GI ID

H Pylori
C Diff
Acute Diarrhea 
Intrabdominal Infection
Diverticultis
Liver Abscess


C Diff 

 Case Based Discussion 
  1. 3-5 episodes of diarrhea of 5 days duration. Recently treated for C Diff. Concern for Mild C. Diff reoccurrence.  GDH and Toxin Negative. PCR positive for toxigenic strain. Other stool culture negative. What to do. 
    1. Treat for reoccurrence. 
    2. No treatment for C. diff.Treat with anti-diarrheal.  
      1. Answer: No treatment for C. diff at this time as it is asymptomatic carrier. Likely it is post-infectious GI diarrhea.
      2. Note: Do not do PCR if either GDH or Toxin are not positive. 
        1. Reference: CR 33, 37 of Clostridium difficile Infection NEJM 2015
  2. 37 yr old lady. C. Diff. Mild/Moderate Disease. 1st occurrence  GDH +, Toxin +, PCR NAP1/BI/027 - Negative. What abx to use to decrease reoccurrence. 
    1. PO Vanc
    2. IV Flagyl
    3. Fidoxamicin
      1. Answer: Fidoxamicin (15 % reoccurrence with Fidoxamicin vs 25 % for PO Vanc) 
      2. Note: Better resolution of diarrhea with C. Diff using PO vanco than Metronidazole even at mild / moderate illness. 
        1. Reference: Clostridium difficile Infection NEJM 2015
  3. 37 yr old lady. C. Diff.  Mild/Moderate Disease.  1st occurence. GDH +, Toxin +, PCR NAP1/BI/027 - Positive. What abx to use to decrease reoccurrence. 
    1. PO Vanc
    2. IV Flagyl
    3. Fidoxamicin
      1. Answer: PO Vancomycin (15 % reoccurrence with Fidaxomicin vs 25 % for PO Vanc is seen for non- NAP1/BI/027 strain. Among NAP1/BI/027 strain more reoccurrence with Fidaxomicin. 
      2. Note: Marked rise in Reoccurance with Flagyl on NAP1/B1/027 strain
        1. Reference: Clostridium difficile Infection NEJM 2015

C. DIFF COLITIS - NAP1/BI/027 or not - Initial episode / 1st or 2nd recurrence -  Mild / Moderate / Severe / Severe Complicated - Improving / Worsening - Treatment plan
  • Recurrence Rate:
    • First Recurrence: 25 % with Metronidazole, and Vancomycin; 15 % with Fidaxomicin
    • Subsequent recurrence: 
      • 65 % following standard therapy with Metronidazole and Vancomycin
  • Metronidazole (IV) vs. Vancomycin (PO):
    • Mild to Moderate CDI treatment response rate: 98 % with Vancomycin vs 90 % with Metronidazole
    • Severe CDI treatment response rate: 97 %  with Vancomycin as  76 % with Metronidazole; this is statistically significant
Current Concepts: Clostridium difficult — More Difficult Than Ever NEJM 2008
  • Fidaxomicin (PO):
    • Initial response rate is 88 % vs 86 % in Vancomycin
    • If risk of reoccurrence is higher then Fidaxomycin is preferred BUT Do not use if NAP1/BI/027 as there is more risk of treatment failure on this strain
  • Rifaximin (PO): 
  • Probiotics: 
  • FMT (Fecal Microbiota Transplant):
  • Phamacokinetics: IDSA 2010 Guideline 
    • PO metronidazole is absorbed rapidly and almost completely, with only 6%–15% of the drug excreted in stool. Fecal concentrations of metronidazole likely reflect its secretion in the colon, and concentrations decrease rapidly after treatment of CDI is initiated: the mean concentration is 9.3 mg/g in watery stools but only 1.2 mg/g in formed stools. Metronidazole is undetectable in the stool of asymptomatic carriers of C. difficult.  Consequently, there is little rationale for administration of courses of metronidazole longer than 14 days, particularly if diarrhea has resolved. 
    • In contrast, vancomycin is poorly absorbed, and fecal concentrations following oral administration (at a dosage of 125 mg 4 times per day) reach very high levels: 64–760 mg/g on day 2 and 152–880 mg/g on day 4.  Doubling the dosage (250 mg 4 times per day) may result in higher fecal concentrations on day 2.  Fecal levels of vancomycin are maintained throughout the duration of treatment. Given its poor absorption, orally administered vancomycin is relatively free of systemic toxicity. IDSA 2010 Guideline











Acute Diarrhea 

Clinical Infectious Diseases 2001;32:331–50 

Clinical Infectious Diseases 2001;32:331–50 

Clinical Infectious Diseases 2001;32:331–50 

Clinical Infectious Diseases 2001;32:331–50 

Clinical Infectious Diseases 2001;32:331–50 

Clinical Infectious Diseases 2001;32:331–50 

Clinical Infectious Diseases 2001;32:331–50 

Intra-abdominal Infection 
Clinical Infectious Diseases 2010;50:133–64 

Clinical Infectious Diseases 2010;50:133–64

Clinical Infectious Diseases 2010;50:133–64

Clinical Infectious Diseases 2010;50:133–64

Clinical Infectious Diseases 2010;50:133–64

DIVERTICULITIS 

Liver Abscess
STJ 
52 yo M with history of EtOH abuse is seen for 6 days of F, C, Sore throat and congestion. 3 days prior was diagnosed with Pneumonia by PCP and started on Levofloxacin. CXR is as below. Initial lab is as below. 



 


 

Given elevated LFT, US shows multiple lesions, and hence CT with contrast is ordered given the concern of Abscess




What is the DDx for complex cystic liver lesion?
  • Hydatid Cyst
  • Liver Abscess

    • Strep or Enteric GNR infection, vs Amaebic abscess, vs Candidal infection, vs less likely Histoplasma 

  • Metastatic Disease 
What are the imaging characters of various liver lesions
Investigating focal liver lesions BMJ 2012

Now how should this patient be managed? 
  • Tissue Biopsy
What precaution should be taken before doing a biopsy on a patient with suspected hydatid cyst as an illness?
  • Serum test for echinococcus : Negative

  • Serologies for amoeba : Negative

What abx to start as patient is also septic?
  • CAP (Ceftriaxone and azithromycin)
  • Flagyl + Fluconazole + Ceftriaxaone (For liver abscess)
However, azihtromycin can be discontinued as such disease causing Liver abscess simultaneously is less likely 

Eventually, all tests from Liver biopsy remained negative, and patient was discharged home on abx that included Flagyl, and Ceftriaxone. Fluconazole was discontinued due to absence of any tests to suggest a fungal infection 




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