Lecture 7.2: Other Disorders of the Bowel Flashcards
What is Constipation?
- Difficulty with defecation
- Infrequent and/or hard to pass stool
- Rome IV criteria: <3x a week
- Sensation of incomplete evacuation or anorectal
blockage
What is Chronic Constipation?
Constipation for >3months
What is Faecal Loading/Impaction?
Retention of faeces to the extent that spontaneous evacuation is unlikely (might require manual disimpaction)
What is Functional (primary or idiopathic) Constipation?
Chronic constipation without a known cause
What is Secondary Constipation?
Cause by medication or an underlying condition
How much higher is constipation in women than in men?
2-3 times
Risk Factors for Constipation: Social (7)
- Low Fibre/Calorie Diet
- Access to Toilet
- Reduce Exercise
- Privacy when Toileting
- Low Educational Levels
- Socio-Economic Deprivation
- Family History
Risk Factors for Constipation: Psychological (4)
- Anxiety
- Depression
- Eating Disorders
- Abuse
Risk Factors for Constipation: Physical (6)
- Female Sex
- Older Age
- Pyrexia
- Poor Fluid Intake
- Immobility
- Sitting Position on Toilet Seat
What are the 2 categories of Secondary Causes of Constipation?
- Organic Causes
- Medication Related
Secondary Causes of Constipation: Medications (7)
- Opiates
- Tryciclics
- NSAIDs
- Antihistamines
- Iron Supplements
- Beta-Blockers
- Calcium Channel Blockers
What are Organic Causes of Secondary Causes of Constipation (5)
- Endocrine
- Myopathic Conditions
- Neurological Conditions
- Structural Abnormalities
- Other
Secondary Causes of Constipation: Endocrine (2)
- Hypothyroidism
- Hypercalciaemia
Secondary Causes of Constipation: Myopathic Conditions (3)
- Scleroderma
- Amyloidosis
- Myotonic Dystrophy
Secondary Causes of Constipation: Neurological Conditions (3)
- Multiple Sclerosis
- Parkinson’s Disease
- Spinal Cord Injury
Secondary Causes of Constipation: Structural Abnormalities (3)
- Anal Fissures
- Structuring IBD
- Obstructive Mass
Secondary Causes of Constipation: Other (3)
- CVD
- IBS
- Coeliac Disease
- Hirschprungs
What is Hirschprungs?
- Congenital
- Developmental failure of Auberbach and Meissner
plexuses - Absent from anorectal junction
- Gut aperistaltic and spastic
- Causes constipation and gut dilatation
- Megacolon
What is Stool Impaction?
A faecal impaction is a large, hard mass of stool that gets stuck so badly in your colon or rectum that you can’t push it out
When should the diagnosis of Impaction be considered? (4)
- Hard, lumpy stool which may be large and infrequent
- Small and relatively frequent - ’rabbit droppings’ * Need manual methods to extract faeces
- Overflow incontinence/loose stool
What is a Colonic Transit Study?
- A test that shows how quickly food passes through the
digestive system - It starts when you give your child some pellets to
swallow on three consecutive days - On the fourth day, they will need to come into hospital
for an x-ray
Red Flags in Bowel Issues (5)
- PR bleed
- Unintentional Weight Loss
- Recent Change in Bowel Habit
- New Abdominal Pain
- Iron Deficiency/Anaemia
How to treat Constipation? (6)
- Dietetic Referral
- Lifestyle Adjustments
- Rectal Suppositories
- Laxatives
- Disimpaction
- Obstructive defecation – refer for balloon expulsion
test/anorectal manometry and biofeedback sessions
What is Irritable Bowel Syndrome (IBS)
It is a chronic, relapsing, and often lifelong disorder of the lower gastrointestinal tract, with no discernible structural or biochemical cause
Symptoms of IBS
- Stomach Pain/Cramps
- Bloating
- Diarrhoea
- Constipation
When can IBS be diagnosed?
Abdominal pain/discomfort, in association with altered bowel habit, for at least 6 months, in the absence of alarm symptoms or signs
What are possible mechanisms of IBS? (6)
- Visceral hypersensitivity
- Abnormal gastrointestinal immune function
- Changes in colonic microbiota
- Abnormal autonomic activity
- Abnormal central pain processing of afferent gut
signals (altered ‘brain-gut interactions’) - Abnormal gastrointestinal motility
Possible Risk Factors of IBS? (6)
- Genetic
- Enteric infection (e.g. following gastroenteritis)
- Gastrointestinal inflammation (e.g. secondary to
inflammatory bowel disease) - Dietary factors (alcohol, caffeine, spicy and fatty
foods) - Drugs (antibiotics)
- Psychosocial (stress, anxiety and/or depression)
What demographic is IBS most common in?
- 20-30 years
- Women > men
Consider the diagnosis of IBS in a person who has
had any of the following symptoms for at least 6 months: ABC
Abdominal Pain
Bloating
Change in bowel habit
Make a diagnosis of IBS if a person has
abdominal pain which is associated with either..? (8)
- Related to defecation
- Associated with altered stool frequency
- Associated with altered stool form or appearance
- Altered stool passage
- Abdominal bloating
- Symptoms worsened by eating
- Passage of rectal mucus
- Alternative conditions with similar symptoms have.
been excluded
Investigations for IBS- most;y to rule out other conditions (6)
- Full blood count (FBC)
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP)
- Antibody testing for coeliac disease
- Fecal calprotectin to r/o IBD
- Consider FIT testing in 50+ population
Treatment of IBS: Lifestyle Changes (6)
- Encourage addressing psychological causes
- Increase water intake
- Reduce insoluble fibre (wholemeal)
- Reduce food that exacerbate (caffeine, alcohol,
carbonated drinks, gas-producing food) - Fibre supplements
- Encourage 30mins exercise 5x a week
Treatment of IBS: Pharmacological (5)
- Antispasmodics (mebeverine, peppermint oil capsules)
- Laxatives (avoid lactulose)
- Loperamide (for antimotility)
- TCA second line (Amitriptyline/Nortryptilline): for IBS-D
- SSRI second line (Citalopram): for IBS-C
When should Linaclotide be considered for treating IBS? (3)
- Optimal or maximum tolerated doses of previous
laxatives from different classes have not helped - Constipated 12months +
- Need follow up after 3months
What causes Bile Acid Malabsorption?
An over-production of bile acids (BA) due to defective feedback inhibition of hepatic bile acid synthesis
Small Intestinal Bacterial Overgrowth (SIBO)
Excessive amount of bacteria (dysbiosis) populates the small intestines
Symptoms of SIBO (7)
- Bloatiness
- Abdominal Pain
- Diarrhoea
- Loss of appetite
- Nausea/Vomiting
- Unintentional Weight Loss
- Malnutrition
Conditions associated with SIBO (4)
- Gut Dysmotility
- Anatomical Changes
- Altered GI Secretions
- Impaired Gut Immunity
Investigations to diagnose SIBO (2)
- Gold standard dg: quantitative culture of jj aspirates
(invasive, non-practical) - Real life dg tests: glucose and lactulose breath tests
Treatment of SIBO (5)
- Avoid Sugar
- Smoking Cessation
- Avoid NSAIDs
- Low FODMAP Diet
- Antibiotics: Rifaximin 550mg bd for 7-14/7,
Ciprofloxacin 500mg bd, Metronidazole 500mg tds
What is Coeliac Disease?
Chronic immune-mediated systemic disorder in
genetically predisposed people, triggered by exposure to dietary gluten
What is Potential Coeliac Disease?
Symptomatic patients or those who are asymptomatic with +ve antibodies but no villous atrophy on biopsy
What is Non-Responsive Coeliac Disease?
Persistent symptoms and enteropathy that do not response after 6-12 months of treatment
What is Refractory Coeliac Disease?
Persistent or recurrence of otherwise unexplained symptoms and villous atrophy despite 12+ adherence to treatment
What is Coeliac Disease characterised by? (3)
- Inflammatory small bowel enteropathy
- GIT and /or systemic symptoms
- Presence of coeliac-specific autoantibodies
Predisposing Factors of Coeliac Disease (4)
- Genetic : strong association with HLA-DQ2/-DQ8
- Immune-mediate disorder driven by immune
response to gluten - Link with other auto-immune diseases (diabetes,
thyroid disease) - Gluten exposure
What signs indicate that Coeliac Disease should be suspected? (8)
- Persistent, unexplained GI symptoms
- IBS
- Faltering growth/delayed development
- Prolonged fatigue/lethargy
- Unexplained Fe, B12 or folate deficiency/anaemia not
responding to treatment - At diagnosis of auto-immune disease
- Selective IgA deficiency
- First degree relative with condition
Consider a diagnosis of Coeliac Disease in a person with what conditions? (8)
- Osteomalacia/-penia/-porosis or fragility fracture
- Unexplained anxiety/depression
- Unexplained Peripheral neuropathy
- Unexplained Recurrent miscarriage or subfertility
- Unexplained Persistently raised LFTs
- Dental enamel defects
- Hyosplenism
- Downs/Turners/Williams syndrome
What is Dermatitis Herpetiformis?
A chronic, intensely itchy, blistering skin manifestation of gluten-sensitive enteropathy, commonly known as celiac disease
Treatment of Coeliac Disease
Gluten Free Diet
Complications of uncontrolled/undiagnosed Coeliac Disease (9)
- Reduced quality of life
- Mental health disorders
- Faltering growth and delayed puberty in children
- Nutritional deficiencies
- Anaemia
- Reduced bone density
- Hyposplenism
- Malignancy/risk of lymphoma
- Refractory coeliac disease
What is the Valsalva Maneuver?
It is the performance of forced expiration against a closed glottis
