gi infectious disease week

7/26/2019 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


14/28

!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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!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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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&

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