fluid stools >25%

Mixed IBS:
firm/lumpy stools >25%, loose/fluid stools>25%

Undifferentiated IBS:
insufficient abnormality of stool to categorize

Question 15

Evaluation of IBS with diarrhea

Answer 15

stool cultures, celiac cuases
24 hr stool collection
colonoscopy or flexible sigmoidoscopy and biopsy

Question 16

Evaluation of IBS with constipation:

Answer 16

radiography

flexible sigmoidoscopy and colonoscopy

Question 17

what is proctalgia fugax

Answer 17

benign self limited condition of recurrent and severe rectal pain that occurs in 15% of the population.
it’s a functional disorder

diagnosis is through exclusion of other GI causes of anal and rectal pain (hemorrhoids, cryptitis, ischemia, intramuscular abscess, anal fissures, and rectoceles or malignancy.

pathphysiology is via anal sphincter spasm /hypertrophy
pudendal nerve compression, or neuralgia, psychological factors

Question 18

what is proctalgia fugax presentation?

Answer 18

an attack of severe rectal pain that lasts for a few seconds to 2 hours.

pain is unrelated to bowel movements.

Question 19

diagnosis of proctalgia fugax?

Answer 19

• anorectal pelvic exam will be normal
• anorectal manometry - normal and shows elevated internal anal sphincter pressure
• colonoscopy is performed to exclude other diseases and is frequently normal

Question 20

proctalgia fugax must also be differentiated from chronic proctalgia which presents from chronic rectal pain

Answer 20

symptoms of chronic proctalgia must be present for at least 6 months prior to diagnosis.

Question 21

mild proctalgia fugax

Answer 21

no specific treatment except reassurance and explanation of the condition

Question 22

proctalgia fugax treatment

Answer 22

benefit from warm baths

those with psychological dysfunction should be treated appropriately.

Question 23

Treatment of irritable bowel dx: contipation predominant

IBS-c

Answer 23

treat with polyethylene glycol = 1st line

insoluble fiber or psyllium tends to worsen symptoms.