Gi Infectious Disease Week
Transcript of Gi Infectious Disease Week
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INFECTIOUS DISEASWEEK
Foundations of Clinical Practice 201
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Case 1
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!istor"
#A $#"ear#old %an &resents to t'e e%er(enc" roa *#da" 'istor" of se+ere, constant, )orsenin( le-uadrant &ain, )it' associated diarr'ea, anore.ife+er of */c
#!is %edical 'istor" is si(nicantl" for '"&ertens
an(ina &ectoris, and '"&ot'"roidis%
#3edications include '"drala4ine, as&irinle+ot'"ro.ine
#!e li+es alone 5ut is inde&endent and acti+e
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P'"sical E.a%ination
#!e is fe5rile 6*/7c8 and tac'"cardic, at 110 5e%inute, )it' a 9P of /0:0 %% !(, res&irator"1;:%in
#On clinical e.a%ination, t'e a5do%en is distenri(id )it' direct < re5ound tenderness at t'e le
-uadrant, 5o)el sounds are '"&oacti+e
#!is %ucus %e%5ranes are dr" and 'e is dia&'or
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Considerations=
Patient &resents )it' e+idence of se&sis and &ossi5le earl" se Initial (oal 6after ta>in( 'istor" and PE8 is resuscitation
Ade-uate intra+enous access is o5tained and a((ressi+e ?uid resusc6*0%l:>(8 is &ursued
A 5ladder cat'eter is inserted to %onitor urinar" out&ut
Su&&le%ental o."(en 6'i ?o)8 %a" 5e re-uired and intra+enous o&iois ad%inistered as necessar"
@i+en t'e clinical &icture and sus&icion of intra#a5do%inal infeintra+enous 5road#s&ectru% anti5iotics 6for (ra% ne(ati+e rodanaero5es8 are (i+en to t'e &atient
Once resuscitation is under)a", t'e ne.t ste& is to &roceed )in+esti(ations
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In+esti(ations
F9C re+eals leu>oc"tosis of 2 9UN of *0 %(:dB, and creatinine of 12 %(:dB
9lood culture 6to 5e ta>en &ossi5le 5efore startin( anti5iotilactate le+els
A%"lase and li&ase )ere )it'in nor%al ran(e
A5do%inal radio(ra&'= no e+idence of free air under t'e di
A5do%inal CT S'o)s si(%oid di+erticulosis and an in?a%%ator" &'le(%on and
%esenteric fat strandin( in t'e re(ion of t'e si(%oid colon, )it'e.tra+asation of t'e rectall" ad%inistered contrast, and free intra(as
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Dia(nosis
Perforated si(%oid di+erticulitis
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3ana(e%ent
E%er(enc" sur(er" is re-uired for t'is &atient )&erforated di+erticulitis
T'e 5asic tenet of %ana(e%ent is control of intra5do%inal se&sis )it' e.cision of t'e se&tic focusource control8, )'ere &ossi5le
Firstl", a&&ro&riate resuscitation is re-uired for t&atient )it' se&tic s'oc> and acute renal inur"
Once resuscitation is under)a", &roceed to sur(
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3ana(e%ent
3ost &atients )it' &erforated si(%oid di+erticul5enet fro% an initial sta" in t'e Sur(ical IntensUnit 6SICU8
Intra+enous 5road#s&ectru% anti5iotics 6es&ecia(ra% ne(ati+e and anaero5es8 s'ould 5e contin
Duration of anti5iotic t'era&" is deter%ined 5" t&atient7s clinical course
9ot' %ec'anical and &'ar%acolo(ic +enoust'ro%5oe%5olis% &ro&'"la.es are 5enecial
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Co%&lications
Posto&erati+e co%&lications in t'e settin( of intra5do%inal se&sis include intra#a5do%inal or &el+a5scess
Sus&icion for a5scess for%ation s'ould 5e aroust'e occurrence of a &rolon(ed ileus, nonfunction
sto%a, &ersistent fe+er, or leu>oc"tosis CT#(uided draina(e of intra#a5do%inal a5scesse
t"&icall" successful in %ana(in( se&sis
Wound infections are co%%on after a !art%ann&rocedure and are %ana(ed 5" o&enin( t'e )ou
draina(e of t'e a5scess
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Case Conclusion
T'e &atient under(oes a successful !art%ann7s&rocedure and is e.tu5ated in SICU t'e follo)in(
!is sto%a functions on da" 2 and 'e reco%%encon t'e fourt' &osto&erati+e da"
!e s&ends ; da"s in t'e 'os&ital and is disc'ar(
and i%&ro+ed !e 'as 'is &ro.i%al colon assessed endosco&ica
to successful re+ersal of !art%ann7s &rocedure $%ont's later
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Case 2
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!istor"
A $#"ear#old %an )it' a 'istor" of '"&ertensiono5esit", and to5acco use &resents to t'e e%er(ede&art%ent
!is &ri%ar" co%&laint is e&i(astric and ri('t u&&-uadrant a5do%inal &ain of 2#'our duration !et'at 'e 'as 'ad si%ilar &ain on occasion 5efore al)a"s 'ad co%&lete resolution of &ain )it'in a of 'ours
!e re&orts 'is urine 'as 5een +er" dar> for t'e l'ours
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P'"sical E.a%ination
!e is fe5rile on arri+al )it' a te%&erature of */75lood &ressure of /:$, and a 'eart rate of /$
On e.a%ination, t'e sclerae are %ildl" icteric Naundice is &resent
T'e a5do%en is soft )it' direct tenderness at t'
u&&er -uadrant area, 6#8 re5ound tenderness 5osounds are nor%oacti+e
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Considerations
Consider t'e follo)in( as dierentials= C'olec"stitis
C'oledoc'olit'iasis
C'olan(itis
!e&atitis
Pancreatitis Pe&tic ulcer disease
Acute (astritis
Colonic carcino%a
Presence of fe+er indicates a &ossi5le infectious
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Presentation Continued
Patient )as ad%itted for furt'er e+aluation IG ?uids started
F9C, seru% electrol"tes, 9UN:crea, a%"lase, li&acoa(ulation &role, 'e&atitis serolo(" and li+er ftest ordered
Hesults s'o)ed leu>oc"tosis of 1,*00:%B )it' a&redo%inance of neutro&'ils, 5ot' 5iliru5in and&'os&'atase )ere ele+ated
9ot' t'e AST and t'e ABT are ele+ated at 210 anIU:B, res&ecti+el"
E%&irical anti5iotics initiated
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In+esti(ations
Ultrasound of t'e li+er, (all5ladder, 'e&ato5iliarand &ancreas )as orderedT'e li+er is nor%al in si4e )it' no a5nor%al %asses n
T'e (all5ladder is not distended )it' t'ic>ened )allsare se+eral stones noted inside )it' si4es ran(in( fro1c%
T'e co%%on 5ile duct is dilated )it' a dia%eter of 1)it' note of sin(le stone at t'e distal &ortion
T'e &ancreas cannot 5e +isuali4ed 5ecause of o+erl"(as
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Dia(nosis
O5structi+e aundice secondar" to c'oledoc'olit
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Presentation Continued
On t'e rst 'os&ital da" &atient still fe5rile and )a5do%inal &ain no) de+elo&ed '"&otension 60and 5eca%e disoriented
A dia(nosis of ascendin( c'olan(itis )as %ade
After initial resuscitation &atient )as sc'eduled
e%er(ent deco%&ression +ia endosco&ic retro(rc'olan(io&ancreato(ra&'" 6EHCP8
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Case Conclusion
Patient under)ent successful EHCP )it' stone 5ae.traction and a s&'incteroto%"
!e )as afe5rile on da" 2 &ost EHCP
He&eat F9C and li+er function test 5ot' s'o)eddecreasin( le+els of W9C and 5iliru5in
IG anti5iotics s'ifted to oral and IG ?uids disconton da"
Disc'ar(ed i%&ro+ed on )it' a sc'edule to doelecti+e la&arosco&ic c'olec"stecto%"
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Case *
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!istor"
T'e &atient is a ;#"ear#old (entle%an )it' a &ast 'ist'"&ertension, &eri&'eral +ascular disease, and dia5ete
T)o )ee>s a(o, 'e under)ent carotid endarterecto%" recentl" treated as an out&atient )it' ci&ro?o.acin for
!e &resents 5ac> to t'e 'os&ital )it' a5do%inal &ain a&rofuse )ater" diarr'ea !e descri5es t'is as 10 5o)el
%o+e%ents a da" and states t'at t'e stool is foul s%e !e denies nausea:+o%itin(, %elena, or 'e%atoc'e4ia
denies an" unusual food inta>e or recent tra+el, and 'eonl" cit" ta& )ater No one else in 'is 'ouse'old is sic>
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P'"sical E.a%ination
U&on e.a%, 'e is fe5rile 6*7c8, %ildl" tac'"ca5ut nor%otensi+e
!e a&&ears de'"drated )it' dr" %ucous %e%5rand dr" s>in
!is a5do%en is soft, %ildl" distended, and dius
tender )it'out &eritoneal si(ns !e 'as no a5do%inal scar
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Considerations
Acute onset of &rofuse diarr'ea is %ost co%%onl" fro% ancause 6causes include +iral infections suc' as noro+irus, roand adeno+irus8
9acterial infections usuall" cause %ore se+ere diarr'ea anare usuall" due to Vibrio, Escherichia coli, Salmonella,Campylobacter or Shigella.
In &atients )it' recent anti5iotic use, Clostridium difcile in
s'ould 5e considered Parasitic infections are also &ossi5le and can 5e due to Gia
lamblia, Cryptosporidium, and Entamoeba histolytica.
Noninfectious causes can include os%otic anti5iotic#associdiarr'ea
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Initial 3ana(e%ent
Hesuscitate In+esti(ations
9lood in+esti(ations
Stool culture:sensiti+it", identif" an" o+a or &arasites
I%%unoassa" for C. difcile to.in
E%&iric PO %etronida4ole is started due to 'i(' sus&icion for C. difcile colitis
T'is test co%es 5ac> &ositi+e on 'os&ital da" 2
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Deniti+e 3ana(e%ent
Discontinue t'e oendin( anti5iotic if t'e" are sta>in( it
Caution a5out usin( 5road s&ectru% anti5iotics
Pre+ent de'"dration 6IG '"dration8
3edication= 3etronida4ole, Ganco%"cin, Fida.o%icin
Pro5iotics
Sur(er" if co%&lications de+elo&