27-Constipation & Irritable Bowel Syndrome

1. tricyclic antidepressants (desipramine) for IBS-D 2. SSRIs for IBS-C 3. duloxetine for IBS-C and IBS-D

According to the drug list, which medications are used to treat IBS with severe pain? (3)

1. Lubiprostone 2. SSRI (Escitalopram, citalopram, sertraline) 3. rifaximin 4. osmotic laxatives (polyethylene glycol, milk of magnesia)

According to the drug list, which medications are used to treat IBS-C? (4)

1. rifaximin 2. alosetron 3. loperamide

According to the drug list, which medications are used to treat IBS-D? (3)

1. lubiprostone 2. osmotic laxatives: polyethylene glycol, milk of magnesia

According to the drug list, which medications are used to treat IBS-M? (2)

1. feces distends rectum wall which activates stretch-R and leads to a release of serotonin 2. serotonin stimulates afferent enteric neurons 3. neurons stimulate contraction in proximal part of colon and relaxation in distal part of colon

Describe how a poop moves in the rectum :)

1. Feces distend the rectum and activate stretch receptors 2. Receptors transmit signals along afferent fibers to spinal cord neurons which triggers a spinal cord reflex 3. parasympathetic (efferent) fibers stimulate internal anal sphincter (IAS) relaxation 4. now stool is under voluntary control

Describe how poop moves from the rectum to the outside

1. high fiber diet 2. make him sit on the toilet after each meal to increase peristaltic contraction (and ensure him that he wont get flushed down the toilet, I presume) 3. put his legs on a stool

Remember poor little Sammy? He became constipated around when he was toilet trained, had a low fiber diet, and would do the doody dance. How might we treat a little guy like this? (3 things)

No- these are not approved for use in children Need to give him Miralax

Sammy comes back a few weeks later and he is still pooping pellets. Would you give him Lubiprostone and Linaclotide, the only FDA approved treatments for chronic constipation?

True

T/F: IBS Likely encompasses multiple diseases that present with similar symptoms •Host Factors -Altered pain perception •Visceral hypersensitivity -Altered brain-gut interactions -Dysbiosis -Increased intestinal permeability -Increased gut mucosal immune activation Chey et

false: its abnormal so often their brains are not aware that they have to poop

T/F: people with slow transit constipation have normal "call to stool"

1. alterations in IL10/IL12 (pro-inflammatory state) 2. defects in serotonin receptors in enterocromaffin cells

There are two leading theories about what is affected in IBS-C. Name them.

1. normal transit constipation 2. slow-transit constipation 3. pelvic floor dysfunction

What are 3 types of primary constipation?

1. Early life stressors (Abuse, psychosocial) 2. Food intolerance (short-chain carbohydrates) 3. Antibiotics 4. Enteric infections

What are 4 environmental factors of IBS

1. Altered pain perception (Visceral hypersensitivity) 2. Altered brain-gut interactions 3. Dysbiosis (microbial imbalance of gut) 4. Increased intestinal permeability 5. Increased gut mucosal immune activation

What are 5 predisposing host factors for IBS?

1. Colonoscopy with biopsies 2. Full-thickness rectal biopsy (Hirschsprung disease) 3. Colonic motility testing (Slow-transit constipation) 4. Anorectal manometry (pressure & strength of anal and rectal muscles) 5. CT colonography

What are some work-ups that gastro-docs can do for constipation?

1. reservoir for food waste 2. resorbs fluid

What are the 2 major jobs of the colon?

1. primary constipation 2. secondary constipation 3. Constipation-predominant Irritable bowel syndrome (IBS-C)

What are the 3 broad groups that constipation etiologies are divided into?

1. IBS-Constipation predominant 2. IBS-Diarrhea predominant 3. IBS-Mixed constipation and diarrhea

What are the 3 subtypes of IBS?

Recurrent abdominal pain or discomfort at least 3 days/month in the last 3 months associated <2 of the following: -Improvement with defecation -Onset associated with a change in frequency of stool -Onset associated with a change in appearance of stool (sorry its long...)

What is the Rome Criteria for IBS?

bloating and abdominal pain

What is the major complaint that patients with IBS-constipation complain about?

constipation

What is the most common digestive complaint in the US?

15%

What percent of north america suffers from constipation?

1. < 3 bowel movements per week 2. Straining 3. Lumpy or hard stools 4. Sensation of anorectal obstruction 5. Sensation of incomplete defecation 6. Manual maneuvering required to defecate

You need to have at least 2 symptoms over the preceding 3 months to be diagnosed with constipation. List the 6 symptoms.

no- long term they cause constipation

are SSRIs good for long term use in constipation?

they sure do!

do patients with pelvic floor dysfunction have normal colonic transit time?

not usually

do you usually use an x-ray to dx constipation?

decreases

does IBS prevalence increase or decrease with age?

yes

has long term laxative use been shown to cause constipation?

hard/lumpy stools >25% of time

how do you classify IBS-C in terms of stool?

You put the patient in the left lateral decub position and wink and their anus. Jk: Cotton applicator in 4 quadrants around anus •absent anal contraction may indicate sacral nerve pathology

how do you do the anal wink?

rectum (rectal fecal impaction)

how far does a suppository reach when you put it ***********?

mid sigmoid colon

how far does an enema reach when you squirt it into the body?

8 glasses (good thing we have our swell bottles)

how many glasses of water should you drink/day?

<30 L/day

how much fluid does the colon resorb each day?

>18 yo b/c all the mouse pups died!

how old must be you to use linaclotide?

biofeedback- reteach pts how to contract and relax anal sphincters

how would you treat pelvic dyssynergia?

there is less fluid available for the stool

in general, what is the reason for secondary constipation?

women (1.5-2x)

is IBS more common in men or women?

women (2-3x)

is constipation more likely to occur in men or women?

mineral oil (slip and slide)

name a lubricative

senna

name a stimulative laxative

Mg, sulfate, citrate, phosphate ions

name the active ingrediates in saline laxatives

2 weeks

the different kinds of laxatives are first line drugs for constipation. How long should you use them for before you switch?

flax seed psyllium

what are 2 dietary supplements that people use?

Dehydration, diuretics, limited fluid intake, low fiber

what are some common, non-muscle related disorders, reasons for secondary constipation?

Hirchsprung's Dz

what are some enteric nervous system disorders related to secondary constipation?

Muscular dystrophy, hypotonia from autism

what are some muscle related disorders for secondary constipation?

any condition where the voluntary aspect of stooling is disrupted: stroke head injury parkinsons MS

what are some neurological conditions that might cause secondary constipation?

lactulose polyethylene glycol

what are some osmotic laxatives (not on drug list)

-↓Hgb -↑ WBC -↑ ESR/CRP -Abnormal chemistry -Abnormal TSH -Abnormal celiac screen

what are some red flags to look for with labs?

Abrupt onset Unintentional weight loss Family history of cancer, IBD or celiac disease Rectal bleeding-usually a fissure Symptom onset after 50

what are some red flags to look out for from the history?

+ stool guiaic (bleeding)

what are some red flags to look out for on the physical?

1. squatty potty 2. decrease coffee 3. exercise

what are some things medical students can do to help constipation?

Lubiprostone Linaclotide

what are the only 2 FDA approved drugs for constipation

1. prolonged or excessive straining 2. soft stools difficult to pass 3. feeling of incomplete evacuation 4. rectal discomfort 5. manual aid to evacuate stool

what are the symptoms of pelvic floor dysfunction? (5)

hemorrhoids due to pressure on the veins

what are these and how do you get them?

1. relaxing 2. relaxing 3. relaxing

what are these muscles doing when you LET YOUR POOP FLY? 1. puborectalis 2. external anal sphincter 3. internal anal sphincter

1. contracted 2. contracted 3. contracted

what are these muscles doing when you are holding in poop? 1. puborectalis 2. external anal sphincter 3. internal anal sphincter

1. segmentation 2. peristaltic

what are two types of colonic movement?

hold water in the stool and soften it

what do osmotic laxatives do?

draw water into colon for a full clean out effect (good for before colonoscopy)

what do saline laxatives do?

irritates the intestinal mucosa to stimulate muscle contraction and secretion

what do stimulative laxatives do?

keeps it contracted at a 90 degree angle so poop cant dribble out

what does the contracted puborectalis do to the anorectal angle?

it is like a "call to stool" makes the brain aware that the poop is there!

what does the relaxation of the internal anal sphincter do?

5-HT3 receptor antagonist

what is the MOA of Alosetron?

non-absorbable antibiotic

what is the MOA of Rifaximin?

stimulates CFTR via cGMP

what is the MOA of linaclotide?

chloride channel 2 activator

what is the MOA of lubiprostone?

normal: have normal colonic transit times slow-transit: decreased colonic motility and increased colonic transit time

what is the difference between normal transit and slow transit constipation?

diet! high fiber (brings water into the stool)

what is the initial treatment of constipation?

there is a discoordination of puborectalis and internal and external sphincters (puborectalis contracts when person strains to deficate)

what is the major reason for pelvic floor dysfunction constipation?

normal transit constipation

what is the most common type of constipation?

major movement purpose: to move food out--happens 6-8x/day

what is the purpose of peristaltic contraction? and is it the major type of movement?

not major movement purpose: to mix shit together every 25 minutes

what is the purpose of segmentation? and is it the major type of movement?

Left Lateral Decubitus Position

what is this position called? (besides the position that I usually like to sleep in)

anal fissure- very painful to pass stool

what is this?

rectal prolapse partial on L and full on R

what is this?

skin tag

what is this?

metabolic panel (ONLY FOR CHRONIC CONSTIPATION) blood cell tests inflammatory markers Celiacs Dz

what labs should you get for chronic constipation and IBS-C?

40%

what percent of people over 65 yo suffer from constipation?

potty training age

when is a common time children are prone for constipation?

seizures- aspiration would be bad

when is mineral oil contraindicated?

IBS (someone with constipation would more likely have hx of hard poops and straining)

when obtaining a hx (which is REALLY important for constipation/IBS history) what would a patient presenting with abdominal pain and bloating most likely have? IBS? or constipation?

after 3-6 mo of medial management or concerning symptoms

when would you do a work up for constipation?