Rosen & Barkin's 5-Minute Emergency Medicine Consult (401 page)

CODES

964.0 Poisoning by iron and its compounds

BASICS

• Syndrome of abdominal pain or discomfort associated with altered bowel habits and no other pathology explaining symptoms
  
• Prevalence estimated to be 10–20%
  

• Uncertain pathophysiology, but many possibilities
  
• Altered GI motility:
  
  • Increased gut sensitivity (visceral hyperalgesia):
    
    • Exaggerated response to normal GI physiology
      
• Mucosal inflammation:
  
  • Postinfectious:
    
    • After bacterial enteritis, 10% have persistent IBS symptoms
      
• Mucosal lymphocyte infiltration
  
• Altered microflora in small bowel or feces
  
• Food sensitivity is a possibility but not proven
  
• Psychosocial dysfunction:
  
  • More anxiety, somatoform disorders, and history of abuse in patients who seek care
    
  • No evidence of increased psychiatric illness in those who do not seek care
    

DIAGNOSIS

• Abdominal pain or discomfort:
  
  • Relief with defecation
    
• Altered stool frequency
  
• Altered stool consistency
  
• Bloating or distention
  
• Passage of mucus
  
• Feeling of incomplete emptying
  

• Rome III diagnostic criteria: Recurrent abdominal pain or discomfort 3 days/mo in the last 3 mo associated with ≥2 of:
  
  • Improvement with defecation
    
  • Onset associated with a change in frequency of stool
    
  • Onset associated with a change in form (appearance) of stool
    
• Other symptoms consistent with IBS:
  
  • Abdominal distention or bloating
    
  • Passage of mucus in stools
    
  • Altered stool passage (straining, urgency, or feeling of incomplete evacuation)
    
  • Postprandial upper abdominal discomfort
    
  • Symptoms of gastroesophageal reflux
    
  • Flatulence
    
• Female < male, 1.5–2:1 overall, higher in those who seek care
  

• Usually well appearing with normal physical
  
• May have tender sigmoid or palpable sigmoid cord
  

Clinical diagnosis: Careful history crucial

• Typically no abnormalities found
  
• Labs to be considered (to exclude other pathology), but not required:
  
  • CBC:
    
    • Should not have leukocytosis or anemia
      
  • Normal ESR and CRP useful in excluding inflammatory conditions
    
  • Serum chemistry, thyroid studies unlikely to be useful
    
  • Stool for ova and parasites:
    
    • Most useful for diarrhea workup
      
  • Consider outpatient serum test for celiac
    

Only necessary if excluding emergent pathology

Colonoscopy/flexible sigmoidoscopy for select patients (outpatient)

• Celiac disease
  
• Inflammatory bowel disease:
  
  • Ulcerative colitis/proctitis
    
  • Crohn's disease
    
• Infectious enteritis
  
• Small-intestinal bacterial overgrowth
  
• Lactose intolerance
  
• Colorectal cancer
  
• Diverticular disease
  
• Biliary disease
  
• Diabetic gastroparesis
  
• Pancreatitis
  
• Thyroid malfunction
  
• Obstruction
  
• Peptic ulcer disease
  
• Acute intermittent porphyria
  

TREATMENT

No specific treatment required

• Symptomatic treatment
  
• Pain control
  
• Administer fluids if dehydrated
  

• Empathetic approach and therapeutic physician–patient relationship is most important.
  
• Exercise:
  
  • Improves gastric emptying and constipation
    
• Diet:
  
  • Many believe symptoms have a food trigger, but not yet proven.
    
  • Exclusion diets starting with gluten or lactose can be empirically considered.
    
  • Avoid beans, cabbage, uncooked broccoli, other flatulent foods if symptomatic.
    
• Constipation symptoms:
  
  • High-fiber diet, fiber supplements
    
• Abdominal pain:
  
  • Antispasmodics like hyoscyamine and dicyclomine may be helpful short-term
    
• Probiotics:
  
  • Bifidobacteria appear more effective than lactobacilli
    
• Antidepressants:
  
  • TCAs and possibly SSRIs appear to be effective at relieving global IBS symptoms and reducing abdominal pain.
    
• Psychological therapies appear effective.
  

• Dicyclomine: 10–20 mg PO q6h
  
• Hyoscyamine: 0.125–0.25 mg PO or sublingual not to exceed 12 tab/day
  

• Amitriptyline: 25 mg PO at bedtime (or another TCA)
  
• Fluoxetine: 20 mg PO daily (or another SSRI)
  
• Bifidobacteria probiotic
  

FOLLOW-UP

Uncertain diagnosis with suspicion of an emergent abdominal condition

Almost all patients can be managed as outpatients.

Some may benefit from GI or psychiatric referral.

Most important is follow-up with primary care physician to foster a therapeutic physician–patient relationship.

• Beware of other emergent pathology.
  
• IBS is common, so it is likely the underlying cause of many abdominal workups done in the ED.
  

• American College of Gastroenterology Task Force on Irritable Bowel Syndrome, Brandt LJ, Chey WD, et al. An evidence-based position statement on the management of irritable bowel syndrome.
  Am J Gastroenterol
  . 2009;104 (Suppl 1):S1–S35.
  
• Whelan K, Quigley EM. Probiotics in the management of irritable bowel syndrome and inflammatory bowel disease.
  Curr Opin Gastroenterol
  . 2013;29(2):184–189.
  
• Videlock EJ, Chang, L. Irritable bowel syndrome: Current approach to symptoms, evaluation, and treatment.
  Gastroenterol Clin North Am
  . 2007;36(3):665–685, x.
  

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