W11 IBS, Coeliac disease, Diverticular disease, Diverticulitis Flashcards
1
Q
Diarrhoea
How is it diagnosed?
How long is the duration ti be classed as acute?
Causes of acute diarrhoea?
Causes of Chronic?
A
- Passage of 3 or more loose stools per day, or more frequently than is normal for an individual
- Acute (less than 4 weeks) or Chronic (more than 4 weeks)
- Acute causes – Bacterial or viral infection, anxiety, food allergy/intolerance, acute appendicitis, drugs
- Chronic causes – IBS, diet, IBD, coeliac disease, bowel cancer
- Diagnosis – History – Onset, duration, frequency, severity of symptoms,
RED FLAGS, ascertain cause,
complications – dehydration, recent travel, recent Abx treatment - Treatments - Loperamide, Rehydration
2
Q
Constipation
What is the definition
Types of constipation? (4)
A
- Difficulty and problems passing stool, straining to pass stool, infrequent and/or hard stools, feeling of incomplete emptying or blockage, may have abdominal pain
- Chronic, Faecal Impaction, Primary, Secondary
- Passing of stool that is less frequent that what is normal for the individual
- Diagnosis – History – Onset, duration, frequency, severity of symptoms,
RED FLAGS, ascertain cause,
complications
Treatment
* Self-care – Healthy balanced diet - fruit, veg, wholegrains, inc. fluids, toilet routine
* Laxatives
3
Q
Irritable Bowel Syndrome (IBS)
What is the definition?
What are some common symptoms? (4)
What are the 4 subtypes?
A
- Chronic, relapsing and often debilitating disorder of gut-brain interaction (NICE, 2022)
- Symptoms – Change in stool form and/or frequency, abdominal pain,
abdominal bloating - 4 subtypes - Rome IV Classification
- IBS-D – Most common
- IBS-C
- IBS-M
- IBS-U
4
Q
What are the Causes/Risk Factor of IBS?
A
- GI infection
- Genetic link?
- GI inflammation
- Diet – Caffeine, Alcohol, Spicy food, Fatty Food
- Psychological – Stress, Anxiety, Depression
5
Q
What are the steps in diagnosis of IBS?
A
- Difficult – History Key
- Suspect IBS - Symptoms for 6 months+ of either Change in bowel habit, abdominal pain or bloating
- Diagnose IBS – Abdo pain 6 months + which is either relieved by defecation or associated with change in frequency or form
- Rome IV – Sec. Care
- Subgrouping
6
Q
Prognosis of IBS? (3)
A
- Fluctuation of symptoms
- Improved prognosis with infection as cause
- Poorer prognosis – Long duration of symptoms, Hx surgery,
Anxiety/Depression related
7
Q
What is the differential diagnosis of IBS?
A
- Cancer
- Drug-induced – Opioids, Laxatives, Antibiotics
- Hypo or Hyperthyroidism
- IBD
- Coeliac Disease
- GI – Infection, GORD, Diverticulitis, Peptic Ulcer, Gallstones, Pancreatitis
- Lactose Intolerance
- Bile acid malabsorption
- Gynae –PMS, Endometriosis
- Anxiety/Depression
8
Q
What are the Tests/Examinations/Investigations to be done in diagnosing IBS? (6)
A
- Rule out or identify alternative illness
- Weight/BMI – unexplained weight loss
- Abdominal palpation – tenderness, pain, mass
- Rectal Exam
- Blood tests – FBC, Inflammation markers, Coeliac Serology
- Faecal Calprotectin – Diarrhoea predominant and aged over 45
- Referral – if concerned re: cancer related cause
9
Q
Management of IBS
What is the non-pharmacological treatment? (4)
A
- Individualized - Symptom management
- Aim – Improve symptoms and manage symptoms, improve QoL, likely long-term management
- Reassurance – No inc. risk of cancer or mortality
- Signposting and information – IBS Network, self-help support, UK association of Dieticians
- Diet/Lifestyle advice – Healthy & Balanced, trigger avoidance, fibre intake, fluids, exercise/weight manageme
10
Q
Management of IBS
What are the Pharmacological treatments? (5)
A
Antidepressants
Laxatives
Loperamide
Antispasmodics
Linaclotide
11
Q
Laxatives
What are the different types? (4)
A
- Bulk forming – Ispaghula, Methylcellulose, Sterculia
- Osmotic – Macrogol, Phosphate enema, Lactulose – AVOID in IBS – Inc. gas, worsens symptoms
- Stimulant – Senna, Bisacodyl, Sodium Picosulfate, Docusate
- Prokinetic - Prucalopride
12
Q
Bulk Forming Laxatives:
Function?
Onset of action?
SE?
C/I?
A
- Retain fluid in stool, inc. stool mass, stimulate peristalsis, stool softening element
- Onset of action up to 72 hours
- Maintain adequate fluid intake - risk of intestinal obstruction
- Side effects – Abdominal distension/discomfort e.g. bloating, flatulence, cramping, diarrhoea
- Contraindications – Swallowing difficulty, faecal impaction, intestinal obstruction, reduced gut motility
13
Q
Osmotic Laxatives
Function?
Onset of action?
SE?
Cautions?
C/I?
A
- Increase the amount of water in the large bowel - drawn in or retained
-abdominal distension & peristalsis - Can also soften stool
- Macrogol
- Lactulose - can take up to 48 hours to work
- Side effects – Abdominal pain, diarrhoea, flatulence, nausea, vomiting, electrolyte imbalance (discontinue)
- Cautions – Macrogol in CV impairment (max 2 full strength sachets/4 half strength),
Lactulose – Lactose intolerance,
Macrogol products high in sodium – care in low salt diet - Contraindications – GI obstruction, GI perforation (or risk of), Galactosaemia, IBD
14
Q
Stimulant Laxatives
Function?
Onset of action?
SE?
Cautions?
C/I?
A
- Fast acting - Onset 8–12 hours
- 3 modes of action
1. Senna – Stimulates colonic nerves
2. Bisacodyl & Sodium Picosulfate – Stimulate colonic and rectal nerves
3. Docusate – Reduces stool surface tension, allowing penetration of water into the stool ( a.k.a stool softener) - Side effects - abdominal cramps, diarrhoea, nausea and vomiting. yellow-brown discolouration of urine (Senna),hypokalaemia
- Cautions – Prolonged use
- Contraindications - intestinal obstruction, undiagnosed abdominal pain, acute IBD, severe dehydration
15
Q
Prucalopride (prokinetic laxative)
Function?
Onset of action?
SE?
Cautions?
C/I?
A
- Selective serotonin (5HT4) receptor agonist
- Stimulates intestinal motility
- Side effects - Decreased appetite, nausea, diarrhoea, vomiting, abdominal pain/discomfort, headache
- Cautions – Hx Arrythmia and IHD
- Contraindications – Crohn’s Disease, intestinal obstruction, intestinal perforation, toxic megacolon,
ulcerative colitis - Counselling – Advised to use effective contraception during treatment, reduced doses in renal and hepatic
impairment - Specialist advice only*
16
Q
Linaclotide
SE?
Cautions?
C/I?
A
- Increases fluid secretion – helps pass stool along
- Moderate to severe IBS with constipation (Adults only)
- Only use if max tolerated or optimal doses of other laxatives haven’t helped & if constipated for at least 12 months
- 290 micrograms once daily, at least 30 minutes before food
- Review treatment after 4 weeks if no response
- Side effects – Abdominal distension, pain, dizziness, flatulence, diarrhoea (stop if prolonged), decreased appetite,
dehydration, hypokalaemia - Cautions – Predisposition to fluid/electrolyte imbalance, co-prescribing with NSAIDs and PPIs, narrow TI drugs absorbed from the gut (levothyroxine)
- Contraindications – Pregnancy & Breastfeeding, GI obstruction, IB
17
Q
Loperamide
Function?
SE?
Cautions?
C/I?
Counselling?
A
- Binds to opiate receptor on gut wall, reduces peristalsis, increases GI transit time, inc. water and electrolyte
reabsorption. Also inc. anal sphincter tone - Side effects – Dizziness, headache, nausea, abdominal pain, dry mouth, skin reactions, vomiting, urinary
retention - Cautions – Hepatic impairment, Hx drug abuse, children under 12 (unlicensed)
- Contraindications – Acute UC, antibiotic associated colitis, bacterial enterocolitis, abdominal distention,
conditions where peristalsis is inhibited - Counselling – Maximum dose or duration not to be exceeded – reports of serious cardiac events with overd
18
Q
Antispasmodics
Types?
Function?
SE?
Cautions?
SE?
Cautions?
C/I?
Counselling?
A
- Direct smooth muscle relaxants - Alverine Citrate, Mebeverine, Peppermint Oil
- Antimuscarinics – Hyoscine Butylbromide, Dicycloverine HCl
- Used for relief of pain or spasm in IBS
- Side effects – Dizziness, dyspnoea, skin reactions (itching, rash, swelling), headache, GI symptoms & discomfort, ataxia,
GORD, palpitations, tachycardia, visual problems - Cautions – Menthol sensitivity (Peppermint oil)
- Contradindications – Pregnancy & Breastfeeding, intestinal obstruction, paralytic ileus, glaucoma, urinary retention, UC, toxic megacolon, bladder obstruction
- Counselling – Take before food
19
Q
Antidepressants
Use?
A
For management of pain in IBS
* Off-label use
* Tricyclic antidepressants (TCAs)
-Amitriptyline – low doses (max 30mg)
* Selective Serotonin Reuptake Inhibitors (SSRIs)
-Sertraline, Citalopram, Fluoxetine
-Only use if poor response to amitriptyline
-NICE & British Society of Gastroenterology (BSG) don’t specify an SSRI of choice
