Gastrointestinal disorders and infection

Question 1

What are the 2 types of diarrhoea of the GT tract? what are their causes?

Answer 1

1. Infectious diarrhoea, caused by:
   Clostridium difficile
   Klebsiella oxytoca
   Clostridium perfringens
   Salmonella spp
2. Non-infectious diarrhoea:
   Antibiotics side effect
   Post-infectious irritable bowel syndrome
   Inflammatory bowel disease
   Microscopic colitis
   Ischaemic colitis
   Coeliac disease

Question 2

What findings from the History, Examination & Investigation would suggest infectious diarrhoea?

Answer 2

• Post surgery: risk of infection
• generalised tenderness
• mild abdominal pain
• low temp
• tachycardic
• dry skin
  Investigations show:
• ↑ed WCC & CRP indicating an inflammatory/infective process
• creatinine high
• albumin very low (leaky gut= lose of albumin)
• Also has an acute kidney injury indicating dehydration.

Question 3

What investigations are used to distinguish infectious diarrhoea from non-infectious?

Answer 3

1. Stool sample for C. difficile toxin
2. Stool culture
3. Imaging (AXR, CT)
4. Endoscopy

Question 4

What is fulminant colitis?

Answer 4

• Fulminant colitis occurs in a portion of patients with severe UC who have more than 10 stools per day, continuous bleeding, abdominal pain, distention, and acute, severe toxic symptoms including fever and anorexia (1)
• Hypotension or shock, ileus, toxic megacolon (tranverse colon & secum enlarged)

Question 5

How is severe infection of C.difficile managed vs non severe disease?

Answer 5

Non severe disease:
- Antibiotic therapy with oral vancomycin or fidaxomicin or metronidazole
- Role of Faecal Microbiota Transplantation (FMT)

Severe disease or fulminant colitis:
- Antibiotic therapy, supportive care and close monitoring
- Early surgical consultation

Question 6

How is fulminant colitis with toxic megacolon treated?

Answer 6

1st line treatment
- Medical therapy with antibiotics and supportive management

Patient is transferred to ITU for invasive monitoring
- IV fluid resuscitation & inotropic support
- Afebrile, HR 83, 115/73
- Abdomen remains distended but less tender
- Improves on treatment and is stepped down to the ward
- Discharged 10 days later on extended course of oral vancomycin

Question 7

What presentations indicate the need for surgery?

Answer 7

• Colonic perforation
• Necrosis or full-thickness ischaemia
• Intra-abdominal hypertension or abdominal compartment syndrome
• Clinical signs of peritonitis or worsening abdominal exam despite adequate medical therapy
• End-organ failure

Question 8

What is Pseudomembranous colitis?

Answer 8

• Pseudomembranous colitis is inflammation (swelling, irritation) of the large intestine.
• In many cases, it occurs after taking antibiotics. Using antibiotics can cause the bacterium Clostridium difficile (C. diff) to grow and infect the lining of the intestine, which produces the inflammation.
• Certain antibiotics, like penicillin, clindamycin make C. diff overgrowth more likely
• Manifestation of severe colonic disease
• Characteristic yellow-white plaques that form pseudomembranes on the mucosa

Question 9

How do you diagnose suspected Pseudomembranous colitis?

Answer 9

Confirmed on endoscopy +/- biopsy

Question 10

What is ulcerative colitis?

Answer 10

• Ulcerative colitis is a long-term condition where the colon and rectum become inflamed.
• The colon is the large intestine (bowel) and the rectum is the end of the bowel where poo is stored.
• Small ulcers can develop on the colon’s lining, and can bleed and produce pus.

Question 11

What are the different types of ulcerative colitis you can have?

Answer 11

VARIED SEVERITY:
1. Mild:
4 x BMs (bowel movements) /day, no systemic toxicity, normal ESR/CRP, mild symptoms.
2. Moderate
> 4x BMs/day, mild anaemia, mild symptoms, minimal systemic toxicity, nutrition maintained and no weight loss.
3. Severe
> 6 BMs/day, severe symptoms, systemic toxicity, significant anaemia, increased ESR/CRP and weight loss.

Question 12

What is Crohn’s disease?

Answer 12

Crohn’s disease is a long-term condition that causes inflammation of the lining of the digestive system.

Inflammation can affect any part of the digestive system, from the mouth to the back passage, but most commonly occurs in the last section of the small intestine (ileum) or the large intestine (colon)

Question 13

What is the difference between crohn’s and ulcerative collitis?

Answer 13

UC= without granuloma, continuous patches/ ulcers
Crohn’s= granuloma, ulcers/ patches discontinuous