Dr Vu Kwan - CIDM Public Health
Download
Report
Transcript Dr Vu Kwan - CIDM Public Health
Dr Vu Kwan
Staff Specialist
Department of Gastroenterology
Westmead Hospital
72
year old male
Background:
• Ischaemic heart disease
NSTEMI 2009
Coronary stent
Echocardiogram: EF 25%
• Atrial fibrillation
Warfarin
• Chronic kidney disease
Baseline creatinine ~180
Per rectum bleeding
• Admitted for observation
• Discharged for outpatient colonoscopy
Recurrent bleeding
• Admitted for inpatient colonoscopy
Colonoscopy:
• Multiple large colonic polyps
• Endoscopic mucosal resection performed
• Histology
Multiple tubular adenomas
Invasive malignancy not excluded
Represented 3 days post-procedure with
recurrent rectal bleeding
ED assessment:
• “Post-polypectomy bleeding”
• “Possible peptic ulcer bleeding”
Commenced on high dose proton-pump
inhibitor infusion
Observed for several days bleeding cessation
Discharged home
Represented
2 days later with bloody
diarrhoea
Up
to 10 episodes per day
Initially
assumed to be ongoing postpolypectomy bleeding
No
stool tests performed
Pseudomembranous colitis
No
history of recent antibiotics
Only
history:
• Elderly male
• Multiple co-morbidities
• Repeated hospitalisations
• Only new medication = PPI
Commenced
on oral metronidazole
Ongoing fluid balance problems
Dehydration due to diarrhoea
Worsening renal function
Fluid therapy resulting in pulmonary oedema
Prolonged HDU admission with other medical
complications
Eventual
resolution of diarrhoea &
discharge 3 weeks later
One
of the most common healthcareassociated infections
Spectrum
of disease ranging from
asymptomatic carriage to fulminant
colitis
Commonly
a result of antibiotic therapy
due to alteration of normal gut flora
Can
occur without antibiotic use,
importantly via nosocomial transmission
Mortality
rates of up to ~25% reported,
particularly in elderly1
1. Crogan et al, Geriatr Nurs 2007
Asymptomatic carriage
C.difficile diarrhoea
C.difficile colitis
Pseudomembranous colitis
Fulminant colitis
Approximately
20% of hospitalised
patients are C. difficile carriers
Significant
reservoir for disease
transmission
Contribution
is unclear
of host’s immune response
Watery diarrhoea
• >3 times per day
• >2 days duration
More severe cases
•
•
•
•
Up to 15 motions per day
Lower abdominal pain and cramping
Low grade fever
Leucocytosis
Onset may be during antibiotic therapy or 5-10
days after treatment
• Can present up to 10 weeks after antibiotic cessation
More
significant illness than diarrhoea
alone
Constitutional
symptoms, fever,
abdominal pain + watery diarrhoea
Colonoscopy:
• Non-specific diffuse or patchy erythematous
colitis
The
classic manifestation of full-blown
C.difficile colitis
Symptoms
similar to, but often more
severe than, colitis due to other causes
Unwell, WCC, hypoalbuminaemia
Colonoscopy:
• Classical raised white/yellow plaques
Severe
manifestation affecting ~3%
Account for the
Perforation
Prolonged ileus
Toxic megacolon
Death
Clinical
most serious complications:
features of fever, leucocytosis,
abdominal distension
1
Small bowel
2
Bacteraemia
3
Reactive arthritis
4
Others
Particularly
described in small bowel
subjected to recent surgery
• Inflammatory bowel disease post ileal-anal
anastomosis
Pseudomembrane
May
formation
act as a reservoir for recurrent
colonic infection?
Uncommon
Associated
with high mortality rate1
May
be more common in patients with
underlying gastrointestinal diseases2
1.
Daruwala et al, Clin Med Case Reports 2009
2. Libby et al, Int J Infect Dis 2009
Polyarticular
arthritis
• Knee and wrist in 50% of cases
Onset
average 11 days after diarrhoea1
Prolonged
resolve2
illness : average 68 days to
1.
2.
Birnbaum et al, Clin Rheumatol 2008
Jacobs et al, Medicine (Baltimore) 2001
Cellultis
Necrotising
fasciitis
Osteomyelitis
Prosthesis infection
Intra-abdominal abscess
Empyema
etc
General risk factors
1. Long duration antibiotics
2. Multiple antibiotics
3. Nature of faecal flora
4. Production of requisite cytotoxins
5. Presence of host risk factors
Specific risk factors
1. Immunosuppressive drugs
2. Gastric acid suppression
3. Cancer chemotherapy with antibiotic properties
Advanced
age
Nasogastric tube
Severe underlying illness
Prolonged hospitalisation
Enema therapy
GI stimulants
Stool softeners
Chronic, relapsing
inflammatory
disorders of the bowel of unknown
aetiology
Ulcerative colitis
Crohn’s disease
Enteric
infections account for ~10% of
‘relapses’
• C.difficile in about half
• May mimic a relapse, OR trigger a true relapse
Crucial
that C.difficile is considered in the
differential diagnosis of every ‘flare’
Otherwise
inappropriate escalation of
immunosuppression may result in severe
infection
High
index of suspicion required as
classical pseudomembranes don’t form in
IBD
Treatment
is to REDUCE their usual
immunosuppressive drugs
Gastric
acid inhibits germination of
ingested C.dificile spores
Therefore, medications
lowering gastric
acid could increase risk of C.difficile
infection
• Clinical data are conflicting
Abdominal
CT
xray
scan
Colonoscopy
Important
in patients who are unwell with
C.difficile infection
Findings:
• Ileus
• Toxic megacolon
• Perforation
Diagnosis
Several
can often be made on CT alone
characteristic findings:
• Gross bowel wall thickening
• Luminal narrowing
• Characteristic signs:
“Accordion sign”
“Target sign”
Pathognomonic
appearance of
pseudomembranes
• Raised, white/yellow plaques
Up
to 1/3 right-sided only, so full
colonoscopy better than sigmoidoscopy
Biopsies
reveal spectrum of mucosal
inflammation and necrosis
Beware
colonoscopy in unwell patients
with ileus or megacolon
• Risk of perforation
If
clinical picture and stool tests are
suggestive, minimal role for colonoscopy
Health-care
associated infection of great
clinical significance
Spectrum
of disease ranging from
asymptomatic infection to fuliminant
colitis and death
Imaging
investigations are
complimentary to clinical index of
suspicion
Approximately
15-20% of patients with
CDAD relapse following successful
treatment
• One relapse predicts further relapses!
Sudden
recurrence of diarrhoea within
~1 week of treatment cessation