Dr Vu Kwan - CIDM Public Health

Report
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

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