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CMT-dos > infectious/drug-induced esophagitis/C Diff > Flashcards

infectious/drug-induced esophagitis/C Diff Flashcards

1
Q

Infectious esophagitis

general

A

Occurs primarily in patients with impaired host defenses
AIDS
Solid organ transplantation
Alcohol use
Diabetes
Cancer
Poor nutrition
Esophageal motility disorders

Primary agents of infection:
Candida albicans
Herpes simplex virus
Cytomegalovirus

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2
Q

Candida esophagitis

general
Seen in pts with

A

Common in patients with uncontrolled diabetes, those on swallowed or inhaled steroids or on systemic antibiotics, HIV patient with CD4 count < 100 cells/mcL

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3
Q

Candida esophagitis

S/Sx

A

Odynophagia
Dysphagia
Substernal chest pain
Signs of oral thrush (2/3 of patients)

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4
Q

Candida esophagitis

Dx

A

Endoscopy for direct visualization and culture
Performed if there is no improvement with empiric treatment for 5-7 days

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5
Q

Candida esophagitis

Tx

A

Fluconazole 200-400 mg PO daily for 14-21 days
Fluconazole 200-400 mg IV daily for 14-21 days

IV if they cant take meds by mouth

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6
Q

Herpes simplex virus esophagitis & Cytomegalovirus esophagitis

RF

A

AIDS patients
Patient on immunosuppressive therapy or chemotherapy
Transplant patients

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7
Q

Herpes simplex virus esophagitis & Cytomegalovirus esophagitis

S/Sx

A

Odynophagia (more severe with CMV)
Dysphagia
Retrosternal chest pain
+/- fever

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8
Q

Herpes simplex virus esophagitis

Dx

A

Endoscopy with cytology or biopsy

HSV: vesicular lesions (early); punched-out ulcerations

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9
Q

Cytomegalovirus esophagitis

Dx

A

Endoscopy with cytology or biopsy

CMV: linear or longitudinal deep ulcerations

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10
Q

Herpes simplex virus esophagitis

Tx with dosage

A

HSV
acyclovir 5 mg/kg IV every 8 hours for 7-14 days
acyclovir 400 mg PO 5 times daily for 7-14 days
valacyclovir 1 g PO 3 times daily for 7-14 days

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11
Q

Cytomegalovirus esophagitis

Tx

A

CMV
ganciclovir 5 mg/kg IV every 12 hours for 14-21 days with maintenance at 5 mg/kg IV once daily for immunocompromised patients

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12
Q

Herpes simplex virus esophagitis & Cytomegalovirus esophagitis

Tx If positive for HIV/AIDS

A

Antiretroviral therapy

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13
Q
A
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14
Q

Drug-induced Esophagitis

general and mechanisms

A

Medications can cause injury to the esophagus
Mechanisms:
Direct, prolonged mucosal contact
Disruption of mucosal integrity (irritation, erosions, and ulcerations)

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15
Q

Drug-induced Esophagitis

Most common medications:

A

Anti-inflammatory - NSAIDs, Aspirin
Antibiotics – tetracycline, doxycycline, clindamycin
Bisphosphonates
Potassium chloride
Iron supplements
Ascorbic acid

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16
Q

Drug-induced Esophagitis

RF

A

Elderly patients
Position of the patient (supine > upright)
Size of the medication (delayed transit with large tablets)
Amount of fluid ingested with medication

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17
Q

Drug-induced Esophagitis

S/Sx

A

Heartburn
Retrosternal chest pain
Odynophagia
Dysphagia

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18
Q

Drug-induced esophagitis

Endoscopy

A

Discrete punched-out ulcer(s) with normal bordering mucosa – acute
Esophagitis with strictures, hemorrhage, or perforation – chronic or recurrent

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19
Q

Drug-induced esophagitis

Treatment for acute presentation

A

Remove the offending agent and use an H2 blocker or a PPI to promote healing

20
Q

Drug-induced esophagitis

Prevention

A

Take pills with a minimum of 4 oz. of water
Remain upright for 30 minutes after ingestion
Avoid known offending agents in patients with esophageal dysmotility, dysphagia, and/or strictures

21
Q

A diagnosis of gastroesophageal reflux disease implies that a patient has which of the following functional abnormalities?

A. Compression of the esophagus from a double aortic arch
B. Cricopharyngeal incoordination
C. Denervation of esophageal muscle
D. Lower esophageal sphincter incompetence

A

D. Lower esophageal sphincter incompetence

22
Q

Dysphagia is best defined as

A. Difficulty swallowing
B. A feeling of a lump in the throat → globus sensation
C. An aversion to food or eating
D. A blockage in the pharynx

A

A. Difficulty swallowing

23
Q

In patients with nondysplastic Barrett esophagus due to gastroesophageal reflux disease, which of the following is the recommended interval to monitor for malignant transformation?

A. Every 4 to 6 months
B. Every 1 to 2 years
C. Every 3 to 5 years
D. Every 5 to 7 years

A

C. Every 3 to 5 years

24
Q

When associated with nausea and vomiting, which of the following raises suspicion of a more serious etiology of chronic constipation?

A. Occasional bouts of diarrhea
B. Distended abdomen
C. Change in color of stool
D. Early satiety

A

B. Distended abdomen
indication of full impaction

25
Q

A 30-year-old man is evaluated for ongoing symptoms of dysphagia. He was previously diagnosed with eosinophilic esophagitis on upper endoscopy and has completed an 8-week course of swallowed aerosolized fluticasone, which did not alleviate his symptoms. He takes no other medications.
On physical examination, vital signs are normal; BMI is 25. Other findings, including those of an abdominal examination, are unremarkable.
Upper endoscopy shows an area of high-grade constriction in the distal esophagus.
Which of the following is the most appropriate treatment?

A. Increase fluticasone
B. Endoscopy with dilation
C. Omeprazole
D. Oral prednisone

A

B. Endoscopy with dilation

26
Q

Pseudomembranous colitis

general

A

Pseudomembranous colitis

C diff

Inflammation of colonic mucosa caused by the toxins released bythe bacterium Clostridioides difficile, previously known as Clostridiumdifficile

Majority of cases are hospital acquired
Community-acquired cases are increasing – 40%

27
Q

Clostridium difficile

general about bacteria

A

Gram-positive, obligate anaerobe
Exist in 2 forms:
Spore form: outside the colon; resistant to heat, acid, and antibiotics
Vegetative form: in the intestine
Highly contagious
Spores transmitted via fecal-oral route

28
Q

C diff

RF

A

Recent antibiotic treatment
Clindamycin
Cephalosporins (3rd and 4th generation)- cefepime, cefdinir, ceftriaxone
Fluoroquinolones- ciprofloxacin and levofloxacin
Ampicillin
Amoxicillin

Prior episodes of C. difficile
Advanced age > 65
Hospitalization
Nursing home resident
Severe medical comorbidities
Use of proton-pump inhibitors & H2 blockers (gastric-acid suppression)
Chemotherapy

29
Q
A
30
Q

C diff

patho

A

~5% of healthy adults are colonized
8%–10% of hospitalized adults are colonized
Disruption of the normal flora using antibiotics leads to the overgrowth ofC. difficile
Intestinal damage is due totoxinrelease

31
Q

c diff

Enterotoxin A:

A

Targets brush-border enzymes → altered fluid secretion (watery diarrhea)

32
Q

c diff

Cytotoxin B:

A

(10x more potent):
Disrupts the cytoskeleton of enterocytes leading to apoptosis (pseudomembranous colitis)

33
Q

c diff

Non-fulminant colitis
clin man

A

Foul-smelling, watery diarrhea
Rarely bloody
Cramping abdominal pain
Fever
Nausea and vomiting (rare)

mild form, most cases

34
Q

c diff

Fulminant colitis
clin man

A

Significant systemic toxic effects
Acute abdominal pain with distention

Signs of sepsis:
Hypotension
Tachycardia
Change in mental status

Toxic megacolon
Colonic perforation, ischemia, and necrosis

35
Q

c diff

Toxic megacolon

A

Large bowel dilatation >7 cm; cecum >12 cm

36
Q

c diff

A
37
Q

C diff

Dx

A

Suspect C. difficile in any patient who has developed diarrhea within 2 months of antibiotic use or 72-hours of hospital admission

Stool studies:
Testing should only be done on symptomatic patients

Enzyme immunoassay (EIA) forC. difficileantigen- first
* Glutamate dehydrogenase (GDH) antigen
* Rapid test that is widely available
+ results confirms presence of the organism, but not if it is toxigenic

  • EIA forC. difficiletoxins A and B
  • Nucleic acid amplification test using polymerase chain reaction (PCR) forC. difficiletoxin genes

Can remain + after successful treatment

38
Q

c diff

CMP/CBC
Electrolyte???

A

Leukocytosis (often > 20,000/μL)
Significant bandemia with fulminant colitis

Hypokalemia (due to diarrhea)

39
Q

c diff

imaging/Dx

A

Abdominal X-ray:
Can show colonic dilatation
Free air in case of perforation

Computed tomography (CT) scan:
Can detect colitis, ileus, or toxic megacolon
Can reveal complications such as perforation

NO- colonoscopy due to risk of rupture

40
Q

c diff

A

toxic megacolon

41
Q

c diff

Non pharm Tx

A

Intravenous fluid resuscitation
Electrolyte correction
Discontinuation of the offending antibiotic if possible

42
Q

c diff

pharm Tx for non-fulminant

A

vancomycin
First-line therapy
125-500 mg PO every 6 hours x 10 days
Can be given by enema in cases of ileus
NO IV VANCO- does not absorb into GI

fidaxomicin
Alternative option
200 mg PO every 12 hours for 10 days
Decreases the risk of recurrence

Severe disease: add IV metronidazole (if worsening)

43
Q

c diff

recurrences

A

15-20% of patients
Within a few weeks of stopping therapy
First recurrence, treat with the same regimen as the primary episode

Multiple recurrences
Oral vancomycin or oral fidaxomicin to be dosed by infectious disease
Fecal microbiota transplantation (FMT)
Donor feces is introduced via nasal-duodenal tube, enema, or colonoscopy (200-300 ml)
Resolution as the result of restoring normal fecal microbiota

use whatever you used for first occurance for the recurrance

44
Q
A
45
Q

C diff

Prevention of Hospital Transmission

A

Use of gloves

Isolation of the patient with designated bathroom facilities

Use of hypochlorite (bleach) solution to decontaminate the rooms of patients

Hand washing with soap (alcohol-containing hand gels are not sporicidal)

Restricting the use of specific antibiotics:
Clindamycin
3rd and 4th-generation cephalosporins

46
Q
A

CMT-dos (95 decks)

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