IM II: IRRITABLE BOWEL SYNDROME,

INTESTINAL OBSTRUCTION, ACUTE APPENDICITIS

INTERNAL MEDICINE II
IRRITABLE BOWEL SYNDROME, INTESTINAL
OBSTRUCTION, ACUTE APPENDICITIS
Dr. Gari Recodo
Kruis Criteria
IRRITABLE BOWEL SYNDROME
Patientshistory
INTRODUCTION Abdominal pain
o 12% - seen by GP Flatulence
o >30% seen by GI Irregularity of bowel movements
o Common diagnosis when all tests were done and Symptoms more than 2 years
everything is normal Mixed diarrhea constipation
o Female IBS-C Pellet-like stools or mucus
o Male IBS-D Physicians Assessment
IMPORTANCE Abdominal physical findings
o To limit costs in diagnostic procedures Erythrocyte sedimentation rate >20mm/2 hr
o Only symptom-directed therapy rather than Leukocytosis (>10,000cm3)
disease-modifying treatments are available Hemoglobin (female <12g/dL; malw ,14g/dL)
OBJECTIVES History of blood in stool
o To know the signs and symptoms of IBS
o To learn how to make a diagnosis of IBS
o To understand the pathophysiological
CLINICAL FEATURES
explanations of IBS ABDOMINAL PAIN KEY SYMPTOM
o To give some of the available treatment of IBS o Variable in intensity and location
Functional disorder o Episodic and crampy
Characterized by o Present only during waking hours
o Abdominal pain or discomfort o Exacerbated by eating and stress
o Altered bowel habits o Improved by flatus or bowel movement
o Absence of structural abnormalities ALTERED BOWEL HABITS MOST CONSISTENT
o No diagnostic markers o Constipation alternating with diarrhea (with one of
Diagnosis based on clinical presentations these predominating)
o No bleeding
Gas and flatulence
o Distention
o Belching, flatulence
Dyspepsia
Heartburn
Nausea and vomiting
Physical Exam: NORMAL
BRISTOL STOOL FORM SCALE

Manning Criteria
Abdominal pain eased after bowel movement
Looser stools at onset of abdominal pain
More frequent bowel movements at onset of abdominal pain
Abdominal distension
Mucus per rectum
Feeling of incomplete emptying

Transcribed by: ALPAY GENERALAO LANDRITO 1 of 6

 IM II: IRRITABLE BOWEL SYNDROME,
INTESTINAL OBSTRUCTION, ACUTE APPENDICITIS
ALARM FEATURES CONSIDERED POTENTIALLY o Prefrontal lobe activation - increase alertness and
RELEVANT IN THE DIAGNOSIS OF ORGANIC DISEASE AS perception of pain
OPPOSED TO IBS Abnormal psychological features
HISTORY o Exaggerated symptoms in response to visceral
Blood in the stool distention
Family history of colon cancer, inflammatory bowel disease or o May result from CNS enteric nervous system
celiac disease dysregulation
Fever Bacterial gastroenteritis BEST ACCEPTED RISK
Onset after age 50 years FACTOR IN IBS; >30% developed IBS
Night-time symptoms (awakening the patient from sleep) Post infectious IBS risk factors:
Chronic diarrhea o Prolonged initial illness
Progressive dysphagia o Toxicity of infecting bacterial strain
Recurrent vomiting o Smoking
Severe chronic constipation o Mucosal markers of inflammation
Short history of symptoms o Female gender
Travel history to locations endemic for parasitic diseases o Depression
Weight loss o Hypochondriasis
o Adverse-life events
PHYSICAL EXAMINATION
o Younger individual with mild symptoms requires a
Abdominal mass minimal diagnostic evaluation
Arthritis (active) o Older person or an individual with rapidly
Dermatitis herpetiformis or pyoderma gangrenosum progressive symptoms should undergo a more
Occult or overt blood on rectal examination thorough exclusion of organic disease
Signs of anemia Immune activation and mucosal inflammation
Signs of intestinal obstruction o Activated lymphocytes, mast cells, enhanced
Signs of intestinal malabsorption expression of proinflammatory cytokines
Signs of thyroid dysfunction contribute to abnormal epithelial secretion and
PATHOPHYSIOLOGY visceral hypersensitivity
Altered gut flora
GI motor abnormalities o Small intestinal bacterial overgrowth
o Increased RS motor activity 3 hours after Other risk factors for IBS:
eating o Affluent childhood environment
o Recordings from the transverse, descending, and o Estrogen use
sigmoid colon motility index and peak o Postmenopausal estrogen use
amplitude of HAPCs increased in IBS-D rapid o Recent antibiotic use
colonic transit time o Food intolerance
Visceral hypersensitivity o Extraintestinal somatic symptoms
o Exaggerated sensory responses o Poor quality of life
o Post prandial pain due to entry of food into o Campylobacter infection toxin-positive
cecum in 74% of patients
o Gastric and esophageal hypersensitivity in DIAGNOSTICS
patients with no ulcer dyspepsia and non-cardiac No pathognomonic abnormalities
chest pain Elimination of organic diseases
o Lipids lower threshold for sensation of gas, CBC
discomfort and pain Stool specimens
o May be due to: Hydrogen breath test
Increased end-organ sensitivity with GI radiographs
recruitment of silent nociceptors Ultrasonogram
Spinal hyperexcitability with activation of Upper and lower GI endoscopy
nitric oxide and possibly other
neurotransmitters APPROACH TO PATIENT
Endogenous (cortical and brainstem)
Clinical features suggestive of IBS:
modulation of caudad nociceptive
o Recurrence of abdominal pain
transmission
o Altered bowel habits over a period of time
Over time, the possible development of
o Without progressive deterioration
long-term hyperalgesia due to
o Onset of symptoms during periods of stress or
development of neuroplasticity, resulting
emotional upset
in permanent or semi-permanent
o Absence of other systemic symptoms such as
changes in neural responses to chronic
fever and weight loss
or recurrent visceral stimulation
o Small-volume stool without any evidence of blood
Central neural dysregulation
o Absence of symptoms when asleep
o Mild-cingulate cortex (attention processes and
response selection) - greater activation in IBS

Transcribed by: ALPAY GENERALAO LANDRITO 2 of 6

 IM II: IRRITABLE BOWEL SYNDROME,
INTESTINAL OBSTRUCTION, ACUTE APPENDICITIS
o Antibiotic e.g., Neomycin x 10 days
DIFFERNTIAL DIAGNOSIS o Non absorbed oral antibiotic e.g., Rifaximin
Biliary tract disease Intestinal infestation with 400mg TID x 10 to 14 days
Giradia lamblia or other o Probiotics
parasites Serotonin receptor agonist and antagonist
Peptic ulcer disorders Lactase deficiency o 5-HT3 antagonist (Olasetron)
IBS-D
Intestinal ischemia Laxative abuse
Reduces painful visceral stimulation;
Carcinoma of the stomach Malabsorption
induces rectal relaxation, increases
and pancreas
rectal compliance, delays colonic transit
Diverticular disease of the Celiac sprue o 5-HT4 receptor agonists (Tegaserod)
colon IBS-C
Inflammatory bowel Hyperthyroidism Exhibit prokinetic activity by stimulating
disease (incuding peristalsis; accelerated intestinal and
ulcerative colitis & Crohns ascending colon transit
disease)
Carcinoma of the colon Infectious diarrhea
Gastroparesis or partial Drugs such as
intestinal obstruction anticholinergic,
antihypertensive. And anti-
depressant medications
Hypothyroidism and Acute intermittent
hypoparathyroidism porphyria and lead
poisoning
TREATMENT
Patient counseling and dietary alterations
o Reassurance
o Careful explanation of the nature of disease
o Avoid food precipitants
Stool-bulking agents high-fiber, bran, hydrophyllic colloid
o Increase stool bulk increase fecal output of SUMMARY
bacteria
o Prevent excessive hydration and dehydration of IBS should be recognized early
stools Avoid costly and life-threatening procedures
Antispasmodics anticholinergics Treatment usually involves education, reassurance, and
o Relief of painful cramps dietary/lifestyle changes
o Inhibit gastrocolic reflex
o 30 mins before meals
ACUTE INTESTINAL OBSTRUCTION
Antidiarrheal agents peripherally acting opiate-based INTRODUCTION
agents agents (IBS-D) e.g., loperamide o Impairment to the aboral passage of the intestinal
o Increases segmenting colonic contractions contents can result from either a mechanical
o Delays in fecal transit obstruction of the bowel or failure of normal
o Increases in anal pressures intestinal motility in the absence of an obstructing
o Reductions in rectal perceptions lesion (ileus)
Antidepressant drugs o Intestinal obstruction may be categorized
o Tricyclic antidepressant (imipramine) IBS-D according to the degree of obstruction to flow
Motor inhibitory effect (partial or complete), the absence or presence of
Slows jejunal migrating motor complex intestinal ischemia (simple or strangulated) and
transit propagation the site of obstruction (small bowel or colonic).
Delays orocecal and whole-gut transit IMPORTANCE
o Selective serotonin reuptake inhibitor (SSRI) o Early identification and diagnosis of complete or
(paroxetine) IBS-C incomplete intestinal obstruction is usually
Accelerates orocecal transit lifesaving.
Blunts perception of rectal distention o Early medical and surgical procedures will not be
Reduces the magnitude of the delayed.
gastrocolonic response OBJECTIVES
Antiflatulence o To recognize signs of intestinal obstruction.
o Eat slow o To know common causes of intestinal
o Avoid carbonated drinks obstruction.
o Pancreatic enzymes o To institute effective and definitive treatment in
o Lifestyle modifications intestinal obstruction.
Modulation of gut flora insufficient data

Transcribed by: ALPAY GENERALAO LANDRITO 3 of 6

 IM II: IRRITABLE BOWEL SYNDROME,
INTESTINAL OBSTRUCTION, ACUTE APPENDICITIS
Results from adhesive bands or internal hernias Foreign bodies
secondary to previous abdominal surgery or from external Gallstones
hernias 75% of patients post operative intestinal Polypoid neoplasm
adhesions o Neoplastic strictures
o 10-50% - surgical intervention o Surgical anastomosis
o Open sx > lap sx Extrinsic Bowel Lesions
25% - due to diverticulitis, ca, enteritis, gallstone o Abscess
(Bouverets Syndrome), intussusception, fecal impaction o Adhesions
Two conditions that must be differentiated from acute o Carcinomamtosis
intestinal obstruction: o Congenital bands
Pseudo-obstruction o Endometriosis
o Chronic motility disorder, mimics mechanical o Hernias
obstruction; exacerbated by narcotic use. o Volvulus
Adynamic Ileus
SYMPTOMS
o Mediated via the hormonal component of the
symphatoadrenal system. Crampy mid-abdominal pain more severe the higher the
o May occur after any peritoneal insult; obstruction
abdominal operation. o Localized if with strangulation; steady
o Severity and duration dependent on injury Vomiting earlier and more profuse the higher the
HCl, colonic contents, pancreatic obstruction
enzymes most irritating o Feculent the lower the obstruction
Blood, urine less Obstipation complete obstruction
o Ureterolith, pyelonephritis Diarrhea (overflow) partial obstruction
o Pneumonia Rectal Bleeding
o Fractured ribs, vertebrae Hiccups
o MI
o Electrolyte imbalance (K) PHYSICAL EXAM
o Intestinal ischemia Abdominal distention hallmark
Ogilvies Syndrome o Least marked high in SI
o Acute colonic pseudo-obstruction o Most marked colon
o Is characterized by acute massive colon Fever, shock, rigidity, tenderness peritonitis has
dilatation involving primarily the right side of occurred
the colon and without a mechanical cause. Hypo/hyperactive bowel sounds
o Most often diagnosed in hospitalized, Metallic tingling sounds, flask sign
debilitated medical or surgical patients with a Palpable mass
wide array of medical conditions
LABORATORY & RADIOGRAPHY
PATHOPHYSIOLOGY
Leukocytosis with shift to the left
Distention accumulation of gas and fluid. Mild elevation of amylase
Fluid Loss movement of Na and water into the lumen Step ladder pattern, paucity of colonic gas
(after 24h) pathognomonic for SI obstruction
o Hypovolemia, renal insufficiency, shock Coffee bean shaped mass strangulating closed loop
Massive loss of fluid and electrolytes CT scan most commonly used for evaluation of
o Vomiting, accumulation of fluids within the lumen, obstruction
sequestration of fluids into edematous wall and Avoid thick barium in complete obstruction
peritoneal cavity.
Closed Loop most feared complication. TREATMENT
o Occlusion at 2 points by a single mechanism Fluid and electrolyte balance
such as hernia or bands; strangulation is Decompression NGT
common Antibiotics (eg Quinolones, Metronidazole)
CAUSES OF INTESTINAL OBSTRUCTION TREATMENT: SI
10% mortality
Intrinsic Bowel Lesions o Non-strangulating 5-8%
o Congenital atresia or stenosis o Strangulating 20-75%
o Inflammatory causes Surgery
Diverticulitis TREATMENT: COLON
Inflammatory bowel disease 20% mortality
Ischemic injury L>R
Radiation injury
Incomplete colonoscopic decompression; stent
o Intussusception
insertion; dilatation
o Obturation
Complete surgery
Bezoars
TREATMENT: ADYNAMIC ILEUS
Feces

Transcribed by: ALPAY GENERALAO LANDRITO 4 of 6

 IM II: IRRITABLE BOWEL SYNDROME,
INTESTINAL OBSTRUCTION, ACUTE APPENDICITIS
o Treatment of primary cause o Tumors
o Decompression Bacteria multiply, invade wall, venous engorgement and
o Supportive arterial compromise, gangrene, perforation
Localized abscess or free access to peritoneum
SUMMARY Perforation rare before 24h, 80% after 48h
Early detection leads to early intervention CLINICAL MANIFESTATION
Most intestinal obstruction requires surgery
Not all abdominal distention are due to intestinal ABDOMINAL DISCOMFORT & ANOREXIA
obstruction PATHOGNOMONIC
o Periumbilical localizing to RLQ (classic)
ACUTE APPENDICITIS o Periumbilical or epigastric visceral type; mild;
INTRODUCTION lasting 4-6h
o 15th century appendix was first mentioned o RLQ parietal ; somatic, steady, severe,
by Leonardo Da Vinci aggravated by
o 1711 first case of appendicitis by German o motion or cough
surgeon Lorenz Heister N, V, change in BM
o 1736 first inflamed appendix was removed by Diarrhea, urinary frequency, dysuria if appendix is
Claudius Amyand, a Sergeant Surgeon to Queen adjacent to sigmoid or UB, tachycardia
Ann, King George I, and King George II
PHYSICAL EXAMINATION
o 1886 Reginald Fitz presented a paper to the
Massachusetts Medical Society in which he The diagnosis cannot be established unless
coined the term appendicitis and espoused early tenderness can be elicited
surgical intervention as its appropriate treatment Tenderness
o 1880 first now-customary appendedctomy for o McBurneys point
classic acute appendicitis was performed by o Absent if retrocecal or pelvic
Lawson Tait Rovsings sign
o 1889 Charles McBurney recommended early o Referred rebound tenderness
laparotomy for the treatment. McBurneys point is Rebound tenderness
described as the point of maximum tenderness, Psoas sign
to 2 inches inside the right anterior spinous o Increased abdominal pain
process of the ileum on a line drawn from the Obturator sign
umbilicus o Right hypogastrc pain
o 2000 first laparoscopic Cutaneous hyperesthesia
approach to appendectomy was described Rigidity peritonitis
by Kurt Semm Palpable mass
o 2009 development of natural orifice T usually normal or slightly elevated [37.2-38C]
transluminal endoscopic surgery (NOTES), the T > 38.3C suggest perforation
first successful transvaginal appendectomy was Distention rare; severe diffuse peritonitis
reported by Sanntiago Horgan and Mark A.
Talamini LABORATORY
IMPORTANCE Moderate leucocytosis
o Appendicitis is the most common acute o 10k-18k cells/uL
abdominal emergency o >20k possible perforation
o Early recognition of the disease is important to Urinalysis; PT
perform early surgical intervention Radiograph opaque fecalith (5% of pateintes); observed
o Mortality rates of 1% to 4% and complication in the RLQ (especially in children)
rates of 12% to 25% have been reported for Ultrasound enlarged and thick-walled appendix
perforated appendicitis o Most useful to exclude ovarian cysts, ectopic
OBJECTIVES pregnancy, or tuboovarian abscess
o To discuss the pathogenesis and clinical CT Scan
manifestations of acute appendicitis o Thickened appendix with periappendiceal
o To introduce some available diagn stranding, fecalith
MOST COMMON ABDOMINAL SURGICAL o PPV 95-97%. Accuracy 90-98%
EMERGENCY
o 2nd and 3rd decades of life SPECIAL PATIENTS
o Perforation more common in infant and elderly
Infant or child - Diarrhea, vomiting, abdominal pain, fever,
PATHOGENESIS distention
Elderly - Pain and tenderness blunted; Painful RLQ
Due to appendiceal luminal obstruction mass
o Fecalith PREGNANT MOST COMMON EXTRA-UTERINE
o Enlarged lymphoid follicles CONDITION
o Inspissated barium o Missed or delayed due to:
o Worms

Transcribed by: ALPAY GENERALAO LANDRITO 5 of 6

 IM II: IRRITABLE BOWEL SYNDROME,
INTESTINAL OBSTRUCTION, ACUTE APPENDICITIS
Frequent mild abdominal discomfort, N.
V
Shift of appendix RUQ
o 2nd trimester
DIFFERENTIAL DIAGNOSIS

TREATMENT
4-6h observation if not sure
No antibiotics if not sure
Early operation and appendectomy once prepared
Phlegmon or abscess palpable mass 3-5 days after
onset of symptoms
o Broad-spectrum antibiotics
o Drainage of abscess >3cm
o IV fluids
o Bowel rest
o Interval appendectomy 6-12 weeks later
SUMMARY
The modern treatment of simple acute appendicitis is
associated with excellent outcomes
Factors responsible for these outcomes are advances in
anesthesia, antibiotics, IV fluids, radiologic tests and blood
products
Mortality and morbidity should be reduced from acute
appendicitis

Transcribed by: ALPAY GENERALAO LANDRITO 6 of 6