infectious/drug-induced esophagitis/C Diff Flashcards
Infectious esophagitis
general
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
Candida esophagitis
general
Seen in pts with
Common in patients with uncontrolled diabetes, those on swallowed or inhaled steroids or on systemic antibiotics, HIV patient with CD4 count < 100 cells/mcL
Candida esophagitis
S/Sx
Odynophagia
Dysphagia
Substernal chest pain
Signs of oral thrush (2/3 of patients)
Candida esophagitis
Dx
Endoscopy for direct visualization and culture
Performed if there is no improvement with empiric treatment for 5-7 days
Candida esophagitis
Tx
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
Herpes simplex virus esophagitis & Cytomegalovirus esophagitis
RF
AIDS patients
Patient on immunosuppressive therapy or chemotherapy
Transplant patients
Herpes simplex virus esophagitis & Cytomegalovirus esophagitis
S/Sx
Odynophagia (more severe with CMV)
Dysphagia
Retrosternal chest pain
+/- fever
Herpes simplex virus esophagitis
Dx
Endoscopy with cytology or biopsy
HSV: vesicular lesions (early); punched-out ulcerations
Cytomegalovirus esophagitis
Dx
Endoscopy with cytology or biopsy
CMV: linear or longitudinal deep ulcerations
Herpes simplex virus esophagitis
Tx with dosage
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
Cytomegalovirus esophagitis
Tx
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
Herpes simplex virus esophagitis & Cytomegalovirus esophagitis
Tx If positive for HIV/AIDS
Antiretroviral therapy
Drug-induced Esophagitis
general and mechanisms
Medications can cause injury to the esophagus
Mechanisms:
Direct, prolonged mucosal contact
Disruption of mucosal integrity (irritation, erosions, and ulcerations)
Drug-induced Esophagitis
Most common medications:
Anti-inflammatory - NSAIDs, Aspirin
Antibiotics – tetracycline, doxycycline, clindamycin
Bisphosphonates
Potassium chloride
Iron supplements
Ascorbic acid
Drug-induced Esophagitis
RF
Elderly patients
Position of the patient (supine > upright)
Size of the medication (delayed transit with large tablets)
Amount of fluid ingested with medication
Drug-induced Esophagitis
S/Sx
Heartburn
Retrosternal chest pain
Odynophagia
Dysphagia
Drug-induced esophagitis
Endoscopy
Discrete punched-out ulcer(s) with normal bordering mucosa – acute
Esophagitis with strictures, hemorrhage, or perforation – chronic or recurrent
Drug-induced esophagitis
Treatment for acute presentation
Remove the offending agent and use an H2 blocker or a PPI to promote healing
Drug-induced esophagitis
Prevention
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
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
D. Lower esophageal sphincter incompetence
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. Difficulty swallowing
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
C. Every 3 to 5 years
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
B. Distended abdomen
indication of full impaction
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
B. Endoscopy with dilation
Pseudomembranous colitis
general
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%
Clostridium difficile
general about bacteria
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
C diff
RF
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
C diff
patho
~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
c diff
Enterotoxin A:
Targets brush-border enzymes → altered fluid secretion (watery diarrhea)
c diff
Cytotoxin B:
(10x more potent):
Disrupts the cytoskeleton of enterocytes leading to apoptosis (pseudomembranous colitis)
c diff
Non-fulminant colitis
clin man
Foul-smelling, watery diarrhea
Rarely bloody
Cramping abdominal pain
Fever
Nausea and vomiting (rare)
mild form, most cases
c diff
Fulminant colitis
clin man
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
c diff
Toxic megacolon
Large bowel dilatation >7 cm; cecum >12 cm
c diff
C diff
Dx
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
c diff
CMP/CBC
Electrolyte???
Leukocytosis (often > 20,000/μL)
Significant bandemia with fulminant colitis
Hypokalemia (due to diarrhea)
c diff
imaging/Dx
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
c diff
toxic megacolon
c diff
Non pharm Tx
Intravenous fluid resuscitation
Electrolyte correction
Discontinuation of the offending antibiotic if possible
c diff
pharm Tx for non-fulminant
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)
c diff
recurrences
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
C diff
Prevention of Hospital Transmission
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
