Ibs And Ibd

Front 1

What is IBS?

Back 1

Irritable bowel syndrome; gastroinestinal syndrom characterized by chronic abdominal pain and altered bowel habits in the absence of an organic cause

Front 2

What is IBD?

Back 2

inflammatory bowel disease; two types: ulcerative colitis (inflammatory condition confined to the rectum and colon) and crohn's disease (inflammatory condition of the GI tract that can affect any part from the mouth to the anus)

Front 3

What are the S/sx of IBS?

Back 3

lower abdominal pain, ab bloating and distention, extreme urgency, mucous passage, psychosocial symptoms such as depression and anxiety

Front 4

What are the two types of IBS?

Back 4

IBS-D or diarrhea predominant: >3stools/d; IBS-C or constipation predominant: <3 stool/wk, straining, incomplete evacuation

Front 5

What are the S/sx of Ulcerative colitis?

Back 5

abdominal cramping, frequent bowel movements often with blood in the stools, weight loss, fever and tachycardia in severe disease, hemorrhoids and fissures, decreased hematocrit and hemoglobin, increased erthrocyte sedimentation rate

Front 6

What are the S/Sx of crohn's disease?

Back 6

Malaise and fever, ab pain, frequent bowel movements, hematochezia, fistula, weight loss, increased white blood count and erythrocyte sedimentation rate

Front 7

What are the two types of IBS diag criteria?

Back 7

Manning and Rome III

Front 8

What are the characteristics of the Manning IBS diag criteria?

Back 8

Chronic or recurrent ab pain for at least 6 months and two or more of the following: ab pain relieved by defecation, ab pain associated with more freq stools, ab pain associated with looser stools, ab distension, feeling of incomplete evacuation after defecation, mucus in stools

Front 9

What are the characteristics of the Rome III IBS diag criteria?

Back 9

Recurrent ab pain or discomfort at least 3 d per month in the last 3 months associated with 2 or more of the following: relieved with defecation, onset associated with a change in freq of stool, onset associated with change in form (appearance) of stool

Front 10

What other tests can be used to rule out other causes than IBS?

Back 10

sigmoidoscopy or colonoscopy, stool tests for occult blood or ova or parasites, CBC, erythrocyte sedimentation rate, electrolytes, other imagining studies

Front 11

What is the IBD diag criteria for classification of mild ulcerative colitis?

Back 11

fewer than 4 stools per day with or without blood; no systemic disturbances and normal erythrocyte sedimentation rate

Front 12

What is the IBD diag criteria for classification of moderate ulcerative colitis?

Back 12

more than 4 stools per day but with minimal systemic disturbances

Front 13

What is the IBD diag criteria for classification of severe ulcerative colitis?

Back 13

more than 6 stools per day with blood, evidence of systemic disturbances (fever, tachycardia, anemia, or erythrocyte sedimentation rate >30)

Front 14

What is the IBD diag criteria for classification of fulminate disease ulcerative colitis?

Back 14

more than 10 stools per day, continous bleeding, toxicy, abdominal tenderness, need for a blood transfusion

Front 15

What is the IBD diag criteria for classification of mild-moderate crohn's disease?

Back 15

ambulatory and no evidence of dehydration, systemic toxicity, weight loss, or abdominal tenderness

Front 16

What is the IBD diag criteria for classification of moderate-severe crohn's disease?

Back 16

failure to response to treatment for mild to moderate disease, fever, weight loss, abdominal pain, significant anemia

Front 17

What is the IBD diag criteria for classification of severe/fulminate crohn's disease?

Back 17

persistent symptoms despite steroids or use of biologic agents (TNF-a antagonists), cachexia, rebound tenderness, intestinal obstruction, or abscess

Front 18

What is the IBD diag criteria for classification of symptomatic remission crohn's disease?

Back 18

patient is asymptomatic or without symptomatic inflammatory issues; does not include patients controlled on steroids

Front 19

What is the pathophys of IBS?

Back 19

unknown; thought to be CNS processing abnormailites of afferent signal processing may lead to visceral hypersensitivity. Serotonin is currently being studied as the receptors involved particularly in diarrhea predominant

Front 20

What are factors that can lead to IBS?

Back 20

genetics, motility factors, inflammation, colonic infections, mechanical irritation due to local nerves, stress, or psychosocial factors

Front 21

What are the dietary treatments for IBS?

Back 21

fiber: 1 tbsp with 1 meal/d and increase gradually to 2-3 meals/d; if fiber is not tolerated may substitute bulking form agents such as psyllium

Front 22

What are the two mentioned antispasmodics used for treating IBS?

Back 22

dicyclomine and hyoscayamine

Front 23

What is the MOA of the antispasmodics?

Back 23

anticholonergic agent which decreases GI motility

Front 24

What are the adverse effects of antispasmodics?

Back 24

dry mouth, nausea, constipation, dizziness, syncope, insomnia, blurred vision, urinary hesitancy, tachycardia, sweating

Front 25

What are the drug interactions with antispasmodic agents?

Back 25

antihistamines (increase SEs of antispasmodics), antiglaucoma meds (antispasmodics decrease the effects of the antiglaucoma meds)

Front 26

What is the MOA of loperamide?

Back 26

increase intestinal transit time, enhances water and electrolyte absoprtion, and strengthens rectal sphincter tone by binding to the opiate receptor in the gut wall

Front 27

What are the adverse effects of loperamide?

Back 27

constipation

Front 28

What is the brand name of loperamide?

Back 28

imodium

Front 29

What is the brand name of Tegaserod?

Back 29

Zelnorm

Front 30

What is the moa of Tegaserod?

Back 30

Serotonin-4 agonist in the GI tract leading to increased GI motility and decrease visceral sensations

Front 31

What are the adverse effects of Tegaserod?

Back 31

diarrhea and some reports of CV events (not on the market; have to do special paperwork)

Front 32

What are the drug interactions of Tegaserod?

Back 32

no clinical significant interactions

Front 33

What is the indication for Tegaserod?

Back 33

women in constipation predominant IBS

Front 34

What is the brand name for Alosetron?

Back 34

Lotronex

Front 35

What is the moa of Alosetron?

Back 35

serotonin-3 antagonist

Front 36

What are the adverse effects of Alosetron?

Back 36

constipation, ischemic colitis

Front 37

What are the drug interactions of Alosetron?

Back 37

fluvoxamine and 3A4 inhibitors

Front 38

What is the indication for Alosetron?

Back 38

women with diarrhea predominant IBS symptoms of longer than 6 months not relieved by conventional therapy

Front 39

What is the moa of lubiprostone?

Back 39

c-2 chloride channel activator; causes chloride secretion into the intestine which causes sodium to enter the lumen and water follows

Front 40

What are the adverse effects of lubiprostone?

Back 40

nausea, diarrhea, HA

Front 41

What are the drug interactions of lubiprostone?

Back 41

no clinically significant interactions

Front 42

What is the indication for lubiprostone?

Back 42

women with constipation dependent IBS

Front 43

What are the three types of adjunct tx for IBS?

Back 43

tricyclic antidepressants, SRIs, Rifaximin

Front 44

What is the moa of tricyclic antidepressants in adjunct tx for ibs?

Back 44

modulates perception of visceral pain, alters GI transist time, and maybe treatment underlying psychosocial issues

Front 45

What is the moa of rifaximin in adjunct tx for ibs?

Back 45

works by decreasing gut bacteria and bacteria products that lead to IBS symptoms and may alter the bacteria and host response to the bacteria's effect

Front 46

What are the potential etiologies of IBD?

Back 46

infections, genetics, environmental factors (diet, smoking: protective in Ulcerative colitis but risk factor in crohn's), immune defects, psychological factors

Front 47

What is the current theory behind the pathophys of IBD?

Back 47

defects in the immune system allow bacteria into the gut mucosa which causes an exaggerated immune response which leads to bowel damage

Front 48

What are the differences between Crohn's and ulcerative colitis in terms of anatomic sites involved?

Back 48

ulcerative colitis involves the rectum and colon only while crohn's is in the terminal ileum most commonly but may occur anywhere and sites may be discontinuous

Front 49

What are the differences between Crohn's and ulcerative colitis in terms of depth of involvement?

Back 49

ulcerative colitis affects the mucosa and submucosa only usually while crohn's affects the bowel wall leading to extensive injury and has intestinal lumen narrowing

Front 50

Between crohn's and ulcerative colitis, which usually has cobblestone appearance upon colonscopy?

Back 50

crohn's disease

Front 51

What is the treatment focus in IBD?

Back 51

agents to reduce the inflammatory process, nonpharmacologic tx are just as important, adjunct tx may be needed to treat the complications of these disorders

Front 52

What are the non-pharmacological types in tx of IBD?

Back 52

nutritional support and surgery

Front 53

What are the characteristics of nutritional support in IBD tx?

Back 53

used to prevent malnutrition, have patient watch for foods that exacerbate sysmtoms (lactose intolerance is a common problem), enteral and parenteral nutrition may be needed

Front 54

Is surgery curative for ulcerative colitis?

Back 54

it can be

Front 55

Is surgery curative for crohn's?

Back 55

no

Front 56

What is the moa of aminosalicylates in tx of IBD?

Back 56

block production of prostaglandins and leukotrienes, inhibit central peptide induced neutrophil chemitaxis, scavenge reactive oxygen metabolites, but true moa is unknown

Front 57

How can mesalamine be superior to sulfasalazine in some case?

Back 57

pts with sulfa allergy

Front 58

What are the adverse effects of sulfasalazine?

Back 58

most of the effects are due to the sulfapyridine portion so less side effect with mesalamine; dose related sides include N/V, diarrhea, anorexia, HA, arthralgia, folic acid deficiency; also idiosyncratic effects of rash, fever, hepatotoxicity, bone marrow suppression, thrombocytopenia, pancreatitis, hepatitis

Front 59

What are the drug interactions with sulfasalazine?

Back 59

decrease absorption of folic acid and digoxin

Front 60

What are the drug interactions with mesalamine?

Back 60

no clinically significant interactions

Front 61

What is the MOA of corticosteroids in IBD?

Back 61

modulate immune systems and inhibit production of cytokines and mediators

Front 62

What are the adverse effects of steroids in IBD?

Back 62

hyperglycemia, hypertension, osteoporosis, acne, fluid retention, electrolyte disturbances, myopathies, muscle wasting, increased appetite, reduced resistance to infection, adrenocortical suppression

Front 63

What are the drug interactions of corticosteroids?

Back 63

hepatic enzyme inducers increase the clearance of steroids while inhibitors decrease cl

Front 64

What are the two immunosuppressive agents used in IBD?

Back 64

azathiopurine and mercaptopurine

Front 65

What is the moa of azathiopurine or mercaptopurine in IBD tx?

Back 65

unknown

Front 66

What are the adverse effects of azathiopurine or mercaptopurine in IBD tx?

Back 66

Dose related (type a): malaise, nausea, infectious complications, hepatitis, myleosuppression; idiosyncratic (type b): fever, rash, arthralgia, pancreatitis, lymphomas, nephrotoxicity

Front 67

What is the moa of cyclosporine in ibd tx?

Back 67

inhibits the action of t-cells

Front 68

What are the adverse effects of cyclosporine?

Back 68

nephrotoxicity, tremor, hirsutism (a condition where women have excess facial and body hair that is dark and coarse), hypertension

Front 69

What are the drug interactions of cyclosporine?

Back 69

drugs that increase cyclosporine conc: calcium channel blockers, antifungals, erythromycin abxs, steroids; drugs that decrease cyclosporine conc: naficillin, rifampin, phenytoin, phenobarbital, carbamazepine, st john's wart

Front 70

Which condition in IBD is cyclosporine predominantly used?

Back 70

ulcerative colitis; mainly a rescue therapy to avoid surgery, only works in pts who respond to azathiopurine

Front 71

What is the moa of antimicrobials in IBD tx?

Back 71

may interrupt the bacterial role in the inflammatory process

Front 72

Which type of IBD is antimicrobials indicated in?

Back 72

crohn's disease not ulcerative colitis

Front 73

What are the adverse affects of antimicrobials in IBD tx?

Back 73

nausea, metallic taste, urticaria (flagyl)

Front 74

What drug interactions does flagyl present in ibd tx?

Back 74

increase effects of warfarin, disulfiram rxn

Front 75

What are the possible SEs with TNF-a blockers in IBD tx?

Back 75

infusion rxns, serum sickness, increase infections, reactive antibodies to TNF-a blockers (only occurs in infliximab) that renders tx useless

Front 76

What are the drug interactions of TNF-a blockers?

Back 76

watch in combination with other immunosuppresive agents

Front 77

What is the MOA of selective anti-adhesion molecules (natalizumab/Tysabri)?

Back 77

blocks adhesion and subsequent leukocyte migration into the gut

Front 78

What are the adverse effects of selective anti-adhesion molecules (natalizumab)?

Back 78

progressive multifocal leukoencephalopathy

Front 79

In ulcerative colitis, what is the tx recommendations for mild to moderate disease in distal disease?

Back 79

topical mesalamine agents are superior to oral aminosalicylates or steroids and the combination of oral and topical aminosalicylates is more effective than either agent alone

Front 80

In ulcerative colitis, what is the tx recommendations for mild to moderate disease in colitis?

Back 80

Sulfasalazine or oral mesalamine; steroids are only used in pts who are not responding to above tx or who need quick relief of sx; if not responding to steroids, consider azathiopurine or 6-mercaptopurine as long as patient is not acute enough to need iv therapy; infliximab is last line

Front 81

In ulcerative colitis, what is the tx recommendations for severe disease?

Back 81

if the pt is refractory to max tx with pred, oral aminosalyciate therapy, and topical meds then pt should be started on infliximab as long as immediate hospitalization is not needed; if toxicity is present then pt should be admitted for iv steroids; if not improvement in 3-5 days the pt should be considered for colectomy or IV cyclosporine

Front 82

What is the remission tx in distal ulcerative colitis?

Back 82

mesalamine suppositories or enemas are the most effective, can also use sulfasalazine or mesalamine oral, combining oral and topical mesalamine may be most effect, DO NOT use steroid for remission, if these agents all fail then tryL 6-mercaptopurine, azathiopurine, or infliximab

Front 83

What is the remission tx in colitis for ulcerative colitis?

Back 83

sulfasalazine or mesalamine can all be used, DO NOT treat chronically with steroids, azathiopurine or 6-mercaptopurine should be considered in pts who can not get off steroids

Front 84

What is the remission tx in severe ulcerative colitis?

Back 84

addition of 6-mercaptopurine to the regimen may be helpful, may need to consider longterm infliximab

Front 85

What is the tx for ileocolonic or colonic mild crohn's?

Back 85

sulfasalzine or oral mesalamine

Front 86

What is the tx for perianal mild crohn's?

Back 86

sulfasalazine or oral mesalamine and/or metronidazole

Front 87

What is the tx for small bowel mild crohn's?

Back 87

oral mesalamine or metronidazole. Budesonide (entrocort) for terminal eleal or ascending colonic disease

Front 88

What is the tx for moderate crohn's?

Back 88

same as mild plus prednisone 40-60mg/d, if refractory and fistulizing disease add infliximab; taper pred after 2-3 wks if improved, if not add azathiopurine, mercaptopurine, or methotrexate or switch to adalimumab

Front 89

What is the tx for severe crohn's?

Back 89

Hydrocortisone 100mg IV q 6-8h, if no response in 7 days add cyclosporine IV 4mg/kg/d

Front 90

What is the tx for remission maintenance in crohn's?

Back 90

start with sulfasalazine and mesalamine derivatives but seems to be less effective then in ulcerative colitis, again steroids should not be used for remission, may consider immunosuppressant agents

Front 91

What are the possible complications of ulcerative colitis?

Back 91

toxic megacolon, colonic perforation, colonic hemorrhage, colonic stricture, clon cancer, liver complications, joint complications, ocular complications, dermatologic and mucosal complications

Front 92

What are the possible complications of crohn's disease?

Back 92

small bowel strictures and obstructions, fistual formation, colon cancer but risk is not as high as with ulcerative colitis, joint complications, ocular complications, dermatologic and mucosal complications, gallstones, nutritional deficiencies (wt loss, iron deficiency anemia, vit b12 deficiency, folate deficiency, hypoalbuminemia, hypokalemia)