Gastrointestinal Infections (Complete)

Question 2

List 4 examples of causes of infectious diarrhoea in patients who have investigation findings indicative of inflammation/infection (e.g. elevated CRP and WCC)

Answer 2

Clostridium difficile

Klebsiella oxytoca

Clostridium perfringens

Salmonella spp

Question 3

List 6 examples of causes of non-infectious diarrhoea in patients who have investigation findings indicative of inflammation/infection (e.g. elevated CRP and WCC)

Answer 3

Antibiotics side effect

Post-infectious irritable bowel syndrome

Inflammatory bowel disease

Microscopic colitis

Ischaemic colitis

Coeliac disease

Question 4

List 4 examples of investigations that can help determine whether the diarrhoea has an infectious or non-infectious cause

Answer 4

Stool sample for C. difficile toxin

Stool culture

Imaging (AXR, CT)

Endoscopy (e.g. Flexible sigmoidoscopy, Colonoscopy)

Question 5

Stool sample findings show a positive for C. diff. What is the management plan for this patient?

Answer 5

Move patient to a side room (Infection control)

Discontinue any antibiotics (e.g. co-amoxiclav) the patient is on and start them on vancomycin, fidaxomicin or metronidazole.

Management of fluids, nutrition & diarrhoea

Question 6

What two investigation parameters can be looked at to measure the severity of a c.diff infection?

Answer 6

WCC

Creatinine (Measure of kidney function)

Question 7

What values must WCC and creatinine levels fall under to consider a c. diff infection as being non-severe?

Answer 7

WCC<15

Creatinine <150

Question 8

What values must WCC and creatinine levels fall under to consider a c. diff infection as being severe?

Answer 8

WCC>15

Creat >150

Question 9

What is a rare but severe consequence of a c. diff infection?

Answer 9

Fulminant colitis

Question 10

What are some of the sypmtoms associated with fulminant colitis?

Answer 10

Toxic megacolon

Hypotension or shock

Ileus (lack of muscles contractions in intestines)

Question 11

Define toxic megacolon

Answer 11

Non-obstructive widening of the colon due to swelling and inflammation

Question 12

Patient has a c.diff infection with WCC 14 and creatinine 140. What is the management/treatment plan for this patient?

Answer 12

Isolate the patient in a side room

Stop any current antibiotics and place them on vancomycin, fidaxomicin or metronidazole.

Role of Faecal Microbiota Transplantation (FMT) [If its an option]

Management of fluids, nutrition & diarrhoea

Question 13

Patient has a c.diff infection with WCC 16 and creatinine 170. What is the management/treatment plan for this patient?

Answer 13

This patient has a severe infection and potentially may have fulminant colitis.

Isolate the patient in a side room

Stop any current antibiotics and place them on vancomycin, fidaxomicin or metronidazole.

Supportive care and close monitoring

Early surgical consultation

Question 14

What is the management plan for a patient with fulminant colitis with toxic megacolon?

Answer 14

Medical therapy with antibiotics and supportive management

ITU transfer for invasive monitoring

Potential surgery

Question 15

What are the 5 main indications for surgery in patients with fulminant colitis?

Answer 15

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 16

What severe manifestation of colic disease is most associated with a c. diff infection?

Answer 16

Pseudomembranous colitis

N.B. This has a chance of leading to toxic megacolon and fulminant (severe) colitis

Question 17

Define pseudomanas colitis

Answer 17

Pseudomembranous colitis is an inflammatory condition of the colon characterized by elevated yellow-white plaques that coalesce to form pseudomembranes on the mucosa.

N.B. Most commonly caused by overgrowth of C.diff (which usually occurs due to AB use)

Question 18

How is pseudomonas colitis confirmed?

Answer 18

Via endoscopy +/- biopsy

Question 19

How does inflammation differ between ulcertaive colitis and crohn’s disease?

Answer 19

Ulcertaive colitis inflammation is usually continous and starts in the rectum towards the rest of the colon

Crohns disease has discontinous inflammation with and inflammation can be anywhere within the GI tract (mouth to anus)

Question 20

26F presenting with a long history of loose motions & PR bleeding who is clinically stable . Blood tests showing ↑ed WCC & CRP indicating an inflammatory/infective process with no complications.

A colonoscopy has showed continuous left sided inflammatory changes. What is the likely diagnosis?

Answer 20

Ulcerative colitis

Question 21

A patient has been diagnosed with ulcerative colitis. What are the 5 potential management options for this patient?

Answer 21

Steroids

5 ASA

Immune suppressants (e.g. Azathioprine, Methotreaxate)

Biologic therapy

Others –diet, FMT, antibiotics, probiotics, novel agents

Question 22

Give 2 examples of immune suprpesants used in treatment of ulcerative colitis?

Answer 22

Azathioprine

Methotreaxate

Question 23

What are the 3 different types of measures of severity of ulcerative coltiis (UC)?

Answer 23

Clinical Disease Activity Index (DIA)

Montreal classification

Trulov & Witt scores

Question 24

List the 4 criteria that suggest UC is mild in severity

Answer 24

4 or less bowel movements a day

No systemic toxicity

Normal ESR/CRP

Mild symptoms

Question 25

List the 4 criteria that suggest UC is moderate in severity

Answer 25

\> 4x BMs/daily Mild anaemia Mild symptoms Minimal systemic toxicity Nutrition maintained and no weight loss.

Question 26

List the 6 criteria that suggest UC is severe in severity

Answer 26

•\> 6 BMs/day Severe symptoms Systemic toxicity Significant anaemia Increased ESR/CRP Weight loss

Question 27

A patient with intially mild ulcerative colitis who was placed on steroids and 5 ASA has returned to hospital as their symptoms have recurred. What is the next step of actions to be taken?

Answer 27

Repeat blood tests to establish severity Manage with steroid (prednisolone) to establish remission acutely Educate on side effects Prepare for next method of treatment: Immuno-modulators e.g. Azathioprine and blood tests in preparation

Question 28

List 10 blood tests that should be ordered before deciding to place a person on immuno-suppresants such as azithioprine in treatment of ulcerative colitis.

Answer 28

FBC, LFT (Can cause liver damage) Renal profile (Meds can cause kidney damage) CRP **TPMT** (Enzyme which helps to break down azithioprine. Low levels may increase risk of side effects so may choose a diffrent medication instead) Hep B/C/ HIV (Azithioprine incraeses risk of re-infection) Chicken pox Vaccinations Tuberculosis N.B. Reasons CP, TB, Hep ect are ordered is because the medication is immuno-suppresant)

Question 29

Name the enzyme responsible for breaking down immuno-modulators such as azithioprine.

Answer 29

TPMT (thiopurine methyltransferase)

Question 30

Patient with ulcerative colitis on azithioprine has returned to hospital with the following findings: What is the management plan for this patient?

Answer 30

Rule out infection and c.diff Order imaging to rule out complications (e.g. toxic megacolon) If no infection, detected, put on IV steroids If steroids ineffective, give infliximab (a biologic) alongside azithioprine and educate on side effects

Question 31

List 8 potential serious side effects of biologics

Answer 31