W11 IBS, Coeliac disease, Diverticular disease, Diverticulitis Flashcards
Diarrhoea
How is it diagnosed?
How long is the duration ti be classed as acute?
Causes of acute diarrhoea?
Causes of Chronic?
- 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
Constipation
What is the definition
Types of constipation? (4)
- 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
Irritable Bowel Syndrome (IBS)
What is the definition?
What are some common symptoms? (4)
What are the 4 subtypes?
- 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
What are the Causes/Risk Factor of IBS?
- GI infection
- Genetic link?
- GI inflammation
- Diet – Caffeine, Alcohol, Spicy food, Fatty Food
- Psychological – Stress, Anxiety, Depression
What are the steps in diagnosis of IBS?
- 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
Prognosis of IBS? (3)
- Fluctuation of symptoms
- Improved prognosis with infection as cause
- Poorer prognosis – Long duration of symptoms, Hx surgery,
Anxiety/Depression related
What is the differential diagnosis of IBS?
- 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
What are the Tests/Examinations/Investigations to be done in diagnosing IBS? (6)
- 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
Management of IBS
What is the non-pharmacological treatment? (4)
- 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
Management of IBS
What are the Pharmacological treatments? (5)
Antidepressants
Laxatives
Loperamide
Antispasmodics
Linaclotide
Laxatives
What are the different types? (4)
- 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
Bulk Forming Laxatives:
Function?
Onset of action?
SE?
C/I?
- 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
Osmotic Laxatives
Function?
Onset of action?
SE?
Cautions?
C/I?
- 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
Stimulant Laxatives
Function?
Onset of action?
SE?
Cautions?
C/I?
- 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
Prucalopride (prokinetic laxative)
Function?
Onset of action?
SE?
Cautions?
C/I?
- 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*
Linaclotide
SE?
Cautions?
C/I?
- 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
Loperamide
Function?
SE?
Cautions?
C/I?
Counselling?
- 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
Antispasmodics
Types?
Function?
SE?
Cautions?
SE?
Cautions?
C/I?
Counselling?
- 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
Antidepressants
Use?
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
Treatment summary: Constipation
Constipation
1. Diet & Lifestyle advice
2. Bulk forming laxative
3. Other form of laxative
4. Linaclotide trial if persistent for 12 months
5. Specialist referral
Treatment summary: Diarrhoea
Predominant
- Diet & Lifestyle advice
- Loperamide
- Specialist Referral
Treatment summary:Pain/Spasm
- Antispasmodic
- TCA
- SSRI (or step 2 is TCA contraindicated or not tolerated)
- Specialist referral
Coeliac Disease
What is the definition?
Symptoms?
- “Chronic, immune mediated systemic disorder in genetically pre-disposed people, triggered by exposure to dietary gluten” – NICE, 2020
- Inflammatory small bowel enteropathy
- GI and /or systemic symptoms
- Presence of coeliac specific antibodies in blood
- Damage to gut lining when gluten eaten
- Symptoms – Acid reflux, diarrhoea, steatorrhoea, weight loss, abdominal pain, reduced appetite,
bloating, constipation
What are the causes/risk factors of Coeliac? (3)
Heightened immune response to gluten
Genetic predisposition
T1 diabetes and autoimmune thyroid disease have inc risk of development of coeliac
What are the complications of Coeliac disease? (8)
- Reduced Quality of Life
- Depression, anxiety, eating disorder
- Faltered growth, delayed puberty
- Nutritional
deficiency/malabsorption - Anaemia
- Osteoperosis & osteopenia
- Hyposplensim & aspelenism
- Hodgkins & Non-Hodgkins
Lymphoma - Refractory Coeliac Disease
What is the prognosis of Coeliac disease?
- Improvement with Gluten-free diet
- Some slow/non responders – up to 30% report
persistent symptoms despite GF diet - Up to 10% no responders could have refractory disease
- No excess risk of GI, Respiratory or Cardiovascular disease mortality
- Conflicting evidence of excess mortality in coeliac patients compared with general population
What is the diagnosis of Coeliac disease?
- Difficult
- Suspect if:
- persistent, unexplained GI symptoms
- IBS
- Faltering growth, short stature or delayed
puberty in children - Prolonged fatigue or lethargy
- Persistent or recurrent mouth ulcers
- Unexplained iron, b12 or folate deficiency
- Diagnosed T1DM or Autoimmune Thyroid
Disease or Autoimmune liver disease - IgA deficiency
- Relative with coeliac disease
- Suspected Dermatitis Herpetiformis
Management of Coeliac Disease
monitoring?
- Gluten Free Diet
- Long term is the only effective treatment
- Advice – Signpost to info. & support, Dietician referral
Annual Review in Primary care
* Assess and review for persistent symptoms – Diet adherence check?
* Assess for nutritional deficiencies – treat if deficiency present
* Assess risk of osteoperosis – DEXA Scan
* Mental Health assessment – anxiety or depression screen
* Blood Monitoring – Coeliac Serology, FBC, Ferritin, TFT, LFT, Calcium, Vitamin D, B12, Folate
* Weight, Height, BMI check
- Specialist Referral
-Refractory disease suspected
-Child with faltering growth
-Suspected malignancy
Gluten Free Product Prescribing:
How are GF products prescribed?
*Monthly Unit allocations per patient
*Units allocated dependent on age, gender and home country/local guidelines
*GF items given a unit value
*Unit value based on cost, carbohydrate and energy content
*Single prescription charge per item
*Borderline substance in Drug Tariff so Endorse prescription as ‘ACBS’
*Coeliac UK guide - How much should be prescribed? - Coeliac UK
*Can only prescribe bread and flour in England
*Wales, NI & Scotland allow other items – Cereal, pizza bases, pasta etc.
*Hywel Dda Health Board Top Up Scheme
*Improved access to GF product
Terminologies:
What is the difference between Diverticula,Diverticulosis, Diverticular Disease?
What are the Symptoms?
- Diverticula – Sac-like protrusions in muscular wall of colon
- Diverticulosis – Diverticula present but no symptoms
- Diverticular Disease – Diverticular cause symptoms e.g. abdominal pain, no inflammation or infection
- Symptoms - Bloating, constipation, diarrhoea, nausea, rectal bleeding, dysuria
What is Diverticulitis?
- Diverticulitis –Diverticula become inflamed
- Infection? - Severe abdominal pain, fever, malaise, possible rectal bleeding
- Uncomplicated – Inflammation but no acute symptoms or perforation or abscess
- Complicated – Inflammation accompanied by complications - abscess, peritonitis, fistula, obstruction, or perforation
What are the risk factors of diverticulitis?
- Older age
- Genetics
- Low fibre diet
- Red meat rich diet
- Smoking
- Obesity
- Medication – NSAIDs, Opioids
- Immunosuppressio
What are the complications of diverticulitis?
- Diverticular Haemorrhage
- Intra-abdominal abscess
- Perforation
- Peritonitis
- Stricture or Fistula
Formation - Intestinal obstruction
- Sepsis
What is the Diagnosis and Prognosis of Diverticulitis?
Diagnosis:
* Difficult to diagnose as most are asymptomatic & overlap of symptoms with other GI conditions
* Suspect if intermittent abdo pain in lower left quadrant that may be triggered by eating or relived by passing stool or flatus
* Or tenderness in lower left quadrant on abdominal exam
Prognosis:
* 5% diverticulosis patients develop
diverticulitis
* Diverticulitis can resolve, become chronic or lead to complications
* Diverticulitis recurs in around a 1/3 of
patients following medical teatment
Management of Diverticulosis?
- Advise that condition is asymptomatic and no treatment needed
- Signpost to advice & info.
- Advice on healthy balanced diet
- Advice on fluid intake
- Advice on exercise & weight loss if overweight/obese
Management of Diverticular disease?
- Urgent admission if significant rectal bleeding
- Advice on avoiding use of NSAIDs and Opioids
- Advice on diet, lifestyle, exercise, weight loss, smoking cessation, fluids
- Advice on when to seek urgent medical attention
- Consider bulk forming laxative, paracetamol, antispasmodic
Management of Diverticulitis?
- Admission if complicated, dehydrated, no oral tolerance, aged over 65, co-morbidity or immunosuppressed
Oral antibiotic
* Co-amoxiclav
* Cefalexin + Metronidazole OR
* Trimethoprim + Metronidazole in penicillin allergy
Definitions of Nausea and Vomiting?
- Nausea - Sensation of uneasiness in the stomach which may or may not lead to vomiting i.e. “feeling sick”
- Vomiting – the act of being sick – body’s way of getting rid of evacuating harmful substance from the
stomach or has irritated the stomach
When/Why would people experience N&V? (7)
- Pregnancy – 1st trimester, hyperemesis gravidarum
- Palliative Care
- Ingestion of a toxic substance e.g. drugs & alcohol
- Post surgery
- During travel
- Migraine
- Medication related – Chemotherapy or radiotherapy induced, Dopaminergic drugs in PD
Drugs in treatment of N&V
Metoclopramide:
- direct action on gastric smooth muscle to stimulate gastric emptying
- Causes Parkinsons-like side effects – avoid in Parkinsons Disease patients (Extrapyramidal Side effects - EPSE)
- Max. 5 days treatment – for n&v post-op, radio & chemotherapy induced or symptomatic tx of n&v
- Dose generally 10mg TDS
What are the Drugs used in treatment of N&V? (6)
Metoclopramide
Domperidone
Antihistamines
Hyoscine hydrobromide
Dexamethasone
5HT3- receptor antagonists e.g Ondansetron and Haloperidol
Drugs in treatment of N&V
Domperidone
- Less likely to causes EPSE than metoclopramide
- CI in Cardiac disease – causes arrythmia and QT interval prolongation
- Max. 7 days treatment
- Dose 10mg TDS
Drugs in treatment of N&V
Antihistamines:
What are examples?
- e.g. Cyclizine, Promethazine, Cinnarizine
- Treatment of postop, palliative n&v, travel sickness, n&v related to meniere’s disease
- Can cause drowsiness as a side effect so advice that this may affect performance of skilled tasks (e.g. cycling, driving); sedating effects enhanced by alcohol.
Drugs in treatment of N&V
Hyoscine hydrobromide?
Dexamethasone?
Used for?
Treatment of travel sickness
Treatment of N&V in palliative care
Drugs in treatment of N&V
5HT3-receptor antagonists:
examples?
cautions or c/i?
- Block 5HT3 receptors in GI tract
1. ONDANSETRON – mainly used to treat postoperative or chemotherapy induced n&v - High risk of oral cleft development in babies if used during first 12 weeks of pregnancy
2. HALOPERIDOL – Prophylaxis of postop n&v, treatment of n&v in palliative care - Also causes PD like side effects and used in caution in patients with CVD
N&V in Pregnancy
When does it occur?
What treatments are used?
- Mainly in 1st trimester
- Some experience prolonged or severe n&v – hyperemesis gravidarum
- Offer advice, information & support, reassurance that symptoms will subside
- Self care - rest, fluids, avoid triggers, small, low carb/fat meals, plain food, cold meals, ginger, acupressure to wrist
- Treatments –
- 1st line - Cyclizine, Promethazine, Prochlorperazine, Chlorpromazine or Doxylamine/Pyridoxine combination
- Doxylamine/Pyridoxine – only prep. specifically licensed for n&v in pregnancy (Xonvea)
- 2nd line – Metoclopramide p.o. for 5 days or Domperidone p.o. for 7 days or Ondansetron for 5 days
(avoid in first 12 weeks) - Refer to specialist if no relief with 2nd line treatments
- Most of these treatments are off-licence as manufacturers advise to avoid use but there are no recorded teratogenic effect
Name 3 types of Laxatives?
Bulk forming e.g. Methycellulose
Osmotic e.g. Macrogol, Phosphate enema, Lactulose
Stimulant e.g. Senna, Bisacodyl, Docusate
Which laxative should be avoided in IBS?
Lactulose! Increases gas and worsens symptoms
