PANCE Blueprint GI and Nutrition (9%)

Irritable bowel syndrome

Patient will present as → a 40-year-old woman comes to your office with a several-year history of lower abdominal pain associated with constipation (one hard bowel movement every 3 days) and frequent mucous discharge. She states that her abdominal pain is better after a bowel movement. She has never passed blood per rectum. She describes no fever, chills, weight loss or gain, jaundice, or any other symptoms. There is no relationship between the abdominal pain and specific food intake. On physical examination, the abdomen is scaphoid, and no hepatosplenomegaly or masses are palpated. There is a mild generalized abdominal tenderness, but it does not localize.

The Rome criteria are standardized symptom-based criteria for diagnosing IBS

The Rome criteria require the presence of abdominal pain or discomfort for at least 3 days/mo in the last 3 mo along with ≥ 2 of the following:

  • Improvement with defecation
  • Onset (of each episode of discomfort) associated with a change in frequency of defecation
  • Change in consistency of stool

IBS subtypes are defined for clinical practice as follows:

  • IBS with predominant constipation: Patient reports that abnormal bowel movements are usually constipation
  • IBS with diarrhea: Patient reports that abnormal bowel movements are usually diarrhea
  • Mixed IBS: Patient reports that abnormal bowel movements are usually both constipation and diarrhea (more than one-fourth of all the abnormal bowel movements were constipation and more than one-fourth were diarrhea)
  • Unclassified IBS: Patients who meet diagnostic criteria for IBS but cannot be accurately categorized into one of the other three subtypes

The cause is unknown, and the pathophysiology is incompletely understood

  • Bloating and N/V are common
  • Pain often relieved by defecation
  • BM's are irregular and vary from constipation to diarrhea

The diagnosis of IBS can reasonably be made using the Rome criteria as long as patients have no red flag findings, such as rectal bleeding, weight loss, and fever, or other findings that might suggest another etiology.

  • Patients with one of these red flag findings require further imaging studies and/or colonoscopy
  • Routine laboratory studies (complete blood count, chemistries) are normal in IBS

Treatment is symptomatic, consisting of dietary management and drugs, including anticholinergics and agents active at serotonin receptors.

  • Increased fiber, decrease dietary fat, drug therapy
  • Drug therapy is directed toward the dominant symptoms. Anticholinergic drugs (eg, hyoscyamine 0.125 mg po 30 to 60 min before meals) may be used for their antispasmodic effects.

IM_NUR_IrritableBowelSyndromeAssessment_v1.2_ Irritable bowel syndrome (IBS) is characterized as a chronic gastrointestinal disorder that includes symptoms of abdominal pain, alterations in bowel patterns, excessive flatulence, and fatigue. However, these symptoms are widely individualized, which makes IBS difficult to diagnose. Symptoms may be exacerbated by psychosocial stressors and certain foods. This condition is more commonly diagnosed in women. Although there is no specific test to identify IBS, diagnostic tests for other health conditions are performed to rule them out.

Irritable Bowel Syndrome (IBS) Assessment Picmonic

irritable-bowel-syndrome-ibs-interventions_5868_1484333277 The goal of treatment includes decreasing symptoms by increasing dietary fiber and administering medications such as anticholinergics, loperamide, tricyclic antidepressants, and linaclotide. Medications specific to women include lubiprostone, tegaserod, and alosetron. Identifying and reducing risk factors that exacerbate IBS is critical to help avoid exacerbations of the condition.

Irritable Bowel Syndrome (IBS) Interventions Picmonic

Question 1
A 32-year-old woman reports frequent bouts of constipation alternating with diarrhea. She frequently experiences abdominal discomfort, which is relieved with bowel movements. Stress tends to aggravate her symptoms. The most appropriate treatment includes
A
Steroid enemas
Hint:
See C for explanation
B
Mesalamine enemas
Hint:
See C for explanation
C
Peppermint oil
D
Metoclopramide
Hint:
See C for explanation
E
None of the above
Question 1 Explanation: 
Irritable bowel syndrome is defined as abdominal discomfort or pain associated with altered bowel habits for at least 3 days per month in the previous 3 months, with the absence of organic disease. Cramping abdominal pain is the most common symptom along with diarrhea, constipation, or alternating diarrhea and constipation. The goals of treatment are symptom relief and improved quality of life. Exercise, antibiotics, antispasmodics, peppermint oil, and probiotics appear to improve symptoms. Over-the-counter laxatives and antidiarrheals may improve stool frequency but not pain. Treatment with antidepressants and psychological therapies are also effective for improving symptoms compared with usual care. Lubiprostone is effective for the treatment of constipation-predominant irritable bowel syndrome.
Question 2
Which of the following is incorrect about Irritable bowel syndrome (IBS)
A
It is a diagnosis of exclusion
Hint:
See B for explanation
B
It is an organic disorder
C
Young women are affected 2–3 times more often than men
Hint:
See B for explanation
D
May occur following an episode of gastroenteritis
Hint:
See B for explanation
Question 2 Explanation: 
IBS is a functional disorder, not an organic disorder. All other statements are correct.
Question 3
A 25-year old lady presents at the clinic with complaint of 8-month history of intermittent crampy lower abdominal pain, with passage of loose stools 4 times a day. Pain is usually worse during her menstrual period, and is relieved by defecation. She also feels bloated. On inquiring, she says she has been undergoing work-related stress for months. No ALARM symptoms. Nothing significant was found on physical examination. What is her most likely diagnosis?
A
Irritable bowel syndrome
B
Lactase deficiency
Hint:
Presents as diarrhea and flatulence following ingestion of milk.
C
Ulcerative colitis
Hint:
Presents as bloody diarrhea
D
Crohn disease
Hint:
Physical examination would reveal a mass at the right lower quadrant.
Question 3 Explanation: 
Irritable bowel syndrome is a functional bowel disorder. It’s commoner in young women. Presents as recurrent abdominal pain associated with change in bowel habit. May be precipitated by certain food or stress.
Question 4
Which of the following is essential in investigating the above mentioned patient?
A
Colonoscopy
Hint:
See D for explanation
B
Barium enema
Hint:
See D for explanation
C
Abdominal radiograph
Hint:
See D for explanation
D
None of the above
Question 4 Explanation: 
The American College of Gastroenterologists does not recommend laboratory testing or diagnostic imaging in patients younger than 50 years with typical symptoms of IBS and without ALARM symptoms.
Question 5
Which of the following is associated with irritable bowel syndrome (IBS)?
A
Alvarado score
Hint:
Is used in making a diagnosis of acute appendicitis.
B
Ranson criteria
Hint:
Is used in assessing the severity of acute pancreatitis.
C
Rome criteria
D
Revised Jones criteria
Hint:
Is used in diagnosing rheumatic fever.
Question 5 Explanation: 
The Rome III criteria is used in diagnosing IBS.
Question 6
Which of the following infections has been associated with an increased prevalence of IBS?
A
Giardia lamblia
B
Escherichia coli
C
Shigella
D
Salmonella
Question 6 Explanation: 
Infection with G lamblia has been shown to lead to an increased prevalence of IBS as well as chronic fatigue syndrome. In a historic cohort study of patients with G lamblia infection as detected by stool cysts, the prevalence of IBS was 46.1% as long as 3 years after exposure, compared with 14% in controls.
Question 7
Which of the following is a symptom consistent with a diagnosis of IBS?
A
Painless diarrhea
B
Fever
C
Postprandial urgency
D
Steatorrhea
Question 7 Explanation: 
Postprandial urgency is common, as is alternation between constipation and diarrhea. Symptoms not consistent with IBS should alert the clinician to the possibility of an organic pathology. Inconsistent symptoms include the following: Onset in middle or older age Acute symptoms (IBS is defined by chronicity) Progressive symptoms Nocturnal symptoms Anorexia or weight loss Fever Rectal bleeding Painless diarrhea Steatorrhea Gluten intolerance
Question 8
Which of the following is not recognized as a symptom that supports the diagnosis of IBS according to the Rome criteria?
A
Altered stool frequency
B
Mucorrhea
C
Abdominal bloating or subjective distention
D
Frequent nausea
Question 8 Explanation: 
A consensus panel created and then updated the Rome criteria to provide a standardized diagnosis for research and clinical practice. The Rome III criteria for the diagnosis of IBS require that patients have had recurrent abdominal pain or discomfort at least 3 days per month during the previous 3 months that is associated with two or more of the following: Relieved by defecation Onset associated with a change in stool frequency Onset associated with a change in stool form or appearance Supporting symptoms include the following: Altered stool frequency Altered stool form Altered stool passage (straining and/or urgency) Mucorrhea Abdominal bloating or subjective distention
Question 9
Which of the following symptoms indicates a need for laboratory testing or diagnostic imaging in patients with IBS younger than 50 years?
A
Iron deficiency anemia
B
Abdominal pain
C
Amenorrhea
D
Hypokalemia
Question 9 Explanation: 
The 2009 American College of Gastroenterologists (ACG) evidence-based position statement on the management of IBS does not recommend laboratory testing or diagnostic imaging in patients younger than 50 years with typical IBS symptoms and without "alarm features." Alarm features include the following symptoms and history: Weight loss Iron deficiency anemia Family history of certain organic GI illnesses (eg, inflammatory bowel disease, celiac sprue, colorectal cancer) Although rectal bleeding and nocturnal symptoms have also been considered alarm features, they are not specific for organic disease.
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