Motility Disorders Flashcards
1
Q
Jackhammer (nutcracker) Esophagus and Hypertensive LES are classified under THIS esophageal dysmotility disorder?
A
HYPERcontraction
2
Q
Ineffective Esophageal Motility is classified under THIS esophageal dysmotility disorder?
A
HYPOcontraction
3
Q
Distal (diffuse) Esophageal Spasm is what type of esophageal dysmotility disorder?
A
Uncoordinated contraction
4
Q
What is the Deglutitive EGJ Relaxation Window?
A
10 SECOND window of what occurs at the EGJ, pressure-wise from time of SWALLOW
5
Q
The LOWEST mean RELAXATION PRESSURE for a 4 SECOND period WITHIN the Deglutative EGJ Relaxation Window is called? and what is considered NORMAL?
A
IRP (Integrated Relaxation Pressure) < 15 mmHg
anything >15 mmHg is considered IMPAIRED EGJ Relaxation
6
Q
The VOLUME of the contraction BELOW the transition zone of the esophagus that contains ONLY SMOOTH MUSCLE is called?
A
Distal Contractile Integral (DCI)
Normal is >450 but < 8,000 mmHg/cm/sec
7
Q
The point in the swallow curve that SHARPLY BENDS away from the donwslope indicating a TRANSITION from the esophageal PERYSTALTIC CLEARANCE to esophageal EMPTYING?
A
Contractile Deceleration Point (CDP)
8
Q
The TIME from the start of a SWALLOW to the contractile deceleration point (CDP) is called what? What is NORMAL?
A
Distal Latency (DL)
Normal is >4.5 seconds (if its shorter, its a SPASTIC contraction)
9
Q
If DYSPHAGIA is NOT explained by stenoses or inflammation, CHEST PAIN is not explained by heart diseae or PRIOR to fundoplication procedure to exclude ACHALASIA, this TEST should be done?
A
High-resolution esophageal manometry
10
Q
Do esophageal MANOMETRY abnormalities mean that there is actual underlying DISEASE?
A
NO
11
Q
SECONDARY ACHALASIA is caused by what two disorders?
A
CHAGAS disease (trypanosoma cruzi)
MALIGNANCY
12
Q
Swallowing that fails to induce perystalsis and fails to induce LES relaxation is called?
A
ACHALASIA
13
Q
What is COMMON to ALL THREE subtypes of ACHALASIA?
A
IRP >15 mmHg
ABNORMAL peristalsis
14
Q
What DISTINGUISHES the THREE subtypes of ACHALASIA?
A
PRESSURE response in the BODY of the ESOPHAGUS
15
Q
In this TYPE of ACHALASIA, you see TWO HIGH PRESSURE zones where SWALLOWING FAILS to result in PERISTALSIS and the LES FAILS TO RELAX with SWALLOWING (therefore IRP >15 mmHg)?
A
CLASSIC TYPE-I ACHALASIA
16
Q
In this TYPE of ACHALASIA, you see a “TREE TRUNK” appearance where there is SIMULTANEOUS PRESSURIZATION >30 mmHg, of the ENTIRE ESOPHAGUS?
A
TYPE-II ACHALSIA (most treatable)
17
Q
In this TYPE of ACHALASIA, >20% of SWALLOWS result in PREMATURE CONTRACTION of the esophagus with DISTAL LATENCY < 4.5 SECONDS?
A
TYPE-III (SPASTIC ACHALASIA) - hypercontractions with DCI >8,000 worst response to treatment
18
Q
What MEDICATIONS are used to treat ACHALASIA?
A
Calcium Channel Blockers & Nitrates (only used when other methods don’t work)
19
Q
What are the only TWO DEFINITIVE treatments for ACHALASIA?
A
Pneumatic Dilation (balloons 30-40 mm to TEAR the LES)
Heller Myotomy (or POEM)
20
Q
What is the most COMMON complication post LES tearing for ACHALASIA (dilation, Heller, POEM)?
A
GERD
21
Q
What is the TREATMENT of CHOICE for TYPE-III ACHALASIA?
A
POEM (can get a longer myotomy than with a HELLER)
22
Q
WHEN should BOTOX be used to TREAT patients with ACHALASIA?
A
When PNEUMATIC DILATION, HELLER MYOTOMY of POEM are not options
23
Q
What is TRUE of ALL treatments for ACHALASIA that patients MUST be informed about?
A
ALL DETERIORATEover TIME and will eventually need other treatments
24
Q
Is ACHALASIA curable?
A
NO
25
In a patient undergoinf high-resolution esophageal manometry and they are found to have an **IRP >15 mmHg** **AND** they have **NO PERISTALSIS AT ALL**, what's the diagnosis?
**ACHALASIA**
26
In a patient undergoinf high-resolution esophageal manometry and they are found to have an **IRP >15 mmHg** **AND** they have **ANY PERISTALSIS AT ALL**, what's the diagnosis?
**EGJ OUTFLOW OBSTRUCTION**
27
Achalasia **VARIANT**, **EoE**, infiltrative **CANCER**, extrinsic **VASCULAR** obstruction, **HIATAL** hernia, **OBESITY**, **OPIOIDS** can all result in?
**ELEVATED IRP** with **PRESERVED PERISTALSIS**
28
Does an **ELEVATED IRP by** itself mean much?
**NO** (20-40% resolve spontaneously)
29
**SUPINE IRP** measurements are **HIGHER** than those done **UPRIGHT**, so what does an **UPRIGHT IRP** distinguish?
**IMPORTANT** from unimportant EGJ **outlet obstruction**
**UPRIGHT IRP >12** 98% **EGJ outlet obstruction**
30
**IRP > ULN** in **BOTH SUPINE** and **UPRIGHT** positions, there is **SOME PERISTALSIS** and **>20%** of swallows, there is **INTRABOLUS PRESSURE**?
**EGJ Outlet Obstruction**
31
**EGJ Outlet Obstruction** means what **CLINICALLY**?
It is **INCONCLUSIVE** (must distinguish cilinically **RELEVANT** - symptoms of dysphagia, chest pain and a test supporting the obstruction such as BARIUM tablet or FLIP from **IRRELAVANT**)
32
What is considered a **NORMAL EGJ DI** (Distensibility Index) in **FLIP**?
**>2** with a 60 mL FILL VOLUME
33
What is considered a **NORMAL EGJ DIAMETER** in **FLIP**?
**>16** with a 60-70 mL FILL VOLUME
34
During **FLIP** test, what is CONSIDERED an **ABNORMAL** Rapid Drink Challenge (RDC)?
**BOTH** the **IRP >12** mmHg **AND** there is **PAN-PRESSURIZATION** of the esophagus
If **EITHER** but not both are present, then its **INTERMEDIATE**
N**ormal is IRP < 12 mmHg AND no pan-pressurization**
35
Clinical **DYSPHAGIA**, **CHEST** pain, **TERTIARY** contractions on imaging and **PREMATURE** contractions on manometry?
**Distal Esophageal SPASM** (short Distal Latency < 4.5 seconds)
36
**Normal IRP** and **>20% of swallows** with **DCI >8,000**?
**HYPERcontractile** (jackhammer) esophagus
37
What **MUST** be **RULED OUT** when diagnosing a **HYPERcontractile/SPASTIC** esophagus?
**OPIOID** use, **GERD**, **EoE**
38
**PPI** trial, **Calcium Channel Blockers**, **Nitrates**, **Sildenafil**, **Peppermint Oil** are all treatments for what **ESOPHAGEAL** disorder?
**HYPERcontractile/SPASM** esophagus
39
What is the **MOST COMMON** cause of a **HYPOcontractile** esophagus?
**SCLERODERMA** (fibrous and vascular oblitertion of esopahgeal muscle and nerves) - low amplitude contractions and hypotensive LES
Otherwise Ineffective Esophageal Motility (DM, amyloidosis, GERD)
40
**>70% INEFFECTIVE** swallows (weak contraction with **DCI >100 & < 450**)
**FAILED PERISTALSIS** (**DCI < 100**)
**FRAGMENTED** swallows (peristaltic break **>5 cm**) and DCI >450
**OR**
**>50% FAILED SWALLOWS**
**Ineffective Esophageal Motility**
41
What **TEST** can you use to **PREDICT** post fundoplication **DYSPHAGIA**?
**Multiple Rapid Swallows** test
42
If a patient undergoes high-resolution esophageal manometry and is found to have one of these three (**EGJ Outlet Obstruction**, **Distal Esophageal Spasm** or **HYPOcontractile Esophagus**), what else **MUST** they have to make the **DIAGNOSIS**?
**SYMPTOMS**
43
What class of medications **IMPAIRS LES RELAXATION**, causes **HYPERcontraction** with **ELEVATED DCI** and causes **SPASM** with **SHORTENED DL**?
**OIPIDS** (can mimic achalasia type III, EGJ outflow obstruction, distal esopahgeal spasm and HYPERcontractile esophagus on manometry) - STOP the opioids
44
What nerve controls the **UGI** and **SMALL BOWEL** motiliy?
**VAGUS**
45
**Pelvic** and **Lumbar** nerves (sympathetics and parasympathetics) control motility for which portion of the **GIT**?
**Colon**
46
In patients with **POST-INFECTIOUS Functional Dyspepsia**, what motility phase was affected most?
Gastric **ACCOMODATION** (no effect on gastric emptying)
47
What **medication** has been shown to significantly **REDUCE** symptoms in **FUNCTIONAL DYSPEPSIA**?
**BUSPIRONE**
48
What are the **THREE** most common causes of **GASTROPARESIS**?
**IDIOPATHIC**
**DM**
Upper GI, heart/lung **SURGERY** (VAGUS injury)
49
Patients with **WHAT** condition present with **APPARENT GATROPARESIS** even with slowed emptying (due to the disorder itself)?
**Eating Disorders**
50
**TCAs**, **OPIATES**, **SMOKING**, **LITHIUM**, **PPIs** and **CANNABINOIDS** can all cause this GI disorder?
**GASTROPARESIS**
51
What do you see on an **UPPER GI SERIES** that is diagnostic for gastroparesis?
**POOLING** of contrast in the **STOMACH** in the **ABSENCE** of an obstruction
52
What finding on **EGD** is highly-suggestive for **GASTROPARESIS**?
**BEZOAR**
53
What is considered **GOLD** standard **TEST** for **GASTROPARESIS**?
**SOLID-PHASE** Gastric Emptying Study (nuclear)
54
Does **GASTRIC EMPTYING** correlate with **SYMPTOMS** (nausea, vomiting, abdominal pain)?
**NO**
55
What is considered the **UPPER LIMIT** of **NORMAL** for a **STANDARD** (**4 HOUR**) Gastric Emptying Scan for **DELAYED GASTRIC EMPTYING** at **4 HOURS?**
**>10% retention** at 4 HOURS is abnormal
56
What constitutes a **GASTROPARESIS DIET**?
**SMALL FREQUENT MEALS** (6/day), **LOW-FAT** (carbs and proteins are best), **LOW-FIBER**, liquid **SUPPLEMENTATION**
57
What is the **RECOMMENDED** treatment of **FUNCTIONAL** (post-infectious) **DYSPEPSIA** with **ABNORMAL GES** (gastroparesis symptoms post infection)?
**METOCLOPRAMIDE**
58
What is the **ONLY** approved drug for **GASTROPARESIS** that **IMPROVES MOTILITY**, **NAUSEA** and **VOMITING**?
**METOCLOPRAMIDE**
59
Besides **NEUROLOGIC** side effects of **METOCLOPRAMIDE**, what other side effect is seen in some?
**HYPERprolactinemia**
60
**HOW LONG** should a patient take **METOCLOPRAMIDE** before its **STOPPED** (higher risk of side effects, tardive dyskinesia)?
No more than **9 MONTHS**
61
Is **DOMPERIDONE** approved in the US for use for gastroparesis?
**NO**
62
Is **BOTOX** recommended for treatment of **GATROPARESIS**?
**NO** (because **NO** difference to **PLACEBO**)
63
Is it **RECOMMENDED** to place a **GASTRIC STIMULATOR** in a patient who has a **NORMAL GES**, or has **PRIMARILY ABDOMINAL PAIN** and uses **OPIATES**?
**NO**
64
What is the **ONLY** role of a **GASTRIC STIMULATOR**?
Improve **symptoms** of **NAUSEA & VOMITING** (not pain, not motility) in **DIABETIC GASTROPARESIS ONLY**
65
For what **ETIOLOGY** of **GASTROPARESIS** does a gastric stimulator treat the **NAUSEA** and **VOMITING** symptoms?
**DIABETES**
66
When is the **ONLY** time a **G-POEM** should be **CONSIDERED** (must be **VERY SELECTIVE**)?
**GES >20% retention** at 4 HOURS
and
**GCSI score** (1-5) **>2.6** (**moderately-severe** symptoms)
67
Is a **GASTRECTOMY** (completion) recommended for **GASTROPARESIS**?
**NO**
68
Does **ERYTHROMYCIN** have **ANY EFFECT** on **NAUSEA** and **VOMITING**?
**NO**
69
In a patient with gastroparesis **SYMPTOMS** of **NAUSEA**, **VOMITING** and abdominal pain with a **HISTORY** of **MIGRAINES/ANXIETY/DEPRESSION**, how do you treat?
**NORTRIPTYLINE** (cyclical vomiting syndrome)
70
**RECURRENT** episodes of **SEVERE NAUSEA** and **VOMITING** separated by **SYMPTOM-FREE** intervals with **NO WEIGHT LOSS** and gastric emptying is **RAPID** or **NORMAL**?
**Cyclical Vomiting Syndrome** (nortriptyline)
71
**Cyclical Vomiting Syndrome** associated with **COMPULSIVE HOT WATER BATHING**, **NO response to TCAs** (nortriptyline)?
**CANNABINOID HYPEREMESIS** (stop smoking marijuana for at least **6 MONTHS**)
72
What is the **TREATMENT** of **Cyclical Vomiting Syndrome** (non-cannabinoid ie no hot water bathing compulsion)?
**TCAs** or **Neurokinin-1 Antagonists**
73
The **MMC** (Migrating Motor Component) of the **SMALL BOWEL** exists **ONLY** in what state?
**FASTING** (to keep SB free of bacteria and debris)
74
What is **Chronic Intestinal Pseudoobstruction** (myopathic or neuropathic)?
Intestine does **NOT MOVE** contents as expected
75
Familial, **COLLAGEN, THYROID** disease, **AMYLOIDOSIS**, **HIRSCHPRUNG's** (full thickness intestinal biopsy), **CHAGAS**, **PARANEOPLASTIC** syndromes can all cause this **MOTILITY DISORDER**?
**Chronic Intestinal Pseudoobstruction**
76
**GI Motility Disorder** that affects most **PROMINENTLY** the **ESOPHAGUS, ANAL SPHINCTERS & SB** and advanced cases cause **SIBO** and **MALABSORPTION** with **WEIGHT LOSS**?
**SCLERODERMA** (abdominal bloating, distention, diarrhea, weight loss) - check scleroderma antibodies and Hydrogen (GLUCOSE) breath test
77
A patient is well, then **SUDDENLY** develops **WEIGHT LOSS** caused by **AUTOIMMUNE** attack on **ENTERIC NEURONS** causing **CHRONIC INTESTINAL PSEUDOOBSTRUCTION**?
**PARANEOPLASTIC SYNDROME** (stain MYENTERIC NEURONS)
78
If suspecting **PARANEOPLASTIC SYNDROME** for cause of **CHRONIC INTESTINAL PSEUDOOBSTRUCTION**, what **TWO** tests should you do?
**CT CHEST** (most malignancies causing this will be in the **MEDIASTINUM**)
**MAYO** paraneoplastic **antibody** panel
79
If suspecting **AMYLOID** as a cause of **INTESTINAL CHRONIC PSEUDOOBSTRUCTION** or **DYSMOTILITY**, what is the **BEST DIAGNOSTIC** method?
**RECTAL BIOPSY**
80
If in **>25%** of the time, a patient experiences **≥2** of: **STRAINING**, **LUMPY** or **HARD** stools, sense of **INCOPLETE** evacuation, **ANORECTAL** obstruction, uses **MANUAL MANUVERS** to help move bowels or **< 3 Spontaneous BMs/week**, what is the **DIAGNOSIS**?
**FUNCTIONAL CONSTIPATION**
81
If a patient is experiencing **INFREQUENT BOWEL MOVEMENTS** alone, is that sufficient to diagnose **FUNCTIONAL CONSTIPATION**?
**NO**
82
If a patient has only **ONE BM** per week, is that enough to diagnose **FUNCTIONAL CONSTIPATION**?
**NO** (need at least one more of the ROME criteria)
83
SEROTONIN agonists (5H3), **OPIATES**, Ca-CHANNEL BLOCKERS, ALUMINUM, IRON SUPPLEMENTS and ANTIDEPRESSANTS, ANTIPSYCHOTICS can all cause this GI motility disorder?
CONSTIPATION
84
**DO STIMULANT LAXATIVES** (bisacodyl, Senna, picosulfate) **HARM** the colon (melanosis, etc.)?
**NO**
85
With what **FREQUENCY** should **FIBER** or **OSMOTIC** laxatives be used?
**DAILY**
86
When using **STIMULANT** laxatives (bisacodyl, picosulfate, Senna) what should the **GOAL** in **BMs** be?
**2-4** BMs/week
87
**LEAST ESPENSIVE**, **SAFEST** and **MOST EFFECTIVE** laxatives are what?
**OTC** (psyllium, lactulose, PEG, Senna, bisacodyl)
88
Which **LAXATIVE** should **NOT** be used in **PREGNANCY**?
**LINACLOTIDE**
89
If **PEG** fails in a **PREGNANT** patient, what **LAXATIVE** should be recommended?
**SENNA**
90
**SAFEST LAXATIVE** to be used in **PREGNANCY**?
**PEG** (if not effective, SENNA)
91
A patient with **constipation** that becomes **unresponsive** to **multiple laxatives of different classes** should have what evaluation done?
**BALLOON** expulsion test and **ANORECTAL MANOMETRY**
92
What is the **FIRST** best method to assess an issue with **DEFECATION**?
**DIGITAL RECTAL EXAM**
93
Why is **ANORECTAL MANOMETRY ALONE**, insufficient to diagnose defecation problems?
Because many of its **patters** can be seen in **NORMAL** individuals
94
What is considered a **SLOW BALLOON EXPULSION** test?
Anything **>60 seconds** once balloon is inflated
95
When is **BARIUM DEFACOGRAPHY** used?
When **BOTH STRUCTURE** and **FUNCTION** is being tested (looking for a poorly contacting musle or anatomic obstruction suce as a **RECTOCELE**)
96
Does the **BALLOON EXPULSION** test **+ ANORECTAL MANOMETRY** test for **STRUCTURE** and **FUNCTION** of defecation?
**NO**, **FUNCTION ONLY**
97
**SLOW** colonic transit (sitz marker study) with a **NORMAL** colon **DIAMETER**, **NORMAL ANORECTAL** function (balloon expulsion and anorectal manometry) with a **DECREASED** repsonse to **FATTY** meals, cholinergics and laxatives and decreased contractions?
**COLONIC INERTIA**
98
What is the **FIRST TEST** to perform for **REFRACTORY CONSTIPATION** (no or poor response to multiple laxatives)?
**BALLOON EXPULSION + ANORECTAL MANOMETRY** (function)
99
If the **BALLOON EXPULSION + ANORECTAL MANOMETRY** (function only) studies are **BOTH NORMAL**, what's **EXCLUDED** and what do you test for next, in a patient with **REFRACTORY CONSTIPATION** (no or poor response to multiple laxatives)?
**DEFECATION DISORDER** is **EXCLUDED**
**NEXT**: colonic **TRANSIT study** (**SITZ** markers)
100
What does the colonic **TRANSIT** (**SITZ** marker) sudy tell you if its **SLOW** (>60 seconds)?
**COLONIC INERTIA**
101
If the **BALLOON EXPULSION + ANORECTAL MANOMETRY** (function only) studies are **BOTH ABNORMAL**, what's the **NEXT STEP**?
**BIOFEEDBACK**
102
How do you **TREAT INTRACTABLE COLONIC INERTIA**?
**MISIPROSTOL** (+/- PEG) - effective in 40%
**EXCEPT** in **WOMEN of CHILDBEARING AGE** (abortive agent)
103
What is **RECOMMENDED** for a patient that has **INTRACTABLE COLONIC INERTIA** with no response to **ANY** meds including **MISOPROSTOL**, has intractable and disabling symptoms, a colonic inertia **PATTERN**, no intestinal **PSEUDOOBSTRUCTION** and **NORMAL ANORECTAL FUNCTION** and **ABDOMINAL PAIN IS NOT** the **PROMINENT FEATURE**?
**SUBTOTAL COLECTOMY**
104
Should a **SUBTOTAL COLECTOMY** be recommended for a patient with **PREDOMINANLTY ABDOMINAL PAIN** in **INTRACTABLE COLONC INERTIA**?
**NO** (won't help)
105
Institutionalized **ELDERLY**, patients with **SCHIZOPHRENIA** and other **PSYCHOTIC** disorders, those with **PARKINSONS** and other neurologic disorders are at risk for this **COLONIC COMPLICATION**?
**CHRONIC MEGACOLON**
106
How is **CHRONIC MEGACOLON** treated **MEDICALLY**?
**LOW FIBER** diet, low-dose **PEG**, **ENEMAS** (this is a FAILED colon, not constipation)
107
If a patient with **CHRONIC MEGACOLON** has **DISABLING SYMPTOMS**, how do you treat?
**DIVERTING** ostomy or subtotal **COLECTOMY** with ileostomy
108
What is the **FIRST CHOICE** in treating **OPIOID-INDUCED** constipation in a patient with **CHRONIC PAIN** who needs the opioids?
**TRADITIONAL LAXATIVES** like **PEG** not PAMORAS (naldemedine, naloxagol or methylnaltrexone)
109
What is **TENAPANOR**?
Similar to **LINACLOTIDE**, used for **IBS-C therapy**, reduces absorption of sodium and phosphate in the colon thus increasing water
110
When are **PAMORAs** used to treate **OPIOID-INDUCED CONSPITATION**?
**PAMORAS** (naldemedine, naloxagol or methylnaltrexone) are used **ONLY** when **TRADITIONAL LAXATIVES FAIL**
111
**GI SYMPTOMS** not explained by **STRUCTURAL** or **BIOCHEMICAL** abnormalities?
**FUNCTIONAL BOWEL DISORDERS**
112
A **DISORDER** of **GUT-BRAIN** interaction?
**IBS** (visceral hypersensitivity)
113
**CHRONIC** or **RECURRENT** lower abdominal **PAIN** and **DISCOMFORT**, **ALTERED** bowel habits and **BLOATING**?
**IBS**
114
What **demographic** is most likely to have *post-infectious IBS*?
**FEMALE**, **ANXIOUS**
115
By what **MECHANISM** does **STRESS INCREASE** colonic **MOTILITY** and this is **MORE PRONOUNCED** in patients with **IBS**?
Hyothalamic release of **CORTICOTROPIN RELEASING FACTOR** (CRF)
116
Which **DIAGNOSTIC TESTS** are **RECOMMENDED** when working up **IBS**?
**CELIAC** serologies, fecal **CALPROTECTIN/LACTOFERRIN**, **GIARDIA**
117
In a patient with **IBS-like symptoms** that started in **>50 years OLD**, is this likely to be **IBS**?
**NO**
118
In a patient experiencing a **STEADY-PROGRESSIVE** **IBS-like symptom** course, is this likely to be **IBS**?
**NO**
119
In a patient with **IBS-like symptoms** that experiences **FREQUENT AWAKANING** by **PAIN**, is this likely to be **IBS**?
**NO**
120
In a patient with **IBS-like symptoms** that expereinces **WEIGHT LOSS NOT ASSOCIATED WITH DEPRESSION**, is this likely to be **IBS**?
**NO**
121
If a patient **>50** presents with a **CHRONIC** history of intermittent **CRAMPS**, **BLOATING**, **DIARRHEA**, **without weight loss** and normal **CBC**, what should yuo check for **NEXT**?
ITS **NOT IBS**, check a **fecal calprotectin** (IBD) and **COLONOSCOPY if POSITIVE**
122
Does a **RELIABLE BREATH TEST** exist for **SIBO**?
**NO!!!**
123
What **SUBSTRATE** should **NOT** be used for **SIBO** testing?
**LACTULOSE**
124
What is the **ONLY SUBSTRATE** that should be used for **SIBO** testing?
**GLUCOSE**
125
What measures can **IMPROVE** symptoms and quality of life in IBS patients?
**FODMAP** diet and **QUALITY** of physician/patient **interaction** and patient **education**
126
For a patient with **IBS**, what is the **LENGTH** of the **FODMAP** diet **TRIAL RECOMMENDATION**?
**4-6 WEEKS** (this is N**OT a permanent diet**, it is meant to **IDENTIFY** certain **problem-foods** for the patients)
127
What is the **UNIVERSALLY** recommended **MEDICATION** for **ALL IBS** patients (costipation or diarrhea predominant)?
**NORTRIPTYLINE**
128
If **ALL OTHER** meds **FAIL** to treat **IBS-C**, what is the **RECOMMENDED** medication for a **WOMAN < 65 yo**?
**TEGASEROD**
129
Is **LOPERAMIDE** recommended for **IBS-D** treatment?
**NO**
130
If a patient has a history of **CHOLECYSTECTOMY**, **PANCREATITIS**, **ALCOHOL >3** dinks/day, **HEPATIC IMPAIRMENT** (CHILD's C), **SOD**, **BILIARY OBSTRUCTION**, what **IBS-D** drug **CANNOT BE USED**?
**EULOXADOLINE**
131
If **AMYTRIPTYLINE** or **NORTRIPTYLINE** cause side effects such as **DISORIENTATION**, **PALPITATIONS**, **FATIGUE**, in a patient with **IBS**, what do you do?
**STOP** the DRUG, start **DESIPRAMINE** (fewer side effects than the other 2)
132
What **DOSAGE** should be used in patients with **IBS** when using **TCAs** (amitriptyline, nortriptyline) and when do you **INCREASE**?
Start **LOW**, increase every **2-3 WEEKS**, wait at least **3 WEEKS** to see effect
133
A patient with **IBS-C** has tried **FODMAP**, **LINACLOTIDE**, **LUBIPROSTONE**, **PEG**, normal colonoscopy, normal labs, no constipating meds. What do tou **RECOMMEND** next?
**COGNITIVE BEHAVIORAL THERAPY**
134
Can you safely use **MISOPROSTOL** in a woman of **CHILD-BEARING** age who is **NOT** on birth control?
**NO** (abortifacent drug)
