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450 CASE FILES: FAMILY MEDICINE
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Table 40–3 • MEDICATIONS USED FOR IRRITABLE BOWEL SYNDROME
Drug Name Mechanism of Action Comments
Medications for constipation-predominant IBS (IBS-C)
Polyethylene glycol (PEG) Osmotic laxative that improves
symptoms of constipation by
increasing stool frequency
Linaclotide (Linzess) Stimulates cGMP production to
increase intestinal motility and
fluidsecretion
Lubiprostone (Amitiza) Selectively activates intestinal
chloride channels to increase
fluid secretions, increase motility,
and promote spontaneous bowel
movements
Plecanatide (Trulance) Guanylate cyclase-C agonist that
increases intestinal fluid transit,
increases stool frequency, and
decreases visceral pain
Medications for diarrhea-predominant IBS (IBS-D)
Loperamide (Imodium) Opioid receptor agonist that
decreases activity of the
myenteric plexus, which reduces
the frequency of loose stools
Rifaximin (Xifaxan) Nonsystemic antibiotic used in the
treatment of traveler’s diarrhea
Alosetron (Lotronex) Serotonin antagonist that slows
fecal movement through the GI
tract, decreasing volume and water
content of stool
Eluxadoline (Viberzi) Mixed opioid receptor agonist/
antagonist that reduces visceral
hypersensitivity and decreases
GI motility
Limited evidence for global
symptom improvement
Modest improvement
in abdominal pain and
complete spontaneous
bowel movements,
improvement in global
symptoms of IBS
Demonstrated global
symptom relief
Also decreases bowel
urgency
Has shown improvement in
abdominal pain, bloating,
stool consistency, and
IBS-related global symptoms
Demonstrated improvement
in abdominal pain and
IBS-related global
symptoms; currently FDA
approved for women with
IBS-D
cGMP, cyclic guanosine monophosphate; FDA, Food and Drug Administration, GI, gastrointestinal.
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CASE CORRELATION
See Case 23 (Lower Gastrointestinal Bleeding) and Case 31 (Abdominal
Pain and Vomiting in a Child).
COMPREHENSION QUESTIONS
40.1 A 65-year-old man reports a lifelong history of IBS with alternating bouts
of constipation and diarrhea. He denies blood in the stool, unintentional
weight loss, fevers, or nighttime symptoms that awaken him. He now reports
that his symptoms have worsened over the last several months. He has never
had a colonoscopy. Which of the following is the recommend initial step in
management?
A. Esophagogastroduodenoscopy (EGD)
B. Trial of polyethylene glycol
C. Explore possible underlying psychiatric symptoms
D. Colonoscopy
E. Increase in fiber intake
40.2 A 47-year-old woman reports a 10-year history of intermittent abdominal
pain and constipation alternating with diarrhea. She has no weight loss, fever,
or alarm features on history or examination. Which of the following agents
can be used for treatment of mild-to-moderate abdominal pain associated
with IBS?
A. Amitriptyline
B. Lubiprostone
C. Dicyclomine
D. Fluoxetine
40.3 A 27-year-old man in graduate school is evaluated for intermittent abdominal
pain and frequent loose stools. He has no fevers, weight loss, bloody stools,
or symptoms that wake him up at night. His family history is negative for
colorectal cancer and IBD. He is diagnosed with IBS-D and asks about getting a colonoscopy to support his diagnosis. Although not indicated as part
of his workup, a colonoscopy in this patient would likely show which of the
following?
A. Focal ulcerations adjacent to normal mucosa
B. Normal colonic mucosa
C. Pseudopolyps and mucosal inflammation
D. Intestinal villous atrophy
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40.4 A 22-year-old woman is a college student who has been increasingly stressed
with coursework this semester. She has been using over-the-counter antacids
more days out of the week than not for an upset stomach. She typically has
two to three bowel movements per week but recently has only been having
one or two hard bowel movements a week. She reports no blood in the stool.
She feels immediate relief after passage of stool and flatulence, but she often
feels like her bowel movements are incomplete. She has tried several diets
eliminating foods that create GI symptoms and has increased her exercise
regimen from once a week to daily without improvement. Which of the following therapies is recommended in IBS-C to improve motility, abdominal
pain, spontaneous bowel movements, and IBS-related global function?
A. Hyoscyamine
B. Fluoxetine
C. Linaclotide
D. Loperamide
40.5 A 35-year-old woman comes to your office worried that she might have IBS,
which she heard about from her colleagues at work. She reports abdominal
pain and diarrhea for 3 months. She also reports observing several bloody
stools. She is worried about the impact that frequently having to use the
bathroom is having on her job as an attorney. Her physical examination is
unremarkable except for a guaiac-positive test after a rectal examination.
When reviewing her medical records, you notice that she has lost 15 pounds
since she last saw you 4 months ago. Which of the following is an appropriate
next step?
A. Refer her for cognitive behavioral therapy.
B. Offer her symptomatic relief with loperamide.
C. Recommend that she take fiber for better bowel regulation.
D. Obtain a colonoscopy.
E. Recommend that she keep a food diary and follow up in 1 month.
ANSWERS
40.1 D. Age-appropriate colorectal cancer screening (eg, colonoscopy) is indicated,
even in the setting of an established diagnosis of IBS. Dietary modifications,
fiber supplementation (answer E), and addressing psychiatric contributions
to GI symptoms (answer C) should be considered after colorectal cancer
screening is performed. EGD (answer A) is not part of routine screening for
colon cancer or workup for IBS. Answer B (polyethylene glycol) is an osmotic
laxative and would likely worsen the patient’s symptoms.
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40.2 C. Dicyclomine, an antispasmodic anticholinergic medication, can be used on
an as-needed basis for mild-to-moderate abdominal pain associated with IBS.
For more persistent and severe pain, low-dose TCAs, such as amitriptyline
(answer A), are beneficial. Lubiprostone (answer B) is indicated for patients
with IBS-C. SSRIs like fluoxetine (answer D) have shown no improvement
in those with abdominal pain and global symptoms related to IBS.
40.3 B. Irritable bowel syndrome is a functional disorder with no identifiable
organic cause. Colonoscopy in a patient with IBS would show normal colonic
mucosa. Colonoscopy is not indicated in a young patient without alarm features or family history of IBD or colon cancer. Focal ulcerations (answer A)
adjacent to normal mucosa describe skip lesions and cobblestoning, which
are found in Crohn disease. Patients with Crohn disease often present with
abdominal pain, weight loss, diarrhea, oral ulcers, malabsorption, and manifestations outside the GI system, including arthritis and eye and skin disorders. Pseudopolyps (answer C) and mucosal inflammation can be found
in patients with ulcerative colitis (UC). Patients with UC may present with
fever, bloody stool, weight loss, and colicky abdominal pain. Intestinal villous
atrophy (answer D) is found in celiac disease. Patients with celiac disease may
present with diarrhea, abdominal distention, malabsorption, and nutritional
deficiencies.
40.4 C. Linaclotide is a recommended pharmacologic therapy in IBS-C. Patients
may try this medication after initial treatment with lifestyle modifications.
Patients may choose to discontinue treatment due to diarrhea as a common
side effect. Loperamide (answer D) can be used in IBS-D, and hyoscyamine
(answer A) can be used to treat mild-to-moderate abdominal pain associated
with IBS. Evidence regarding the efficacy of fluoxetine (answer B) in treating
IBS has shown conflicting results; sertraline has been shown to be moderately effective, especially for IBS-C and when there are comorbid conditions
such as depression and/or anxiety.
40.5 D. This patient presents with alarm signs of blood in the stool and weight
loss. Although a psychiatric diagnosis or IBS is possible, more serious conditions should be evaluated and ruled out. Therefore, neither answer A (cognitive behavioral therapy) for a psychiatric diagnosis nor answer B (loperamide)
for the diarrhea is the best treatment at this time. Evaluation should include
a colonoscopy, complete blood count, basic metabolic panel, stool cultures,
C-reactive protein, and fecal calprotectin to rule out malignancy, infection,
or IBD. Recommending fiber supplementation (answer C) or keeping a food
diary with later follow-up (answer E) is not appropriate at this time.
454 CASE FILES: FAMILY MEDICINE
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CLINICAL PEARLS
» The cornerstone of management of IBS is the therapeutic relationship
between patient and the clinician, who can collaborate on an individualized plan of care that best manages the patient’s symptoms. In the
absence of alarm features, laboratory testing may not be required to
make an accurate diagnosis.
» Alarm features include fever, weight loss, bloody stools, severe abdomi-
nal pain, and denial of recent antibiotic use. These may indicate an underlying organic pathology and require additional diagnostic workup such
as laboratory, radiographic, and/or endoscopic evaluation.
» Treatment should be symptom specific and should include dietary and
lifestyle changes, examination of any psychosocial factors that contribute to IBS symptoms, and appropriate pharmacotherapy.
REFERENCES
Böhn L, Störsrud S, Liljebo T, et al. Diet low in FODMAPs reduces symptoms of irritable bowel
syndrome as well as traditional dietary advice: a randomized controlled trial. Gastroenterology.
2015;149:1399.
Chey WD, Kurlander MD, Eswaran S. Irritable bowel syndrome: a clinical review. N Engl J Med.
2015;313(9):949-958.
Heidelbaugh JJ. These 3 tools can help you streamline management of IBS. J Fam Pract. 2017;66(6):
346-348, 350-353.
Heidelbaugh JJ, Hungin P, eds. ROME IV: Functional Gastrointestinal Disorders for Primary Care and
Non-GI Clinicians. Rome Foundation, 2016.
Hungin APS, Becher A, Cayley B, et al. Irritable bowel syndrome: an integrated explanatory model for
clinical practice. Neurogastroenterol Motil. 2015;27(6):750-753.
Lembo AJ, Lacy BE, Zuckerman MJ, et al. Eluxadoline for irritable bowel syndrome with diarrhea.
N Engl J Med. 2016;374;242-253.
Weinberg DS, Smalley W, Heidelbaugh JJ, Sultan S. American Gastroenterological Association Institute
guideline on the pharmacological management of irritable bowel syndrome. Gastroenterology. 2014;
147(5):1146-1148.
CASE 41
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A 20-year-old woman who is a college student is brought to the emergency
department (ED) complaining of chest pain that started 45 minutes ago. She
describes the chest pain as substernal, 10/10 in intensity, radiating to her jaw,
and associated with headache, sweating, nausea, and palpitations. She was given
oxygen, aspirin, and nitroglycerin by emergency medical services in route to the
ED and received morphine on her arrival at the ED. The patient is accompanied by
her roommate, who mentions that the patient came back from a concert about an
hour ago and complained of feeling nauseated, anxious, and somewhat paranoid.
The patient has no history of health problems and has not had similar episodes
in the past. She is currently sexually active with one male partner and takes oral
contraceptive pills for birth control. She reports drinking alcohol and smoking
cigarettes occasionally. On questioning about use of illicit drugs, she hesitates,
then says that she drank “a few beers,” smoked “a few joints,” and “took a capsule” at
the concert. She swears that this is the first time she has used any illicit substances.
On examination, she is anxious and restless with heightened alertness.
Her temperature is 101 °F (38.3 °C), pulse is 119 beats/min, respiratory rate is
24breaths/min, blood pressure is 165/90 mm Hg, oxygen saturation is 97% on
room air, height is 60 inches, and weight is 100 lb. Eye examination reveals dilated
pupils bilaterally with sluggish light reflex, along with occasional twitching of her
right eye. Extraocular movements are found to be normal. Her heart examination
reveals tachycardia with no murmurs. Respiratory examination reveals tachypnea
with shallow breathing, but lung fields are clear to auscultation. Neck is without
carotid bruit or jugular venous distention. Distal extremity pulses are brisk and
symmetrical. The remainder of her examination is unremarkable.
▶ What is the differential diagnosis for this case?
▶ What is your first diagnostic step?
▶ What is the next step in management of this patient?
456 CASE FILES: FAMILY MEDICINE
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ANSWERS TO CASE 41:
Substance Use Disorder
Summary: A 20-year-old woman presents with
No significant past medical history
Symptoms of coronary ischemia and other symptoms that signify increased sympa-
thetic activity (substernal chest pain, 10/10 in intensity, radiating to her jaw, and
associated with headache, sweating, nausea, and palpitations)
Report of drinking alcohol, smoking “a few joints,” and ingesting unknown
substances
Fever, tachycardia, and hypertension
Dilated pupils bilaterally with sluggish light reflex, along with occasional twitching
of her right eye
Differential diagnosis: Cocaine-induced myocardial ischemia; cocaine- and ecstasyinduced mental status changes (eg, anxiety, paranoia); panic attack; cardiac arrhythmia; and pulmonary embolism.
First diagnostic step: 12-lead electrocardiogram (ECG); markers of myocardial
damage, including serum troponin I, creatine kinase, and creating kinase MB
isoenzyme (CK-MB) performed stat; urine toxicology screen; blood alcohol
level; comprehensive metabolic panel (electrolytes, glucose, kidney and liver
function tests); complete blood count (CBC); prothrombin time (PT); partial thromboplastin time (PTT); international normalized ratio (INR); and a
chest x-ray.
Next step in management: Telemetry, oxygen, assessment of ABC’s, aspirin, sublingual nitroglycerin, and morphine. Beta-blockers should be avoided initially, especially if cocaine intoxication is suspected, rule out acute coronary syndrome with
serial ECG and cardiac enzymes.
ANALYSIS
Objectives
1. Be able to state the definition and epidemiology of substance use disorders
(SUDs). (EPA 12)
2. Be able to state the most commonly used illicit and prescription drugs, as well
as their adverse and toxic effects. (EPA 2)
3. Be able to name the components of a validated ambulatory care screening protocol, history taking, physical examination, and laboratory findings in patients
consistent with substance intoxication and SUDs. (EPA 1, 3)
4. Be able to name the medications available to control alcohol use disorder
(AUD). (EPA 4)
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Considerations
This is a healthy young woman who presents with acute chest pain unrelated to
respiration and position but associated with nausea, fever, tachycardia, tachypnea,
anxiety, heightened alertness, paranoia, and mydriasis. The events preceding her
arrival include ingestion of alcohol and other likely illicit substances that might
have caused her to have chest pain. The initial management of this patient will be
the same as for any other patient presenting with acute chest pain, as she should
be placed on telemetry and oxygen. Airway, breathing, and circulation should be
ensured followed by administration of aspirin, sublingual nitroglycerin, and morphine. Beta-blockers should be avoided initially, especially if cocaine intoxication is
suspected, due to risk of unopposed alpha constriction, which can induce ischemia.
Ruling out acute coronary syndrome with serial ECG and cardiac enzymes should
occur every 8 hours over three intervals. She should be monitored closely for mental status changes and withdrawal symptoms of potentially ingested illicit drugs.
After ruling out the cardiac causes of chest pain, it is very important to screen for
signs and symptoms of acute illicit drug intoxication and drug abuse in this patient.
Urine toxicology screening should be performed to detect the most commonly
abused illicit substances.
When people consume two or more psychoactive drugs together, such as
cocaine, ecstasy, and alcohol, the danger of experiencing adverse effects of each drug
is compounded. In this patient, the history and physical examination suggest that
she may have used a combination of cocaine and alcohol, which may have led to the
formation of a third substance, cocaethylene, which intensifies cocaine’s euphoric
effects. Cocaethylene is associated with a greater risk of coronary vasospasm than
cocaine alone, resulting in myocardial ischemia and sudden death.
DEFINITIONS
DETOXIFICATION: A process that enables the body to rid itself of a drug.
RELAPSE: Resumption of illicit drug use after an attempt or multiple attempts
to quit.
SUBSTANCE USE DISORDER: The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) no longer uses the terms substance abuse and
substance dependence. Instead, the term substance use disorder is used, with SUD
defined as mild, moderate, or severe to indicate the level of severity. SUDs occur
when the recurrent use of alcohol and/or drugs causes clinical and functional
impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. A diagnosis of SUD is based on evidence of the
craving of a substance, failure to be able to control use, social impairment, risky use,
and pharmacological criteria.
APPROACH TO:
Substance Use Disorder
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CLINICAL APPROACH
Pathophysiology
Primary care providers are well positioned to identify patients at risk for drug
abuse early in the course. Since addiction and dependence are equal opportunity
afflictions, clinicians should screen all new patients for substance abuse. Abrupt
changes in behavior or functioning of the patient should also prompt the provider
to screen for substance use. As with many other chronic illnesses, early recognition and management of the substance abuse leads to better outcomes. The most
common SUDs in the United States are AUD, tobacco use disorder (see Case 7),
cannabis use disorder, stimulant use disorder, hallucinogen use disorder, and opioid
use disorder (see Case 59).
Vulnerability and affinity to addiction differs from person to person and is considered multifactorial in origin. Factors include gender, ethnicity, developmental
stage, and socioeconomic environment. Genetic susceptibility accounts for between
40% and 60% of a person’s vulnerability to addiction. Populations at increased risk of
drug abuse include adolescents and persons with psychiatric disorders. Table 41–1
includes the most commonly abused substance categories, street names, route of
administration, intoxication effects, and potential health complications.
Screening. The United States Preventive Services Task Force (USPSTF) recommends adults 18 and above be screened both for AUD (Grade B) and for illicit drug
use (Grade B). Screening, brief intervention, and referral to treatment (SBIRT) is
broadly recommended by multiple federal agencies, the USPSTF, and all of the
primary care physician groups. The National Commission on Prevention Priorities
ranked SBIRT among its top five priorities, ahead of 20 other effective services,
including colorectal cancer screening, hypertension screening and treatment, and
influenza immunization.
Clinician offices can integrate annual tobacco, alcohol, and substance use screening. Tobacco and alcohol screening and brief interventions are measures for the
Merit-Based Incentive Payment System (MIPS) used for reimbursement for valuebased population health medicine. Annual SBIRT screens are reimbursed by all
major insurers. If an individual is identified as having an SUD, the history should
be geared to determine what, how, and when the patient is using the drug; the level
of counseling and treatment should be based on the pattern and severity of use.
Information about co-occurring psychiatric or medical conditions and a personal
or family history of substance abuse should be obtained. The clinician should ask
open-ended questions and should remain nonjudgmental, respectful, and empathetic at all times. Information should also be elicited about health, family, social,
career, financial, and legal impacts of the drug use.
Alcohol Use Disorder. Excessive alcohol use can increase a person’s risk of developing serious health problems in addition to those issues associated with intoxication behaviors and alcohol withdrawal symptoms. According to the Centers for
Disease Control and Prevention, excessive alcohol use causes 88,000 deaths a year.
Data from the National Survey on Drug Use and Health show that in 2017, slightly
more than half of Americans ages 12 and up drank alcohol. Most people drink
alcohol in moderation, but an estimated 16.7 million are considered heavy drinkers
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Table 41–1 • COMMONLY ABUSED ILLICIT AND PRESCRIPTION
DRUGS
Intoxication Effects
Category and
Name
Cannabinoids
Hashish Boom, chronic,
Marijuana Blunt, dope, ganja,
Depressants
Barbiturates Amytal, Nembutal,
Benzodiazepines Ativan, Halcion, Librium,
GHB γ-Hydroxybutyrate and
Methaqualone Quaalude, Sopor, Parest
Dissociative Anesthetics
Ketamine Ketalar SV and cat
PCP and analogs Phencyclidine and angel
Commercial and
Street Names
gangster, hash,
hash oil, hemp
grass, herb, joints,
Mary Jane, pot, reefer,
sinsemilla, skunk, weed
Seconal, Phenobarbital
and barbs, red,
phennies, tooies,
yellow jackets
Valium, Xanax and
candy, downers,
sleeping pills, tranks
G, Georgia homeboy,
grievous bodily harm,
liquid ecstasy
and ludes, mandrex,
quad, quay
Valiums, K, Special K,
vitamin K
dust, boat, hog, love
boat, peace pill
Route of
Administration
Swallowed,
smoked
Swallowed,
smoked
Injected,
swallowed
Swallowed,
injected
Swallowed
Injected,
swallowed
Injected,
snorted, smoked
Injected,
swallowed,
smoked
and Potential Health
Consequences
Common features: euphoria,
slowed thinking and reaction
time, confusion, impaired bal-
ance and coordination and
cough, frequent respiratory
infections; impaired memory
and learning; tachycardia, anxi-
ety; panic attacks; tolerance,
addiction
Common features: reduced
anxiety; feeling of well-being;
lowered inhibitions; slowed pulse
and breathing; lowered blood
pressure; poor concentration and
fatigue; impaired coordination,
memory, judgment; addiction;
respiratory depression and
arrest; death. Also, for Barbi-
turates: sedation, drowsiness
and depression, excitement,
poor judgment, dizziness, life-
threatening withdrawal. Also,
for Benzodiazepines: sedation,
drowsiness and dizziness. Also,
for GHB: drowsiness, nausea
and vomiting, headache, loss of
consciousness, loss of reflexes,
seizures, coma, death. Also, for
Methaqualone: euphoria and
depression, poor reflexes
Common features: tachycar-
dia, increased blood pressure,
impaired motor function, and
memory loss; numbness; vomit-
ing. Also, for Ketamine: at high
doses, delirium, depression,
respiratory depression, and
arrest. Also, for PCP and ana-
logs: possible decrease in blood
pressure and heart rate, panic,
aggression and loss of appetite,
depression, nystagmus
(Continued)
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