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Questions and Answers
Which of the following is a common cause of infectious diarrhea?
Which of the following is a common cause of infectious diarrhea?
- Viral infections (correct)
- Food preservation
- Allergic reactions
- Stress
What is a known complication associated with Campylobacter jejuni?
What is a known complication associated with Campylobacter jejuni?
- Ileal perforation
- Guillain Barre syndrome (correct)
- Chronic kidney disease
- E. coli infection
Infectious diarrhea can be caused by consuming contaminated food or water.
Infectious diarrhea can be caused by consuming contaminated food or water.
True (A)
Name a common symptom of infectious diarrhea.
Name a common symptom of infectious diarrhea.
Azithromycin 500mg is routinely indicated for treatment in cases of small bowel diarrhea.
Azithromycin 500mg is routinely indicated for treatment in cases of small bowel diarrhea.
Infectious diarrhea is typically characterized by __________ and abdominal cramping.
Infectious diarrhea is typically characterized by __________ and abdominal cramping.
What type of toxin is Toxin B produced by Clostridium difficile?
What type of toxin is Toxin B produced by Clostridium difficile?
The incubation period for Campylobacter jejuni infection is __________ days.
The incubation period for Campylobacter jejuni infection is __________ days.
Match the following terms related to infectious diarrhea with their definitions:
Match the following terms related to infectious diarrhea with their definitions:
Match the following conditions with their associated factors:
Match the following conditions with their associated factors:
What is the recommended induction therapy for mild to moderate gastroenterology management?
What is the recommended induction therapy for mild to moderate gastroenterology management?
Maintenance therapy is required for all patients in gastroenterology management.
Maintenance therapy is required for all patients in gastroenterology management.
Name one newer drug used in gastroenterology management.
Name one newer drug used in gastroenterology management.
In the case of fistulizing disease, the recommended therapy includes Anti-TNFα plus _____ followed by surgery.
In the case of fistulizing disease, the recommended therapy includes Anti-TNFα plus _____ followed by surgery.
Match the following medications with their respective classifications:
Match the following medications with their respective classifications:
What is the mainstay treatment for mild ulcerative colitis?
What is the mainstay treatment for mild ulcerative colitis?
Oral mesalamine is the drug of choice for mild ulcerative colitis.
Oral mesalamine is the drug of choice for mild ulcerative colitis.
What is the recommended treatment for moderate ulcerative colitis?
What is the recommended treatment for moderate ulcerative colitis?
In severe ulcerative colitis, the treatment includes IV steroids and IV ______.
In severe ulcerative colitis, the treatment includes IV steroids and IV ______.
Match the following ulcerative colitis treatment strategies with their severity:
Match the following ulcerative colitis treatment strategies with their severity:
Which of the following is a source of Vibro parahaemolyticus?
Which of the following is a source of Vibro parahaemolyticus?
Bacillus cereus produces a heat labile toxin that is preformed.
Bacillus cereus produces a heat labile toxin that is preformed.
What is the primary treatment for dehydration caused by cholera?
What is the primary treatment for dehydration caused by cholera?
The incubation period for the heat stable toxin of Bacillus cereus ranges from _____ hours.
The incubation period for the heat stable toxin of Bacillus cereus ranges from _____ hours.
Which organism is most commonly associated with secretory diarrhea?
Which organism is most commonly associated with secretory diarrhea?
Non-typhoid salmonella is an invasive organism associated with large bowel diarrhea.
Non-typhoid salmonella is an invasive organism associated with large bowel diarrhea.
Match the following clinical feature with its associated pathogen:
Match the following clinical feature with its associated pathogen:
What is the incubation period for Staphylococcus aureus food poisoning?
What is the incubation period for Staphylococcus aureus food poisoning?
Which malignancy is specifically associated with Ulcerative Colitis due to primary sclerosing cholangitis?
Which malignancy is specifically associated with Ulcerative Colitis due to primary sclerosing cholangitis?
The most common cause of shigellosis is __________.
The most common cause of shigellosis is __________.
Which serological marker correlates with disease activity in ulcerative colitis?
Which serological marker correlates with disease activity in ulcerative colitis?
The age of onset for IBD-related colorectal carcinoma is generally older than that of sporadic colorectal carcinoma.
The age of onset for IBD-related colorectal carcinoma is generally older than that of sporadic colorectal carcinoma.
Primary sclerosing cholangitis is more common in patients with ulcerative colitis than in patients with Crohn's disease.
Primary sclerosing cholangitis is more common in patients with ulcerative colitis than in patients with Crohn's disease.
What is the common pathological feature of IBD-related colorectal carcinoma?
What is the common pathological feature of IBD-related colorectal carcinoma?
Match the following organisms with their type of diarrhea:
Match the following organisms with their type of diarrhea:
What are the two fecal markers that help differentiate IBD relapse from infectious diarrhea?
What are the two fecal markers that help differentiate IBD relapse from infectious diarrhea?
The genetic sequence followed in sporadic colorectal carcinoma is the __________ sequence.
The genetic sequence followed in sporadic colorectal carcinoma is the __________ sequence.
Patients with ulcerative colitis have a ___% chance of developing primary sclerosing cholangitis.
Patients with ulcerative colitis have a ___% chance of developing primary sclerosing cholangitis.
Match the types of malignancy associated with Crohn's Disease and Ulcerative Colitis:
Match the types of malignancy associated with Crohn's Disease and Ulcerative Colitis:
Match the type of inflammatory bowel disease with its associated serological marker:
Match the type of inflammatory bowel disease with its associated serological marker:
What are some side effects associated with sulfasalazine?
What are some side effects associated with sulfasalazine?
Procto-colectomy with ileoanal anastomosis is indicated for medically refractory disease.
Procto-colectomy with ileoanal anastomosis is indicated for medically refractory disease.
Name a biologic agent used in the treatment of Crohn's Disease.
Name a biologic agent used in the treatment of Crohn's Disease.
Which organism is most commonly associated with Hemolytic Uremic Syndrome (HUS)?
Which organism is most commonly associated with Hemolytic Uremic Syndrome (HUS)?
The __________ level of Crohn's Disease is characterized by fever, cachexia, and obstruction.
The __________ level of Crohn's Disease is characterized by fever, cachexia, and obstruction.
Reactive arthritis can be caused by a Shigellosis infection.
Reactive arthritis can be caused by a Shigellosis infection.
Match the following drugs to their side effects:
Match the following drugs to their side effects:
What is the drug of choice for treating Shigellosis?
What is the drug of choice for treating Shigellosis?
The main toxin produced by Shigella dysenteriae is called __________.
The main toxin produced by Shigella dysenteriae is called __________.
Match the type of bacteria with their associated toxins:
Match the type of bacteria with their associated toxins:
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Study Notes
Gastroenterology Management
- Avoid smoking and NSAIDs.
- Mild to Moderate Ulcerative Colitis: Oral Budesonide 9mg/day
- Moderate to Severe Ulcerative Colitis: Oral steroids, Methotrexate
- Severe to Fulminant Ulcerative Colitis: IV Steroids, IV anti TNF-α
- Maintenance Therapy: Not required for Ulcerative Colitis
- Medications to Avoid in Ulcerative Colitis Maintenance: Oral 5-ASA, Corticosteroids, Budesonide
- Newer Drugs for Ulcerative Colitis: Natalizumab, Ustekinumab, Vedolizumab
- Fistulizing Disease: Anti-TNFα ± Immunomodulators followed by surgery.
Infectious Diarrhea
- Acute Diarrhea: Diarrhea that lasts less than 14 days.
- Campylobacter Jejuni: Source: Feco-oral, Incubation period: 2-4 days, Complications: Risk factor for Inflammatory bowel disease, Trigger for GBS (Guillain Barre syndrome), Associated with immune proliferative small intestinal disease (IPSID)/lymphoma.
- Campylobacter Jejuni Management: Indications: >70 years, Fever, Abdominal pain, Hypovolemia, ≥6 stools/day, Investigation: Culture (Shigella, Salmonella, Campylobacter), Treatment: Azithromycin 500mg
- Note: Not routinely indicated in small bowel diarrhea.
Pseudomembranous Enterocolitis
- Genesis: Clostridium difficile
- Toxins: Toxin A: Enterotoxin, Toxin B: Cytotoxic (most potent)
- Incubation period: 2 days
Treatment of Ulcerative Colitis
TrueLove & Witt's Classification
- Mild Ulcerative Colitis: 37.5°C temperature, HR >90 bpm, Anemia with Hb level 30 mm/hr
Medical Management
- 5-ASA (Aminosalicylic acid): Mainstay Rx, Disadvantage: Absorbed at small intestine → Does not reach rectum (site of active disease).
- Mesalamine: Delayed/controlled release 5-ASA, DOC for mild UC.
Management
Induction Therapy
| UC Severity | Treatment |
|---|---|
| Mild UC | Topical 5-ASA / Oral mesalamine |
| Moderate UC | Oral mesalamine + Oral steroids / Steroid resistant/refractory: Azathioprine/6-mercaptopurine |
| Severe UC | IV steroid + IV anti-TNF-α / IV Cyclosporine |
Maintenance
| UC Severity | Treatment |
|---|---|
| All UC | Topical 5-ASA + Azathioprine/6-mercaptopurine No role of steroids |
Inflammatory Bowel Disease: Part 2
Others
- Primary sclerosing cholangitis (PSC): Most common in ulcerative colitis, Fibrosing destruction of intra and extrahepatic bile ducts, Two-thirds of patients with PSC have ulcerative colitis, 5% of patients with ulcerative colitis have PSC.
- Stones: Cholelithiasis, Nephrolithiasis (Oxalate).
Other Investigations
- Fecal Calprotectin and Lactoferrin: Helps differentiate IBD relapse from infectious large bowel diarrhea, Levels increase in IBD relapse. Relapse identified by:
- a.Fecal calprotectin & lactoferrin
- b.Correlation with extraintestinal manifestations
- Ulcerative colitis: Atypical P-ANCA: Correlates with disease activity, Anti-goblet cell antibody
- Crohn's disease: ASCA: Anti-saccharomyces cerevisiae antibody, OmP-C: Outer membrane porin C antibody, APB: Anti-pancreatic antibody, Anti-la: Elevated → Bad prognosis, need for surgery, Anti-flagellin
- Note: ASCA is common to Crohn's disease and Behçet's disease.
Musculoskeletal
- Osteopenia, osteoporosis, Most common (>40% of patients) due to long-term drug use
Liver Steatosis
↑ Risk of thromboembolism
Malignancy In IBD
- The risk of malignancy is present in both UC and CD.
Crohn's Disease
- Non Hodgkin's lymphoma, Leukemia, Myelodysplastic syndrome
Ulcerative Colitis
- Cholangiocarcinoma (d/t association with primary sclerosing cholangitis)
SPORADIC VS IBD-RELATED COLORECTAL CARCINOMA
| Feature | Sporadic Colorectal Carcinoma | IBD related carcinoma |
|---|---|---|
| Age of onset | >50yrs | 10-15yrs younger |
| 5-yr survival rate | 50% for both | 50% for both |
| Genetic sequence | Adenoma-carcinoma sequence | Inflammation-Dysplasia-Carcinoma sequence |
| Site of lesion | Common on left side | Any segment of diseased colon |
| Pathological feature | Adenocarcinoma | Signet ring cell carcinoma |
| Genetics | P53 mutation: Late APC mutation: Early | P53 mutation: Early APC mutation: Late |
Gastroenterology
BACILLUS CEREUS
| Feature | Heat stable toxin | Heat labile toxin |
|---|---|---|
| Toxin | Preformed | Formed |
| Incubation Period | 1-6 hours | 6-12 hours |
| Clinical Features | Vomiting | Diarrhea (↑ CAMP) |
| Source | Undercooked fried rice | meat, pudding, dried potato |
VIBRIO CHOLERA
- Pathogenesis: Non-invasive, Enterotoxin → Activates adenyl cyclase, Toxin co-regulated pilus: mediates attachment to intestinal mucosa
- Clinical Features: Watery diarrhea: Large volume, Dehydration, Hypokalemic acidosis (Normal anion gap metabolic acidosis).
- Treatment: Ringer lactate (Fluid of choice), Drug of choice: Doxycycline, Azithromycin (In pregnancy).
VIBRIO PARAHEMOLYTICUS
- Source: Raw fish
- Clinical Features: Acute diarrhea
- Diagnosis: Kanagawa phenomenon
- Treatment: No role of antibiotics.
Large Bowel Diarrhea
ENTEROTOXIGENIC E.COLI (ETEC)
- m/c cause of community acquired diarrhea, traveler's diarrhea
- Toxin: Heat labile toxin (LT) →↑ CAMP.
- Note: The table format for the Bacillus Cereus section may not entirely reflect the intended original layout.The layout formatting isn't consistent.
Infectious Diarrhea
Small Bowel
- Secretory diarrhea: In vivo toxin production (↑CAMP → ↑water absorption → Secretory diarrhea), ETEC (Enterotoxigenic Escherichia coli): m/c, Vibrio cholera, Preformed toxins (Food poisoning): Staphylococcus aureus, Bacillus cereus, Clostridium perfringens, Cryptosporidium, Microsporidium, Giardia lamblia
Large Bowel
- Invasive organisms: Shigella flexneri (0a organisms): Causes shigellosis (m/c), Campylobacter, Non-typhoid salmonella, EIEC (Enteroinvasive Escherichia coli), Vibrio parahemolyticus, Entamoeba histolytica
- Note: Salmonella typhi: Typhoid (Small bowel invasion → Fever with chills, pain abdomen, no diarrhea).
Small Bowel Diarrhea
STAPHYLOCOCCUS AUREUS
- Preformed toxin: Heat stable enterotoxin
- Incubation period: 1-6 hours
- Source: Custard, pork, canned meat
- Clinical features: Vomiting (most prominent) : D/t 5-HT3 stimulation, Abdominal cramps
- Note: Organisms producing heat stable enterotoxin: Staphylococcus aureus, Bacillus cereus, Clostridium perfringens, Yersinia, E.coli
Inflammatory Bowel Disease: Part 2
- Note: Sulfasalazine: 5-ASA + Sulfapyridine (Carrier) → Absorbed at rectum, S/E (D/t sulfapyridine): Hypersensitivity, bone marrow suppression, G6PD deficiency → No longer used, S/E of azathioprine: Hepatotoxicity, bone marrow toxicity, pancreatitis.
SURGICAL MANAGEMENT
- Procto-colectomy with ileoanal anastomosis.
- Indications: Colonic dysplasia or carcinoma, Uncontrollable colonic hemorrhage, Colonic perforation, Toxic megacolon, Medically refractory disease.
Crohn's Disease
GRADING OF SEVERITY
| Severity Level | Features |
|---|---|
| Mild - Moderate | No dehydration, No obstruction, No weight loss, No systemic features |
| Moderate - Severe | Between mild and severe |
| Severe - Fulminant | Despite steroid intake, patient has: Fever, Cachexia, Obstruction, Peritoneal signs |
MEDICAL MANAGEMENT
- Objectives: Endoscopic mucosal healing, Prevent complications (Strictures, fistulae etc).
- Drugs: Antibiotics, Corticosteroids (High risk of dependency and/or resistance), 5-ASA, Immunomodulators.
- Biologics- Anti TNF agents: Infliximab, Adalimumab, Certolizumab pegol. Play an important role in the treatment of continuously active disease/prolonged symptomatic remission.
Infectious Diarrhoea
Clinical features: Hemolytic Uremic Syndrome (HUS)
- 90%: Enterohemorrhagic E.coli 0157:H7 (most common)
- Shiga-like toxin (verocytotoxin)
- 10%: Streptococcus pneumoniae
- Neuraminidase toxin
- Shigella dysenteriae: Shiga toxin
- Note: Heat stable toxin of ETEC ↑cGMP.
SHIGELLA
Pathogenesis
- Invasion by plasmid antigen (affects all 4 layers of intestinal wall)
- Shigellosis (severe inflammatory diarrhea)
- Reactive arthritis
Treatment
- Ciprofloxacin (DOC)
- Azithromycin
Note: Differential Diagnosis for Diarrhea with Arthritis
- IBD (Inflammatory Bowel Disease)
- Identified by:
- Elevated fecal lactoferrin/calprotectin
- Extraintestinal manifestations
- Erythema nodosum
- Episcleritis
- Type-1 (peripheral) arthritis
- Identified by:
NON-TYPHOID SALMONELLA
- Source: Fecal-oral
- Incubation: 6-72 hours
- Pathogenesis: Invasive enterotoxin
- Complications:
- Aortoarteritis (most severe)
- Endovascular infection
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