Abdominal Pain: Objectives A Common Complaint in College Health  Upon completion of this lecture, the participant will be able to: Wendy L. Wright, MS, RN, ARNP, FNP, 1. Perform a comprehensive abdominal FAANP examination Adult/Family Nurse Practitioner 2. Differentiate between a variety of diagnoses pertaining to the patient with an abdominal Owner – Wright & Associates Family Healthcare complaint Owner – Anderson Family Healthcare 3. Identify various abdominal emergencies Partner – Partners in Healthcare Education, LLC Wright, 2012

Statistics History  Description of onset  Abdominal pain is one of the most common sudden, gradual presenting complaints in primary care  Progression since onset  Acute abdominal pain is the most common bttbetter, worse, same cause of hospitalization  History of previous episode  One study: Approximately 40% of patients who present with abdominal pain have no  Location identifiable cause and <15% have surgical RUQ, RMQ, RLQ, LUQ, LMQ, LLQ, epigastric, periumbilical, or suprapubic etiology

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History History  Character  Aggravating Factors intermittent, steady, colicky Movement, coughing, eating, respirations  Severity  Alleviating Factors 1-10 sca le PitiPosition, vom itifltliting, flatulence, ea ting, me ds Has it affected the person’s ADL’s  Associated Symptoms  Radiation Nausea, vomiting, constipation, diarrhea, Intraabdominal fever, chills, bloating, flatulence, eructation, black or bloody stools or vomitus, jaundice Extraabdominal locations

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Wright, 2012 1 Review of Systems Additional History

 Past surgical history  Cardiac  Medications Chest pain, palpitations  Druggg, food, or environmental allergies  Respiratory  Shortness of breath, cough, dyspnea Cigarette, alcohol, drug or caffeine use  Genitourinary  Diet and food intolerance's Dysuria, frequency, urgency, hematuria,  Travel gynecologic complaints, LMP  Family history  Psychosocial information Wright, 2012 Wright, 2012

Physical Examination Physical Examination  General appearance  Skin Restless Pallor: dissecting aneurysm, gastric ulcer Rigid and motionless Diaphoresis: peritoneal inflammation LiLying in a ftlfetal pos ition or roc king bac kifk in for th Mottli ng: dissec ting aneurysm  Vital signs Turgor: pancreatitis Orthostatic pulse and blood pressure Jaundice: hepatitis  Tachycardia-acute abdomen  Eyes Temperature Scleral Icterus: hepatitis  Infectious or inflammatory process Wright, 2012 Wright, 2012

Abdominal Examination Abdominal Examination

 Inspection  Inspection Contour of abdomen Skin

 Flat  Color and moisture  Scaphoid  Scars and incision  Malnourished  Striae (Cushing’s syndrome)  Protuberant  Dilated veins (Portal hypertension, cirrhosis)  Obesity  Rashes or lesions (Cherry angiomas, herpes zoster,  Gas distention from obstruction linea nigra)  Tumor  Pregnancy

 Ascites Wright, 2012 Wright, 2012

Wright, 2012 2 Abdominal Examination Abdominal Examination

 Inspection  Inspection Symmetry Umbilicus Visible Organ Enlargement/Masses  Contour (normally round; inverted or

 Hernia: defect in the wall of the abdomen through eeverted)verted) which a mass of tissue and occasionally the  Bulge-umbilical hernia intestine protrudes  Oomphylitis  Should be reducible  Staphylococcus infection of the umbilicus  Can be chronic in some individuals  Thought to be caused by a remnant of the umbilical cord attachment

Wright, 2012  Treated with 1stWright, Generation 2012 Cephalosporin

Abdominal Examination Abdominal Examination

 Auscultation  Palpation Bowel sounds Essential when assessing the abdomen  Very unreliable Light palpation

 Can be normal in the setting of serious pathology  Lightl y pa lpa te the en tire a bdomen  Borborygmi: loud, prolonged gurgles that are  Purpose: indicative of hyperperistalsis  Identify abdominal tenderness  Intestinal obstruction  Superficial masses  Gastroenteritis  Muscular rigidity or guarding

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Abdominal Palpation Liver Palpation  Deep palpation  Majority of the liver is under the right rib cage Palpate all 4 quadrants  Place left hand behind and parallel to the Purpose patient to support the 11th and 12th ribs  Identify masses  Press up with the left hand  Peritoneal inflammation  Place your right hand on the abdomen in the  Rebound Tenderness (Blumberg’s sign): Press fingers firmly and slowly in the area above the pain. Quickly withdraw your fingers RUQ with your fingertips well below the lower . Watch the individual and listen for pain border of the liver . Pain induced by withdrawal: +rebound  Press in with the right hand while the patient takes a deep breath Wright, 2012 Wright, 2012

Wright, 2012 3 Palpation of the Spleen Liver  Located in the left upper quadrant  Enlarges anteriorly, downward, and medially Liver normallyy,p, feels soft, sharp,  Palpation can confirm an enlargement identified with percussion but often misses the regular, smooth, and slightly splenomegaly that doesn’t descend below the tender. costal margin  A small percentage of individuals normally have a palpable spleen edge

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Technique Costovertebral Angle Tenderness

 With left hand, reach over and around the  Tap gently on the area above the 10-12th patient placing left hand under the lower ribs posteriorly rib cage  Continue tapping as you move downward  With right hand, palpate the right upper  “What if anything do you feel?” quadrant while the patient takes a deep  CVAT-pyelonephritis breath  Tip may descend to meet your fingers

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Differential Diagnosis According to Differential Diagnosis According to Location Location

 Right Upper Quadrant  Left Upper Quadrant Cholelithiasis Splenic rupture Cholecystitis Splenic infarction Hepatitis Left kidney stone Hepatic carcinoma Left pyelonephritis Right kidney stone Gastritis Right pyelonephritis Left lower lobe pneumonia Right lower lobe pneumonia

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Wright, 2012 4 Differential Diagnosis According to Differential Diagnosis According to Location Location

 Epigastric Region  Right Lower Quadrant Gastritis Appendicitis Gastric ulcer Meckel’ s diverticulum Gastric cancer Crohn’s disease Esophagitis Right ovarian cyst Duodenal ulcer PID Pancreatitis Inguinal hernia Pancreatic cancer Diverticulitis Wright, 2012 Ectopic pregnancyWright, 2012

Differential Diagnosis According to Differential Diagnosis According to Location Location  Left Lower Quadrant  Hypogastric Diverticulitis (Sigmoid) PID Left ovarian cyst Irritable Bowel Syndrome PID Ulcerati ve Co litis Inguinal hernia Ectopic pregnancy Ectopic pregnancy Cystitis Appendicitis (rarely)

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Differential Diagnosis According to Location Don...  Generalized Pain Don is a 17 yowm who presents with an 8 hour Peritonitis history of worsening abdominal pain. Woke him Gastroenteritis from sleep. Epigastric at onset. Now seems Obst ructi on liihtidfbdAitdithlower in right side of abdomen. Associated with Dissecting Aortic Aneurysm nausea and vomiting for the past 2 hours and a temp of 100. Denies bowel changes, urinary symptoms. Meds: none; Allergies: NKDA What is going on with Don? Wright, 2012 Wright, 2012

Wright, 2012 5 Appendicitis Appendicitis  Inflammation/Infection of the Appendix Can lead to ischemia and perforation of the  Mortality and morbidity rates remain high appendix  Perforation rates: 17-40%  Etiology Perforation has been known to occur within Most common age: 10-19 years 1st 24-48 hours of the infection Incidence: 1.1/1000 Persons each year Males>females Whites>Nonwhites Summer-most common time of year Midwest-highest incidenceWright, 2012 Wright, 2012

History of a patient with History of a patient with appendicitis Appendicitis  Pain precedes anorexia, nausea or vomiting  Careful history is the most important aspect Nausea and anorexia are very common Individual is usually a teen or young adult Vomiting may or may not be present  Class ic presen ta tion: awa kens in the n ig ht w ith vague periumbilical pain Question the diagnosis if patient is hungry

 Worsens over the period of 4 hours  Subsides as it migrates to the RLQ  Low grade fever or none at all  Worsened with movement, deep respirations,  Usually seek attention within 12-48 hours coughing  Patient will often report feeling constipated Wright, 2012 Wright, 2012

Clinical Pearl Physical Examination

The presence of pain before  Abdominal Examination vomiting is highly suggestive Tenderness at McBurney’s point  1/3 the distance between the anterior iliac of appendicitis. spine and the umbilicus Guarding

 Contraction of the abdominal walls Diarrhea before pain is more  Frequently present likely to be gastroenteritis.  Can be faked or induced

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Wright, 2012 6 Physical Examination Physical Examination  Rebound tenderness  Rigidity Press on area above the pain Important predictor of appendicitis Suddenly withdraw fingers Involuntary spasm of the abdominal musculature  Rovsing’ ssSign Sign Caused by peritoneal inflammation Pain felt in RLQ when examiner presses firmly in  Markle’s sign the LLQ and suddenly withdraws Heel-drop jarring test  Psoas Sign Patient is placed in a supine position Ask patient to life thigh against your hand that you

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Laboratory/Radiologic Testing Physical Examination

 Obturator Sign  CBC with differential May be or may not be positive Normal wbc count doesn’t rule-out the diagnosis Patient is positioned in supine position with White blood cell count mayyy actually decrease the right hip and knee flexed Look for wbc left shift Internally rotate the right leg  Elevated wbc  Internal Examination  Elevated neutrophils  Rectal Examination  Elevated bands This is essential to assist with the diagnosis

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Laboratory/Radiologic Testing Shaun...  Shaun is a 16 year old male who presents with  Urinalysis a one week history of worsening abdominal  CT Scan pain located predominantly in the upper Within past 2 years, new focused appendiceal abdomen radiating through to the back . Worse CT technique has been developed with movement. Constant. Becoming Will decrease the laparoscopy rate progressively worse. Now associated with Ultrasound can still be performed; seems to be vomiting and diaphoresis. PE-BP 90/52; 80/50 best for children and women of childbearing age sitting; Temp-100.8; Pulse 120; Abdomen- tender in LUQ and RUQ. No rebound.

Wright, 2012 What else do we needWright, to 2012 know?

Wright, 2012 7 Pancreatitis Pancreatitis  Etiology  Symptoms  Often a history of alcohol abuse Pain is worsened by coughing and movement  Biliary tract disease Sweating  May have a history of hypertriglyceridemia (10%)  Physical Examination  StSymptoms  Pain is severe and constant; lasting hours-days Tachycardia  Develops suddenly and becomes intense in minutes Postural Hypotension  Often radiates to the back (50%) Temperature of 100-101 degrees  Vomiting is present Abdominal distension and tenderness  If not present, consider another diagnosis Tenderness predominantly in upper quadrants Wright, 2012 Hypoactive bowel soundsWright, 2012

Pancreatitis Treatment  Laboratory Findings and Diagnosis Amylase: elevated mainly in pancreatic disease  Mild Pancreatitis Lipase: good confirmatory test Fasting state until decrease of signs and symptoms (usually within a few days) Leukocytosis

 Typically 12,000 - 20,000 Cessation of alcohol or correct problem Ultrasound May need IV fluids  Detect a biliary obstruction caused by gallstones or  Moderate -Severe Pancreatitis edema of the pancreas Hospitalization CT scan

 Best visualization of the pancreas Wright, 2012 Wright, 2012

Shelley Ectopic Pregnancy Shelley is a 17 yowf who presents with a 3  Ectopic: pregnancy occurring outside of the day history of vaginal bleeding. Positive uterus pregnancy test in the office 4 days ago.  Etiology Based upon dates , she is now 5 weeks Variety of locations of implantation pregnant. Complaining of LLQ ache and Average rupture time: 8-12 weeks mild cramping. Bleeding has not changed Most common cause of maternal mortality in the 1st since onset. Serum quant 2 days ago: trimester and 2nd leading cause of maternal 100; Today-110. mortality in the US What should we do now? 1:100-200 pregnancies is ectopic 4 fold increase in ectopic rates from 1970-89

Wright, 2012 8 Ectopic Pregnancy Ectopic Pregnancy

 hCG is secreted by the developing trophoblast  The woman with an ectopic pregnancy will not starting at day 8 of the pregnancy have the normal doubling  Should double every 36-48 hours  hCG does not go above 6000  By 6 weeks, the normal hCG is approximately  Progesterone levels are low 10,000 <5ng/ml  Lack of doubling indicates an abnormal Normal pregnancy: >10ng/ml pregnancy

Clinical Pearl Ectopic Pregnancy

 Symptoms The absence of an intrauterine sac Asymptomatic Majjyority have irre gular bleedin g on transvaginal ultrasound when Abdominal pain occurs 3-5 weeks after the bleeding the hCG is > 2000 is highly begins suggestive of an ectopic pregnancy

Diagnosis of an Ectopic Ectopic Pregnancy  Abdominal examination  Physical Examination  Pelvic examination Abdominal tenderness (LLQ or RLQ) Caution: May cause a tubal rupture Uterine size (()2/3 will have a normal uterine size) 50% will have an adnexal mass palpable on  Urine hCG physical examination Serum Quantitative hCG  Serum progesterone  Transvaginal ultrasound

Wright, 2012 9 Medical Management of an Ectopic Case Study Pregnancy 17 year old woman presents with a 8+ year history  25% of all ectopic pregnancies can be managed of straining, hard/lumpy stools, and a sense of medically incomplete evacuation. She passes stool  80-90% success rate approximately 2 times per week. Upon further questioning, she also notes frequent  80% of individuals treated with MTX will become bloating, moderate abdominal discomfort, and pregnant again; 11% ectopic partial relief with defecation.  Methotrexate injection  She denies hematochezia, weight loss, family history of  Conceptus < 3.5cm colon cancer, or inflammatory bowel disease.  Unruptured fallopian tube  Rectal exam and abdominal exam are normal. CBC is  hCG levels <1,500 normal.  No fetal heart activity What do you think is going on with her? Wright, 2012

Functional Bowel Disorders  There are numerous types of functional bowel Does This Patient disorders Irritable Bowel Syndrome Have A Functional  IBS-C  IBS-D Bowel Disorder?  IBS-M Chronic Constipation Functional Diarrhea Functional Bloating ROME III Gastroenterology 2006:130:1377-1390.

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Definition of IBS Irritable Bowel Syndrome  Symptom Types  American Gastroenterologic Association Diarrhea predominant IBS (33%) A combination of chronic and recurrent GI  IBS-D symptoms not explained by a structural or biochemical abnormality. Constipation predominant IBS (33%)  IBS-C Attributed to the intestines and associated with bloating, distension, pain which improves with Alternators defecation, and abnormal defecation.  IBS – Mixed (33%)  Many individuals are thought to suffer from IBS - C Drossman DA, Corazziari E, et al. ROME II. The Functional Gastrointestinal predominantly but have occasional breakthrough Disorders Diagnosis, Pathophysioloy and Treatment: A Multinational diarrhea (It is often the diarrhea which brings them in Consensus. 2nd ed. McLean, Va: Degon Associates; 2000. for evaluation). Wright, 2012 ROME III Gastroenterology 2006:130:1377-1390. Wright, 2012

Wright, 2012 10 Stool Form Correlates With Intestinal Irritable Bowel Syndrome: Transit Time A Complex Condition THE BRISTOL STOOL FORM SCALE SLOW Type 1 Separate hard lumps, like nuts  3 million visits to healthcare providers, yet TRANSIT Type 2 SausageSausage--likelike but lumpy only 20 - 25% of people with this disease consult a provider. Type 3 Like a sausage but with cracks in the surface  Approximately 25 - 50% of visits to Type 4 Like a sausage or snake, smooth and soft gastroenterology practices are related to this Type 5 Soft blobs with clearclear--cutcut edges diagnosis.

Type 6 Fluffy pieces with ragged edges, a mushy stool FAST ROME III Gastroenterology 2006:130:1377-1390. TRANSIT Type 7 Watery, no solid pieces Lewis SJ, Heaton KW. Scand J Gastroenterol. 1997;32:9201997;32:920--924.924. Heaton KW, O'Donnell LJ. J Clin Gastroenterol. 1994;19:281994;19:28--30.30. Wright, 2012 Wright, 2012

Statistics on Chronic Constipation  Estimated that chronic constipation affects 2% - 27% of all adults in North America Chronic  Overall prevalence: 15% of population  More common in women: 2 -3:1 ratio  Higher prevalence associated with lower Constipation socioeconomic status, age older than 65 years, and non-white race

An Evidence Based Approach to the Management of Chronic Constipation In North America. American J of Gastroenterology 2005:100;S1.

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There Is Significant Overlap Among GI Motility and Sensory Disorders Bloating Constipation  29% of GERD and Pathophysiology dyspepsia patients Belching Chronic have chronic Constipation constipation*† Dyspepsia of  Diagnoses can shift fdidtfrom one disorder to another over time†

IBS  Possible common Discomfort Abdominal Functional pathophysiological Pain GERD mechanisms†‡ Bowel Disorders Heartburn Regurgitation *Locke GR et al. Neurogastroenterol Motil. 2004;16:12004;16:1--6.6. †Corazziari E. Best Prac Res Clin Gastroenterol. 2004;18:6132004;18:613--631.631. ‡Talley NJ et al. Am J Gastroenterol. 2003;98:24542003;98:2454--2459.2459. Wright, 2012

Wright, 2012 11 Normal Bowel Activity Is Initiated by a Serotonin and Motor Activity in the Bolus Moving Through the Intestine Lower GI Tract Movement of  The presence of a bolus Proximal Distal gut content in the intestine causes distortion of villi and distention of the intestine, Interneurons

resulting in signals being Motor neurons Motor neurons transmitted to afferent (contraction) (relaxation) nerves within the in tes tinal wall via serotonin release IPAN 5-HT4 receptor  These signals result in 5-HT1p or 5-HT3 proximal contraction and receptor distal relaxation of ...... muscles or peristalsis, 5-HT (serotonin) and in transmission of sensory signals to the Enterochromaffin cells in GI tract release 5-HT the CNS IPAN = intrinsic primary afferent neuron. Gershon MD. Rev Gastroenterol Dis. 2003;3:S25-S34. Adapted from Grider JR et al. Gastroenterology. 1998;115:370-380. Wright, 2012 Wright, 2012 Adapted from Gershon MD. Rev Gastroenterol Dis. 2003;3:S25-S34.

Impaired 5-HT Release Leads to Impaired Enteric CC, IBS-C, and IBS-D Are Associated With Reflexes, Dysmotility, and Altered Secretion Symptoms of GI Dysmotility and Altered Sensation

Proximal Distal Dysmotility Symptoms of Symptoms of dysmotility are a hypersensitivity Interneurons Altered Transit result of impaired or altered coordination of Motor neurons Motor neurons perception may (contraction) (relaxation) the muscles and nerves ithGIin the GI be the result of tract alteration of ENS IPAN 5-HT4 receptor IPAN and/or CNS 5-HT1p or 5-HT3 function receptor 5-HT Motility Visceral Altered Secretion Secretion Sensitivity

Impaired release of 5-5-HTHT Lumen Mayer EA, Raybould HE. ENS = Enteric nervous system. Gastroenterology. 1990;99:1688. CNS = Central nervous system. IPAN = intrinsic primary afferent neuron. Adapted from Grider JR et al. Gastroenterology. 1998;115:370-380. Wright, 2012 Wright, 2012 Adapted from Gershon MD. Rev Gastroenterol Dis. 2003;3:S25-S34.

fMRI Imaging with Rectal Pathophysiology Distension in IBS

 Diarrhea and constipation are explained by the alteration in motor function.  Abnormal pain experienced by patients with IBS is believed to be caused by excessive sensitivity to colonic distension. Smaller amounts of distension causes more abdominal distress

Mertz H, Morgan V, Tanner G, et al. Regional cerebral activation in irritable bowel syndrome and control subjects with painful and nonpainful rectal distention. Gastroenterology. 2000;118:842-848.

Wright, 2012 Wright, 2012 Adapted from Mertz, GUT 2002 51, Suppl i29

Wright, 2012 12 The Role of Stress in IBS Role of Infection in IBS  Stress is widely believed to play a  7-30% of patients with newly diagnosed IBS significant role in the pathophysiology and have recently had a bacterial or viral clinical presentation of IBS. gastroenteritis.  Geneticallyyp predis posed individual.  Does infection cause an alteration in the  Sustained stress can result in a permanent number of enterochromaffin cells in the bowel - increased stress response in the central which causes an alteration in the amount of stress circuits/pathways. circulating 5-HT or is there bacterial overgrowth

Drossman DA. Do psychosocial factors define symptom severity and patient status in irritable bowel syndrome? of the bowel? Am J Med 1999;107:41S-50S. Dunlop, SP, Jenkins, D, Neal, KR, Spiller, RC; Relative importance of enterochromaffin cell hyperplasia, anxiety, and Drossman DA. Irritable bowel syndrome and sexual/physical abuse history. Eur J Gastroenterol Hepatol depression in postinfectious IBS. Gastroenterology. 2003 Dec;125(6):1651-9. 1997;9:327-30. Pimentel M, Chow EJ, Lin HC. Eradication of small intestinal bacterial overgrowth reduces symptoms of irritable bowel syndrome. Am J Gastroenterol 2000; 95: 3503-6. Wright, 2012 Wright, 2012

Rome III Diagnostic Criteria for Irritable Bowel Syndrome (all subtypes)  At least 3 months, with onset at least 6 months Diagnosis of previously of recurrent abdominal pain or discomfort (uncomfortable sensation not described as pp)ain) associated with 2 or more Functional Bowel of the following: Improvement with defecation; and/or Onset associated with a change in frequency or Disorders stool; and/or Onset associated with a change in form (appearance) of stool ROME III Gastroenterology 2006:130:1377-1390. Wright, 2012 Wright, 2012

Chronic Constipation and IBS-C Share Diagnostic Criteria: GI Dysmotility Symptoms Chronic Constipation Symptoms >3 months Chronic Constipation IBS- IBS-CC  Characterized by unsatisfactory defecation that Straining +++ +++ results from: Hard/lumpy stools +++ +++ Infrequent stools or <3 BM/wk +++ +++ Feeling of incomplete evacuation +++ +++ Difficult stool passage Bloating/ abdomin al di sten sion ++ +++ Abdominal pain/discomfort + +++  Characterized by: straining, sense of difficulty passing stool, incomplete evacuation, CC and IBS-IBS-CC lie along hard/lumpy stools, prolonged time to stool, or a spectrum of abdominal discomfort and pain need for manual maneuvers to pass stool – Abdominal Discomfort + Or, a combination of both Chronic Constipation IBSIBS--CC An Evidence Based Approach to the Management of Chronic Constipation IBSIBS--CC = irritable bowel syndrome with constipation. In North America. American J of Gastroenterology 2005:100;S1. Thompson WG et al. Gut. 1999;45(suppl 2):II432):II43--II47.II47. Wright, 2012 Drossman DA et al. Gastroenterology.Wright, 20121997;112:21201997;112:2120--2137.2137.

Wright, 2012 13 Diagnosis Red Flags  Because there are no biochemical or  Evaluate for alarm features structural markers available to make an Reported weight loss accurate diagnosis, history is the most Nocturnal symptoms important component. Recent travel history Symptom analysis FilhitflFamily history of colon cancer or ifltinflammatory Diagnostic tests in past bowel disease PMH and FH of GI diseases or autoimmune Family history of Celiac disease conditions Onset in older patients (> 50) Dietary review Fevers Meds, including OTC Oral ulcers  What has been tried? Wright, 2012 Bloody stools Wright, 2012

Red Flags ACG Evidence-Based Guideline: Diagnostic Testing  Evaluate for alarm features Chronic Constipation Abnormal exam (weight loss, arthritis, rashes)  Among CC patient without alarm features, there are Fever, oral ulcers inadequate data to make a recommendation about the routine use of diagnostic tests Anemia Irritable Bowel Syndrome Leukocytosis  Among IBS patients without alarm features, the Abnormal chemistry – abnormal LFT’s, Creatinine routine use of colonoscopy (<50 years old), flexible sigmoidoscopy, thyroid function tests, etc is not Elevated sed rate recommended. Abnormal TSH  Routine testing for celiac disease may be considered. Positive fecal occult blood test  Individuals > 50 years should undergo colorectal cancer screening Wright, 2012 ACG Functional GI Disorder Task Force. Am J Gastroenterol. 2005;100:S1-S21.Wright, 2012 ACG Functional GI Disorder Task Force. Am J Gastroenterol. 2002;97:S1-S5.

If You Decide On Further Evaluation, Laboratory Evaluation The Possible Tests Are…  TSH  CBC with differential  Hypothyroidism and hyperthyroidism  Anemia (Crohn’s, colitis, celiac disease), Eosinophilia (parasites), leukocytosis (infection, IBD), Toxic granulation  Stools for O & P / C&S (inflammation)  Parasites, Giardia, Infectious etiology  ESR and hs-CRP (high sensitivity -C Reactive  CidithConsider with an acu te onse t Protein)  Stool for Clostridium Difficile  Inflammation  Recent antibiotics  Comprehensive Metabolic Panel  Abnormal chemistries (liver, kidney disease, K+ loss)  Lactose Breath Test  Stool for occult blood  Present in up to 25% of the population  Inflammatory bowel disorders, Colon cancer  Often co-existent with IBS  Or…a low lactose diet trial x 2 weeks Wright, 2012 Wright, 2012

Wright, 2012 14 Possible Additional Tests Case Study 17 year old woman presents with a 8+ year history  Celiac Disease Testing of straining, hard/lumpy stools, and a sense of 4.6% of individuals with IBS are likely to have this incomplete evacuation. She passes stool present; Compared with 0.25-0.5% of general approximately 2 times per week. population Upon further questioning, she also notes frequent CliCeliac Pane l: Immunog lbiA(IA)lobin A (IgA), an ti-tissue bloating, moderate abdominal discomfort, and transglutaminase (tTGA), and IgA anti-endomysial partial relief with defecation. antibodies (AEA) What is her diagnosis?  Sigmoidoscopy vs. Colonoscopy Positive occult blood test Nocturnal awakenings Colon cancer Wright, 2012 Wright, 2012

Non-pharmacologic Treatments

Treatment Options for  Dietary modification Given high incidence of concomitant lactose Functional Bowel intolerance, dairy avoidance may be helpful 2 week trial of a lactose free diet can be Disorders helpful Lactaid or similar as an adjunct to dairy products ROME III Gastroenterology 2006:130:1377-1390.

Wright, 2012 Wright, 2012

Non-pharmacologic Treatments

 Dietary modification Avoid potential triggers: caffeine, alcohol, sorbitol, citrus fruits, high fiber foods, high fructose corn Pharmacologic syrup

 Gas producing foods (beer, cauliflower, grapes, onions, beans, brussel sprouts, plums, raisins, red wine) Options High fiber foods may occasionally help some individuals but need to tailor to individual patient

ROME III Gastroenterology 2006:130:1377-1390. Wright, 2012 Wright, 2012

Wright, 2012 15 Most Sufferers Have Tried Traditional Therapies ACG Evidence-Based Position Statement on the and Report Dissatisfaction Management of IBS-C: Treatment Recommendations Agent Efficacy CC* IBS-C† Bulking agents Not more effective than placebo at relieving global 96 100 100 86 IBS symptoms 80 80 80 Antispasmodics* Insufficient data to make a recommendation about Dicylcomine, the efficacy of these agents in patients with IBS

60 rs, % 60 rs, % hyoscyamine 47 e e (available in the US) 40 40 Suffer Suffer 20 20 Tricyclic Not more effective than placebo at relieving global antidepressants† IBS symptoms. Improve abdominal pain in IBS 0 0 patients. May worsen constipation Tried traditional Not completely Tried traditional Not completely n= 557 therapies satisfied n = 318 therapies satisfied Tegaserod Statistically significant improvements in symptoms of IBSIBS--CC *Schiller LR et al. Am J Gastroenterol. 2004;99:S2342004;99:S234--S235.S235. † Hungin AP et al. Am J Gastroenterol. 2002;97(suppl):S281.

Wright, 2012 Adapted from: ACG Functional GI DisorderWright, Task 2012 Force. Am J Gastroenterol. 2002;97:S1-S5.

Chronic Constipation: Treatment Recommendations Agent Efficacy Psyllium Increases stool frequency in patients with CC

Calcium polycarbophil Insufficient data Thank You Tegaserod Statistically significant reduction in CC symptoms Lubiprostone Statistically significant reduction in CC symptoms

Stool softeners Insufficient data; may be inferior to psyllium for improvement in stool frequency Milk of magnesia† Insufficient data I Would Be Happy To Stimulant laxatives Insufficient data Entertain Any Questions Polyethylene glycol Effective at improving stool frequency and stool consistency in patients with CC

Wright, 2012 Adapted from: ACG Functional GI Disorder Task Force. Am J Gastroenterol. 2002;97:S1-S5. Wright, 2012

Wendy L. Wright, MS, RN, ARNP, FNP

Wendyy@[email protected] www.4healtheducation.com

Wright, 2012

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