GI Infections Tutorial Flashcards
Case 1 - 78F
Nursing home resident Day 4 post emergency open left inguinal hernia repair for small bowel obstruction PMH = T2DM, recurrent UTIs Ex-smoker Mobilises w/ stick
Ward round =
6x watery diarrhoea overnight, mild abdominal pain
Observations: T 376, HR 89, BP 108/72, Sats 96% on air
Moderate abdominal distension, mild generalised tenderness on palpation
Dry oral mucosa, reduced skin turgor
On co-amoxiclav day 4
What investigations would be done next?
Urine WCC K+, Mg+, phosphate Creatinine INR and APTR LFTs Albumin CRP
Investigations revealed:
Urine – leucocytes 1+ WCC 16.4, Hb 12.1 K+, Mg+ & Phosphate - normal, Creat 170 INR & APTR Normal LFTs Normal, Albumin 16 CRP 98
What are some potential differential diagnoses to explain her current onset of diarrhoea and generalised tenderness?
Infectious Diarrhoea = Clostridium difficile Klebsiella oxytoca Clostridium perfringens Salmonella spp
Non-infectious diarrhoea = Antibiotics side effect Post-infectious irritable bowel syndrome Inflammatory bowel disease Microscopic colitis Ischaemic colitis Coeliac disease
What does oral mucosa and reduced skin turgor suggest?
Dehydration
What is the management for a C. Diff infection?
Infection control
The patient is moved into a side room
Discontinue inciting antibiotic agents
Co-amoxiclav is stopped
Management of fluids, nutrition & diarrhoea
How do you distinguish severe and non severe C. diff. infection?
Non-severe infection
WCC<15, Creat <150
Severe infection
WCC>15, Creat >150
What is fulminant colitis?
How does it present clinically?
Most severe manifestation of colitis/ c diff
Hypotension or shock, ileus, toxic megacolon
What is the management for non-severe c diff?
Antibiotic therapy with oral vancomycin or fidaxomicin or metronidazole
Role of Faecal Microbiota Transplantation (FMT)
What is the management to severe c diff or fulminant colitis?
Antibiotic therapy, supportive care and close monitoring
Early surgical consultation
On day 7, nurses note a streak of blood in the stool
On examination:
Generalised abdominal tenderness, worsening distension
HR 135, BP 95/64, T 379
Investigations show: WCC 24.7 Hb 11.4 K+ 3.1 Creat 263 Alb 12 CRP 304
What are the management options?
Medical therapy = antibiotics, IV fluid resuscitation & inotropic support
Supportive management
Surgical interventions
What is 1st line treatment for fulminant colitis with toxic megacolon?
Medical therapy with antibiotics and supportive management
Transfer to ICSU
What is done in ICU for fulminant colitis with toxic megacolon?
IV fluid resuscitation & inotropic support
What are the indications for surgery for a patient with fulminant collitis?
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
What is Pseudomembranous colitis and what are its main features?
Most often associated with C. difficile infection
Manifestation of severe colonic disease
Characteristic yellow-white plaques that form pseudomembranes on the mucosa
Confirmed on endoscopy +/- biopsy
Case 2 - 26F, otherwise healthy 3 months history of diarrhoea (4x / day) with rectal bleeding Associated urgency and mucous secretion PMH = nil SH = ex-smoker, stopped 9 months ago No recent travel
Examination shows: soft abdomen, tenderness in left iliac fossa
H2 = 80, BP = 115/70, Temp = 36.9
What investigations would be done next?
Hb WCC Neut Platelets Urea, Creatinine CRP LFTs Coagulation
Investigations reveal: Hb 120 WCC 12 Neut 7 Platlets 400. Ur 5, Cr 70 CRP 50 LFTs – Normal Coagulation- Normal
What are the differential diagnoses for bloody diarrhoea?
Infectious = Clostridium difficile Shigella E. Coli Salmonella spp
Non-infectious = Inflammatory bowel disease Haemorrhoids Post-infectious irritable bowel syndrome Microscopic colitis Ischaemic colitis Coeliac disease
