During this 20-25 minute pre-recorded lecture, Dr. Maia Kayal discusses the topic of GI infections. This in-depth review will provide an update on this topic for your clinical practice as well as supplement your learning for the ABIM Gastroenterology and Hepatology boards. CME pre-requiste of live Q & A webinar, 8th Annual Mount Sinai Intensive Board Review in Gastroenterology & Hepatology on Oct 6. Hello. My name is Maya chaos and I am an assistant professor in the division of gastroenterology. In the next 20 minutes we will discuss gi infections. Our learning objectives today include number one to identify the infectious organisms which affect the esophagus, small bowel, William and colon and number two to develop principles for diagnosing and treating gi infectious entities. We will achieve these objectives through a series of case based questions. We will first talk about self jail infections. Question number one, a 50 year old man presents to the er with seven days of ladin, aphasia, epic gastric pain, low grade fevers. He has a history of hypertensive kidney disease and received a kidney transplant six months ago. His medications include listening, predniSONE tackle LIMAs and Michael. Finally marcato on exam his temperature is 38 his blood pressure is 1 48/97. His hurry is 90 and he's breathing at a rate of 20 And Oscar up is performed and reveals a 2.5 cm. Distal esophageal ulcer with raised borders. Histology is notable for graduation tissue with intra nuclear and intra cytoplasmic inclusion bodies. What is the most likely diagnosis? The correct answer here is CMB esophagitis. The most common pathogens causing infectious esophagitis are Canada HSV and CMB patients can present with dysplasia or dine of asia chest pain, Melanie Auriemma genesis. These infections are typically seen in patients who have some type of immuno suppression being inherent, such as in patients with cancer or malnutrition or exogenous such as in patients receiving immunosuppressive therapies for benign and or malignant disease. Other fungal infections include cryptococcus histoplasmosis and blast on my cozies. Although these have been rarely described, bacterial sacrifice is also quite rare. Micro bacteria occasionally can cause esophagitis in immuno suppressed patients. But again it's quite rare. Candle esophagitis typically presents as white plaques along the esophageal mucosa. Risk factors include broad spectrum antibiotics, steroid, use diabetes and long term assets. Depression therapy, endoscopy with biopsy or brushing is needed to make the diagnosis. HSV esophagitis presents with multiple well demarcated ulcers with intervening normal mucosa and the proximal arm. It esophagus. Endoscopy with biopsy of the edge of the ulcer is necessary to confirm the diagnosis. And on histology HSV has large intra nuclear and intra cytoplasmic inclusion bodies. Cmd esophagitis presents endoscopic lee as one large ulcer at the distal esophagus. In contrast to the multiple ulcers scene with HSV esophagitis on histology, CMB has cytoplasmic inclusion bodies and in contrast to HSV ulcers are linear and deeper in this case. Endoscopy with biopsy of the base of the ulcer is needed so when in doubt and faced with esophageal ulcers, the key is to biopsy both the base and the edge of the ulcer unless the endoscopic appearance is more consistent with HSV or cmd. Candida esophagitis requires systemic antifungal therapy and should not be managed with topical agents alone. The presence of your offering real candiD diocese with dysplasia or a dina Feige is predictive of the sofa jail can't diocese according to the Infectious Disease Society of America. an impaired course of antifungal therapy is appropriate in immuno suppressed patients with symptoms of Odin, aphasia or dysplasia. However, an endoscopy should be performed if symptoms do not improve after 72 hours, The general duration of treatment is 14- 21 days. The treatment of HSV esophagitis requires a cycle of air for 14 to 21 days. Treatment of cmbs. Average ice involves induction with ganciclovir. However, if the patient can tolerate and absorb or medications then induction can be performed with val ganciclovir and Mm continued for three or 6 weeks. We're going to move on now to small intestinal infections. Question number two, A 76 year old man presents to the er with sudden onset Nausea, vomiting and diarrhea. His tools are non bloody but he notes abdominal cramps, he also reports headache and my al jobs multiple other patients from the nursing home he resides and have presented to the air with similar symptoms over the last few weeks on exam, his temperature's 38.3 blood pressure is 1 20/80 heart rate, 70 abdominal exam is notable for active. Bell sounds with mild diffuse tenderness on pal patient, which of the following is the most likely pathogen. The correct answer here is Norovirus. Astro virus could cause a similar presentation but is typically seen in Children. Nicola and campylobacter. Do not cause nausea and vomiting and more appropriately don't cause an outbreak when thinking of diarrhea. It's helpful to split it up into small intestine versus ilia Kalanick ideology. Since they present as two different syndromes, small intestinal pathogens are non invasive and non inflammatory, they cause watery diarrhea, large volume, never bloody diarrhea that's associated with mid abdominal pain and malabsorption viruses are the most common small intestinal pathogen, specifically rotavirus and norovirus. Some cases are due to bacteria most commonly enter toxic genic E. Coli, which is also known as travelers. Diarrhea parasites typically present with a more chronic diarrhea picture. Mhm. Norovirus is the second most common cause of Gi infection. Death in the United States and is responsible for 80% of cruise ship diarrhea cases. Entro toxic genic E. Coli is second, Norovirus is transmitted via fecal oral route and requires as little as 10 variants to catch the infection. It often runs rampant in families and nursing homes and unfortunately alcohol sanitizer does not spread, stop the spread of viruses. Norovirus is the most common cause of gastroenteritis in the United States Is the second most common cause of giant affection death in the United States and causes up to 80% of episodes of cruise ship. Diarrhea is transmitted via fecal oral route and requires as little as 10 variants to catch the infection. It runs rampant and families and nursing homes and unfortunately alcohol sanitizer does not stop the spread of viruses. The incubation period of norovirus is 12 to 24 hours, symptoms are abrupt and include gI upset, such as nausea, vomiting, diarrhea and fever and malaise the symptoms last less than 72 hours, however, can extend up to two weeks and patients may remain contagious for up to three weeks, diagnosis is based on history and still pcr and treatment is supportive. Unfortunately there is no lifelong immunity to norovirus and so patients can continue to catch the virus. Question number three, A 51 year old business executive presents for pre travel counseling. He's planning a two week trip to Southeast Asia in a few months and wants any vaccinations that are recommended. He is on the top row for hypertension and takes a daily aspirin. He inquires if he can bring any medications with him in the event that he developed traveler's diarrhea, which of the following do you recommend? The correct answer Here is azithromycin. The location of travel to Southeast Asia raises the concern for queen alone resistant campylobacter and hence visitor mason is recommended bismuth can be used for travelers but significant doses are required and those on aspirin therapy are at an increased risk of salicylic toxicity. Super fox isn't or leave a flock season wouldn't be recommended as the first line in this case, given the concern about Quinlan resistance in Southeast Asia and Backstrom is rarely used for travelers. Diarrhea given the known widespread resistance. The most common cause of traveler's diarrhea is enter talks the most important strategy to prevent traveler's diarrhea is prudent selection of food and drink while traveling. The idea is to peel it, cook it boil it or forget it. Prophylactic medications are generally not indicated, although there may be useful for select travelers for whom an episode of diarrhea could have severe consequences. Examples include patients with severe vascular cardiac renal disease that would be compromised by dehydration or patients with IBD or that are immuno compromised business. Sub Selous elites have moderate effectiveness as profile access and may be considered for travelers who don't have contraindications and can adhere to the frequent dozing Quinlan's are no longer recommended for prophylaxis due to increasing resistance of enteric pathogens and potential for harm to the nervous system and tendons or muscles. Re fax 1 200 mg three times a day for three days can also be considered. Grace chemo prophylaxis. On to question # four, A 38 year old man with well controlled HIV is referred to you for second opinion regarding a several month history of watery diarrhea. Diffuse abdominal cramping and mount odorous flatulence. He reports £20 weight loss. His nice fevers and has had no blood in his stool at the onset of his symptoms. His id physician sent one stool specimen for analysis, ova and parasites screen and c diff is negative. His previous G. I. Performed a colonoscopy with biopsies that were normal and an upper endoscopy with duodenal biopsies that showed partial villas blending, leading to a diagnosis of silly expert. The patient has not improved despite being compliant with a gluten free diet for the past month. His labs are normal, which pathogen is most likely responsible for this patient's illness. The correct answer in this case is giardia. The patient's history and objective findings are most consistent with chronic geo diocese equally and salmonella do not typically cause chronic illness and strangulated is unlikely given his lack of US and ophelia on labs, Giardia is the most common parasite in the United States, transmission is typically via contaminated food or water or via fecal oral route. The highest risk group includes travelers, daycare workers and patients with hypoglycemic global anemia. Both cysts and trophies. It's can be found in the feces and this is actually their diagnostic stage sits are resistant forms and are responsible for transmission of geo diocese. Unfortunately, these cysts are resistant to coronation and can thus survive several months in cold water infection as I mentioned before, typically occurs by the ingestion of cysts and contaminated water food or via transmission through hands or for mites and Jared diocese can actually affect both immuno competent and immuno compromised patients, acute gero diocese develops after an incubation period of 7 to 14 days and usually lasts 123 weeks. Up to 50% of patients will develop chronic infection that can follow acute disease or can occur without an identifiable acute illness symptoms include diarrhea abdominal pain, bloating, nausea, vomiting and flatulence in chronic Jared diocese. The symptoms are recurrent and malabsorption and debilitation may occur. Several methods exist to detect giardia. Traditionally, microscopic analysis of still using wet mount or try cum stain has been performed when staying the trophies like form of the parasite appears as a smiling face with the to stay nuclear appearing as the eyes and the median bodies as the mouth. One specimen has a sensitivity of 50%. This can be increased in 90% with three samples. While microscopic analysis is the gold standard for identification of parasites, Antigen testing for Giardia has a greater sensitivity of greater than 90% when compared to microscopic analysis. Treatment for Giardia is metro night is all 250 mg three times a day for seven days. We're going to move on now and talk about elio chronic infections. Question number five, A 45 year old man presents with fever, bloody diarrhea and abdominal pain for the past 10 days. He also reports decreased appetite, fatigue, arthur, alga and My algebra. He works as a zookeeper at the Bronx zoo. His vitals are a temperature of 38.5 blood pressure of 95/54 and heart rate of 50. On exam, he had cervical and fan apathy. Hipolito splatter, medley and a red macular rash. What is the most likely cause of his symptoms the correct answer in this case salmonella. This patient has a potential exposure as a zookeeper at the Bronx zoo and has a history that includes typical features such as the rash and the pulse temperature dissociation. Basically, he has bradycardia in the setting of the febrile illness. Alia Kalanick pathogens are more likely to be invasive and inflammatory and caused Erasmus and bloody diarrhea. Pathogens are different when compared to the small intestine. Where we mentioned that the diarrhea is more large volume in water. In ilia chronic infections, there's typically no associated malabsorption. The most common type of a little Kalanick pathogen is bacteria. The four most common in United States are campylobacter, salmonella shigella and shiga toxin. E. Coli cmd is quite rare but can be seen immuno compromised patients and especially in patients with IBD, salmonella are motile, gram negative bacilli that infect or colonized a wide range of million hosts. They cause a number of characteristic clinical infections in human. The spectrum of disease includes gastroenteritis, bacteria, mia typhoid fever, focal infections such as osteomyelitis arthritis and meningitis patients can also be asymptomatic carriers, enteric fever is caused by salmonella typhoid and salmonella. Paradise. Other salmonella stereotypes are collectively known as non T photo salmonella and are a major cause of diarrhea worldwide predisposing conditions to salmonella includes sickle cell disease, lymphoma, leukemia, AIDS ecology Andrea all served colitis and steroids. The five x risks include flies, food fingers, feces and film nights, reptiles are a big salmonella risk as our eggs, peanut butter, spinach, raw almonds, frog and italian salami the diagnosis of typhoid fever is made by isolating someone Taif or paradise if from a culture specimen. In the setting of compatible clinical illness. However, culture is not how he's sensitive and this can take days to incubate. So when cultures are negative are unavailable. We treat empirically by following patients history and physical exam. It's typically treated with one drug. Antibiotic selection depends on the severity of illness, the resistance patterns and the clinical setting in severe disease. We choose to use a third generation cephalosporins and uncomplicated disease. Flora Quinlan's or is information can be used Successful treatment results in clinical improvement within 3- five days. Question number six. A 26 year old medical student with no past medical history traveled to Gambia for a two month rotation. A few weeks after his return, he presents to the er with low grade fevers, abdominal pain and diarrhea with blood and mucus. He has lower abdominal pain and tenderness. His labs are notable for a white count of 17 hemoglobin of 10 abdomen of 3.4 A. S. T. To 50 lt 200 total bilirubin of two. Signal endoscopy reveals diffuse alterations. What is the next best step? And this question? The correct answer is Metro Madison ivy. The parasite that is causing these symptoms is anti amoeba historica and to maybe histological is transmitted via fecal, oral route cysts and trophies. It's our past interfaces, infection by anti amoeba histological occurs by ingestion of the mature cysts and fecal contaminated food, water or hands. Excitation occurs in the small intestine and prophecies are released, which then migrate to the large intestine. There they have the potential to invade and cause dissemination. The amoeba can actually bore into the intestinal law, causing lesions and intestinal symptoms such as bloody diarrhea, pain and 10 Asmus, that maybe you can then reach the bloodstream from there, they can reach different vital organs of the body, including the liver, but even sometimes the lungs, brain and spleen. A common outcome of this invasion of tissues is a liver abscess, which can be fatal if I'm treated. The symptoms can also present as toxic mega colon and can mimic ulcerative colitis or Crohn's disease. Diagnosis of entity of a histological is best accomplished by a combination of serology or antigen testing. Together with identification of the parasite and stool or extra intestinal sites. Sigmoidoscopy with biopsy reveals a flask shaped me big ulster. All infections should be treated even in the absence of symptoms, given the potential risk of developing invasive disease and the risk of spread to family members. Treatment for invasive colitis should be with metro netizen and aluminum agents such as Pamela mason to eliminate inter Luminal cysts. Asymptomatic patients can be treated with a intra Luminal agent only in summary when thinking about gI infections. It's best to divide it according to location. Small intestine versus luo quan. For small intestine infections, viruses are most common and present as a non invasive non inflammatory picture with large volume diarrhea and abdominal pain. For really a chronic infections. Best bacteria are the most common pathogen and cause an invasive inflammatory picture with small volume diarrhea and Tunisia's. I hope this brief review of GI infections was helpful. If there are any questions, please do not hesitate to email me at maya dot ko at Mount Sinai dot org. Thank you for your attention.