CPS: Diarrhea and C. Difficile

Question 1

define diarhea

Answer 1

stool measuring over 300 grams per day sometimes decreased consistency

Question 2

if you have diarrhea for longer than 3 weeks, then its considered to be:

Answer 2

chronic diarrhea

Question 3

most common functional disorder for diarrhea

Answer 3

IBS

Question 4

does C Dif produce bloody or non bloody diarrhea

Answer 4

usually non bloody

Question 5

important aspects of physical exam for diarrhea

Answer 5

temperature, signs of dehydration, abdominal exam for signs of peritonitis and tenderness–> some bacteria can cause toxic megacolon, rectal exam

Question 6

investigative tests for acute diarrhea

Answer 6

CBC with urea, bytes, creatinine stool test- parasites, cultures, CDiff 3 views of abdomen sigmoidoscopy if available

Question 7

6 bacteria tested during stool test

Answer 7

1. campylobacter 2. e coli 3. salmonella 4. shigella 5. yersinia 6. C diff.

Question 8

alternative dx for bloody diarrhea if there’s no bacteria in culture

Answer 8

ischemic colitis

Question 9

how to diagnose cdif

Answer 9

liquid stool only. done through PCR and toxin A and B testing (Elsa) stool cultures are not specific for CDI

Question 10

hypervirulent Cdiff

Answer 10

a hardcore Cdif strain that has a deletion of tcdC- which usually down regulates toxin production. Causes greater toxin A and B production

Question 11

preventing CDI

Answer 11

1. wash with soap and water - avoid empiric BSA antibiotic use 3. probiotics is controversial 4. avoid/discontinue PPI 5. use disinfection with chlorine-based disinfectants

Question 12

treatment for mild CDI

Answer 12

1st line: vancomycin PO QID alternatives: fidaxomicin, metronidazole

Question 13

treatment for severe CDI but uncomplicated

Answer 13

both vancomycin QID and fidaxomicin BID

Question 14

treatment for severe and complicated CDI

Answer 14

vancomycin NG, enema, metronidazole IV

Question 15

treatment for 1st, 2nd and 3rd reoccurrence od Cdif

Answer 15

1st. vancomycin QID OR fidaxomicin BID 2nd. vancomycin 3xdaily for 7 days, BID for 7x, then OD x 7days, and then every second /third day for 2-8 weeks 3. fecal microbiota transplant.

Question 16

why is vancomycin better than metronidazole better for treating CDif?

Answer 16

because vancomycin stays in the lumen of the intestine and kills the Cdif in the gut. metronidazole gets absorbed fast into the bile and then blood and gets excreted. good for UTI or systemic infection or for toxic mega colon.

Question 17

4 ways to have fecal transplant

Answer 17

1. capsules 2. NG tube 3. colonoscope and shoot it into colon. 4. enema

Question 18

what must you do prior to fecal translant

Answer 18

must test for hepatitis C and other fecal-oral diseases.

Question 19

which antibiotics for toxic megacolon

Answer 19

IV metronadazole, oral vancomycin

Question 20

positive Cdif

Answer 20

vancomycin

Question 21

positive culture but negative Cdif, non bloody diarrhea

Answer 21

oral hydration

Question 22

stable signs, but bloody diarrhea

Answer 22

oral rehydration. you can’t give antibiotics all the time– you can contract Cdiff if you give antibiotics. Therefore, only give Vancomycin if there is Cdif, or metronidazole if toxic megacolon

Question 23

difference in amount of diarrhea in someone will small bowel vs large bowel disease

Answer 23

small bowel– LOTS of diarrhea large bowel – not as much

Question 24

if someone has chronic diarrhea with high frequency bms, disease of ____ bowel should be sustpected

Answer 24

LARGE bowel

Question 25

if someone has chronic diarrhea with bleeding symptoms, disease of ___ bowel should be suspected

Answer 25

LARGE bowel

Question 26

if someone has chronic diarrhea with periumbilical pain, disease of ___ bowel should be usspected

Answer 26

SMALL bowel. large bowel presents with lower quandrant pain

Question 27

if someone has chronic diarrhea with steatorrhea, disease of ____ bowel should be suspected

Answer 27

SMALL bowel. also would affect some nutrition because you’re not absorbing the fat, hence fat in the poop

Question 28

if someone has chronic diarrhea with weightless, disease of ___ bowel should be suspected

Answer 28

SMALL bowel. if nutrition and absorption is compromised, you’d lose weight

Question 29

if someone has chronic diarrhea with rectal symptoms and tenesmus, disease of ___ bowels mould be suspected

Answer 29

LARGE bowel.

Question 30

if someone has chronic diarrhea with has decreased diarrhea if they fast, disease of the ___ bowels should be suspected

Answer 30

SMALL bowel. if fasting doesn’t help with diarrhea symptoms, consider large bowel disease

Question 31

if if someone has chronic diarrhea with nutritional deficiencies, disease of the ___ bowels should be suspected.

Answer 31

small bowel. this is the site of absorbing. if there is disease and small bowel integrity is compromised, there would be nutritional defieicneis like B12 def, folate def etc.

Question 32

in chronic diarrhea, what tests to run in ALL Cases (small and large bowel diseases)

Answer 32

1. CBC + Cdiff, urea, lytes, creatinine 2. stool for O and P (leukocytes)–ova and parasites 3. 72 hour stool collection– if comes back at 500 grams of stool, there’s no diarrhea. because diarrhea is defined as 300 grams per day. If you have steattorhea without profuse diarrhea, then it might be PANCREAS related

Question 33

in chronic diarrhea what tests to run in SMALL BOWEL suspect

Answer 33

small bowel biopsies CT/MR enterography 72 hour stool for fat- if steatorrhea, consider pancreatic investigations. - blood work: ferritin, B12, RBC folate, albumin, calcium, INR

Question 34

in chronic diarrhea what tests to run in LARGE BOWEL suspect

Answer 34

1. colonoscopy 2. if non-bloody, do random biopsies (right colon, for microscopic or collagenous colitis)

Question 35

2 types of watery chronic diarrhea

Answer 35

1. secretory: secretory toxins and excess bile acids enter the colon. LARGE VOLUME EVEN WHEN FASTING 2. osmotic: maldigestion/malabsorption. Tons of poorly absorbed ions (ex/ from lactulose or PEG) draws water out from body into lumen of colon.

Question 36

what type of diet can increase osmotic diarrhea

Answer 36

FODMAPS. Can cause IBS-D. gotta have a low-FODMAP diet.

Question 37

causes of fatty diarrhea

Answer 37

maldigestion or malabsorption causes

maldigestion: pancreatic insufficency– not enough lipase. OR chronic pancreatitis – decrease lipase
malabsorption: mucosa integrity decrease – crohns, ulcerative colitis. OR a hepatobiliary problem – can’t absorb because no bile or cholestasis

Question 38

causes of dysmotility

Answer 38

 Functional – most common, IBS/D

 Diabetes – autonomic nervous system dysfunction

 Hyperthyroidism

 Carcinoid tumor

if there’s rapid motility: then theres malabsorption

if there’s too slow motility: bacterial overgrowth or fat malabsorption.

Question 39

colitis vs enteritis

Answer 39

colitis: inflammation and ulceration disrupt mucosal integrety of large bowel. Would see bleeding mucus and pus
enteritis: deranged mucosa usually in small bowel. Impaired carb and electrolyte absorption.

Question 40

common causes of inflammatory chronic diarrhea

Answer 40

Question 41

epidemiology and etiology of chronic diarrhea in developed and developing countries

Answer 41

developed: major (IBS), IBD, malabsorption (lactose intolerance)

developing countries: BUGS

Question 42

A person previously on ciprofloxacin for a UTI comes in with abdominal cramping and diarrhea (non-bloody). they feel urgency and no one else in their family has it. They tested positive for Cdif culture.

CT was done and thumbprinting was seen– waht does this indicate?

biospy of colon was done and this was seen:– what does this indicate? Dx?

Answer 42

Mucopurulent exudate forming a layer (pseudomembrane) on the surface of the mucosa.

this is pseudomembranous colitis

thurmbprinting indicates an inflammation–ischemic, UC, pseudomembranous, micropscopic colitis etc.

Question 43

how woudl you treat C dif

Answer 43

vancomycin, if it’s second time consider also using metronidazole