infectious/drug-induced esophagitis/C Diff

Question 1

Infectious esophagitis

general

Answer 1

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

Question 2

Candida esophagitis

general
Seen in pts with

Answer 2

Common in patients with uncontrolled diabetes, those on swallowed or inhaled steroids or on systemic antibiotics, HIV patient with CD4 count < 100 cells/mcL

Question 3

Candida esophagitis

S/Sx

Answer 3

Odynophagia
Dysphagia
Substernal chest pain
Signs of oral thrush (2/3 of patients)

Question 4

Candida esophagitis

Dx

Answer 4

Endoscopy for direct visualization and culture
Performed if there is no improvement with empiric treatment for 5-7 days

Question 5

Candida esophagitis

Tx

Answer 5

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

Question 6

Herpes simplex virus esophagitis & Cytomegalovirus esophagitis

RF

Answer 6

AIDS patients
Patient on immunosuppressive therapy or chemotherapy
Transplant patients

Question 7

Herpes simplex virus esophagitis & Cytomegalovirus esophagitis

S/Sx

Answer 7

Odynophagia (more severe with CMV)
Dysphagia
Retrosternal chest pain
+/- fever

Question 8

Herpes simplex virus esophagitis

Dx

Answer 8

Endoscopy with cytology or biopsy

HSV: vesicular lesions (early); punched-out ulcerations

Question 9

Cytomegalovirus esophagitis

Dx

Answer 9

Endoscopy with cytology or biopsy

CMV: linear or longitudinal deep ulcerations

Question 10

Herpes simplex virus esophagitis

Tx with dosage

Answer 10

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

Question 11

Cytomegalovirus esophagitis

Tx

Answer 11

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

Question 12

Herpes simplex virus esophagitis & Cytomegalovirus esophagitis

Tx If positive for HIV/AIDS

Answer 12

Antiretroviral therapy

Question 13

Question 14

Drug-induced Esophagitis

general and mechanisms

Answer 14

Medications can cause injury to the esophagus
Mechanisms:
Direct, prolonged mucosal contact
Disruption of mucosal integrity (irritation, erosions, and ulcerations)

Question 15

Drug-induced Esophagitis

Most common medications:

Answer 15

Anti-inflammatory - NSAIDs, Aspirin
Antibiotics – tetracycline, doxycycline, clindamycin
Bisphosphonates
Potassium chloride
Iron supplements
Ascorbic acid

Question 16

Drug-induced Esophagitis

RF

Answer 16

Elderly patients
Position of the patient (supine > upright)
Size of the medication (delayed transit with large tablets)
Amount of fluid ingested with medication

Question 17

Drug-induced Esophagitis

S/Sx

Answer 17

Heartburn
Retrosternal chest pain
Odynophagia
Dysphagia

Question 18

Drug-induced esophagitis

Endoscopy

Answer 18

Discrete punched-out ulcer(s) with normal bordering mucosa – acute
Esophagitis with strictures, hemorrhage, or perforation – chronic or recurrent

Question 19

Drug-induced esophagitis

Treatment for acute presentation

Answer 19

Remove the offending agent and use an H2 blocker or a PPI to promote healing

Question 20

Drug-induced esophagitis

Prevention

Answer 20

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

Question 21

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

Answer 21

D. Lower esophageal sphincter incompetence

Question 22

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

Answer 22

A. Difficulty swallowing

Question 23

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

Answer 23

C. Every 3 to 5 years

Question 24

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

Answer 24

B. Distended abdomen
indication of full impaction

Question 25

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

Answer 25

B. Endoscopy with dilation

Question 26

# Pseudomembranous colitis general

Answer 26

Pseudomembranous colitis C diff Inflammation of colonic mucosa caused by the toxins released by the bacterium Clostridioides difficile, previously known as Clostridium difficile Majority of cases are hospital acquired Community-acquired cases are increasing – 40%

Question 27

# Clostridium difficile general about bacteria

Answer 27

**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

Question 28

# C diff RF

Answer 28

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

Question 29

Question 30

# C diff patho

Answer 30

~5% of healthy adults are colonized 8%–10% of hospitalized adults are colonized Disruption of the normal flora using antibiotics leads to the overgrowth of C. difficile Intestinal damage is due to toxin release

Question 31

# c diff Enterotoxin A:

Answer 31

Targets brush-border enzymes → altered fluid secretion (watery diarrhea)

Question 32

# c diff Cytotoxin B: 

Answer 32

(10x more potent): Disrupts the cytoskeleton of enterocytes leading to apoptosis (pseudomembranous colitis)

Question 33

# c diff Non-fulminant colitis clin man

Answer 33

Foul-smelling, watery diarrhea Rarely bloody Cramping abdominal pain Fever Nausea and vomiting (rare) | mild form, most cases

Question 34

# c diff Fulminant colitis clin man

Answer 34

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

Question 35

# c diff Toxic megacolon

Answer 35

Large bowel dilatation >7 cm; cecum >12 cm

Question 36

# c diff

Question 37

# C diff Dx

Answer 37

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) for C. difficile antigen- first * Glutamate dehydrogenase (GDH) antigen * Rapid test that is widely available + results confirms presence of the organism, but not if it is toxigenic * EIA for C. difficile toxins A and B * Nucleic acid amplification test using polymerase chain reaction (PCR) for C. difficile toxin genes  **Can remain + after successful treatment**

Question 38

# c diff CMP/CBC Electrolyte???

Answer 38

Leukocytosis (often > 20,000/μL) Significant **bandemia** with fulminant colitis **Hypokalemia (due to diarrhea)**

Question 39

# c diff imaging/Dx

Answer 39

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**

Question 40

# c diff

Answer 40

toxic megacolon

Question 41

# c diff Non pharm Tx

Answer 41

Intravenous fluid resuscitation Electrolyte correction Discontinuation of the offending antibiotic if possible

Question 42

# c diff pharm Tx for non-fulminant

Answer 42

**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)

Question 43

# c diff recurrences

Answer 43

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

Question 44

Question 45

# C diff Prevention of Hospital Transmission

Answer 45

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

Answer 46