GASTROINTESTINAL DISEASES

Anticholinergics to relieve spasm of oesophagus. Tab Probanthine or Buscopan, one tablet thrice daily ½ hour before meals.

Nifedipine 10 mg thrice daily is beneficial.2

To avoid irritant substances like salicylates. NSAIDs. Alcohol, spicy food, gulping of food and swallowing unchewed food particles should be avoided.

Avoid lying down for 2-3 hours after taking food.

Oesophageal dilatation using pneumatic bag under fluoroscopic guidance.

Oesophago-cardio-myotomy may be required in a few cases.

Rest in bed.

Nothing to be taken orally.

IV fluids 5 per cent Dextrose/ringer solution.3

Analgesics/sedatives like Fortwin 30 mg slow IV or IM or Phenargan (Morphine is contraindicated as it causes spasm of sphincter of oddi).

Antibiotics are needed.

Injection Ampicillin 500 mg, 6 hourly IV or IM

and injection Gentamycin 60 mg 12 hourly IV or IM

and injection Metrogyl 100 mg 8 hourly IV

Injection B complex 2 ml IM or IV on alternate day

Once acute attack subsides allow fat free liquid diet and later on fat free soft diet may be taken.

Bed rest.

Bland soft diet.

Mucaine gel or digene gel 2 tsf thrice daily after meals.

Tab Ranitidine 150 mg twice daily or Ramotidine 20 mg twice daily.

Tab Probanthine twice daily.

Tab Sucralfate 1 gm tds if NSAIDs induced erosions.

Specific antidotes for corrosive poisons.

Treat infective cause if any.

Rest and soft nutritious diet.

Broad spectrum antibiotic preferably Amoxicillin 1 tds for 7 days.

Fever, leucocytosis, abdominal rigidity/ascites, blood in the faeces means strangulation and immediate surgery is essential.

If in an uncomplicated case with adequate decompression pain does not subside and flatus does not pass, operation is inevitable. Surgery consists of relieving the obstruction and removal of gangrenous bowel with reanastomosis.

Nil orally. Fluid and electrolyte balance to be maintained.

Several litres of IV fluid replacement as patient is invariably dehydrated.8

Continuous gastric suction to reduce vomiting and distension of gut.

For pain, injection Pethidine 100 mg IM or Morphine 15 mg IM.

Injection Atropine 0.6 mg IM or injection Probantheline 15-30 mg six hourly to reduce gastric, duodenal and pancreatic secretion and to relieve spasm of sphincter of oddi.

Antibiotics for secondary infection—Injection Ampicillin 500 mg 6 hourly and Gentamycin 60-80 mg eight hourly.

Calcium gluconate 10 per cent as 10 ml slow IV twice or thrice if serum calcium is low.

Liquid Gelucil or Divol or Siloxagen one table spoonful hourly through Ryle's tube.

If respiratory distress then oxygen.

Avoid alcohol.

Hydration is to be maintained by oral fluids or IV supplementation.

Vitamin K for elevated prothrombin time as 10 mg IM.

Vitamin B supplementation especially thiamine and folic acid.

Low dose steroids to be used only if everything else fails.

If patient has severe dehydration elevated prothrombin time (> 1.5 times of normal), intractable nausea or vomiting, marked rise of bilirubin, hepatic encephalopathy, azotemia person may require hospitalisation.

Tab Metrogyl 800 mg tds for 5 days (children 50 mg/kg/day in three divided doses).

or

11Tinidazole 2 gm/day for 5 days.

or

Tab Secnidazole 2 gm as single dose.

or

Diloxamide furoate 500 mg plus Metrogyl 400 mg tds for 5 days

or

Tab Furamide 500 mg tds for 10 days.

For abdominal pain Tab Buscopan or Capsule Spasmoproxyvon bd or tds.

In dehydration IV fluids may be given.

Tab Diloxamide Furoate 500 mg tds × 10 days.

or

Tab Furamide 500 mg tds × 10 days.

or

Dependal-M 1 tds × 10 days.

Mineral oil and stool softners daily. Mild laxative-Syp Cremaffin 2-3 tea spoon hs.

Anal suppositories twice daily.

Local application of Gentian violet 1 per cent Xylocaine 4 percent jelly locally 1/2 hour before passing stools or sos.

Anal dilatation.

Surgical excision if all above measures fail or recurrence occurs.

Avoid spices, tobacco, hot food.

Bland diet.

Good oral hygiene.

Aqueous Chlorhexidine 0.2 per cent mouth wash.13

Efcorlin pellets (GSK) allow pellet to dissolve in close proximity to ulcer 3-4 times daily.

Tetracycline or Mystecline capsule 250 mg, dissolve one capsule in water and rinse mouth 3 times a day.

Glycerine or Zytee for topical application.

If pain tablet Paracetamol 1 tds.

Patient to be reviewed within 3 weeks to ensure healing has occured otherwise ulcer must be biopsied.

Complete bed rest.

Nothing orally.

Laxatives and narcotics are absolutely contraindicated.

IV glucose saline.

Nasogastric intubation with gastric lavage.

Inj Ampicillin 500 mg 6 hourly IV, Inj Gentamycin 80 mg IM 8 hourly, Inj Metrogyl 1 g 8 hourly IV.

Appendicectomy within 48 hrs.

Correct dehydration IV fluids or Electral powder orally.

Ampicillin 500 mg 6 hourly.

Antispasmodics if needed.

Stomach wash if diagnosed early.

ABC botulinus anti-toxin.

Maintenance of oxygenation and ventilation by good respiratory drainage (elevation of foot end) aspiration or tracheostomy and mechanical respiration if necessary.

Parenteral fluids.

Antibiotics if pneumonitis develops.

Surgical resection of the lesion and its regional lymphatics after adequate bowel preparation in early cases.

In late cases with invasion or obstruction palliative resection.

Preoperative irradiation 2000 to 2500 R, in 10 sittings over 12 days increases resectability and improves survival.

Irradiation is best, if upper half of oesophagus is involved.

In absence of metastasis, tumours of lower half may be treated by resection and oesophago-gastrostomy or jejunal or colonic interposition. Gastrostomy for palliation in hopeless cases may be done to improve nutrition. Cure rate in best hands is only 5 to 10 per cent.

Saturated solution of sodabicarb for mouth wash.

One per cent gentian violet to be painted three times daily on the patches.19

Nystatin tablet or Mycostatin tablet dissolved in Glycerine and applied locally and oral Nystatin 500,000 units three times daily or Nystatin mouth wash.

Oral lesions may respond only to IV Amphotericin with or without Fluconazole or Ketoconazole.

Cytotoxic drugs, irradiation or surgery have not proved effective.

When benign or malignant hepatic neoplasms are encountered in ladies taking oral contraceptives, discontinuation of contraceptives may cause regression of benign tumours (i.e. focal nodular hyperplasia).

Alcohol injection into tumour.

If distant metastasis is present palliation with radiation therapy, with 5 fluorouracil, gastroentero-stomy or palliative resection can prolong life.

If the tumour is localised to stomach sub-total gastrectomy is the standard treatment.

Cholecystectomy and choledochostomy.

Basketting and ECSWL.

Cholecystectomy.

Anti-ulcer regimen, i.e. antacid, anticholinergic, H₂ receptor blockers and mild tranquilizer.

For achlorhydria 1 to 2 tsf of dilute HCl in fruit juice sipped with meals.

Avoidance of alcohol, tobacco, spices and hot foods.

Cathartics and enema should not be used.

Foods with high fibre content such as bran and raw fruits and vegetables may be helpful.

8 to 10 glasses of fluids daily are to be taken.

Dulcolax 10-15 mg acts within 6-12 hours.

Glycerine suppository, a potent rectal agent for lubricating hard faecal matter; 3 gm acts in 30 minutes.

Clear liquid diet.27

If severe disease patient may be hospitalised with bowel rest IV fluids and antibiotics. Combination of Ampicillin and Aminoglycosides with additional amoebic coverage with Metronidazole or Clinamycin is given.

Surgery is indicated if patient does not respond to therapy or develop peritonitis.

Recurrent diverticulitis may lead to stricture perforation and can be an indication for elective hemicolectomy.

Frequent small feeds with high protein, moderately high fat and low carbohydrate.

Fluids should be taken in between meals but not soon after the meals.

Sedatives and anticholinergics.28

2 to 3 weeks of rest.

Nutritious diet taken at regular intervals; restriction of coffee, tea, cola, beverages, alcohol and smoking. First few days with bland liquid diet with gradual change over to soft solid diet in 4 to 8 weeks time.

Antacids—Digene tablet or Get 2 tab or 2 teaspoon 2-3 hrs after meals.29

Aluminium hydroxide in tablet form being inert is not very useful. Magnesium oxide and Calcium carbonate combinations are best. Magnesium is contraindicated in renal impairment and calcium salts may cause hypercalcaemia (polyuria, polydypsia, anorexia, constipation, etc.). Liquid forms are preferable. Initially given hourly then changed to 1 and 3 hours after each meal and at bed time. Antacids may cause phosphate depletion especially the aluminium salts.

Omeprazole 20 mg od for 1 month.

Avoid spicy food, alcohol and smoking.

Intensive antacid therapy and H₂ receptor blockers: H₂ receptor antagonists are more effective than antacids in healing gastric ulcer.

Sucralfate and bismuth salts 1 g qid on empty stomach.

If no response or unsatisfactory improvement is seen with antacid and Cimetidine or Ranitidine surgical resection is the answer.

Injection of sclerosing agents but recurrence occurs in 5 per cent cases.

Band ligation.

Excision.

Local Idoxuridine application or 5 per cent Acyclovir cream (Zovirax).

Oral Acyclovir 400-1000 mg/day for 12 months if frequent cold sores.

Slow deep breathing.

Neooctinum 30 drops in a glass of water every 4 hourly.

or

Neooctinum dragees 1 tds.

Tab Valium 2 mg tds.

If no response then

Injection Largactil (Chlorpromazine) 25 mg IM or 50 mg orally.34

Antispasmodics, i.e. Atropine sulphate 0.3-0.6 mg subcutaneously.

Amylnitrate inhalation may be effective.

Antacids-Gelucil/Digene tab after each meal.

If it still persist

Gastric lavage with ice cold saline or 1 per cent soda bicarb solution.

INH 300 mg od

Rifampicin 450 mg/day if body weight is 55 kg. Above 55 kg body weight 600 mg daily should be given in a single dose before breakfast.

Pyrazinamide.

Ethambutol 25 mg/kg body weight as single dose.

Supplementary multivitamins and Pyridoxin 40 mg daily.

Low residue high protein diet.

Reassure and explain nature of illness to patient.

Avoid stress.

Avoid fried foods, alcohol, tea and coffee.

Regular meals and adequate sleep is essential.

If pain and distension

Tab Lopramide (Imosec) 2 mg once or twice daily.

or

Tab Codeine phosphate 30 mg once or twice daily.

or

Tab Diphenoxylate (Lomotil) 2.5 mg once or twice a day.

Diuretic like Frusemide.

Stop alcohol completely.40

High protein diet (100 gm), if required injection Albumin 5 per cent or 20 per cent IV.

Iron and folic acid for correction of anaemia.

Vitamin K injection 10 mg IM.

Tab Propanolol 20 mg twice to reduce portal pressure.

Tab Spironolactone (Aldactone) 100-200 mg/day increasing by 100 mg every 3 days if no improvement (suggested by 1 kg weight loss in 3 days)

If no response add Frusemide 20 mg increased to a maximum of 120 mg.

Check for electrolyte imbalance especially hypokalaemia and alkalosis.

In large ascites panacentesis is done.

Injection Vitamin K, 10 mg IV for 3 days.

Injection Pitressin 20 CC diluted in 100 ml 5 per cent Glucose over 10 minute.

or

Injection Glypressin 2 mg IV 6 hourly for maximum 4 dose.

or41

Injection Somatostatin 250 mg bolus followed by 250 mg/hour.

Balloon tamponade under vigilant supervision endoscopic sclerotherapy may be done on emergency basis since risk of rebleeding is high.

For long-term endoscopic sclerotherapy-injection of Varcies is done at the interval of 1-2 weeks.

Propanolol is given in increasing daily dosage to achieve a pulse rate of 60/minute to check rebleeding. Shunt surgery and liver transplantation in suitable cases.

Restrict protein.

Neomycin 1 gm 6 hourly orally or through naso-gastric tube, or

Streptomycin 1 gram six hourly by tube, or

Ampicillin 500 mg 6 hourly, or

Lactulose 30 ml tds, or

Metrogyl 800 mg/day.

Hospitalisation and only cooked foods devoid of milk and mild products to be taken.

Prednisolone 20 to 40 mg daily, then reduced to 5 mg per week. Hydrocortisone 100 mg retention enema each night.

Sulfasalazine 2 to 4 gm daily in divided doses. If patient is sensitive to sulphadrugs—Ampicillin, Cephalosporin are the alternatives.

Diet devoid of milk and milk products.

Sulfasalazine 2 to 4 gm orally daily in divided doses as prolonged maintenance therapy.

Hydrocortisone enema 100 mg every night until lesion heals.

In severe cases retention enema of steroid at night daily for 6 days. Injection Efcorline 100 mg or tablet Betnesol 8 tablets dissolved in 100 ml normal saline and given as slow rectal drip with patient in left lateral position. Effort is made to retain enema overnight.

Postoperative ileus responds to restriction of oral fluid intake. Severe and prolonged ileus requires nasogastric suction and IV fluids with complete restriction on oral intake. Potassium depletion in postoperative cases is often a cause for prolonged ileus and needs potassium supplement under proper ECG control.

When conservative treatment fails surgical decompression with enterostomy or caecostomy may be done. If ileus is secondary to electrolyte imbalance, severe infection, pneumonitis, intra-abdominal/back injury, the ileus is managed as above plus treatment of the primary disease.

Advise patient not to lie down immediately after food and to sleep with head end of bed being raised 9″ to 10″.

Weight reduction if obese and avoidance of tight belts/corsets.

Antacid 2 tab to be chewed 1 hr after each meal and at bed time.

Large hiatus hernia or paraoesophageal ones requires surgical correction.

Ranitidine 150 mg twice daily for 4 to 6 weeks.

Cholestyramine to relieve pruritus.

Vitamin A, K and D for steatorrhoea (Parenteral administration).

Corticosteroids and Azathioprine in selected cases.

Portal hypertension (enlarged spleen, ascites, oesophageal varices) to be treated as discussed under nodular cirrhosis.

Liver transplantation.

Simple polypectomy by avulsion.48

Diet should be high in calories and vitamins and low in fat and roughage.

For diarrhoea.

Tab Diaphenoxylate or Loperamide.

For general malaise—Iron vitamin B₁₂ and supplements of potassium and magnesium.49

Tab Salazopyrine 500 mg thrice daily.

Tab Prednisolone 0.25-0.75/k/day for 3-4 months.

If seriously ill-injection Hydrocortisone 100 mg 8 hourly or IV Dexamethasone 8 mg 8 hourly.

Azathioprine 2.5 mg/kg/day

or

Mercaptopurine 1.5/kg/day

If acute suppuration indicated by fever, leucocytosis and tender mass then

Injection Ampicillin 4-8 gm IV daily followed by 2-4 gm orally.

Removal of causative factors are symptomatic treatment.50

Complete rest in severe cases and restriction of activity in mild case.

Diet: High protein, low carbohydrate and low fat diet.

Folic acid 10 to 20 mg daily orally or intramuscularly for a few weeks corrects diarrhoea, anorexia, weight loss, glossitis and anaemia. Once acute symptoms subside patient can be maintained on Folic acid 5 mg daily.

Antibiotics: Broad spectrum antibiotic 250 mg 6 hourly for few days.

Cap Minicycline 100 mg twice daily.51

Prednisolone: 50 mg daily for first few days and then maintained on 15 mg daily. It increases absorption of nitrogen, fat and has a nonspecific effect in producing euphoria and increase appetite. For malabsorption and steatorrhoea-Pancreatic enzymes-Merckenzyme tabs 2 with meals.

Ciprofloxacin 500 mg bd × 10 days or Tefloxacin 400 mg bd or Norflox 400 mg bd or Ofloxacin 200 mg bd or Cefuraxime 500 mg bd × 7 days.

Hydrocortisone 100 mg IV 8 hourly in severely toxic patients, the danger of perforation should be weighed carefully.

Parenteral fluid and vitamins control fever.

High calorie and low residue diet.

Perforation needs immediate surgery.

Complete bed rest. Ice cold saline gastric lavage through Ryle's tube till returning fluid is clear.

Reassure the patient.

Inj Calmpose or Valium 10 mg IM. Repeat after 8 hours if necessary.

Inj Stemetil 12.5 mg IM.

Inj Plasma IV drip.

or Inj Lomodex 500 ml.

Inj Glucose saline 500 ml.

Pulse rate more than 130/minute.

Systolic BP less than 90 mm Hg.

Hb less than 60 per cent.

O₂ inhalation may be required.

Metronidazole 200 mg tds × 5 days.

Cap Becosule 1 daily.

Alkaline mouth wash.

Bed rest at the initial stage of the disease with gradual return to normal activity in convalescence.

Plenty of oral Glucose or IV Glucose 10 per cent if oral intake is hampered due to nausea/vomiting.

A palatable diet with less fat. If patient shows any signs of impending coma, protein should be withheld.

Plenty of vitamin B-Complex and vitamin ‘K’.

Liv-52 can be given empirically at the dose of 2 tab tds for 1 to 2 months.55

If jaundice is progressive, Corticotropin or Prednisolone. Prednisolone is given for 20 days at the dose of 2 tab (5 mg tab) tds for 5 days, 1 tab tds × 5 days, 1 tab bd × 5 days and 1 tab od × 5 days.

Phenobarbitone if restlessness occurs.

1 per cent Phenol with Calamine lotion or Cholestyramine 4 gm daily to reduce itching.

Neomycin/Paramomycin only when precoma occurs. Serum hepatitis is transmitted by infected blood or blood products. Its incubation period is long (6 weeks to 6 months) and its onset is more insidious. The clinical picture is similar to that of infectious hepatitis. The blood of the patient is positive for Australia antigen.

Oral Penicillamine 1 to 1.5 gm daily in divided doses is the drug of choice, to be continued indefinitely.

If patient is intolerant to Penicillamine, Triethylene teramine may be tried.

For prolonged period/Famotidine/Ranitidine/Omeprazole may be given in higher doses.

Omeprazole 40-80 mg od.

If unresponsive to drugs surgical resection is advised.