Hi everyone….I like to imagine there are people reading this, otherwise studying becomes a chore….writing it for you guys makes the journey that much more enjoyable. So before we start a new joyful GI topic, lets recap our previous trip down gastrointestinal lane -What happens when PUD, Bowel Obstruction and Mallory-Weiss Tear walk into a bar ?
So hopefully you enjoyed that little comic. I have to thank husband Simon..again…for giving faces to my mind’s creations
Before I go on with our study session, here’s a little story that you may or may not want to hear. During the stressful days of PA school, where 2-3 exams a week were the norm, myself and one of my closest friends from PA school got a friendly visit from IBS. Almost every exam day, we would spend 10 minutes before the exam sitting on the toilet contemplating the fate of our digestive system. Only the 8th floor at Lenox Hill Hospital will remember the sounds and smells of those happy days The fist year ended and I foolishly thought that IBS has left me and traveled to a land far far away…but it was just waiting for the most opportune moment to come back. At 11 am in the morning…2nd week of surgery rotation….during what would be a 9 hour TRAM flap breast reconstruction sugery…it came back with a gassy vengeance! And ever since that day…IBS became not only my arch nemesis…but my beloved friend as well…I don’t love having it…but I love diagnosing it and ridding patients of it.
Oh…the good old days On with the studying….
IBS – Irritable Bowel Syndrome
- IBS is a functional disorder of the bowel:
- It’s etiology is unclear but theories deem it to be : psychological, post-infectious, altered GI motility and GI hypersensitivity.
- It is a diagnosis of exclusion – which means that all organic/structural pathologies need to be r/o first before the IBS stamp can be put on a patient
- IBS usually starts during the teen to early adulthood years
- affects women more often than men
- patient will usually present complaining of intermittent abdominal cramping in the lower abdomen, bloating, gas, and fecal urgency that happen shortly after meals or during times of stress.
- Pt will report that symptoms are usually resolved with defecation
- looser and more frequent stools that can alternate with bouts of constipation, change in stool form, mucus
- Female patients may complain of worsening symptoms during menses as well as urinary urgency
- Exam is usually normal but may reveal a tender LLQ and resonance on abdominal percussion
- IBS is diagnosed by ruling out other pathology such as gastritis, cholecystitis, infectious diarrhea, lactose intolerance, celiac disease, and most importantly GI malignacy.
- Tests that are of use:
- Hpylori screening, stool culture, C diff A/B, O&P, screening for lactose intolerance, celiac panel
- Thyroid panel can be useful – in case it’s diarrhea/constipation caused by hyper/hypothyroidism respectively
- Abdominal US for gallstones, CT abdomen for pancreatic etiology
- Colonscopy for malignancy
- Constipation type:
- Fiber supplementation – main stay of treatment – Metamucil 1-2 teaspoons in full glass of water up to 3 times a day
- have patient start with one teaspoon once a day and gradually increase as bloating may increase initially
- Diarrhea type:
- Antidiarrheal agent: Loperamide (Imodium) 2-4 mg bid to qid for short period of time
- Antispasmodic agent: dicyclomine (Bentyl) 10-20 mg bid to qid
- Tricyclic antidepressant: Amitriptyline 20-50mg bid
- SSRI: Lexapro 10 -30 mg daily
- Alarm symptoms: not consistent with IBS
- new onset over age 40, nocturnal diarrhea, hematochezia, weight loss, fever
- Celiac disease is an autoimmune genetic disorder:
- It is characterized by inflammation of the small intestine in response to gluten containing foods such as rye, barley, wheat.
- A patient will usually complain of abdominal pain, diarrhea with fatty stool, weight loss, rumbling noises in the abdomen
- 10-20% of patients will also present with Dermatitis Herpatiformis
- Biopsy of small intestine
- immunoglobulin A (IgA), endomysial antibodies, and IgA tissue transglutaminase (tTG) antibodies – (complete Celiac Panel)
- Gluten free diet
- Advise patient to supplement with a multivitamin due to malabsorption component of Celiac disease
- Lactose Intolerance manifests when a malabsorption of lactaose occurs in the small intestine
- Lactase is an enzyme that is produced in the brush border microvillli of the small intestine and helps digest lactose
- Lactose intolerance is when there is no lactase or an insufficient amount of lactase in the small intestine
- The body is unable to digest lactose, which pulls fluids into the intestine
- Diarrhea, gas, bloating, watery stools, abdominal pain
- Usually made based on detailed history taking as well as a trial of dairy avoidance
- Avoidance of dairy products or preferably ingestion of Lactase enzyme supplement – as lack of dairy in a diet can lead to vitamin deficiencies