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CLOSE THIS BOOKClinical Guidelines and Treatment Manual (MSF, 1993, 319 p.)
Chapter 3 - Gastro-intestinal diseases
VIEW THE DOCUMENTStomatitis
VIEW THE DOCUMENTGastritis and Peptic Ulcer
VIEW THE DOCUMENTAcute diarrhoea

Clinical Guidelines and Treatment Manual (MSF, 1993, 319 p.)

Chapter 3 - Gastro-intestinal diseases

Stomatitis

Inflammation of the oral mucosa, with or without infection, frequently found in infants.

If severe can contribute to malnutrition. Always treat carefully, and explain treatment to the mother.

Clinical features

- Sore mouth, dysphagia, anorexia, nausea, vomiting.

- Depending on etiology: red mucosa, aphthous or other ulcers, vesicles, white plaques.

Etiology and treatment

CANDIDA ALBICANS ("THRUSH") (dispensary)

- Common in infants.

- White plaques.

- Clean the mouth with a gauze swab soaked in sodium bicarbonate, then apply gentian violet with a cotton bud. Show the mother how to do this and have her repeat it 6 times a day.

- Often associated with gastro-intestinal candidosis. Treat all cases of oral thrush with: nyststin(PO): 100,000 to 200,000 IU/d divided in 3 doses x 5 to 10 days.

(Use the vaginal tablets if only these are available.)

- Educate the mother about oral hygiene.

- In severe forms, think of HIV infection.

HERPES SIMPLEX (dispensary)

Commoner in older children and adults. Infection causes pain and difficulty eating. Transmission is via microdroplets of saliva. Attacks are often precipitated by a febrile illness or stress.

- Oral toilet and apply gentian violet.

- Continued feeding and ensure good hydration.

- Treat any underlying illness (e.g. malaria, pneumonia).

With a secondary infection (rare if good oral toilet):

cotrimoxazole (PO)
Adult: 1,600 mg/d of SMX divided in 2 doses x 5 days
Child: 40 mg/kg/d of SMX divided in 2 doses x 5 days
or
chloramphenicol(PO): 50 mg/kg/d divided in 3 doses x 5 days

SCURVY (dispensary)

Hemorrhagic stomatitis with bone and joint pains in the lower limbs (due to subperiosteal hemorrages). Caused by dietary vitamin C deficiency.

Local treatment: oral toilet and gentian violet

Curative treatment
ascorbic acid (vitamine C)

Adult: 500-1000 mg/d divided in 3 doses during 2 to 3 weeks
Child: 100-300 mg/d divided in 3 doses during 2 to 3 weeks

Preventive treatment
ascorbic acid (vitamine C)

Adult: 100mg/d
Child: 30-50mg/d

Nutritional education and supplementation with fresh fruit.

Other causes

Vincent's angina

Measles (Koplik's spot)

Diphtheria

Scarlet fever (strawberry tongue): a streptococcal infection.
Treatment:

PPF(or procain penicillin): 100,000 IU/mg/d in a single injection x 5 days
then
penicillin V(PO): same dose divided in 3 doses/d x 10 days

Angular stomatitis of the lips: deficiencies in iron and various vitamins:

multivitamins
and/or
ferrous sulphate +folic acid.

Gastritis and Peptic Ulcer

Inflammatory or ulcerative lesions of the gastro-duodenal mucosae.

Clinical features

- Epigastric burning pain, sometimes made worse and sometimes relieved by food (especially milk) but recurring about two hours after meals.

- Acid regurgitation, nausea.

- Abdomen soft and non-tender (unless perforation).

- Exclude parasitosis (strongyloides): stool examination.

Treatmert (dispensary)

- Diet: avoid spices, alcohol, tobacco, carbonated drinks.
Encourage regular meals, dairy products.

- Antacids: aluminium hidroxide (PO): 300 to 500 mg in a single dose, taken 1 hour after each meal or during attacks of pain

- Reassure the patient: anxiety may be a causative factor. If needed: diazepam (PO): 15 mg/d divided in 3 doses for a brief period (5-10 days)

- If severe pain continues, exclude perforation: examine abdomen for peritonism, PR exam for rectal blood (melena on glove), keep under observation, surgical referral if necessary.

Give: atropine (IM or SC): 1 mg stat.

(hospital)

- If hemorrhage:

· establish IV line,
· give plasma volume expander (Haemacel...),
· nasogastric tube: to observe if hemorrage continues,
· transfuse if possible and refer to a surgical unit.

NB: acetylsalicylic acid and other non-steroidal anti-inflammatories are contraindicated in patients with a history of peptic ulcer.

Acute diarrhoea

Loose, frequent stools. Different cultures have different definitions, but as a guide, diarrhea means at least 3 loose or watery stools in a day.

Major complications:

- Dehydration: the principal reason for the mortality attributable to diarrhea

- Negative effect on nutritional status

Clinical assessment of the patient

HISTORY

- Duration of illness.

- Frequency and consistency of stools (blood, mucus).

- Frequency and duration of vomiting.

- Output, colour and quantity of urine.

- Fever or convulsions.

- Type and quantity of fluids and food ingested.

- Presence of blood or mucus in the stool.

- Presence of other cases in the household.

PHYSICAL EXAMINATION

- Temperature (rectal if possible).

- Respiration (acidosis: Kussmaul breathing).

- Weight:

· as a baseline to monitor rehydration,
· as an indicator of degree of dehydration.

- Nutritional status.

CLINICAL EVALUATION OF DEGREE OF DEHYDRATION

See table 4.

STOOL EXAMINATION

Direct smear, if available, to look for trophozoites of entamaeba hystolitica or giardia lamblia.


Table 4

Etiology


Table 5

Treatment

Basic principles:

- Prevent dehydration.

- Replace fluid if dehydration already exists.

- Maintain nutrition.

PREVENTION OF DEHYDRATION

Cases of diarrhea with no signs of dehydration:

- Advise increasing fluid intake (water, soup, juices, rice water).

- Encourage the use of home-made sugar / salt solutions.

- Continue breast feeding and normal diet.

- Warn mother to bring child back if:

· signs of dehydration appear (explain),
· diarrhea persists.

FLUID REPLACEMENT

- Two tasks:

· Rehydration: correct the deficit in water and electrolytes.
· Maintenance: replace continuing losses (diarrhea and vomiting).

- Two methods of fluid replacement:

· ORS: for mild to moderate dehydration, give by mouth or by nasogastric tube if child unable or unwilling to drink.

· Ringer's lactate: for severe dehydration or if there is intractable vomiting.

- Quantities of fluid are calculated according to the condition of the patient (see tables 6 and 7). As a general rule, for severe dehydration 200 ml/kg/day should be given with the first half during the first 4 hours. For moderate dehydration, give 100 ml/kg/day with first half given during first 4 hours.

- Mild cases can be treated as outpatients, after the mother has been shown how to use ORS. Moderate and severe cases require supervision as to the evolution of the diarrhea and progress of rehydration.

- If it is impossible to place an IV line in a severely dehydrated child, fluids are sometimes given intraperitoneally or subcutaneously. However these techniques should not be encouraged, as they are less safe and no more effective than giving ORS by nasogastric tube.

Note: solution of salt-sugar: 2 pinches of salt (3 g), 4 tablespoons of sugar, or 8 pieces (40 g), dissolved in 1 liter of boiled water, cooled and with added fruit juice.

Table 6: Rehydration protocol

- The volumes indicated are guides only.

- Before using this table, consider all of the following:

· Rehydration must be evaluated in terms of clinical signs, not in terms of volume of fluids given.

· If necessary, the volumes given below can be increased or else the initial high rate of administrahon can be maintained until there is clinical improvement.

· Periorbital edema is a sign of fluid overload in infants.

· Maintenance therapy (table 7) should begin as soon as signs of dehydration have resolved, but not before.


Table 6

Table 7: Maintenance therapy

Notes:

- fluids to be given after correction of dehydration;

- adapt re-hydration treatment to the clinical status of the patient;

- to avoid hyrpernatremia altemate ORS and water.


Table 7

MAINTAIN NUTRITION

It has been shown that there is no physiological reason for discontinuing food during bouts of diarrhea and that continued nutrition is beneficial to both adults and children. Continued feeding should be encouraged.


Table 8

MEDICINES

- Remember that 50-60 % of acute gastro-enteritis is viral (see table 5).

- Certain antibiotics are used to treat specific intestinal infections.


Table 9

- Other anti-diarrhoea indications (e.g. absorbents) are contraindicated in children.

- Always treat the fever and consider other causes for the diarrhoea (e.g. malaria, otitis, pneumonia).

Prevention of diarrhea

HEALTH EDUCATION

Directed at mothers in dispensaries, MCH clinics and feeding centers, at the time ORS is prescribed.

Take-home messages:

1) Breastfeeding:

· on its own up to age 4 months
· continue up to age 2 years

2) Solid foods ("weaning foods" is a very poor term): introduce these from about age 4 months

3) Food preparation

4) Drinking water

5) Hygiene

SANITATION

- Provision of safe drinking water in sufficient quantities

- Disposal of feces

MASS CHEMOPROPHYLAXIS

- This is only ever considered in cholera epidemics. It is of doubtful efficacy in controlling an outbreak and can only be justified in a sequestered populations: a ship, a medium size where the attack rate is high (more than 2 %) and where it is possible to administer an effective prophylactic dose under supervision to the whole group concerned.

- In endemic situation, it can be given to close family contacts.

- Doxycyclineshould be choosen.

Note

Composition of ORS sachets (to be dissolved in 1 litre of clean water (do not tell mothers to boil the water as this is very expensive in terms of time and fuel, and also unnecessary). (See table C).


Table

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