Week 12: Chp 58: Irritable Bowel Syndrome

Question 1

What is IBS?

Answer 1

complex and misunderstood functional disorder characterized by abdominal pain and altered bowel habits for which no other pathophysiological cause can be found

• characterized by areas of bowel spasm and dilation
• unknown etiology with no known cure

Question 2

4 Subtypes of IBS

Answer 2

1. IBS-C (constipation dominant)
2. IBS-D (diarrhea dominant)
3. IBS-M (mixed, or alternating from diarrhea to constipation)
4. IBS unclassified (meets IBS diagnostic criteria but cannot be accurately categorized with the other 3)

Question 3

Many theories regarding the pathophysiology

Answer 3

• gastrointestinal motility
• visceral hypersensitivity
• intestinal inflammation
• post-infection
• bacterial overgrowth
• food sensitivity
• carbohydrate malabsorption
• gluten sensitivity
• genetics
• psychosocial dysfunction

Question 4

Clinical Manifestations

Answer 4

diarrhea, constipation, flatus, and abdominal pain that may vary based on classification

• often report LLQ pain accompanied by abdominal distension and alternating bouts of diarrhea and constipation
• the pain increases after eating and is relieved with bowel movements
• due to the pain and abdominal cramping, the patient may become anorexic with noticeable weight loss

Question 5

Treatment for IBS

Answer 5

is symptom based

• no one treatment is effective for all patients; highly individualized
• may be a lifelong struggle
• patients are encouraged to keep a dietary diet, episodes of stress, and triggers associated with the onset of symptoms

Question 6

How to Diagnose IBS

Answer 6

no test shows a definitive diagnosis of IBS
-number of tests may be performed to rule out other pathophysiological causes for concern:
>flexible sigmoidoscopy, colonoscopy, CT scans, lactose intolerance tests, stool cultures, and blood tests
-after organic causes have been ruled out, the Rome IV or Manning Criteria are used to make diagnosis of IBS

Question 7

Rome IV Diagnostic Criteria for Functional Gastrointestinal Disorders

Answer 7

common diagnostic instruments
-patient must have had recurrent abdominal pain or discomfort at least 1 day per week in the last 3 months associated with two or more of the following:
>improvement (of pain) with defecation
>onset associated with a change in frequency of stool
>onset associated with a change in form (appearance) of stool

Question 8

Manning Criteria

Answer 8

tool used in the diagnosis of IBS
>the more clinical manifestations the patient has the greater the likelihood of being diagnosed with IBS:
-pain relieved with defecation
-more frequent stools at the onset of pain
-looser stools at the onset of pain
-visible abdominal distension
-passage of mucus
-sensation of incomplete evacuation

Question 9

Treatment includes

Answer 9

• medications
• dietary modification
• complementary and alternative therapies

Question 10

Medications used for treatment of IBS

Answer 10

• antispasmodic agents
• antidiarrheal
• guanylate cyclase agonists
• serotonergic agents
• selective type 2 chloride channel (CIC-2) activator
• antidepressants
• selective serotonin reuptake inhibitors (SSRI)
• tricyclic antidepressants (TCAs)

Question 11

Medications: antispasmodic agents

Answer 11

anticholinergic and antimuscarinic components that block acetylcholine, relaxing smooth muscle spasm and GI motility; inhibit gastric secretion
>Dicyclomine (Bentyl, Antispas)

Question 12

Medications: Anti-diarrheals

Answer 12

• slow bowel transit, enhance water absorption, and strengthen anal sphincter tone, resulting in fewer stools but does not relieve pain; Loperamide (Imodium)
• decreases motility, propulsion, and secretions; Diphenoxylate hydrochloride (Lomotil)

Question 13

Medications: Guanylate cyclase agonists

Answer 13

stimulates intestinal fluid secretion and transit

>Linaclotide (Linzess) for IBS-C despite treatment with osmotic laxative

Question 14

Medications: Serotonergic agents

Answer 14

• agonist activity causes release of other neurotransmitters and results in increased peristalsis, increased intestinal secretion, and decreased visceral sensitivity; Tegaserod (Zelnorm) for IBS-C in females
• limits gastrocolic reflexes, which can slow transit time and improve muscle tone; Alosetron (Lotronex) for refractory IBS-D in female patients

Question 15

Medications: Selective type-2 chloride channel (CIC-2) activator

Answer 15

increases fluid secretion in the small intestine and is believed to enhance colonic motility by increasing intraluminal volume
>Lubiprostone for IBS-C in women

Question 16

Medications: Anti-depressants

Answer 16

low doses of antidepressants have been shown to decrease pain

Question 17

Medications: SSRIs

Answer 17

inhibit serotonin uptake and may increase pain threshold while decreasing transit time
>Paroxetine (Paxil); fluoxetine (Prozac); sertraline (Zoloft)

Question 18

Medications: Tricyclic Antidepressants (TCAs)

Answer 18

block norepinephrine reuptake and are believed to slow transit time and improve pain tolerance
>Amitriptyline (Elavil); imipramine (Tofranil); nortriptyline (Pamelor); desipramine (Norpramin)

Question 19

Focus on Medical Management

Answer 19

controlling spasm, minimizing diarrhea, releasing neurotransmitters to promote peristalsis, and addressing depression

Question 20

Dietary Modifications

Answer 20

-diet high in fiber
-diet low in fermentable oligo-, di-, and mono-saccharides and polyols (FODMAPs) are noted to improve symptoms for IBS
-avoid fructose, apples, pears, mangoes, cherries, and wheat
-avoid gas-producing food
-benefit from avoiding lactose
>patient eliminate FODMAPs from their diet for 6 to 8 weeks, after resolution of symptoms, they are gradually re-introduced to determine tolerance for specific foods

Question 21

Complementary and Alternative Therapies

Answer 21

relaxation techniques, acupuncture, hypnosis, and hypnotherapy

• probiotics
• regular exercise, yoga, massage, or meditation to relieve stress and anxiety
• herbs (peppermint and fennel, herbal teas, and ginger) demonstrated some relief of IBS but be used with caution under advice of healthcare provider

Question 22

Complications

Answer 22

involve psychosocial concerns such as social isolation and diarrhea

• if certain food groups are avoided because of onset of symptoms, patients may not be receiving all the nutrients they need
• fluid volume deficit and hypokalemia when the patient has bouts of frequent diarrhea

Question 23

Nursing Management: Assessment and Analysis

Answer 23

patients can often associate foods that may trigger symptoms and keeping a diary can assist in identifying these trigger foods

• patients associate a stressful situation with the onset of symptoms, and the diary helps to identify these sources of stress and find better ways with dealing with them
• may also complain of anxiety, sleep disturbances, and difficulty concentrating

Question 24

Clinical Manifestations for IBS

Answer 24

intermittent abdominal pain and altered bowel habits

• most frequent complaint of abdominal pain is in the LLQ with relief after defecation
• abdominal distention and bloating
• anorexia
• excessive flatulence
• dyspepsia (heartburn)
• eructation (belching)
• a continual urge to defecate
• a sense of incomplete evacuation
• nausea and increased pain may be associated with meals
• in IBS-D there may be mucus in the stool but not blood
• IBS-D nocturnal diarrhea is uncommon and is usually indicative of an organic disease

Question 25

Nursing Diagnoses

Answer 25

- chronic pain r/t spasms and increased motility - ineffective coping r/t the psychosocial effects of IBS - ineffective health maintenance r/t living with a chronic disease

Question 26

Nursing Assessments

Answer 26

- Vital Signs - Intake and Output - Serum Electrolytes - Pain - Bowel Pattern - Weight - Psychosocial Assessment

Question 27

Assessments: Vital Signs

Answer 27

elevated heart rate and blood pressure may develop secondary to severe pain -fever may develop secondary to dehydration, inflammation, or infection

Question 28

Assessment: Intake and Output

Answer 28

with frequent bouts of diarrhea, the patient is at increased risk of fluid volume deficit

Question 29

Assessment: Serum Electrolytes

Answer 29

the patient is at risk for hypokalemia during bouts of diarrhea -serum sodium and blood urea nitrogen may be elevated secondary to dehydration

Question 30

Assessment: Pain

Answer 30

the most frequent complaint of abdominal pain is in the LLQ with relief after defecation and is most likely due to the intestinal spasm and dilation

Question 31

Assessment: Bowel Pattern

Answer 31

patients with IBS may have constipation, diarrhea, or a combination of both

Question 32

Assessment: Weight

Answer 32

the patient is at risk of weight loss, particularly during exacerbations of IBS

Question 33

Assessment: Psychosocial assessment

Answer 33

because onset of symptoms is often associated with stress, a thorough psychosocial assessment can reveal triggers

Question 34

Nursing Actions

Answer 34

- administer ordered IV solutions - establish a trusting relationship - avoid foods that exacerbate clinical manifestations - establish a regular bowel routine - implement complementary and alternative medicines that may relieve symptoms - make appropriate referrals

Question 35

Nursing Actions: Administer ordered IV solutions

Answer 35

based on the degree of fluid volume deficit that results from diarrhea, IV replacement fluids are ordered >0.45 NS with potassium supplementation

Question 36

Nursing Actions: Establish a trusting relationship

Answer 36

IBS is often thought of as a psychological illness rather than a physical illness -a therapeutic, trusting relationship is necessary for the patient to have an open relationship with the caregiver, providing empathy and support

Question 37

Nursing Actions: Avoid Foods that exacerbate clinical manifestations of IBS

Answer 37

caffeine and alcohol increase GI motility and irritate the GI mucosa -indigestible carbohydrates such as beans produce increased gas, leading to abdominal discomfort

Question 38

Nursing Actions: Establish a regular bowel routine

Answer 38

drinking six to eight glasses of water per day helps to regulate stool frequency -increase physical activity to promote GI motility

Question 39

Nursing Actions: Implement complementary and alternative medicines that may relieve symptoms

Answer 39

often help relieve symptoms and should be used only under the advice of the provider >Peppermint (Mentha piperita) and fennel (Foeniculum) are natural antispasmodics and have anti-inflammatory properties; they relax smooth muscle in the intestines and help expel gas >Herbal teas such as chamomile have gentle antispasmodic properties >ginger helps control nausea and expel gas

Question 40

Nursing Actions: Make appropriate referrals

Answer 40

``` to: -dieticians -psychological counseling -support groups >irritable bowel syndrome is a complex disease of unknown etiology that requires an interprofessional approach including a dietitian, case manager, and psychiatric approaches ```

Question 41

Teachings

Answer 41

- avoid trigger foods that exacerbate clinical manifestations - keep a diary - consume regular meals and drink 8 to 10 cups of liquid per day (enhances promotion of regular bowel habits) - encourage regular exercise and 7 to 8 hours of sleep each night (important for regular bowel habits and managing stress and anxiety) - smoking cessation techniques (nicotine increases GI motility leading to increased pain and/or diarrhea)

Question 42

Common Trigger foods for abdominal discomfort

Answer 42

caffeine, alcohol, eggs, wheat products, and beverages containing sorbitol or fructose -these foods may increased GI motility, leading to increased abdominal pain and/or diarrhea

Question 43

Expected outcomes

Answer 43

stable vital signs and weight, decrease in clinical manifestations, and patients understanding and adherence to nutritional and activity recommendation to manage this chronic disease -establish a trusting relationship

Question 44

The nurse recognizes which findings as diagnostic for IBS?

Answer 44

Rome IV and/or Manning Criteria