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GI Exam 2
Long IBS
| Question | Answer |
|---|---|
| What is IBS (Irritable Bowel Syndrome)? | Gastrointestinal syndrome with CHRONIC abdominal pain and altered bowel habits in the absence of an organic cause *more common in women, and thought that 3/4 of the referrals to GI are for IBS KEY here is that its CHRONIC abdominal pain |
| When the definition states *in the absence of an organic cause means we? | don’t really know why they’re having these issues |
| What we need to remember about the Pathophysiology of IBS is that its a? | Brain-gut disorder; connection between the Braine and your intestines and something is going wrong |
| Pts that have IBS typically either have a genetic _________ or certain environmental factors that are triggering it. They typically have anxiety or depression or both (could be severe or could be mild) and they have this visceral __________. | predisposition (family hx of IBS); hypersensitivity (so when they have abdominal distension, when they feel bloated, not just uncomfortable, its painful) |
| When we look at IBS pt’s microbiome, the normal flora of organisms was _____. They also have different transmitters in the brain | different; |
| RED bold of pathophysiology, remember IBS is a brain-gut disorder—> | Altered mucosal and immune function; Altered bowel motility; Visceral hypersensitivity; Altered CNS processing: role of serotonin (5HT-3, 5HT-4); Altered gut microbiota |
| Clinical Presentation of pts with IBS: Signs and Symptoms include? | Lower abdominal pain, Bloating and distension, Extreme urgency, mucus passage, depression or anxiety, urinary symptoms, Fatigue, Pain during intercourse |
| Clinical Presentation of pts with IBS: Common Concurrent Conditions include? | Fibromyalgia, Functional dyspepsia, Chronic fatigue *Really their Quality of Life is much more poor than you would expect *pts stated they would give up 15 years of their life to not have IBS |
| We do not need to know how to diagnose but know that diagnosis is a _______ _______ | Clinical Diagnoisis (meaning we are looking at the symptoms and the pt story |
| T/F: There is not a real test for IBS | TRUE *no biopsy or scan, have to talk to them |
| There are 2 diagnostic criteria for IBS (Manning and _______ _____ _____) | ROME IV Criteria *only need to know ROME |
| ⭐️ ROME IV CRITERIA states: Pts have to have recurrent abdominal pain _____ for the LAST 3 MONTHS associated with >/= 2 of the following: -Related to defecation -Associated with a change in stool frequency -Associated with a change in stool form/appearance *Symptom ONSET >/= ____ months before diagnosis | ⭐️ >/= 1 DAY/WEEK; 6 months *key here is very chronic (over 6 months total) but for the past 3 months have had abdominal pain at least 1 day every week for those 3 months and that abdominal pain was associated (whenever they had it) this pain was related to 2 or more of the points listed (bathroom, loose stools or harder stools) |
| Alarm symptoms of IBS include: | age greater than or equal to 50 yo, no prior colon cancer screening, symptoms, unintentional weight loss, family hx or colorectal cancer or IBD; Palpable abdominal mass or lympadenopathy; overt GI bleeding (i.e Melena); Positive fecal occult blood (FOBT); Iron-deficient anemia; Recent changes in bowel habits; nocturnal pain or stool passage **ROME IV criteria met + NO alarm symptoms==> IBS |
| Dr. Long takeaways for alarm symptoms for IBS: | *weight loss—> cancer; over 50 and have NEVER been screened for colon cancer—> send them to the Doctor, not going to assume they have IBS (let them rule out colon cancer first); BLOOD is not associated with IBS, more so IBD |
| Which pt meets the diagnostic criteria for IBS? -JS, a 27 yo w/ abd pain for -4 days/week x 7 months, increased stool frequency and decreased consistency -RB, a 27 yo w/ abd pain for - 3days/week x 6 months, increased stool frequency and unintentional weight loss -KL, a 33 yo w/ abd pain for - 4 days/week x 6 months, decreased stool consistency and melena | -JS, a 27 yo w/abd pain for -4 days/week x 7 months, increased stool frequency and decreased consistency |
| Classification: IBS subtypes are? | -Diarrhea (Predominant IBS) -Constipation (Predominant IBS) -IBS with Mixed symptoms -Unsubtyped IBS (*so first you have a diagnosis of exculsion, cant figure out why or what type it is) *We have to know which the patient belongs to determine the tx since tx is different |
| IBS Severity of Symptoms can be: | Mild, moderate, severe |
| IBS: Mild, less frequent—> Tx would be? | Lifestyle changes (dietary restrictions, Higher-fiber diet, physical activity, relaxation techniques) |
| IBS: moderate, more persistent—> Tx would be? | PRN use (Anti-spasmodic agents, anti-diarrheal agents) |
| IBS: Severe—> Tx would be? | Targeted therapies (5-HT4 agonists (IBS-C); (5-HT3 receptor antagonists (IBS-D) *need to start something |
| How Dr. Long knows what to give for what for either IBS-C or IBS-D: Constipation has more letters in it than Diarrhea so for IBS-C—> | We would use 5-HT4 agonists; 5-HT3 antagonists is a lower number so less letters for IBS-D *Agonists comes before antagonists (Ag comes before An) and constipation comes before diarrhea) |
| Treatment strategy for IBS—> | 1. Identify and treat exacerbation causes (if possible) while minimizing adverse effects 2. Manage potential dietary causes 3. Relieve symptoms 4. Restore normal bowel habits 5. Prevent morbidity and mortality |
| Diet for IBS—> what foods can make it better? | Key here is you want to give them a LOW FODMAP diet |
| For Constipation-Predominant IBS: Mild, less frequent—> Tx would be? | Lifestyle changes: increased dietary fiber, increase fluid intake *i.e psyllium |
| For Consitpation-Predominant IBS: Moderate, more persistent—> Tx would be? | PRN use: Anti-spasmodic agents; Bulk-forming agents |
| For Constipation-Predominant IBS: Severe—> Tx would be? | Targeted therapies: 5-HT4 receptor agonists |
| For Both IBS-C and IBS-Dl we could also add ___________ ________ modifications (i.e stress reduction +/- anti-depressants) *b/c this is a brain-gut disorder | psychotherapeutic behavior |
| Constipation-Predominant IBS—> All of the following have weak evidence for IBS-C which are? | -Fiber (1 tbsp with 1 meal/day—> 2-3 meals/day until goal achieved (soluble>insoluble); Psyllium (Metamucil), polycarbophil: benefits with minor AE’s and Fluids -PEG laxatives (other laxatives in smallest dose for shortest time) osmotic laxative (off-label use; much more commonly used for non-IBS constipation (no improvement in IBS symptoms such as abdominal pain Remember weak recommendation (low evidence level) |
| #1 drug that you will see most often for Constipation-Predominant IBS is? | Linaclotide (Linzess) |
| Linzess is a _____ and has to be taken on an empty stomach | Prokinetic |
| Dose of Linzess is? | 290 mcg PO daily 30 min before first meal (EMPTY STOMACH) *D/C if severe diarrhea (more common than Plecanatide) |
| Linzess is CI in ________ since it can cause severe dehydration and GI obstruction ⭐️ | PEDIATRICS |
| Another option for Constipation-Predominant IBS is Plecanatide, brand name is? | Trulance |
| Dose of Plecanatide (Trulance) is? | 3 mg PO daily; consider alternative if no improvement after 4 weeks ⭐️ *similar mechanism as linaclotide: less diarrhea |
| Plecanatide (Trulance) is CI in _________ since it can cause severe dehydration and GI obstruction ⭐️ | PEDIATRICS |
| Linaclotide (Linzess) is your Go-to and has the ________ recommendation in the guidelines | STRONGEST |
| Our newest medication for Constipation-Predominant IBS is Tenapanor, brand? | Ibsrela *first in class: inhibitor of the Sodium/H+ exchanger isoform |
| Information about Tenapanor (Ibsrela) is that its 50 mg taken BID IMMEDIATELY PRIOR TO? | BREAKFAST AND DINNER *D/C if severe diarrhea |
| AVOID Tenapanor in ___________due to risk of severe dehydration, or even an adult if suspected GI obstruction | PEDIATRICS |
| Another agent for Constipation-Predominant IBS is Lubiprostone, Brand? | Amitiza |
| Lubiprostone mechanism is a? Indication? | Chloride channel activator (fyi—> increases fluid secretion, promotes motility/fecal transit); Use if pt fails other agents due to high cost and less evidence *Remember, Linaclotide is your go-to but could use this if failed |
| Lubiprostone is contraindicated in _______ ________ | Gastrointestinal Obstruction; avoid in severe diarrhea |
| Dose of Lubiprostone (Amitiza) is? | 8 mcg PO BID with food and water for adult FEMALES with IBS-C ⭐️ |
| For pts with severe hepatic impairment, initial dose of ____ mcg PO daily; increase if tolerated/needed | 8 |
| For Lubiprostone, be sure to monitor for? | dyspnea, nausea, headache, hypotension/syncope |
| The only person that this medication is approved for is an Adult FEMALE that has IBS-C that cannot take LINACLOTIDE is given _______ | Lubiprostone |
| Which of the following treatments would be most appropriate for a child with IBS-C? -Psyllium -Linzess -Trulance -Ibsrela | Psyllium |
| List all 6 options for IBS-C: | 1. Fiber (bulky agents like Psyllium (Metamucil, Polycarbophil), fluids) 2. PEG Laxatives 3. Linaclotide (Linzess) 4. Plecanatide (Trulance) 5. Tenapanor (Ibsrela) 6. Lubiprostone (Amitiza) |
| Diarrhea-Predominant IBS: Mild, less frequent—> Tx options are? | Lifestyle changes (Lactose-free, Caffeine-free, Alcohol-free) |
| Diarrhea-Predominant IBS: Moderate, more persistent—> Tx options are? | PRN use: Anti-Spasmodic agents; Anti-diarrheal agents |
| Diarrhea-Predominant IBS: Severe—> Tx options are? | Targeted therapies: 5-HT3 receptor ANTAGONISTS |
| LOW FODMAP for dietary management for both? | IBS-C and IBS-D |
| Diarrhea-Predominant IBS: 1. Diet-> | avoid GI irritants or laxatives; Focus on FODMAP foods, NOT caffeine, alcohol, herbals, artificial sweeteners; Consider lactose intolerance |
| Diarrhea-Predominant IBS: 2. Loperamide—> | We could try Loperamide (Imodium) but remember that there is very low evidence, and its not really solving the issue (just being used episodically |
| Remember that Loperamide’s mechanism is acts as a? | Opioid receptor agonist (FYI—> inhibits peristalsis and anti-secretory activity; prolongs intestinal time; increases intestinal transit time, increases water/electrolyte absorption, and strengthens rectal sphincter tone |
| The use of Loperamide for Diarrhea-Predominant IBS is for? | EPISODIC management of urgent diarrhea; Avodance of possibility of an acute symptom onset (Not a long-term treatment) |
| Diarrhea-Predominant IBS: 3. Bile Acid sequesterants (i.e. Colestipol, Cholestyramine) mechanism? | decrease fecal bile acids by forming a non-absorbable complex (more commonly see for other indications (i.e. dyslipidemia, purities) **Monitor For Medication interactions due to binding-abilities (Vitamins, NSAIDs, Amiodarone, oral contraceptives, diuretics (DOVAN) |
| George Washington is here to pick up his new prescription for Cholestyramine. Which of his medications can interact with it? -Lisinopril -Furosemide -Multivitamin -All of the above -Furosemide and multivitamin -None of the above | -Furosemide and multivitamin |
| Diarrhea-Predominant IBS: 4. Eluxadoline (Viberzi) Mechanism? | (Fyi—> mixed mu and k-opioid receptor agonist and delta receptor antagonist—> decreases abdominal pain and diarrhea |
| Dose of Eluxadoline (Viberzi)—> | 100 mg PO BID WITH FOOD (Long: VIBERZI like a BURGER (taken with food)) *lower dose if renal/hepatic impairment, lack of tolerability |
| CI of Eluxadoline (Viberzi) is? | CI in severe HEPATIC impairment, lack of gallbladder or > 3 EtOH drinks/day; D/C if severe constipation, pancreatitis, sphincter of Oddi spasm, biliary duct obstruction, or CNS depression |
| Diarrhea-Predominant IBS: 5. Rifaximin (Xifaxan) is: | Nonabsroable rifamycin antibacterial; activity against gram (+) and gram (-) organisms; fyi (improved abd pain, urgency, and QOL; less impact on stool consistency and bloating); *Dr. Long refers to this drug as a kind of side-kick that you can kind of use it but really used more in Cirrhosis |
| Dosing and Indication of Rifaximin (Xifaxan) are? | IBS-D: 550 mg PO TID x 2 weeks; may repeat up to 2x if recurrence but never more than 6 weeks at a time; Currently greater use in Traveller’s diarrhea and Cirrhois Dr. Long: *remember that IBS dosing and Cirrhosis dosing are different *If there is a flare of their IBS, we’re going to give this to treat the microbes that are out of control and then we’re going to stop it becuase now the normal bowel has been restored* |
| Diarrhea-Predominant IBS: 6. Alosetron (Lotronex) is a? | Selective 5-HT3 receptor antagonist; improves urgency, stool consistency, QOL |
| In 2000, Alosetron (Lotrenox) was removed from the market due to: | Severe constipation and Ischemic colitis (fatal, colon died with lack of blood flow) |
| But because of a lack of treatment options, it was brought back in 2002 with FDA approval for a _____ -___ program, so ONLY WOMEN with severe symptoms not relieved by conventional therapy | restricted-use *they have very severe symptoms (very small window of people that can take this drug |
| CI of Alosetron (Lotronex) is in? | SEVERE HEPATIC IMPAIRMENT |
| Dosing (not mentioned by Dr. Long) for Alosetron (Lotronex)? | 0.5 mg BID (lower initial dose) to be d/c immediately if constipation, rectal bleeding, or worsening abdominal pain; REMS: Physician education |
| IBS-C and IBS-D: Anti-spasmodic—> These are not your hero to save the day. Remember that in IBS, your bowel is very irritated. These are a good option for? | Pts with mixed syndrome of both, but these agents should only be used for short-term relief of abd pain(by reducing smooth muscle contraction and possibly visceral hypersensitivity |
| IBS-C and IBS-D: Antispasmodics: Monitor for? Caution use in? | drowsiness, dizziness, blurred vision; CVD, Hepatic impairment, renal impairment, hyperthyroidism *remember that these have weak recommendations w/ low evidence levels |
| Examples of our Antispasmodic agents are? | Dicylcomine (Bentyl) and Hyoscyamine (Levsin) |
| Dicyclomine (Bentyl)—> prescribers will give as supplement to try for pts not ready to try a drug with more SE but with this drug its given? | 200 mg PO QID x 7 days up to 40 mg QID (4 times a day dosing); *D/C if efficacy not achieved in 2 weeks (doesn’t work in 2 weeks, its not going to) |
| Dicylcomine (Bentyl) is Contraindicated in? | Obstructive GI diseases and severe ulcerative colitis |
| (Not mentioned by Dr. Long) Hyoscyamine (Levsin) drug info? | 0.125 to 0.25 mg PO every 4 hours or as needed; Maximum of 1.5 mg/day *give 30-60 min before meals |
| Which of the following pairs does not correctly match a brand name to its generic? -Dicylcomine-Bentyl -Eluxadoline- Viberzi -Alosetron-Lotrenox -Rifaximin- Linzess | Rifaximin- Linzess Brand is Xifaxan |
| IBS-C and IBS-D: Other therapies are? | Gut-Brain Neuromodulators (TCAs) Psychotherapy can’t hurt so cognitive behavioral therapy is #1 here **But again the evidence is very poor so not mainstay of therapy |
| Summary: IBS is diagnosed by _____ abd pain for at least 1 day/week for the last 3 months associated with at least 2 of the symptoms listed in the ____ ____ _____ that began at least 6 months ago | recurrent; ROME IV Criteria |
| Alarm symptoms may be a sign of alternative diagnoses such as: | colorectal cancer, inflammatory bowel disease, and enteric infections and thus warrant additional diagnostic testing |
| Avoiding high FODMAP foods, GI irritants or laxatives such as(caffeine, alcohol, lactose, and artificial sweeteners) in IBS-D and increasing the dietary intake of fiber and fluids in IBS-C may provide _____ ______ | symptom relief |
| An IBS treatment regimen should consider the IBS _______ and ______, as well as pt characteristics and restrictions | subtype; severity |
| Which of the following is NOT a risk factor for constipation? -Pregnancy -Low fiber diet -Poor fluid intake -Opioid medications -Magnesium | Magnesium |
| Which of the following medications is NOT typically used for IBS-C? -Eluxadoline -Hyoscyamine -Linaclotide -Lubiprostone | Eluxadoline |
| Which of the following medications is INCORRECTLY linked with its indication? -Dulcolax for opiod induced constipation -Witch hazel for Hemorrhoids -Docusate for constipation | Dulcolax for OIC *its for constipation but not for OIC |
| Which of the following medications would be able to relieve constipation the quickest? -Docusate -Psyllim -Mineral Oil | Mineral oil |
| Which of the following is a potential complication of diarrhea? -Dehydration -Electrolyte imbalance -Cardiovascular collapse -All of the above | All of the above |
Created by:
Xander635
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