Gastro OI

Question 1

Causes of oropharyngeal infections and oesophagitis

Answer 1

Candidiasis most common

HSV
CMV
TB
Drugs - doxy, nsaids, iron tablets

Question 2

Treatment of oral/oesophageal candidiasis

Answer 2

Oral - 1-200mg fluconazole a day for 7-14 days
Oesophageal - 200-400mg OD for 14-21 days

Question 3

What to do if Candida oesophagitis doesn’t improve with empirical therapy?

Answer 3

Endoscopy with swab and or biopsy - cultures and sensitivities

Question 4

Management of CMV oesophagitis?

Answer 4

Iv ganciclovir 5mg/kg bd for 2-4 weeks or until symptoms have resolved
If able to swallow and absorb then oral valganciclovir can be used instead

Question 5

Management of HSV oesophagitis?

Answer 5

Iv aciclovir 5-10mg TDD followed by PO valaciclovir 1g bd for a total of 14 days

Question 6

Prevention of upper GI tract infection

Answer 6

CART is mainstay

Question 7

Campylobacter treatment

Answer 7

None if CD4 > 200

Azithomycin if < 200

Question 8

Diagnosis c diff

Answer 8

Molecular test, Eia for toxins a and b, toxigenic culture, colonoscopy, biopsy, CT scan

Question 9

Management c diff

Answer 9

Stop causative abx
Non severe treated with metronidazole
Severe treated with vancomycin or fidaxomycin

Question 10

E. coli diagnostic test

Answer 10

Stool culture preferred
EIA for shiga toxin or molecular test

Question 11

E. coli treatment

Answer 11

Only if CD4 <200
As per local guidelines

Question 12

Tx salmonella

Answer 12

Only if CD4 <200

Cipro or ceftriaxone as per local guidelines

Question 13

Shigella treatment

Answer 13

Only if CD4 <200

Cipro or azithromycin as per local guidelines

Question 14

Most cases of CMV disease occur in people with a prior CMV infection and CD4 count of..

Answer 14

<50

Question 15

Symptoms of CMV colitis

Answer 15

Weight loss, anorexia, diarrhoea, abdo pain, fatigue

Fevers

Question 16

What else should you assess if you suspect CMV colitis?

Answer 16

? Oesophagitis
? Retinitis

Question 17

When should cART be started in CMV colitis?

Answer 17

If retinitis present start 2 weeks after CMV tx due to IRIS risk

If just colitis don’t delay cART. If diarrhoea continues may need TDM if VL not suppressing.

Question 18

Cmv biopsy findings

Answer 18

Owls eye inclusions
Positive immunohistochemical staining for CMV

Question 19

Treatment for CMV colitis

Answer 19

Ganciclovir 5mg/kg bd 2-4 weeks/until symptom resolution
Oral valgancyclovir may be used in less severe disease

Question 20

Rotavirus, norovirus, astrovirus, coronavirus treatment

Answer 20

Supportive measures

Question 21

Adenovirus diarrhoea management

Answer 21

Cidofovir iv if clinically significant infection (rare)

Question 22

CMV prophylaxis

Answer 22

Only for retinitis

Valganciclovir 900mg od until CD4 >100 for 6/12

Question 23

how is CMV resistance to ganciclovir confirmed?

Answer 23

Detection of mutations in UL97 gene

Resistance to foscarnet or cidofovir occurs through mutations in CMV UL54 gene

Question 24

Important cART and anti-CMV DDI

Answer 24

Tenofovir and ganciclovir/valganciclovir - renal toxicity

Question 25

Who is at greatest risk of cryptosporidium?

Answer 25

Those with cd4 <100

Question 26

Symptoms of cryptosporidiosis

Answer 26

Profuse watery non bloody diarrhoea Fever and malabsorption common Nausea vomiting and lower abdo pain may occur

Question 27

Non bowel issues with cryptosporidiosis occur in which areas?

Answer 27

Pancreatic duct and biliary tree - cholangitis and pancreatitis may occur Sclerosing cholangitis presents with right upper quadrant pain, vomiting and raised alk phos

Question 28

How to diagnose cryptosporidiosis?

Answer 28

Microscopy of fresh unconcentrated stool Repeat samples may be required due to intermittent oocyst secretion Pcr should be used in addition

Question 29

Treatment of cryptosporidiosis

Answer 29

Restoration of immune system with cART Nitazoxanide 500kg bd for 3/7 but may be required for up to 12 weeks Rehydration, electrolyte replacement, antimotility agents, dietician input

Question 30

How to prevent cryptosporidiosis

Answer 30

Patients with CD4 <200 should avoid drinking unfiltered water and ensure careful hand hygiene Bottles water not enough Specific filtration employing an absolute 1um filter is required - boiling of water should be advocated

Question 31

Microsporidia presentation

Answer 31

Watery, non bloody diarrhoea with associated malabsorption Sclerosing cholangitis can occur Dissemination can lead to encephalitis sinusitis, myosotis and renal and occular infection

Question 32

How is microsporidia diagnosed?

Answer 32

3 stool samples should be examined with chromotrope and chemofluorescent stains PCR to aid diagnosis Small bowel biopsy may be considered if stool samples are consistently negative

Question 33

Treatment of microsporidia

Answer 33

Early cART E. Birneusi - oral fumagillin- haematological toxicity E intestinalis - albendazole

Question 34

Symptoms of giardia

Answer 34

Chronic diarrhoea. Nausea bloating cramp like abdominal pain indigestion bloating.

Question 35

Treatment of giardiasis

Answer 35

Metronidazole Strict hand hygiene If recurs give metro again, test and treat household contacts If recurrent in traveller to Asia seek specialist advice

Question 36

How might amoebiasis present?

Answer 36

Fever, abdo pain, watery or bloody diarrhoea Can be asymptomatic Occurs at any cd4 count Liver abscess can present with fever, RUQ pain and tenderness

Question 37

How is amoebiasis spread?

Answer 37

Ingestion of cysts in contaminated human faeces

Question 38

Diagnosis amoebiasis

Answer 38

3 stool samples for cysts and trophozoites PCR method of choice in uk

Question 39

How is amoebiasis treated?

Answer 39

Metronidazole Afterwards paromomycin for 5-10 days to eliminate luminal infection

Question 40

Symptoms of cyclosporiasis

Answer 40

Watery diarrhoea throughout the tropics and subtropics and in returning travellers

Question 41

Diagnosis of cyclosporiasis

Answer 41

Detection of oocysts in stool Wet prep Examination under UB light for parasite autofluorescence or confirmed using modified ZN staining and accurate measurement PCR can aid and samples should be sent to PHE

Question 42

Treatment of cyclosporiasis

Answer 42

Cotrimoxazole 960mg BD 7/7 Secondary prophylaxis three times a week may be needed while cART is commenced

Question 43

How does cystoisoporiasis present?

Answer 43

Chronic diarrhoea sometimes biliary involvement

Question 44

How is cystoisosporiasis diagnosed?

Answer 44

Oocysts in stool with microscopy with modified ZN staining

Question 45

How is cystoisosporiasis treated?

Answer 45

Septrin 960mg QDS for 10/7 Secondary prophylaxis 960mg three times a week is essential as relapse is common

Question 46

What is strongyloides stercoralis?

Answer 46

Gut nematode that causes chronic GI and skin disorders Autoinfective lifecycle Can disseminate causing life threatening hyperinfection syndromes in immunosuppressed individuals - corticosteroid use seems to be a causative factor in cases of hyper infection syndrome

Question 47

Diagnosis strongyloidiasis

Answer 47

Eosinophilia Larvae in stool specimens Serology may also be useful but can have cross reaction with other parasitic nematodes

Question 48

How is strongyloidiasis treated?

Answer 48

Discuss with specialist Ivermetcin but caution if diagnosed by serology because cross reaction with filaria is possible and encephalopathy can develop If hyperinfection continue ivermectin for at least 2 weeks Repeat stool sample at 2-4 weeks to confirm clearance and serology and stool samples every 6-12m for 2yrs after tx

Question 49

Treatment of schistosomiasis

Answer 49

Praziquantel at dose dependent on species