Infections of the GUT Flashcards
What determines ACUTE diarrhea?
< 14 DAYS (infectious)
What determines PERSISTENT diarrhea?
14-28 DAYS (infetious)
What determines CHRONIC diarrhea?
≥28 DAYS (usualy NON-INFECTIOUS)
Diarrhea that PERSISTS with ASYMPTOMATIC INTERVALS is usually caused by?
C.diff Inection or IBS-D
An INFECTIOUS DIARRHEA that is NON-IVASIVE, WATERY, NON-BLOODY, LARGE-VOLUME, with MID-ABDOMINAL PAIN, with MALABSORPTION is localized to what portion of the GI tract?
SMALL BOWEL
An INFECTIOUS DIARRHEA that is IVASIVE, CAN BE BLOODY, SMALL-VOLUME, with LOWER-ABDOMINAL PAIN, is localized to what portion of the GI tract?
COLON
An INFECTION initially causing NAUSEA and VOMITING, then a WATERY (non-ivasive) or BLOODY (invasive) DIARRHEA?
FOOD POISONING
Which are the FOUR most COMMON INVASIVE (bloody diarrhea) pathogens?
Campylobacter, Shigella, Salmonella, E.coli
Nausea and Vomiting 1-6 HOURS after eating PROTEIN-RICH foods?
Staph aureus
Nausea and Vomiting 3-12 HOURS after eating STARCHY foods (rice)?
Bacilus cereus
When developing Nausea and Vomiting 24-48 HOURS after eating, this is likely caused by?
VIRUSES (norovirus)
Infection with this VIRUS causes NAUSEA and VOMITING for 1-3 DAYS and sheds up to 4 WEEKS (must ISOLATE)?
NOROVIRUS (cruise ship virus)
C.perfringens (meat, poulty, gravy), EnteroToxigenic E.Coli (ETEC) (travelers diarrhea, water), Giardia (stream water, DAYCARE), Cryptosporidium (milk, cheese, produce), Cyclospora (raspberries, basil), Viruses cause what TYPE of diarrhea?
WATERY
BLOODY DIARRHEA 2-5 DAYS after eating MEAT, POULTRY, PRODUCE?
Campylobacter, Salmonella, Shigella
WATERY DIARRHEA that BECOMES BLOODY 1-7 DAYS after eating GROUND BEEF, FRUITS, VEGETABLES, UNPASTEURIZED JUICES, causes HUS (microangiopathic)?
E.coli (shiga-toxin) 0157:H7
BLOODY DIARRHEA after eating UNDERCOOKED PORK or UNPASTEURIZED MILK?
YERSINIA, plesiomonas, aeromonas (LOOKS LIKE CROHN’s - ileocolitis)
BLOODY DIARRHEA after eating RAW FISH?
Vibrio Parahemolyticus
BLOODY DIARRHEA with BULLOUS SKIN RASH after handling FISH?
Vibrio Vulnificus
What infectious BLOODY (invasive) DIARRHEA is associated with DEATH in the immunocompromised or those with chronic liver disease?
Vibrio
How is VIRAL GASTROENTERITIS treated (small bowel, watery diarreha)?
SUPPORTIVE
Does the use of ALCOHOL GELS prevent VIRUS or C.diff transmission?
NO
WATERY DIARRHEA after exposure to FAMILY GATHERINGS, NURSING HOMES, CRUISE SHIPS 24-48 HOURS post exposure with ABRUPT nausea and vomiting, fever and myalgias and lasts < 72 HOURS, contagious for 3 WEEKS?
NOROVIRUS (can be ETEC)
WATERY DIARRHEA, very SEVERE in children, 2 VACCINES exist?
ROTAVIRUS
How is Vibrio Cholera (toxin-producing) watery diarrhea treated?
ORAL REHYDRATION SOLUTION
This watery diarrhea is caused by a TOXIN-PRODUCING bacteria which can be HEAT labile or HEAT tolerant?
ETEC (Entero Toxigenic E.Coli) - food/water fecal-oral route - TRAVELER’s diarrhea
How is TRAVELER’s DIARRHEA (ETEC) treated if it’s MILD, SEVERE or DYSENTERY (bloody)?
MILD: Rifaximin
SEVERE: Cipro or azithromycin
DYSENTERY: azithromycin
What is the best TEST for DIARRHEA caused by PARASITES (large volume, watery?
Stool GIADIA antigen or ACID-FAST test
A patient with LOW IgG (HYPOgammaglobulinemia), with RECURRENT large volume WATERY diarrhea, SINUS INFECTIONS?
Giardia
CRYPTOSPORIDIA (watery diarrhea) is treated HOW?
NITAZOXANIDE (3 DAYS)
SOLID-ORGAN transplant recepients are at RISK for an infection with this ORGANISM that causes watery diarrhea?
STRONGYLOIDES (also those on steroids, HIV, HTLV-1)
POSITIVE SEROLOGY (best for screening) where as serology and stool antigen best for DIAGNOSIS, increased EOSINOPHILS, ELISA, STOOL ANTIGEN in patients on STEROIDS, HIV, HTLV-1 and solid organ transplant recepients?
STRONGYLOIDES
What are the most COMMON bacteria in the COLON that cause INFECTIOUS diarreha?
Campylobacter, Salmonella, Shigella, E.coli
Patient ate UNDERCOOKED (RAW) CHICKEN, developed NAUSEA and VOMITING, WATERY diarrhea that turned BLOODY with ILEOCOLITIS (mimics Crohn’s) and patient develops GUILLAIN-BARRE post infection resolution?
Campylobacter
How are infections (dysentery - bloody diarrhea) with CAMPYLOBACTER treated?
AZITRHOMYCIN, or erythromycin, trtracycline (cipro has resistence)
DYSENTERY (bloody diarrhea) with FEVER and JOINT PAINS after TOUCHING LIZARDS, SNAKES, FROGS, TURTLES and other REPTILES or EATING EGGS, PEANUT BUTTER, SPINACH, SALAMI, MANGOS, CANTALOUPES is usually caused by?
TYPHOID FEVER (SALMONELLA)
Which SALMONELLA cases should be TREATED?
ALL (AZITHROMYCIN or Cipro)
WATERY to BLOODY diarrhea, SHIGELLA - how do you TREAT (highly contagious)?
AZITHROMYCIN or Cipro
Initially WATERY diarrhea, then BLOODY, SEVERE CRAMPS, SEVERE ABDOMINAL PAIN, low grade fever, acts like ischemic colitis. If you TREAT with ANTIBIOTICS, you’ll PRECIPITATE HUS?
SHIGA TOXIN-producing E.Coli (STEC)
If suspecting Shiga Toxin-producing E.COli, what MUST you do?
CULTURE + EIA (ELISA)
and
DO NOT TREAT with ANTIBIOTICS (HUS)
Infection with this causes WATERY to BLOODY diarrhea (SEVERE ABDOMINAL PAIN) can cause HEMOLYTIC ANEMIA, RENAL FAILURE, THROMBOCYTOPENIC PURPURA and if treated with antibiotics, HUS?
Shiga Toxin-producing E.Coli (STEC)
ANTIBIOTICS and ANTIMOTILITY agents (loperamide, immodium) are CONTRAINDICATED for this DYSENTERY-causing bacteria?
Shiga Toxin-producing E.Coli (STEC) - can precipitate HUS
This diarrhea-causing organism presents like CROHN’s, has GRANULOMATOUS APPENDICITIS, causes ILEITIS, MESENTERIC ADENITIS, can be mistaken for SARCOIDOSIS or a FOREIGN BODY and is grown on COLD ENRICHMENT MEDIUM - get it by eating PORK PRODUCTS?
YERSINIA (no treatment needed)
Which diarrhea-causing organisms can cause REACTIVE ARTHRITIS (Reiter’s - can’t see, can’t pee, can’t climb a tree)?
YERSINIA (no treatment needed)
Shigella, Salmonella, Campylobacter (Guillain-Barre)
When HANDLING or EATING RAW SHELLFISH, a patient develops NAUSEA, VOMITING and DIARRHEA and its SELF-LIMITED? What if they developed a BULLOUS-RASH?
No rash: Vibrio Parahemolyticus
RASH: Vibrio Vulnificus
In which patients do you TREAT Vibrio Vulnificus?
Immunocompromised (diabetes as well, achlorhydria) Chronic Liver Disease, Severe Presentation (bullous rash)
Diarrheal illness after eatign ICE CREAM, DELI MEATS, UNPASTEURIZED CHEESE, HOT DOGS, CANTALOUPES (resists cold, salts, acid)?
LISTERIA
WATERY diarrhea with HEADACHE (MENINGITIS) after eating ICE CREAM, DELI MEATS, UNPASTEURIZED CHEESE, HOT DOGS, CANTALOUPES?
LISTERIA
If a patient is found to have diarrhea because of Entamoeba Histolytica (cysts are infectious), what do you do?
ALWAYS TREAT
What is the BEST way to diagnose Entamoeba Histolytica?
Stool Antigen or SEROLOGY
If a patient gets a colonoscopy, where would you SPECIFICALLY biopsy for Entamoeba Histolytica?
ASCENDING colon, ILEUM
An IMMIGRANT or from the TROPICS patient presents with CHRONIC DIARRHEA, COLITIS or DYSENTERY and you find this on colonoscopy?
TRICHURIS (whipworm)
If WATERY DIARRHEA is MODERATE-SEVERE AND there is a TRAVEL HISTORY, how do you TREAT? If NON-TRAVEL?
TRAVEL: ANTIBIOTICS
NON-TRAVEL: TEST FIRST, then ANTIBIOTICS ONLY if FEVER ≥72 HR
If BLOODY DIARRHEA is NO FEVER, what’s the NEXT step?
TEST FIRST then ANTIBIOTICS
If BLOODY DIARRHEA, SEVERE with FEVER, what’s the NEXT step?
TRAVEL: EMPIRIC ANTIBIOTICS (azithromycin)
NO-TRAVEL: TEST FIRST, then ANTIBIOTICS
Which VIRUS causes DISTAL PROCTITIS?
HSV
Which VIRUS causes diarrheal colitis in the immunocompromised (transplant, IBD, chemotherapy?
CMV
In the TROPICS, within 10-30 MINUTES after eating TUNA or MAHI MAHI pt presents with FACIAL RASH and ERYTHEMA, TACHYCARDIA and WHEEZING, a brief DIARRHEA, SEVERE ABDOMINAL PARALYSIS with BLURRED VISION, RESPIRATORY DISTRESS, SWOLLEN TONGUE?
SCROMBOID - treat with ANTIHISTAMINES
SEVERE HISTAMINE REACTION after eating TUNA or MAHI MAHI?
SCROMBOID - treat with antihistamines
Patient ate BARRACUDA, RED SNAPPER, EEL, SEA BASS, MACKEREL and developed N/V/D with MUSCLE PAINS, ABDOMINAL PAIN, DIZZINESS, VERTIGO, RASH and PARALYSIS (can be deadly)?
CIGUATERA toxin poisoning - treat with ANTIHISTAMINES
If suspecting C.diff Infection (CDI), what’s the SCREENING test RECOMMENDED? If POSITIVE?
GDH (glutamate dehydrogenase antigen)
If POSITIVE: PCR or NAAT to confirm toxigenic strain (NAAT can detect non-toxigenic strains too - 3-7% carriers)
ELISA - confirmation
ALL IBD patients who present with a FLARE or POUCHITIS, ALWAYS test for?
C.diff Infection
An IBD patient with C.diff Infection should be treated with WHAT and for HOW LONG?
VANCOMYCIN 125 mg 4x/day PO x 14 DAYS
Should IBD therapy be HELD while treating C.diff Infection?
NO!!
If patient with IBD has C.diff Infection that is RECURRENT, what should be CONSIDERED?
FMT (Fecal Microbiota Transplant)
If NO IBD, FMT after SECOND RECURRENCE (i.e. THIRD episode)
For MILD, MODERATE or SEVERE C.diff Infection (abd pain, WBC ≥15K, Cr >1.5, LOW Alb, fever, high calprotectin) what is the RECOMMENDED treatment?
VANCOMYCIN 125 mg PO 4x/day for 10 DAYS
or
FIDAXOMYCIN 200 mg PO BID for 10 DAYS
FULMINANT C.diff Infection (HYPOtension, SHOCK, ILEUS, MEGACOLON) is treated how?
VANCOMYCIN 500 mg PO 4x/day + METRONIDAZOLE 500 mg IV TID
Use VANCOMYCIN 500 mg ENEMAS 4x/day if ILEUS present
When a C.diff Infection RECURS for the FIRST time, what is recommended for TREATMENT?
A DIFFRRENT regimen that what was initially used
or
PULSED DOSING (Vancomycin 125 mg PO 4x/day for 10 DAYS, then 125 mg PO DAILY every 3 DAYS for an additional 10 DOSES)
When a C.diff Infection RECURS for the SECOND time, what is recommended for TREATMENT?
PULSED DOSING: (Vancomycin 125 mg PO 4x/day for 10 DAYS, then 125 mg PO DAILY every 3 DAYS for an additional 10 DOSES)
or
Vancomycin 125 mg PO 4x/day for 10 DAYS then RIFAXIMIN 400 mg PO TID for 20 DAYS
or
FIDAXOMICIN 200 mg PO BID x 10 DAYS
or
Fecal Microbiota Transplant (FMT) by colonoscopy or capsules or enemas, then REPEAT FMT in 8 WEEKS again
For patients with RECUREENT C.diff Infections who are NOT candidates for FMT or who RELAPSED after FMT, what is RECOMMENDED for PROPHYLAXIS especially when they have to take antibiotic regimens for other infections?
LONG-TERM suppressive VANCOMYCIN prophylaxis
A drug which is an ANTIBODY against the C.diff TOXIN, can be used in patients who are at HIGH-RISK for RECURRENCE?
BEZLOTOXUMAB
Most common cause of DEATH from GI infections in the US?
C.diff Infection (CDI)
Nursing Home outbreak with nausea, vomiting, diarrhea?
NOROVIRUS (hand washing alone will NOT control it)
spreads by fecal-oral, aerosolized
Best ANTIBIOTIC to use in a PREGNANT patient with infectious diarrhea?
AZITHROMYCIN
Traveler’s diarrhea in AFRICA is most likely caused by?
Campylobacter
Watery diarrhea and bloating 4-7 DAYS post eating an affected meal?
Cyclospora (raspberries, fruit plate)
When a patient has bloody diarrhea and fever DOMESTICALLY, what is RECOMMENDED?
STOOL STUDIES, then ANTIBIOTICS
When are STOOL STUDIES recommended DOMESTICALLY for WATERY DIARRHEA?
When FEVER is >101F and diarrhea >72 HOURS
What is RECOMMENDED for TRAVELERS diarrhea whether WATERY or BLOODY?
EMPIRIC ANTIBIOTIC treatment, NO STOOL STUDIES
What is RECOMMENDED for a DOMESTIC patient with WATERY DIARRHEA and LOW-GRADE fever for 2 days?
LOPERAMIDE and REHYDRATION
Best feature on BIOPSY to differentiate IBD from acute colitis?
BRANCHING at the base of the crypts
When should a VANCOMYCIN ENEMA be used to treat C.diff Infection?
ILEUS
When should a patient undergo COLONOSCOPY post DIVERTICULITIS episode?
6-8 WEEKS (to look for malignancy)
NSAIDs, CORTICOSTEROIDS, OPIATES affect DIVERTICULITIS how?
INCREASE the risk of PERFORATION
How is UNCOMPLICATED LEFT sided DIVERTICULITIS treated?
SUPPORTIVE (NO ANTIBIOTICS)
If HAMARTOMATOUS polyps are discovered on colonoscopy what is RECOMMENDED for OVERALL surveillance?
EGD, VIDEO CAPSULE, MRCP (pancreas & bile ducts) NOW and COLONOSCOPY every 2-3 YEARS
How MANY polyps on a colonoscopy are required to make a PEUTZ-JEGHER’s diagnosis?
2 POLYPS
or
If FAMILY HISTORY (in 1st degree relative), ANY POLYPS
WHEN do you survey the SMALL BOWEL (video capsule or MRE), EGD, COLONOSCOPY of a child with family history of PEUTZ-JEGHER’s and thereafter?
Between 8-10 years old IF NO POLYPS, then at age 18, EGD/COLONOSCOPY every 2-3 YEARS otherwise every 2-3 years
For a patient with PEUTZ-JEGHER’s, when do you start ANNUAL MRCP or EUS for surveillance of pancreatic and biliary cancers?
At age 35
When is EUS/FLEX SIG recommended post TRANS-ANAL or ESD resection of a RECTAL CANCER?
3-6 MONTHS (for the first 2-3 YEARS)
When is COLONOSCOPY surveillance after SURGICAL REMOVAL of a COLON CANCER?
1 YEAR, 3 YEARS, 5 YEARS (ongoing)
STUDY of CHOICE when SUSPECTING APPENDICITIS (elevated CRP and WBCs) especially in YOUNG individual?
RLQ ULTRASOUND
Collagenous COLITIS (associated with CELIAC and THYROID disease) can be caused by these meds and when presenting with abdominal pain, diarrhea, STOP the MEDS (if persists, BUDESONIDE)?
NSAIDs, ACE-I
If ≥ 20 (< 10 mm) HYPERPLASTIC POLYPS are found on colonoscopy in the LEFT colon, when do you seuvey again?
10 YEARS (3-5 years if these are >10 mm)
FIRST test to do for DISORDERED DEFECATION?
DRE (Digital Rectal Exam) - then do anorectal manometry and baloon expulsion test, then pelvic floor EMG and MRI defecography
In patients with DISORDERED DEFECATION who have a NORMAL anorectal manometry and baloon expulsion test and do NOT respond to BIOFEEDBACK, what do you TEST next?
COLONIC TRANSIT STUDY
TREATMENT of CHOICE for DISORDERED DEFECATION?
BIOFEEDBACK (anorectal) NOT pelvic floor therapy
In a patient with INTUSSUSCEPTION with pain, distention, what is the RECOMMENDED therapy?
LAPAROSCOPY - 75% of cases are NEOPLASM (reduction is avoided due to perforation and recurrence)
Which INFECTIOUS organism causes intussusception?
YERSINIA
Patient is being treated with an IMMUNE-CHECK inhibitor and develops COLITIS (with or without enteritis) with DIARRHEA >4 STOOLS/DAY , (with or without hepatitis) whats the nex step?
Rule out C.diff or CMV, check CRP, calprotectin, CT scan (if fever, blood, abdominal pain),COLONOSCOPY with BIOPSIES to ASSESS severity of colitis (if mild: mesalamine/budesonide; if severe: IV STEREOIDS + infliximab/vedolizumab)
Patient with ACUTE abdominal PAIN and LGIB, hematochezia with MAROON or BRBPR and clots, no melena, whats the next step?
COLONOSCOPY (after resusscitation and rapid prep)
In a patient with GIB, when SOURCE is not found on ENDOSCOPY, what is the PREFERRED NEXT TEST?
CT ANGIOGRAPHY (not bleeding scan)
Pt develops ILEITIS, with mesenteric adenopathy on CT, has fever, sore throat, PROLONGED DIARRHEA that subsides as well as ERYTHEMA NODOSUM, then develops arthralgias and abdominal pain?
YERSINIA (TMP-SMX) - MIMICS IBD
REACTIVE ARTHRITIS after DIARRHEA
DIARRHEA, ILEITIS, PHARYNGITIS and REACTIVE ARTHITIS?
YERSINIA (TMP-SMX) - mesenteric adenopathy on CT
What constitutes FAMILY HISTORY of COLON CANCER or ADVANCED ADENOMA?
1st degree relative < 60 yo
or 2 1st degree relatives of ANY AGE
if ≥60 yo - AVERAGE SCREENING starting at 40 yo
When should COLORECTAL CANCER SCREENING start for a patient with a FAMILY HISTORY of COLON CANCER or ADVANCED ADENOMA (high-grade dysplasia)?
10 YEARS before the age of diagnosis of the family member or at age 40, whichever EARLIER
What should be done for patients undergoing ELECTIVE/PLANNED (LOW-RISK SCREENING) ENDOSCOPIC procedures while on WARFARIN?
CONTINUE WARFARIN
Is BRIDGING ANTICOAGULATION RECOMMENDED?
NO
BEZLOTUXAMAB is a consideration for patients with RECURRENT C.diff infections (NOT AS A TREATMENT BUT AS PREVENTION) EXCEPT in patients with?
CHF
What is the recommened technique for removal of < 5 mm colon polyp?
COLD SNARE POLYPECTOMY
BEST treatment for hematochezia due to RADIATION PROCTOPATHY (around 3 months after therapy)?
ENDOSCOPY with PULSED APC to DISCRETE AREAS
DO NOT BIOPSY - non-healing ulcers, fistula
What should be FIRST LINE THERAPY for a patient with MEGACOLON or OGILVIE’s or ACUTE COLONIC PSEUDOOBSTRUCTION that is not TOXIC (life threatening)?
NEOSTYGMINE 2 mg IVP
SURGERY if >10-12 cm and prolonged course
