1b Gastrointestinal Infections

Question 1

Rapid onset watery diarrhoea for an elderly hospital patient with high CRP, inflammatory markers, creatinine and albumin. What is the most likely diagnosis?

Answer 1

C. Diff infection

Question 2

What investigations should be done for a suspected C. Diff infection?

Answer 2

STOOL SAMPLE FOR C.DIFFICILE TOXIN
STOOL CULTURE
IMAGING AXR

Question 3

What is the management plan for a patient with suspected C. Diff infection?

Answer 3

1. Isolate the patient - move them to a side room
2. Discontinue the antibiotics which are causing the C. Diff infection
3. Management of diarrhoea, fluids and nutrition

Question 4

What are the three levels of severity with C. Diff infections?

Answer 4

1. Non-severe (WCC<15, Creat <150)
2. Severe (WCC > 15, Creat >150)
3. Fulminant Colitis - Hypotension or shock, ileus, toxic megacolon

Question 5

What might patients experience if they have Fulminant Colitis?

Answer 5

Hypotension, Shock, ileus, Toxic megacolon

Question 6

What is toxic megacolon?

Answer 6

When the colon enlarges as a result of C. Diff infection - can be seen on imaging

Question 7

What is the treatment for severe C. Diff infection / Fulminant Colitis?

Answer 7

Antibiotics, supportive care, early surgical consultation

Question 8

What is the treatment for non-severe C. Diff infection?

Answer 8

Antibiotic therapy with oral vancomycin, metronidazole

Question 9

What is the treatment for fulminant colitis with toxic megacolon?

Answer 9

Medical therapy - antibiotics and supportive management

Question 10

What are the indications for surgery with fulminant colitis with toxic megacolon?

Answer 10

Colonic perforation
Necrosis or ischaemia
Clinical signs of peritonitis
End - organ failure

Question 11

What is pseudomembranous colitis?

Answer 11

Pseudomembranous colitis isinflammation (swelling, irritation) of the large intestine.

Often associated with C Diff infection
Manifestation of severe colitis disease
Characteristic white-yellow plaques form pseudomembranes on the mucosa

Question 12

26 Female with long history of loose motions and PR bleeding and minimal tenderness in the left iliac fossa. Increased WCC and CRP indicating inflammatory process. What is most likely diagnosis?

Answer 12

Ulcerative colitis

Question 13

What histology is seen in UC?

Answer 13

Left sided inflammatory change
Chronic inflammation with no granulomas

Question 14

What is the difference between UC and Crohns?

Answer 14

UC: Limited to the mucosa, limited to the colon, pseudopolyps, bloody diarrhoea with mucus

Crohns: All layers of the gut wall, Entire GI Tract, Patchy lesions, Cobblestone appearance, non-caseating granulomas, bloody diarrhoea

Question 15

What are the management options for UC?

Answer 15

Steroids
5-ASA
Immunosuppressants = Methotrexate, Aziothioprine
Biologics

Question 16

What are the different severity classifications for UC?

Answer 16

MILD - 4 x BMs, no systemic involvement and normal inflammatory markers
MODERATE - >4BM’s a day, mild symptoms, no weight loss
SEVERE - > 6BM’s a day, severe symptoms, system toxicity, severe anaemia, increased CRP and ESR, weight loss

Question 17

What medication is used to manage remission acutely for UC?

Answer 17

Prednisolone, if that still doesnt work then Aziothioprine, if that still not working = Infliximab

Question 18

What are some causes of non-infective diarrhoea?

Answer 18

Antibiotic side effects
IBD
IBS
Colitis
Ischaemic Colitis

Question 19

List the four main bacteria which can cause diarrhoea?

Answer 19

• Clostridium difficile
• Klebsiella oxytoca
• Clostridium perfringens
• Salmonella spp

Question 20

What are the two most common antibiotics to cause C.diff infection?

Answer 20

Co-amoxiclav

Ciproflaxin

Question 21

List non-infectious causes of diarrhoea.

Answer 21

Antibiotics side effect

Post-infectious irritable bowel syndrome

Inflammatory bowel disease

Microscopic colitis

Ischaemic colitis

Coeliac disease

Question 22

When would you offer a faecal microbiota transplantation?

Answer 22

Only for recurrent infection or resistant or prolonged infection

Or if Abx therapy failed

Question 23

What is meant by Abdominal Compartment syndrome?

Answer 23

Significant abdominal distension and no space for fluid to expand so pressure on organs compromising blood supply leading to organ failure

Question 24

How does Pseudomembranous colitis present on endoscopy?

Answer 24

Characteristic yellow-white plaques that form pseudomembranes on the mucosa

Question 25

What are some of the endoscopic findings in Ulcerative colitis?

Answer 25

Continuous

Left-sided colitis

No granulomas

Question 26

Why can steroids not be used as long-term management?

Answer 26

Lose effect after a while

Usually given acutely or short term to induce remission

E.g. Prednisolone

Question 27

What diseases can Azathioprine cause reactivation of? And How can you reduce the risk of this happening?

Answer 27

HepB/C/HIV

Chicken pox

Blood tests to check risk of reactivation of these diseases

Ensure vaccinations have been given

Question 28

What are the side effects of infliximab?

Answer 28

Anti-TNF-Alpha = Infliximab

Autoimmunity, immunogenicity

Demyelination disease

Infection

Bone marrow suppression

Infusion reactions, injection-site reactions

Congestive heart failure

Hepatotoxicity

Malignancy/Lymphoma