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Abdominal Cramp

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					    * A lady with abdominal cramps
    24

                                                                                (b) What speci®c symptoms should be asked
       A 33-year-old lady is referred to clinic                                     about to exclude organic disease?
  by her GP with a 4-month history of
  alternating diarrhoea and constipation,                                       .............................................................................
  and cramping abdominal pain. When diar-                                       .............................................................................
  rhoea is the main feature she passes watery
  stool four to ®ve times a day, mainly in the                                  .............................................................................
  morning. In contrast, during the consti-
  pated phase, she defecates every 3 to 4
                                                                                (c) What symptoms in the above history might
  days, and her stools are like `rabbit pellets'.
                                                                                    help con®rm functional bowel disease?
  Her pain is described as a `cramp-like'
  sensation across her lower abdomen that                                       .............................................................................
  is associated with a degree of urgency in
                                                                                .............................................................................
  needing to open her bowels. The pain eases
  once this has occurred.                                                       .............................................................................
  She hasn't noticed any weight loss but tells
  you that her stomach seems to swell after
  food. This is associated with a `bloated                                      (d) What initial investigations would you
  feeling'.                                                                         request?
  She works as a teacher, has recently started                                  .............................................................................
  at a new school, and has found this change                                    .............................................................................
  in work environment quite stressful.
                                                                                .............................................................................
  There is no signi®cant past medical history
  and she is not taking any medication at
  present.
                                                                                       You see the patient in clinic 3 months
  On examination her abdomen is soft, non-
                                                                                  later. All her investigations are normal. A
  tender and no masses are palpable. Bowel
                                                                                  diagnosis of functional bowel disorder is
  sounds and rectal examination are both
                                                                                  made. She tells you that her symptoms are
  normal.
                                                                                  somewhat better now that she has settled
                                                                                  into her job. Her main complaints at pres-
(a) What is the di€erential diagnosis for this                                    ent are of cramping pain before defaecation
    patient?                                                                      and that she is more constipated than
                                                                                  before.
.............................................................................

.............................................................................
                                                                                (e) What pathophysiological processes are
.............................................................................       thought to be important in functional
                                                                                    bowel disorder?
                                                                                .............................................................................

                                                                                .............................................................................

                                                                                .............................................................................
                               (f ) What initial treatment would you consider                                  (g) What treatment would you suggest now?
                                    given her current symptoms?
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                               .............................................................................
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A lady with abdominal cramps




                               .............................................................................



                                       You receive a letter from her GP a few
                                 months later telling you that her symptoms
                                 have deteriorated, and requesting a further
                                 clinic appointment. When she is seen she
                                 tells you that she is having increased cramp-
                                 ing and bloating associated with more
                                 diarrhoea. At work she has had to take on
                                 extra duties owing to pending exams and
                                 again feels quite `stressed-out'.
     3       Answers and teaching notes                                                                            183




                                                                                                                   A lady with abdominal cramps
Key cases
*   Chronic diarrhoea                                                  Compare and contrast the symptoms
*   Functional bowel disorder (irritable bowel syn-                    and clinical ®ndings of the conditions
    drome)                                                    listed above, to those of FBD. What are the
                                                              similarities and di€erences?
Clinical context
Diarrhoea and abdominal pain have been experi-
enced, to varying extent, by virtually everyone. Often    (b) Features indicative of organic
the symptoms are transient, possibly infective in             disease
origin, following a `good night out'. On other            Despite the frequency, timing and variation of symp-
occasions, these symptoms re¯ect pathology either         toms in FBD some clinical features are not com-
in the intestine, or from an extra-alimentary site (see   patible with this diagnosis. Hence, prompt
pp. 90, 163, 177 and 199). A carefully constructed,       investigation for organic disease is needed if the
thorough, history will help you discriminate between      patient's history includes:
the potential causes.
    Functional bowel disorder (FBD), often referred       *    anorexia
to as `irritable bowel syndrome' (IBS), is the most       *    malnutrition
commonly diagnosed gastrointestinal condition             *    weight loss
a€ecting 10±15% of the population. It is charac-          *    pain, which is progressive, may either wake from,
terised by altered bowel habit, either diarrhoea or            or prevent, sleep
constipation or a combination along with chronic          *    large-volume diarrhoea
abdominal pain, abdominal bloating and rectal             *    bloody stools
hypersensitivity (without an organic cause).              *    nocturnal diarrhoea
Although the actual numbers of people a€ected             *    greasy stools (steatorrhoea).
seem quite high (up to 20% of the population in
some studies), only 15% of those seek medical             (c) Features suggesting functional
advice. Furthermore, FBD still accounts for 25±               bowel disease
50% of referrals to hospital gastroenterology clinics.    The Rome II criteria were developed to help diagnose
It is also worth noting that FBD is second only to the    functional bowel disorder without the need for
common cold as a cause of absenteeism!                    further investigation. Patients should have the
    Organic causes of chronic diarrhoea have been         following recurrent symptoms for at least 3 months
discussed in other scenarios in this book. As the         of a year:
name implies, the cause of this extremely common
                                                          *    abdominal pain, the onset of which is associated
disorder is still unknown. However as the pathophy-
                                                               with:
siology of FBD is gradually deciphered contemporary
                                                                ± a change in stool frequency
management strategies emerge. Pharmacological
                                                                ± a change in stool consistency
treatment, lifestyle modi®cation, and stress relief all
                                                          *    supporting symptoms that include:
have roles in the management of FBD, and their
                                                                ± altered frequency of stool
respective uses are discussed below.
                                                                ± altered form of stool
(a) Di€erential diagnoses                                       ± altered passage of stool
                                                                ± the presence of mucus
*   Functional bowel disorder
                                                                ± abdominal bloating
*   Inflammatory bowel disease (see p. 163)
                                                                ± defecation relieves the pain.
*   Coeliac disease (see p. 199)
*   Malignancy (see p. 90)                                The patient in the scenario has described all of these
                                                          features, making the diagnosis of functional bowel
FBD can present with an array of symptoms that can
                                                          disorder very likely.
mimic other, more sinister gastrointestinal problems,
especially in patients over 45 years of age. Di€er-       (d) Initial investigations
entiating FBD from the conditions listed above can
                                                          *    FBC
be challenging.
                                                          *    U&E
                               *   inflammatory markers (CRP/ESR)                         *    Post-infectious changes
                               *   LFT                                                    *    Stress: psychosocial dysfunction
184                            *   TFT
                                                                                          The exact causes of functional bowel disorder remain
                               *   coeliac serology (transglutaminase antibody/
                                                                                          unknown. They are likely to be heterogeneous given
                                   endomysial antibody/IgA)
                                                                                          the complexity of the systems underlying the control
                               *   colonoscopy (or flexible sigmoidoscopy and bar-
A lady with abdominal cramps




                                                                                          of `normal' gastrointestinal function. Intensive
                                   ium enema).
                                                                                          research centred on the areas outlined above has
                               FBD mimics many common gastrointestinal condi-             generated inconsistent and often con¯icting ®ndings.
                               tions, and basic investigations should be aimed at
                               excluding more sinister pathology, especially in the       Abnormal gastrointestinal motility
                               older patient. Anaemia would be a worrying ®nding          In FBD abnormalities in large and small bowel
                               as this could represent blood loss from in¯ammatory        motility are inconsistent. Some studies have demon-
                               bowel disease, peptic ulcer disease, gastrointestinal      strated a reduced rate of basal unstimulated colonic
                               malignancy, or malabsorption. If profuse diarrhoea is      contractions whilst others have found basal motility
                               present, electrolytes may be deranged and the patient      to be increased.
                               could be dehydrated. Elevation of in¯ammatory                 Similarly the peristaltic response to stress, anger
                               markers would not be expected in FBD and would             and infusions of cholecystokinin (CCK) is variable.
                               point more toward a diagnosis of infection, in¯am-         Increased intestinal reactivity occurs in some patients
                               matory bowel disease or malignancy.                        with FBD, and also in healthy volunteer controls.
                                  The clinical features of coeliac disease cover a wide      Other theories have suggested that motility may
                               spectrum from profuse diarrhoea with malabsorp-            be increased by hypersensitivity of a€erent pathways
                               tion and weight loss, to more vague symptoms such          and changes in a€erent-e€erent re¯exes.
                               as bloating and cramping abdominal pain. Blood for
                               serological markers of this disease (transglutaminase
                               antibody, endomysial antibody, IgA) should be                          Use this opportunity to revise the control
                               obtained. Biopsies from the distal duodenum taken                      of peristalsis and mechanics of digestion
                               during OGD are needed to give a de®nite diagnosis              in the GI tract. What are the gastroileal and
                               (see p. 201).                                                  gastrocolic re¯exes? Which hormones regulate
                                  Colonoscopy is the investigation of choice to               GI tract functions?
                               examine the mucosa of the colon and terminal ileum.
                               Alternatively, ¯exible sigmoidoscopy will allow direct
                               visualisation of large bowel mucosa, and the oppor-        Visceral a€erent hypersensitivity
                               tunity to obtain biopsies that will exclude left-sided     A disproportionate response to visceral pain or
                               colitis, while barium enema examination will exclude       discomfort in patients with FBD leads to the notion
                               any mass lesions in the proximal colon. Subtle             of visceral a€erent hypersensitivity.
                               mucosal irregularities, however, are easily missed            FBD patients often complain of `bloating' or
                               on barium examination.                                     `excess gas', however they have similar volumes to
                                  Further investigations will depend on these initial     asymptomatic healthy people. Interestingly, rectal
                               tests, and patients' response to treatment. Small bowel    sensitivity is increased in patients with FBD. The
                               Crohn's disease, for example, can present with inter-      pain threshold to rectal distension can be lowered
                               mittent diarrhoea and abdominal pain. A colono-            even further by repeated stimulation of the sigmoid
                               scopy and small bowel barium studies will be               colon. This response also occurs in FBD patients who
                               needed to con®rm the diagnosis. However, in contrast       did not initially demonstrate a€erent hyper-
                               with FBD, Crohn's disease would also cause weight          sensitivity. Although the sigmoid colon and rectum
                               loss and raise in¯ammatory markers. Lactose intoler-       have been the most amenable sites for study, visceral
                               ance and bacterial overgrowth could present with           hypersensitivity has also been demonstrated at other
                               similar features to FBD, but diarrhoea is the pre-         sites in the GI tract.
                               dominant symptom (without alternating constipa-               The higher perception of gastrointestinal pain
                               tion). These diagnoses are con®rmed using lactose-         relies on serial neural connections sometimes called
                               hydrogen and lactulose breath-testing respectively.        the `brain±gut axis'. Sensation in the gastrointestinal
                                                                                          tract is controlled by various chemoreceptors and
                               (e) Pathophysiological processes in                        mechanoreceptors in the bowel wall. Sensory infor-
                                   functional bowel disorder                              mation is relayed through the nerves of the enteric
                               *   Abnormal GI motility                                   plexuses to the nuclei in the dorsal horn of the spinal
                               *   Abnormal sensory response: `visceral afferent          cord, and then via a€erent nerves to the brain.
                                   hypersensitivity'                                      Increases in the signal intensity at any point in this
pathway could lead to the disproportionate response        symptoms of FBD. Forming a therapeutic relation-
to bowel distension observed in FBD patients.              ship and giving appropriate reassurance can reduce
                                                           patients' anxiety surrounding their symptoms.              185
         Use this opportunity to revisit the enteric
         nervous system (ENS). What are the                (f ) Initial treatment in functional




                                                                                                                      A lady with abdominal cramps
 roles of the submucosal plexus and myenteric                   bowel disorder
 plexus? What are the e€ects of parasympathetic            *    Development of a `therapeutic relationship' with
 and sympathetic stimulation? Which neurotrans-                 the patient
 mitters are important in ENS function?                    *    Reassurance
                                                           *    Dietary modification
                                                           *    Increase fibre
Post-infectious changes                                    *    Anti-spasmodics (e.g. mebeverine/hyoscine)
In this particular sub group of patients with FBD,
diarrhoea is the predominant symptom and mucosal
in¯ammation is present. The patient's history will                     What are the components involved in the
provide the clues to this particular diagnosis. Jejunal                development of a therapeutic relation-
biopsies taken from these patients have shown                  ship? How do they help in a patient's acceptance
in¯ammatory in®ltration of the myenteric plexus                of a psychosocial component to their disease?
and associated degeneration of the nerves. Similar
immunohistological changes have been observed in
patients with gastroenteritis. The link between FBD        Reassuring patients that no sinister problems have
and infection is made stronger by the observation          been identi®ed despite thorough planned assessment
that persistent FBD symptoms occur in a proportion         can alleviate anxiety that could potentially increase
of patients following an acute episode of bacterial        their symptoms, without re-inforcing the `ill role'.
gastroenteritis.                                           Helping them to understand the possible processes
   This could be part of the pathogenesis of FBD in        underlying the condition (see above) can also be
some ± but not all ± patients.                             bene®cial.
                                                               Vegetables such as beans, broccoli, brussel sprouts
Psychosocial dysfunction                                   and cabbage rely on commensal gut ¯ora in the colon
Anxiety, depression, phobias and somatisation dis-         for their digestion. The production of gas during
orders are common in patients with FBD who                 digestion can lead to uncomfortable distension in
present to their GP or hospital for medical attention.     FBD su€erers with visceral hypersensitivity. Conse-
These psychological disorders are not usually present      quently, a trial of a modi®ed diet with reduced
in patients with FBD who don't seek medical atten-         leguminous or cruciferous vegetable content may
tion. Therefore it appears that psychological distress     help.
might in¯uence the perception that patients have of           Increasing dietary ®bre or adding ®bre supple-
their symptoms, but is probably not the cause of the       ments may help in patients with constipation- or
symptoms.                                                  diarrhoea- predominant FBD. Fibre can facilitate the
                                                           transit of stool and may improve its consistency.
                                                           Increasing ®bre may worsen patients' symptoms so,
         What are the methods of screening for a           if supplements are used, they should be increased
         psychological disorder? What key ques-            gradually over a period of time.
 tions should be asked to assess the presence of              As well as lifestyle modi®cation, a sensible starting
 anxiety or depression? What are the forms of              point for this patient would be to prescribe a course
 formal psychological testing available? Who               of an antispasmodic. Mebeverine (135 mg up to
 usually performs these tests?                             3 times/day) or hyoscine butylbromide (10 mg up
                                                           to 3 times/day) could be of potential bene®t. Hyos-
                                                           cine (buscopan), an antimuscarinic (anticholinergic)
Other observations suggest that `stress' may be            drug, reduces intestinal motility, while mebeverine is
causal. Stressful tasks can alter gastrointestinal moti-   thought to have a direct relaxant e€ect on intestinal
lity and increase the perception of pain to colonic        smooth muscle.
balloon distension in healthy controls.
    Most doctors will have experienced patients with       (g) Further treatment
FBD who present with intolerable symptoms during           *    Loperamide
times of stress. The symptoms often improve when           *    Amitriptyline
the psychosocial stressors are removed.                    *    Anxiety management/referral to psychologist
    Anxiety management can often help with the
                               The management of FBD has been likened to a               of a selective serotonin reuptake inhibitor (SSRI) is
                               triangle or pyramid, in that most patients ± the          worthwhile.
186                            base ± will respond to reassurance. The next `level'         As previously described, psychosocial stressors can
                               will require antispasmodic treatment with or without      worsen the abdominal pain associated with FBD.
                               ®bre supplements. The apex represents the minority        There are many approaches to reducing stress and
                               of patients who will require specialist psychological     anxiety. Relaxation techniques, exercise or support
A lady with abdominal cramps




                               assessment.                                               groups can help some patients. Others with more
                                  Anti-diarrhoeal drugs such as loperamide (Imo-         severe symptoms may bene®t from formal counsel-
                               dium) may be useful in patients who experience            ling or cognitive behavioural therapy (CBT). If
                               uncomfortable or frequent diarrhoea. They should          anxiety is acute and related to stressful life events, a
                               be used sparingly since they can cause signi®cant         short course of benzodiazepines (e.g. diazepam) may
                               constipation.                                             be warranted.
                                  Antidepressants have been shown to have useful
                               analgesic e€ects in FBD. Despite the links between        Web resources
                               anxiety, depression and FBD, the pain relieving e€ect     *   Guidelines for FBD management: www.bsg.org.
                               of antidepressants is unrelated to a reduction in             uk
                               depressive symptoms and much lower doses are              *   Information on FBD: www.gpnotebook.co.uk
                               used than in the treatment of depression. Tricyclic
                               antidepressants such as amitryptiline are often used.     Further reading
                               They have the added bene®t of reducing gastroin-          *   Drossman DA, Creed FH, Olden KW et al. (1999)
                               testinal motility, which may help patients with               Psychosocial aspects of the functional gastroin-
                               diarrhoea. Up to a month of treatment may be                  testinal disorders. Gut. 45 Suppl 2: II25±II30.
                               required for tricyclics to have a therapeutic e€ect.      *   Mertz HR (2003) Irritable bowel syndrome. New
                               If patients are clinically anxious or depressed a trial       England Journal of Medicine. 349: 2136.