GI Infections Flashcards
78F day 4 post op. Left inguinal hernia repair for small bowel obstruction
6x watery diarrhoea overnight, mild abdominal pain
Moderate abdominal distension, mild generalised tenderness on palpation
Dry oral mucosa, reduced skin turgor
Co-amoxiclav day 4
Leukocytes 1+
WCC 16.4
Creatine 170
INR and APTR normal
LFTs normal, albumin 16
CRP 98
Describe the current examination, the investigations and formulate a differential diagnosis
High WCC, creatinine, albumin and CRP, abdominal distension
Differentials:
Infectious diarrhoea
•Clostridium difficile - high WCC, on antibiotics, in hospital setting, older people on co-amoxiclav higher risk
•Klebsiella oxytoca
•Clostridium perfringens
•Salmonella spp
Non-infectious diarrhoea
• Antibiotics side effect
• Post-infectious irritable bowel syndrome
• Inflammatory bowel disease - acute so unlikely
• Microscopic colitis
• Ischaemic colitis
• Coeliac disease
78F day 4 post op. Left inguinal hernia repair for small bowel obstruction
6x watery diarrhoea overnight, mild abdominal pain
Moderate abdominal distension, mild generalised tenderness on palpation
Dry oral mucosa, reduced skin turgor
Co-amoxiclav day 4
Leukocytes 1+
WCC 16.4
Creatine 170
INR and APTR normal
LFTs normal, albumin 16
CRP 98
What investigations would you order next and why?
Investigations for GI infections
1. Stool sample (also C. diff.) - for infectious diarrhoea
2. Imaging (AXR, CT) -
3. Endoscopy - IBD, coeliac, colitis
78F day 4 post op. Left inguinal hernia repair for small bowel obstruction
6x watery diarrhoea overnight, mild abdominal pain
Moderate abdominal distension, mild generalised tenderness on palpation
Dry oral mucosa, reduced skin turgor
Co-amoxiclav day 4
Leukocytes 1+
WCC 16.4
Creatine 170
INR and APTR normal
LFTs normal, albumin 16
CRP 98
positive for C.diff and no other cultures
AXR shows thickened mucosal folds - thumb printing (characteristic of inflammation)
How would you manage this case?
Infection control - isolation
Discontinue antibiotic use (co-amoxiclav disturbs commensal flora) - use vicromicin instead
Management of fluids and nutrition
Potential for faecal transplant
78F day 4 post op. Left inguinal hernia repair for small bowel obstruction
6x watery diarrhoea overnight, mild abdominal pain
Moderate abdominal distension, mild generalised tenderness on palpation
Dry oral mucosa, reduced skin turgor
Co-amoxiclav day 4
Leukocytes 1+
WCC 16.4
Creatine 170
INR and APTR normal
LFTs normal, albumin 16
CRP 98
Confirmed C.diff
AXR - enlarged transverse colon - 10cm
What is the most likely diagnosis?
Fulminant colitis with Toxic megacolon
Case 2
•26F, otherwise healthy.
•3 months history of diarrhoea (4x / day) with rectal bleeding.
•Associated urgency and mucous secretion.
PMHx
•Nil, no medications of note.
SHx
•Ex-smoker, stopped 9 months ago.
•No recent travel.
On examination
•Abdomen soft with minimal tenderness in left iliac fossa.
•HR 80, BP 115/70, Temp 36.9.
Investigations
•Hb 120
•WCC 12
•Neut 7
•Platelets 400.
•Ur 5, Cr 70
•CRP 50
•LFTs – Normal
•Coagulation- Normal
Describe the current examination, the investigations and formulate a differential diagnoses?
Differential diagnoses:
IBD - UC and Crohns
UC more likely as left sided and rectal bleeding
Coeliac - young people with diarrhoea however rectal bleeding suggests otherwise
Infectious - C.diff, shigella, E.coli however unlikely due to duration and no travel
Haemorrhoids
Ischaemic colitis - unlikely due to age
Case 2
•26F, otherwise healthy.
•3 months history of diarrhoea (4x / day) with rectal bleeding.
•Associated urgency and mucous secretion.
PMHx
•Nil, no medications of note.
SHx
•Ex-smoker, stopped 9 months ago.
•No recent travel.
On examination
•Abdomen soft with minimal tenderness in left iliac fossa.
•HR 80, BP 115/70, Temp 36.9.
Investigations
•Hb 120
•WCC 12
•Neut 7
•Platelets 400.
•Ur 5, Cr 70
•CRP 50
•LFTs – Normal
•Coagulation- Normal
What investigations would you do next and why?
Stool sample - foecel calprotectin, C.diff. FIT
Flexi-sig
DRE abdominal film
Not CT due to age
What is the management plan for fulminant colitis with toxic megacolon?
Medical therapy with antibiotics and supportive management
In a patient with fulminant colitis with toxic megacolon, what are the indications for surgery?
Colonic perforation
Necrosis or full-thickness ischaemia
Intra-abdominalhypertensionor abdominal compartment syndrome
• Clinical signs ofperitonitisor worsening abdominal exam despite adequate medical therapy
•End-organfailure
Case 2
•26F, otherwise healthy.
•3 months history of diarrhoea (4x / day) with rectal bleeding.
•Associated urgency and mucous secretion.
PMHx
•Nil, no medications of note.
SHx
•Ex-smoker, stopped 9 months ago.
•No recent travel.
On examination
•Abdomen soft with minimal tenderness in left iliac fossa.
•HR 80, BP 115/70, Temp 36.9.
Investigations
•Hb 120
•WCC 12
•Neut 7
•Platelets 400.
•Ur 5, Cr 70
•CRP 50
•LFTs – Normal
•Coagulation- Normal
C.diff negative, no other cultures, AXR normal,
Flexi-sig shows continuous left sided inflammatory changes, histology shows chronic inflammation with no granuloma
Most likely diagnosis?
Ulcerative colitis
Outline the order of UC treatment
Steroids (prednisolone) induce remission - immunomodulator - biologics - surgery
5ASA maintain remission
Check progression with blood tests
Outline the different categorisations for C.diff
Non-severe infection
• WCC <15, Creat <150
Severe infection
• WCC>15, Creat >150
Fulminant colitis
• Hypotension or shock, ileus, toxic megacolon
What are the signs and symptoms associated with toxic megacolon?
Abdominal pain
Fever
High WCC
Epigastric tenderness
Massively distended transverse colon on X-ray with gas in colon
What is the first line treatment for toxic megacolon?
Medical therapy with antibiotics and supportive management
Fluid rhesus
Inotropic support to increase BP
Define Ileus
Loss of peristalsis without structural obstruction
How does treatment vary between non-severe and severe C.diff?
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
• Better done in ICU/HDU
What is pseudomembranous colitis?
Most often associated withC. difficileinfection
• Manifestation ofsevere colonic disease
• Characteristic yellow-white plaques that form pseudomembranes on the mucosa
• Confirmed on endoscopy +/- biopsy
What is Tenesmus?
A continual or recurrent inclination to evacuate the bowels, caused by disorder of the rectum or other illness
How is ulcerative colitis severity categorised?
Mild
• 4 x BMs/day, no systemic toxicity, normal ESR/CRP, mild symptoms.
Moderate
• > 4x BMs/day, mild anaemia, mild symptoms, minimal systemic toxicity, nutrition maintained and no weight loss.
Severe
• > 6 BMs/day, severe symptoms, systemic toxicity, significant anaemia, increased ESR/CRP and weight loss.
What blood test are done before starting a patient on immunomodulators?
Repeat bloods including FBC, LFT, Renal profile and CRP• TPMT - monitoring• Hep B/C/ HIV• Chicken pox• Tuberculosis- can be reactivated on starting immunosuppressants• Vaccinations
