Irritable Bowel Syndrome buttaro ch. 139

Any pt with bloating, gas, distention, and diarrhea who cannot be dx as having IBS on s/s alonge should undergo

a two week trial of lactulose free diet or hydrogen breath test to exclude lactase defciency alternative is to have patient drink a court of milk, if no s/s...then lactose intolerance is unlikely

Clinical Manifestation of IBS constipation

abn. passage of stool like straining, urgency or feeling of incomplete evacuation, changes in the form of feces. effort needed to defecate, passage of mucus, and bloating, abd. distention,

Bleeding is not associated with IBS but may occur due to

anal fissure or hemorrhoids

treatment w/ dietary modification

common gas forming foods: beans, beer, broccoli, brussels sprouts, cabbage, carbonated beverages, cauliflower, coffee, grapes, plums, raisins, raw onions, and red wine dairy products can cause gi s/s food diary w/ s/s no evidence to support food allergies or diet restriction in IBS pt, but many recognize triggers and avoid the foods

If fecal leukocytes are present on stool sample then

culture specimens for ova and parasites, and C dif

DD for IBS

endocrine> thyroid dz, Diabetes related diarrhea GI> cholecystitis, fructose or lactose problem, malabsorption syndrome, pancreatic insuff. viral gastroenteritis Psych d/o > anxiety depression, somatization GU> PID, indometriosis, ovarian cysts, uterine fibroid

Identify factors associated with risk of developing IBS

factor seeing medical attention: not associated with symptoms severity, interferences with quality of life, associated psychological factors, disease associated with stress

Post infectious IBS

>acute diarrheal illness precedes the onset of IBS-diarrhea predominant

What would indicate or differentiate IBS from an organic pathology

>acute onset of GI s/s or onset of IBS symptoms in pt older than 50. >if pt is having nocturnal s/s bloody or greasy stool, weight loss, malnutrition, evidence of gi bleed, anemia, recurrent nausea, vomiting, fever all of these s/s should be referred and are not consistent with IBS

IBS pathophysiology

>altered GI motility >visceral afferent hypersensitivity >microscopic inflammation >post infectious >alteration in fecal microflora >genetics >psychosocial dysfunction

Describe the epidemiology of irritable bowel syndrome

>chronic functional bowel disorder >characterized by abd pain and altered bowel in the absence of any organic cause >most common gi complaint seen in primary care and most common dx for gi docs

Manning Criteria

>pain relieved with defecation >more frequent stools at the onset of pain >looser stools at the onset of pain >visible abdominal distention >passage of mucus >sensation of incomplete evacuation

ROME III Diagnostic Criteria

>recurrent abd pain or discomfort at least 3 days per month in the last 3 months associated with 2 or more of the following >improvement with defecation >onset associated with a change in frequency of stool >onset associated with a change in form of stool

Patho of motility

>signals between the intestinal cells and brain between brain and intestine

Crohns dz

All layers and any portion of intestinal tract Variable presentation and response to treatment Patchy, strictures and fistulas

Rome III diagnostic criteria for irritable bowel syndrome

for dx, criteria must be met at least once per week for at least 2 months before dx 1> abd. discomfor or pain at least 3 days per month in last 3 months with two or more of the following *improvement w/ defication *onset associated w/ change in frequency of stool (fewer than 3 BMs per week or more than 3 BMs per day) *onset associated with change in appearance of stool (lumpy and hard or loose and watery) 2>no evidence of other explaination for s/s

Young person diagnostic

get thyroid function r/o celiac

Diagnostics for IBS

goal is to exclude alternative or other dx and avoid unnecessary testing few if any diagnostic tests are required in young healthy pt who meets the Rome II criteria and who do not have red flags suggesting organic dz screen limited to organic dz like a CBC, erythrocyte sedimentation rate (ESR), BUN, albumin, elytes, creat, and glucose, TSH, and stool specimen for occult blood and fecal leukocytes

When is a colonoscopy recommended for someone <40

healthy patient w/ acute change in bowel habits or rectal discomfort

psychosocial factors r/t IBS

higher psychosocial stressors and abuse in patients w/ IBS Have higher incidences of depression, anxiety

patho "enhanced visceral sensation

hyperalgesia...basically higher than normal pain with little stimulus in bowel. increased somatic referral of visceral pain and incrased sensitivity to normal intestinal function may have altered receptor sensitivy at viscus or incresed excitability of spinal cord

Fiber and IBS

if one does not seem to work, tell them to try another psylium (Metamucil) calcium polycarbophil (fibercon) methylcellulose (Citrucel) take daily with food or 8 ounces of liquid alternative is intake of fluid of 64 ounces and a set time each day to use bathroom along with whole foods and natural fiber. exercise has not shown to improve s/s of IBS

Fiber for IBS

soluble fiber therapy is recommended, decreases constipation, but unsure about pain and diarrhea insoluable fiber like that is found in wheat bran and corn can increase bloating and abd. pain due to colonic distention fiber after initial period of bloating at a min. of 20 g /day and add to it synthetic fibers more soluble than natural may be better tolerated introduce fiber slowly to reduce gas and bloating

referral of IBS pt if

suspicioun of organic dz initial tx failed change in bowel habits in pt older than 50 change in usual IBS symptom pattern

Treatment for IBS-c

synthetic fiber increase fluid and exercise lacking evidence for stool softeners and osmotic laxatives like lactulose and polyethylene glyco (Miralax) but poor evidence stimulant laxatives should be avoided Lubiprostone (Amitiza): approved for constipation linaclotide (Linzess)..decreases absorption of sodium and allows secretion of water to help w/ defecation. highest evidence888newest med:

when should a colonsocopy be performed on patient older than 50 ...w/ what s/s

when wt. loss, anemia, occult blood, or risk factors for colorectal cancer

10% of IBD can not be distinguished as Ulcerative colitis or Crohn's disease and is considered

"Unclassified"

stats on IBS

*50% more common in females appears to be familial *10-30% of US population *no good evidence to support dif. in stats with race or socioeconomic status *late adolescence to early adulthood with peak at 30-40 and ususally dx by 50 *IBS miss three times more work, see health care provider more often for GI and non GI complaints and use healthcare resources 50% more

Recognize a diagnostic approach to an individual presenting with possible IBS

1. Identify -abdominal pain, discomfort -bloating -bowel dysfunction 2. Probe -look for additional symptoms to confirm the diagnosis -also inquire about previous use of GI medications 3. Eliminate -rule out red flags

Unlikely to be IBS symptoms 1 2

1. nocturnal symptoms 2. weight loss

Distinguish between 4 subtypes of IBS compare the differing pathophysiology mechanism that may be involved in IBS-C or IBS-D

>IBS with constipation >IBS with diarrhea >Mixed IBS >Unsubtyped IBS

ulcerative colitis

Lining of the colonic mucosa (part or entire), some submucosal layer Diffuse and continuous

Treatment of IBS-D

Loperamide (imodium) 2-4 mg qid prn decreases intestinal transit time enhan ce water absorption, and strenghtens rectal sphencter tone which decreases diarrhea (max dose is 16 mg/day) polycarbophil can be added to increase bulk of stool pepto bismol, kaopectate, and bile acid sequestering agents ...cholestyramine (Questran Prevalite) Alosetron (Lotronex) when other therapy has not worked. but should only be prescribed by physician

List the potential therapies for people with either IBS-c or IBS-D including dietary changes and medications.

Treatment -pt/doctor relationship -dietary modifications -psychotherapy -medications

REd flags for emergency

nocturnal s/s rectal bleeding and bloody stools fever unintentional weight loss anemia recurrent n/v first degree relative w/ gi malginancy, IBS or ovarian cancer abnormal phsycial exam evlevated CA 125 rectal mass

s/s of IBS

nonradiating, intermittent, crampy pain can occur anywhere but usually is located in left lower abd. quadrant. s/s happen more often w/ food or alcohol consumption. S/s vary over time, so make sure there is no nocturnal s/s bloating, nausea, lethargy, and backache most likely reflect increast sensitivty to narmal amounts of gas and NOT actual increase in gas.

Medications of IBS >antispasmodic agents

poor evidence but some say antispasmotics decrease d/d of diarrhea and pain anticholinergics reduce signmoid motility in response oto a fatty meal dicyclomine (Bentyl) 10-40 mg qid prn good for postprandial abd. pain, gas and bloating. take this med 30-60 min before meals hyoscyamine sulafate: active ingredient in Levsin and Donatal- s/e tho for this one is urinary retention, tachycardia, and dry mouth. clidinium: Librax and clindex- s/e fatigue **dicyclomine: fewer side effects because it is more specific to GI tract do not use analgesics if at all possible

classified as functional because

problems w/ gut function, but no identifiiable organic or structural causes explain the development