DISORDERS OF THE GASTROINTESTINAL TRACT

DISORDERS OF THE GASTROINTESTINAL TRACT



DIARRHEA


Although diarrhea is included here in the “minor problems” section, severe diarrhea can be devastating. Diarrhea can be due to a number of causes, which include bacterial infection, viral infection, protozoal infection, food poisoning from toxin(s), unusual parasites (such as Cyclospora cayetanensis, which can contaminate fresh berries, or Cryptosporidium species, which are waterborne), inflammatory bowel disease, allergies, and anxiety. It is not always easy to determine the cause of loose bowel movements, but there is a general approach to therapy that ordinarily suffices until a precise diagnosis can be made.


In all cases of diarrhea, a common discomfort is the irritated anus (particularly one that has been wiped with leaves or newspaper). Every traveler should carry a roll of toilet paper, baby wipes, and 1% hydrocortisone lotion or steroid ointment for an irritated bottom. Desitin diaper cream and A&D ointment also work well.



General Therapy for Diarrhea




Diet. If nausea and vomiting do not prevent eating, adjust the diet:


1. When diarrhea is severe, stick to clear fluids such as mineral water, soda, Kool-Aid, or broth. Electrolyte-containing sports beverages are fine. Apple and grape juices are good, but orange, tomato, pineapple, and grapefruit juices may irritate the stomach. Avoid milk products, tea, coffee, raw fruits and vegetables, and fatty foods. Do not take aspirin.

2. As soon as there is improvement (less frequent bowel movements, decreased cramping, increased appetite), begin solid foods, starting with broth, crackers, toast, gelatin, and hard-boiled eggs.

3. As the diarrhea subsides, add applesauce, mashed bananas, rice, boiled or baked potatoes, and plain pasta.

4. When stools begin to harden, add cooked lean meat, cooked vegetables, yogurt, and cottage cheese. Avoid alcohol, spicy foods, and stewed fruit.

Dehydration can be estimated as follows:


1. Mild dehydration: thirst, dry mucous membranes (mouth, eyes), dry armpits, dark urine, decreased sweating, normal pulse rate.

2. Moderate dehydration: the above plus sunken eyes, doughy skin, weakness, scant darkened urine, rapid and weak pulse rate.

3. Severe dehydration: the above plus altered mental status, elevated body temperature, no urine, no tears, no sweating, collapse, shock (see page 60).

In a baby, dehydration is manifest as dry diaper (decreased urine output), sunken eyes, sunken “soft spot” (fontanel) on the top of the head, dry tongue and mouth, rapid pulse, poor skin color (blue or pale), lethargy (“floppy baby”), and fast breathing (greater than 30 breaths per minute in a small child, or 40 per minute in an infant). For purposes of estimation, a normal pulse rate (per minute) in a newborn averages 120; at 2 years, 110; at 4 to 6 years, 100; and at 8 to 10 years, 90.


Fluid replacement. If fluid losses are significant (more than five bowel movements per day), begin to replace liquids as soon as you can.


1. Mild diarrhea/dehydration: Drink soda water, clear juices, broth, and electrolyte-containing sports beverages. Try to replace each diarrheal stool with 10 mL of oral rehydration salts (ORS) per 1 kg (2.2 lb) of body weight. If the child is vomiting, try to replace each episode of vomiting with 2 mL of ORS per 1 kg (2.2 lb) of body weight.

2. Moderate diarrhea/dehydration: Drink diluted (by half, with water) electrolyte-containing sports beverages, mineral water (bottled), or a homemade solution (1 quart or liter of disinfected water plus ½ to 1 tsp, or 1.3 to 2.5 mL, of sodium chloride [table salt], ½ tsp of sodium bicarbonate [baking soda], ¼ tsp, or 0.6 mL, of potassium chloride [salt substitute], and glucose [6 to 8 tsp, or 30 to 40 mL, of table sugar; or 1 to 2 tbsp, or 15 to 30 mL, of honey]). Take care not to oversweeten (exceed 2% to 2.5% glucose) the solution with sugar, because this may worsen the diarrhea; too high a sugar concentration inhibits water absorption through the gastrointestinal tract. Each quart of this “home brew” should be alternated with ½ to 1 quart of plain disinfected water. Try to replace fluid losses at least every 2 hours.

Oral rehydration salts (ORS) that meet World Health Organization standards are available in a dry mix; use one packet per quart (liter) of water. One packet contains sodium chloride 3.5 g, potassium chloride 1.5 g, glucose 20 g, and trisodium citrate 2.9 g (or sodium bicarbonate 2.5 g). Cera Lyte 70 oral rehydration salts are based on a rice solution. One packet is mixed with a quart (liter) of water. After the solution is prepared, it should be consumed or discarded within 12 hours if kept at room temperature or 24 hours if kept refrigerated. Other ORS products available over-the-counter include Pedialyte, Enfalyte, Naturalyte, and Rehydralyte.

Try to get the victim to ingest a quart per hour until the frequency of urination begins to increase and the urine color turns light or clear. To begin, start with small (e.g., 5 mL or 1 teaspoon) amounts every 1 to 2 minutes, to avoid collection of a large amount of fluid in the stomach that might cause vomiting. A child should be given 1½ oz (44 mL) of ORS per pound (0.45 kg) of body weight over the first 4 hours, then 1 oz (30 mL) of ORS per pound of body weight per 8-hour period until the diarrhea resolves. Another estimate of fluid replacement for children is 100 mL (approximately 3 oz) of fluid per significant loose bowel movement. For an infant with diarrhea, decrease the amount of milk in the diet, and add more water, diluted juices, half-strength sports beverages, and ORS. Sweetened carbonated beverages (soda pop) are not good replacement fluids, because they contain too much sugar and little or no sodium and potassium. If the child is breast-fed, keep nursing (offer the breast more often). If the child is formula-fed, use ORS for 12 to 24 hours, and then try switching back to formula. If the diarrhea persists switch back to ORS for another cycle. It is important to continue to provide nourishment with food (and calories) to children with diarrhea, not fluid alone. Avoid foods high in simple sugars (including tea, juices, and soft drinks). Try complex carbohydrates (rice, wheat, potatoes, bread, cereals), yogurt, lean meat, fruits, and vegetables.

If premeasured salts are not available with which to supplement water, you can alternate glasses of the following two fluids, as recommended by the U.S. Public Health Service:
• Glass one—8 oz fruit juice with ¼ tsp (a “pinch”) table salt and ½ tsp honey or corn syrup (237 mL juice, 1.3 mL table salt, 2.5 mL honey or corn syrup)

• Glass two—8 oz disinfected water with ¼ tsp baking soda (sodium bicarbonate) (237 mL water, 1.3 mL baking soda)

Another homemade fluid mixture is 1 tsp (5 mL) table salt and 1 cup (275 mL) rice cereal in a quart (liter) of water; this must be used within 12 hours or discarded. If only fruit juice (without supplementation) is available, remember to cut it to half strength with water. Otherwise, the sugar content will be too high and may contribute to continued diarrhea. Estimation techniques to measure powdered ingredients (such as a “pinch” of table salt) are notoriously inaccurate, and can even be dangerous if you add excessive amounts. Use a proper measuring implement whenever possible.

3. Severe diarrhea/dehydration: Same as moderate. After a certain point, as with cholera, intravenous hydration may be lifesaving. See a physician as soon as possible.

If nausea and vomiting are present to a degree sufficient to inhibit or prevent oral rehydration, consider administration of an antiemetic drug, such as ondansetron (Zofran: adult dose 4 mg oral dissolving tablet; pediatric dose 0.15 mg/kg body weight of the oral dissolving tablet every 8 hours).

Antimotility (decreased bowel activity) drugs. If fever, severe cramping, and bloody diarrhea are absent, it is safe to use antimotility drugs, although they should be immediately discontinued if diarrhea lasts for more than 48 hours. If diarrhea lasts longer than 3 days, if the victim has a fever greater than 101°F (38.3°C), if he cannot keep liquids down because of vomiting, if there is blood in or on the stool, if the abdomen becomes swollen, or if there is no significant pain relief after 24 hours, seek a physician immediately.


The antimotility drug of choice is loperamide (Imodium A-D). The initial adult dose is 4 mg (two 2 mg capsules, or 4 tsp—20 mL—of the liquid), followed by 2 mg after each loose bowel movement, not to exceed 16 mg (eight capsules) per day or 2 days of administration. With uncomplicated (no fever or blood in stools), watery diarrhea, this drug can be given to children age 2 years and older. Give children a 0.2 mg/kg (2.2 lb) of body weight dose every 6 hours. The liquid preparation contains 1 mg/tsp (5 mL).


For adults, diphenoxylate (Lomotil) is an alternative, but has side effects of dry mouth and urinary retention. Pepto-Bismol is another, less effective choice (see page 212).


Kaopectate (kaolin plus pectin) is of limited value; it does not shorten the course of diarrheal illness, and acts only to add a little consistency to stools. Lactobacillus preparations (acidophilus beverages or yogurt) do not shorten the course of acute diarrheal illness, but they may be useful to repopulate the gastrointestinal tract with normal bacteria after a severe bout of diarrhea or administration of antibiotics used to treat diarrhea.


In foreign countries, drugs are on occasion recommended for diarrhea without a specific diagnosis. These drugs include chloramphenicol (Chloromycetin), Enterovioform, MexaForm, Intestopan, clioquinol, and iodoquinol. This may be dangerous, because these drugs can have certain adverse direct effects or side effects. Therefore, they should not be taken without a specific diagnosis for which they are felt to be indicated.




Antibiotics. These should be used if diarrhea is moderate to severe (more than eight bowel movements per day), particularly if it is bloody and associated with severe cramping, vomiting, and fever.


1. Administer ciprofloxacin (Cipro) 500 mg twice a day, or trimethoprim-sulfamethoxazole (Bactrim or Septra) one double-strength pill twice a day for 3 days. These will treat E. coli and Shigella, may be of use for Salmonella, and will not adversely affect the course of viral, Staphylococcus, or Campylobacter infections. The duration of cholera caused by Vibrio cholerae may be shortened by treating with azithromycin (1 g single dose), ciprofloxacin (1 g single dose; increasing resistance is being noted to this drug) or doxycycline (300 mg single dose) for adults, or trimethoprim-sulfamethoxazole for children (5 mg/kg, or 2.2 lb, of body weight, based on the trimethoprim component, for 3 days). Resistant strains are very common; for instance, in Bangladesh, cholera is resistant to tetracycline, erythromycin, and trimethoprim-sulfamethoxazole. Enteric fever caused by Salmonella typhi (typhoid fever) is best treated in adults with ciprofloxacin.

Alternative drugs include norfloxacin (Noroxin) 400 mg twice a day for 3 days, ofloxacin (Floxin) 200 or 300 mg twice a day for 3 days, or fleroxacin 400 mg once a day for 3 days. Another alternative drug is doxycycline (Vibramycin) 100 mg twice a day. Children younger than 12 years of age should not be given doxycycline, because it may cause discoloration of the permanent teeth. Because ciprofloxacin may affect bone growth in children, it should only be given to adults.

If the clinical picture clearly points to Giardia lamblia (see page 216), administer metronidazole (Flagyl) 250 mg three times a day for 7 days. (A woman who is possibly pregnant should not use this drug except under the advice of her physician.)

Sometimes diarrhea is caused by antibiotic administration. This is called “Clostridium difficile–associated disease,” “antibiotic-associated diarrhea,” or “antibiotic-associated colitis.” It is caused by infection with the organism Clostridium difficile, which thrives in the bowel after the normal germs are killed by the initial antibiotic therapy. Another causative factor may be administration of a proton pump inhibitor drug, which lowers gastric acid, which helps C. difficile to survive and therefore be able to elaborate its toxin. Therapy against C. difficile is metronidazole (Flagyl) 500 mg by mouth three times a day or 250 mg by mouth four times a day, or vancomycin 125 mg by mouth four times a day for 10 days. It is important to note that C. difficile spores are not destroyed by disinfectant hand gels; thus handwashing remains extremely important to prevent the spread of this infectious organism.

Probiotics are harmless microorganisms (mostly bacteria and yeast) that are thought to provide health benefits. Examples include Lactobacillus rhamnosus and casei, which are found in certain yogurt products, and CULTURELLE, which is an all-natural dietary supplement containing the probiotic, L. rhamnosus GG (LGG). Probiotics, therefore, are a class of “friendly” bacteria that live in the digestive tract where they help to restore and maintain a healthy balance of “good” versus “bad” bacteria. They may be helpful in helping the bowel recover its normal function if ingested during and after a bout of diarrhea, particularly if antibiotics are used to treat the victim. They may also lessen the propensity for a person to develop C. difficile infection after being treated with an antibiotic for gastroenteric infection.


Traveler’s Diarrhea


Traveler’s diarrhea (“turista,” “Kathmandu quickstep,” “Montezuma’s revenge,” “Delhi belly,” “Aztec two-step,” “Hong Kong dog,” and many other synonyms) is frequent, loose bowel movements (three or more loose stools in a 24-hour period associated with one or more of nausea, vomiting, abdominal cramps, fever, urge to defecate, cramping and straining with defecation, or bloody or mucus-laden stools) caused by waterborne or food-borne pathogens, most commonly produced by forms of the bacterium Escherichia coli, which is introduced into the diet as a fecal contaminant in water or on food. Someone has described it as “stool that fits the shape of the container.” When caused by E. coli, symptoms usually occur 12 to 36 hours after ingesting the bacteria, and include the gradual or sudden onset of frequent (four to five per day) loose or watery bowel movements, rarely explosive, and far less violent than diarrhea associated with classic food poisoning (see below). Fever, bloating, fatigue, and abdominal pain are of minor to moderate severity. Nausea and vomiting are less frequently found than with viral gastroenteritis. Most traveler’s diarrhea is caused by bacteria, but a small percentage may be caused by viruses or parasites.


The affliction will resolve spontaneously in 2 to 5 days if untreated, but may be hastened to a conclusion if an antibiotic is administered. The current recommendation is to treat adults with ciprofloxacin (Cipro) 500 mg twice a day for 1 to 3 days or a single dose of 1 g, norfloxacin 800 mg in a single dose, or azithromycin 1 g single dose (10 mg/kg [2.2 lb] of body weight in children once a day for 3 days). Trimethoprim-sulfamethoxazole (e.g., Bactrim or Septra) is no longer recommended for traveler’s diarrhea, because of bacterial resistance. Another effective drug is rifamixin in a dose of 200 mg by mouth three times per day for 3 days. For known traveler’s diarrhea, the addition of loperamide (Imodium A-D) to the antibiotic regimen can be of significant benefit, with the precaution that it should be used only in the absence of high fever or bloody diarrhea. Alternatively, the diarrhea can be treated with bismuth subsalicylate (Pepto-Bismol); give two 262 mg tablets (or the liquid equivalent) every 30 minutes for eight doses, which may be repeated the second day. Kaolin and pectin given orally in combination may make the stools less runny, but do not shorten the duration of the diarrhea. Yogurt and lactobacillus preparations are not effective treatments.


During the recovery period, it is fine to advance the diet fairly rapidly over a few days from clear liquids to bland foods to a normal diet.


To prevent traveler’s diarrhea, a person traveling to high-risk regions with questionable hygiene and municipal water-disinfection standards (developing countries of Latin America, Africa, the Middle East, and Asia) can take rifamixin 200 mg once a day or ciprofloxacin 500 mg (or norfloxacin 400 mg or ofloxacin 200 mg) once a day, during the journey. Southern Europe (Spain, Greece, Italy, Turkey) and parts of the Caribbean pose a lesser risk. Another drug that can be used is doxycycline (Vibramycin) 100 mg twice a day. This should be done under the guidance of a physician, who will explain the risks (allergic reactions, blood disorders, antibiotic-associated colitis, vaginal yeast infection, skin rashes, photosensitivity) versus the benefits (particularly for those prone to infectious diarrhea or who would suffer unduly from an episode of severe diarrhea). Ingesting lactobacilli may improve certain aspects of digestion, but does not prevent traveler’s diarrhea.


Alternatively, it has been recommended that you can drink 4 tbsp (60 mL) of Pepto-Bismol (bismuth subsalicylate) four times a day; this necessitates carrying one 8 oz bottle for each day. The tablets (two 262 mg tablets four times a day) are less palatable. However, this prophylaxis is not intended to substitute for dietary discretion. In addition, large doses of bismuth subsalicylate can be toxic, particularly to people who regularly use aspirin. Anyone with an aspirin allergy should not use bismuth subsalicylate. Side effects include blackened stools and a black tongue, nausea, constipation, and ringing in the ears.


People who would be advised to consider taking a drug to prevent infectious diarrhea include those with a significant underlying medical problem (such as acquired immunodeficiency syndrome [AIDS], inability to produce stomach acid, or inflammatory bowel disease) and those with an itinerary rigid enough that it would be catastrophic to the mission to be laid up with diarrhea.


Some experts and the medical literature argue that conventional advice to avoid specific foods and liquids doesn’t really help prevent traveler’s diarrhea. However, on the chance that certain behaviors might be helpful, here are some commonly accepted notions. In general, it is safe to brush your teeth with foreign or mountain water, so long as you spit and don’t swallow. Salads (particularly lettuce), raw vegetables, raw or undercooked meat (particularly hamburgers), raw or undercooked snails or seafood, unpeeled fruits and vegetables, cold sauces, ice cream, fresh cheese, spicy sauces in open containers, tap water, and ice are risky business. Fresh produce should, when possible, be purchased not bruised or damaged. Produce should not be packed with raw meat, poultry, or seafood products. Fruits and leafy vegetables should be washed in iodinated water, washed with dilute soap and previously boiled water, or immersed in boiling water for 30 seconds. In some underdeveloped countries, melons are injected with contaminated water to increase their weight before sale. Be cautious with buffets, food from street vendors, and the salads served on flights that originate from developing countries. Food prepared in restaurants in developing countries probably poses greater risk than does self-prepared food.


Probiotics have not yet been demonstrated to reduce the risk of traveler’s diarrhea.


If possible, wash your hands with soap and water before you handle food or eat. If a disinfectant gel or lotion is available, use it, even after handwashing. This will significantly reduce the risk for transmission of bacteria and viruses that cause infections. Disinfectant gels do not provide protection, however, against spore-forming bacteria, such as Clostridium difficile, so handwashing retains its importance when this bacterium is a possible environmental contaminant.


In addition to proper handwashing (or wiping with disinfectant gel or cream) and disinfection of drinking water, there come a number of important actions, such as “food rules” (proper washing, cooking, and serving; what foods to avoid), bathroom hygiene, not sharing items such as towels and toothbrushes, and so on.


One important topic is how best to wash dishes to remove diarrhea-causing bacteria and viruses. One effective washing-up system is removal of most food residue with detergent (5 milliliters or 1 teaspoon) in the water in bowl 1, followed by a finishing wash (scrub until clean) with bleach (10 milliliters or 2 teaspoons of 4% chlorine bleach) in the water in bowl 2, followed by a final rinse in drinkable water in bowl 3. The final rinse is felt to remove the taste of the detergent and bleach (the latter considered to be a disinfectant). A few final recommendations are to use hot water in bowl 1, use a scouring pad or brush in bowl 2 with the bleach to avoid contamination of the scourer, allow all utensils to air dry after washing, and clean the washing-up bowls and allow them to dry between uses. Another suggestion is to use up to 100 milliliters or 20 teaspoons (3 teaspoons = 1 tablespoon) of bleach in bowl 2 if there is a current outbreak of diarrhea and vomiting. This increases the disinfection power of the second bowl.


Water disinfection is discussed on page 433. Stick to boiled water, food that is served steaming hot, dry foods (bread), bottled carbonated beverages, and reputable food establishments. Alcohol in mixed drinks does not disinfect water. Packaged butter and packaged processed cheese are usually safe to eat. Unpasteurized dairy products should be avoided. Avoid casseroles, quiches, lasagna, and other foods that are prepared in advance and then may be allowed to sit for a prolonged period before consumption. During that time period, they can be contaminated by bacteria from fingers, insect legs, and contaminated serving utensils. With regard to seafood, raw or undercooked products, particularly shellfish, are especially hazardous. Vibrio organisms—which cause, among other problems, cholera—frequently reside in crabs and oysters. Cook all shellfish for a minimum of 10 minutes of boiling, or 30 minutes of exposure to full steam.

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Aug 11, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on DISORDERS OF THE GASTROINTESTINAL TRACT

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