Session 5- IBD/IBS Flashcards
what things should you ask about in the assessment/history of diarrhoea? and what might the answers indicate?
frequency and consistency: diarrhoea classed as more than 3 a day with increased liquidity
onset/duration: if under 10 days, likely infection, if more than 10 days likely another cause, if intermittent, likely functional
associated N/V- gastroenteritis
foreign travel, pet/animal contact, antibiotics/drugs, hospital admission, change in diet, any one else in house feeling unwell- acute things which might have caused it.
RED FLAGS
family history
surgery to GI tract
What are the red flags with diarrhoea?
nocturnal diarrhoea- think IBD
blood in stool - cancer?
unintentional weight loss - cancer?
symptoms >4weeks
history of fever
history of foreign travel
history of eating out
what are red flags for colorectal cancer?
change in bowel habit: over 60 with increased frequency and looseness of stools for over 6 weeks
over 60 with rectal bleeding with no itching or soreness for over 6 weeks
change in bowel habit: over 40 with increased frequency/looseness of stools and rectal bleeding
palpable right iliac fossa mass
palpable rectal mass
unexplained iron deficiency anaemia
what things would you include in the examination of a patient with diarrhoea?
BP, pulse, temp
check for dehydration signs! - consider admission for children and diabetics etc
signs of jaundice/liver disease
examination of abdomen- palpate all 9 quadrants, liver kidney and spleen
(PR maybe if there is blood in stool/CRC is suspected)
What investigation would you do for someone coming in with diarrhoea?
FBC! check for anaemia
U+E,
ESR and CRP- inflammation
LFTs
stool culture and sensitivities- if think infection with bacterial which they are not recovering from/foreign travel/eaten out etc
FAECAL CALPROTECTIN- released into i intestines when there is inflammation - differentiate between IBD and IBS
Faecal elastase- if pancreatic insufficiency is suspects (i.e. malabsorption)
differential diagnosis of diarrhoea
infection
virus: noro, rota
bacterial: shigella, salmonella, ecoli, campylobacter, cholera, c.diff
parasitic: giardia, cryptosporidium
medications (ie anitbiotics, esp those beginning with c)
IBD- Crohns, UC
Coeliac disease
Diverticular disease
Cancer
IBS
what are the histological markers in coeliac disease?
loss of villi and crypt hyperplasia in the small intestine (no villi in large intestine anyway)
what tests would you do for someone coming in with chronic diarrhoea?
Full blood count, ferritin,
CRP, ESR,
Stool culture
Anti- Tissue Transglutaminase and Endomysial antibodies - coeliac serology
Faecal Calprotectin- released into intestines inflammation (IBD)
feacal elastase- pancreactic insufficiency
CEA- carcinoembryonic antigen (tumor marker)
what is the different between organic vs functional diarrhoea?
organic: there is a biochemical/physiological/structural change to the tissues, causing the pathology and therefore the symptoms: e.g IBD: crohns, UC, infection, cancer etc
functional: the symptoms are not associated with any pathology to be found e.g IBS- irritable bowel syndrome
what are the difference you would expect when differentiating between function or organic diarrhoea?
functional: small volumes, with no blood/mucus or incontinence, no nocturnal stools, and occurs intermittently
organic: large volumes, may be blood/mucus present, nocturnal stool and incontinence likely occur, and the onset is acute/continuous
Management of IBS (irritable bowel syndrome)
Non Pharmacological:
increase exercise
increase relaxation time
DIET: low FODMAP
Pharmacological: depends on predominant symptoms or may be mixture if varies
Constipation: Laxatives
Diarrhoea: Anti-motility (loperamide)
Abdo pain/cramping: antispasmodics cause smooth muscle relaxation- Buscapan, or peppermint oils/teas
if the above doesn’t work, psychological intervention i.e. CBT, hypnotherapy may work.
Management of coeliac disease
GLUTEN FREE DIET
pneumococcal vaccine
what criteria is used to diagnose IBS?
Rome III criteria
(improvement with defecation, onset associated with: change in frequency and change in consistency of stool)
with symptoms for at least 3 days/month, for last 3 months
What are the main differences between the two types of IBD?
UC- limited to the colon and rectum, will be continuous and have defined cut off point. Only mucosa effected
NON GRANULOMATOUS
Crohn’s- patchy cobblestone appearance can occur anywhere from mouth to anus (whole of GI tract) and is transmural- GRANULOMATOUS
What are the 5 different types of drugs which will be used in the treatment in order of which they would be tried and what they are used for?
5-ASA- Aminosalicylates i.e Sulphasalazine used for both inducing remission (active disease) and maintaining remission
Corticosteroid- ie prenisolone, hydrocortisone. only used for flare ups/inducing remission. No role in maintenance due to side effects (cushing’s syndrome, osteoporosis)
Thiopurines (like azathioprine)- immunomodulates but inducing T cell apoptosis. Both in remission and maintenance.
Methotrexate- anti inflammatory effects but we don’t know why are previously used for cancer treatment. Need folate supplement, can cause pneumonitis. Can be used for remission or maintenance.
If all else fails, expensive biologics- Anti-TNF monoclonal antibodies: Infliximab
