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Phase 1b - Gastroenterology > Group Teaching - Gastrointestinal infections > Flashcards

Group Teaching - Gastrointestinal infections Flashcards

1
Q

Case 1

  • 78F Nursing home resident
  • Day 4 post emergency open left inguinal hernia repair for small bowel obstruction
  • PMHx
    • CVA 2003 with residual left sided weakness
    • HTN
    • AF
    • T2DM
    • Recurrent UTIs
  • DHx
    • Apixaban
    • Metformin
    • Gliclazide
    • Ramipril
    • Nitrofurantoin
  • SHx
    • Ex-smoker
    • No EtOH
    • Mobilises with a stick
  • Ward round review:
    • 6x watery diarrhoea overnight, mild abdominal pain
    • Observations: T 37Co, 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
  • Investigations:
    • Urine – leucocytes 1+
    • WCC 16.4, Hb 12.1
    • K+, Mg2+ & Phosphate - normal, Creat 170
    • INR & APTR Normal
    • LFTs Normal, Albumin 16
    • CRP 98

Describe the current examination and the investigations.

A
  • Day 4 post surgery, on antibiotics, with new onset diarrhoea, generalised tenderness.
  • Investigations show:
    • Increased WCC & CRP indicating an inflammatory/infective process
    • Also has an acute kidney injury indicating dehydration
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2
Q

Case 1

  • 78F Nursing home resident
  • Day 4 post emergency open left inguinal hernia repair for small bowel obstruction
  • PMHx
    • CVA 2003 with residual left sided weakness
    • HTN
    • AF
    • T2DM
    • Recurrent UTIs
  • DHx
    • Apixaban
    • Metformin
    • Gliclazide
    • Ramipril
    • Nitrofurantoin
  • SHx
    • Ex-smoker
    • No EtOH
    • Mobilises with a stick
  • Ward round review:
    • 6x watery diarrhoea overnight, mild abdominal pain
    • Observations: T 37Co, 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
  • Investigations:
    • Urine – leucocytes 1+
    • WCC 16.4, Hb 12.1
    • K+, Mg2+ & Phosphate - normal, Creat 170
    • INR & APTR Normal
    • LFTs Normal, Albumin 16
    • CRP 98

Formulate a differential diagnosis.

A
  • 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
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3
Q

Case 1

  • 78F Nursing home resident
  • Day 4 post emergency open left inguinal hernia repair for small bowel obstruction
  • PMHx
    • CVA 2003 with residual left sided weakness
    • HTN
    • AF
    • T2DM
    • Recurrent UTIs
  • DHx
    • Apixaban
    • Metformin
    • Gliclazide
    • Ramipril
    • Nitrofurantoin
  • SHx
    • Ex-smoker
    • No EtOH
    • Mobilises with a stick
  • Ward round review:
    • 6x watery diarrhoea overnight, mild abdominal pain
    • Observations: T 37Co, 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
  • Investigations:
    • Urine – leucocytes 1+
    • WCC 16.4, Hb 12.1
    • K+, Mg2+ & Phosphate - normal, Creat 170
    • INR & APTR Normal
    • LFTs Normal, Albumin 16
    • CRP 98

What investigations would you order next and why?

A
  • Stool sample for C. difficile toxin
  • Stool culture
  • Imaging (AXR, CT)
  • Endoscopy
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4
Q

Case 1

  • 78F Nursing home resident
  • Day 4 post emergency open left inguinal hernia repair for small bowel obstruction
  • PMHx
    • CVA 2003 with residual left sided weakness
    • HTN
    • AF
    • T2DM
    • Recurrent UTIs
  • DHx
    • Apixaban
    • Metformin
    • Gliclazide
    • Ramipril
    • Nitrofurantoin
  • SHx
    • Ex-smoker
    • No EtOH
    • Mobilises with a stick
  • Ward round review:
    • 6x watery diarrhoea overnight, mild abdominal pain
    • Observations: T 37Co, 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
  • Investigations:
    • Urine – leucocytes 1+
    • WCC 16.4, Hb 12.1
    • K+, Mg2+ & Phosphate - normal, Creat 170
    • INR & APTR Normal
    • LFTs Normal, Albumin 16
    • CRP 98

Further investigations show:
* Stool sample for C. difficile toxin: Positive
* Stool culture: No other cultures grown
* Imaging (AXR, CT): AXR attached
* Endoscopy: Not ordered yet

How would you manage this case?

A
  • Infection control
    • The patient is moved into a side room
  • Discontinue inciting antibiotic agents
    • Co-amoxiclav is stopped
  • Management of fluids, nutrition & diarrhoea

Management:
* Severity of C. Diff. Infection:
* Non-severe infection
* WCC < 15, Creat < 150
* Severe infection
* WCC > 15, Creat > 150
* Fulminant colitis
* Hypotension or shock, ileus, toxic megacolon
* 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

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5
Q

Case 1

  • 78F Nursing home resident
  • Day 4 post emergency open left inguinal hernia repair for small bowel obstruction
  • PMHx
    • CVA 2003 with residual left sided weakness
    • HTN
    • AF
    • T2DM
    • Recurrent UTIs
  • DHx
    • Apixaban
    • Metformin
    • Gliclazide
    • Ramipril
    • Nitrofurantoin
  • SHx
    • Ex-smoker
    • No EtOH
    • Mobilises with a stick
  • Ward round review:
    • 6x watery diarrhoea overnight, mild abdominal pain
    • Observations: T 37Co, 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
  • Investigations:
    • Urine – leucocytes 1+
    • WCC 16.4, Hb 12.1
    • K+, Mg2+ & Phosphate - normal, Creat 170
    • INR & APTR Normal
    • LFTs Normal, Albumin 16
    • CRP 98

Further investigations show:
* Stool sample for C. difficile toxin: Positive
* Stool culture: No other cultures grown
* Imaging (AXR, CT): AXR attached
* Endoscopy: Not ordered yet

Initial management:
* The patient is started on oral vancomycin and is closely monitored
* Ongoing diarrhoea 10x a day
* 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 37Co

Current investigations:
* WCC 24.7
* Hb 11.4
* K+ 3.1
* Creat 263
* Alb 12
* CRP 304

What is the most likely diagnosis?
* Toxic megacolon
* Small bowel obstruction
* Large bowel obstruction
* Ileus

A

Fulminant colitis with toxic megacolon

Management:
* 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
* Indications for surgery
* 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

Pseudomembranous colitis
* 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

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6
Q

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 36.9Co
  • Investigations
    • Hb 120
    • WCC 12
    • Neut 7
    • Platelets 400
    • Ur 5, Cr 70
    • CRP 50
    • LFTs – Normal
    • Coagulation- Normal

Describe the current examination and the investigations.

A
  • 26F presenting with a long history of loose motions & PR bleeding who is clinically stable
  • Blood tests showing increased WCC & CRP indicating an inflammatory / infective process with no complications.
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7
Q

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 36.9Co
  • Investigations
    • Hb 120
    • WCC 12
    • Neut 7
    • Platelets 400
    • Ur 5, Cr 70
    • CRP 50
    • LFTs – Normal
    • Coagulation- Normal

Formulate a differential diagnosis.

A
  • 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
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8
Q

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 36.9Co
  • Investigations
    • Hb 120
    • WCC 12
    • Neut 7
    • Platelets 400
    • Ur 5, Cr 70
    • CRP 50
    • LFTs – Normal
    • Coagulation- Normal

What investigations would you order next?

A
  • Stool sample for C. difficile toxin
  • Stool culture
  • Imaging (AXR, CT)
  • Endoscopy
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9
Q

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 36.9Co
  • Investigations:
    • Hb 120
    • WCC 12
    • Neut 7
    • Platelets 400
    • Ur 5, Cr 70
    • CRP 50
    • LFTs – Normal
    • Coagulation- Normal
  • Further investigations:
    • Stool sample for C. difficile toxin: Negative
    • Stool culture: No other cultures grown
    • Imaging (AXR, CT): AXR Normal
    • Endoscopy
      • Colonoscopy (See findings):
        • Reported as continuous left sided inflammatory changes
        • Histology confirms chronic inflammation with no granulomas

What is the most likely diagnosis?
* Toxic megacolon
* Ulcerative colitis
* Large bowel obstruction
* Pseudomembranous colitis
* Crohn’s disease

A

Ulcerative colitis

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10
Q

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 36.9Co
  • Investigations:
    • Hb 120
    • WCC 12
    • Neut 7
    • Platelets 400
    • Ur 5, Cr 70
    • CRP 50
    • LFTs – Normal
    • Coagulation- Normal
  • Further investigations:
    • Stool sample for C. difficile toxin: Negative
    • Stool culture: No other cultures grown
    • Imaging (AXR, CT): AXR Normal
    • Endoscopy
      • Colonoscopy (See findings):
        • Reported as continuous left sided inflammatory changes
        • Histology confirms chronic inflammation with no granulomas

Leading Diagnosis: Ulcerative colitis

What would you do next?

A

Repeat bloods including FBC, LFT, Renal profile and CRP
* TPMT
* Hep B/C/ HIV
* Chicken pox
* Vaccinations
* Tuberculosis

Establish UC severity:
* Different scopes including clinical disease activity index, Montreal classification and Trulov & Witt scores.
* 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.

Manage with steroid to establish remission acutely - Commence on prednisolone
Educate on side effects.
Prepare for next method of treatment
Immuno-modulators e.g. Azathioprine
Blood tests in preparation.

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11
Q

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 36.9Co
  • Investigations:
    • Hb 120
    • WCC 12
    • Neut 7
    • Platelets 400
    • Ur 5, Cr 70
    • CRP 50
    • LFTs – Normal
    • Coagulation- Normal
  • Further investigations:
    • Stool sample for C. difficile toxin: Negative
    • Stool culture: No other cultures grown
    • Imaging (AXR, CT): AXR Normal
    • Endoscopy
      • Colonoscopy (See findings):
        • Reported as continuous left sided inflammatory changes
        • Histology confirms chronic inflammation with no granulomas

Leading Diagnosis: Ulcerative colitis

Management:
* Started on 5 ASA 1g suppository
* Improved temporarily
* Symptoms recurred
* Treated with PR + PO combination
* Currently flaring again (BO x8 blood/ mucus ++)
* On Azathioprine following steroids
* In clinical remission for 6/12
* Currently unwell again:
* Diarrhoea x12/day. Blood ++
* Anaemic
* Tachycardic
* Low grade temperature

What would you do next?

A
  • Rule out infection and C Diff.
  • Imaging to rule out complications
  • Surgical consult early on
  • IV steroids x 3 days
    • No response.
  • Commence on Infliximab while continuing Azathioprine
    • Educated on side effects

Excellent response:
* Remission achieved
* Follow up colonoscopy showed mucosal healing
* Maintained on combination therapy

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Phase 1b - Gastroenterology (13 decks)

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