GASTROINTESTINAL DISEASES

Anticholinergics to relieve spasm of esophagus. Tab Probanthine or Buscopan, one tablet thrice daily ½ hour before meals.2

Nifedipine 10 mg thrice daily is beneficial.

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.

Endoscopic dilatation using pneumatic bag under fluoroscopic guidance.

Esophago-cardiomyotomy may be required in a few cases.

Botulinum toxin (Botox) therapy in the lower esophageal sphincter is recommended for patients who cannot risk surgery.

Rest in bed.3

Nothing to be taken orally.

IV fluids 5 percent Dextrose/ringer solution.

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 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 tsp thrice daily after meals.

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

Proton pump inhibitors such as omeprazole, lansoprazole, rabeprazole, and esomeprazole can also be given.

Tab Probanthine twice daily.

Tab Sucralfate 1 gm tds in case of NSAIDs induced erosions.

Specific antidotes for corrosive poisons.

Treat infective cause, if any.

General supportive case includes hydration and pain relievers.

In moderately to severly ill patients, broad spectrum antibiotics may be used and should cover Yersinia streams.

Fever, leukocytosis, abdominal rigidity/ascites, blood in the feces indicates strangulation and immediate surgery is essential.

If in an uncomplicated case with adequate decompression pain does not subside and flatus does not pass, surgery 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 liters of IV fluid replacement as patient is invariably dehydrated.

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 in cases of necrotizing acute pancreatitis—injection imipenem cilastin 500 mg 8 hourly for 7 days.

Treat the etiology.

In cases of damaged and/or infected tissue, necrosectomy can be done.

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.

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 hospitalization.9

In patients with severe alcoholic hepatitis (discriminate function ≥ 32), Prednisone 40 mg/day or Prednisolone 32 mg/day for 4 weeks followed by 2 steroid tapes.

Alternatively pentoxifylline 400 mg thrice a day for 4 weeks.

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

             or

Tinidazole 2 gm/day for 3 days.

             or

Tab Secnidazole 2 gm as single dose.

             Plus

Diloxamide furoate 500 mg tds for 5 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.

Inj Metrogyl 1 gm IV followed by 0.5 gm 8-12 hourly till oral therapy is started

             or

Tab Tinidazole 2 gm/day

             Plus

Tab Diloxamide furoate 500 mg tds for 5 days

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

Sitz bath.

Topical nitroglycerin ointment (0.2%), topical nifedipine 0.3% with topical lidocaine 1.5% ointment.

Botox injection may provide initial relief of symptoms

Anal dilatation.

Surgical excision, if all above measures fail or recurrence occurs.

Avoid spices, tobacco, hot food.

Bland diet.

Good oral hygiene.12

Aqueous Chlorhexidine 0.2 percent mouthwash.

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

             or

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

Glycerine or Zytee for topical application.

Topical sucralfate 5 ml, 4 times/day

If pain tablet Paracetamol 1 tds.

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

Nothing orally.

IV fluids.

Nasogastric intubation with gastric lavage.

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

In uncomplicated cases, appendicectomy is performed, often via a laparoscopic approach.

Correct dehydration with IV fluids or Electral powder orally.

Tab Ciprofloxacin 500 mg (children 15 mg/kg) twice a day for 3 days.

             or

Inj Ceftriaxons 50-100 mg/kg once a day IM for 2-5 days.

             or

Tab Azithromycin 1-1.5 gm (children 6-20 mg/kg) once a day for 5 days.

Stomach wash if diagnosed early.

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

Botulinum antitoxin; bivalent preparation is routinely given, monovalent type E antitoxin is given in addition when exposure to type E toxin is suspected (after seafood ingestion).

For infant botulism, supportive case and Botulism Immune Globulin Intravenous—Human (BIG-IV or Baby BIG) is given.

Antibiotics such as penicillin should be given in wound botulism.

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 is done.

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

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

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

Saturated solution of sodabicarb for mouth wash.

One percent gentian violet to be painted three times daily on the patches.

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

In reverse cases, Tab Ketoconazole 200 mg once or twice daily.18

             or

Tab Fluconazole 200 mg on first day followed by 100 mg once daily.

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

Cytotoxic drugs, irradiation or surgery have not proved effective.19

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

Alcohol injection into tumor.

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

If the tumor is localized to stomach, subtotal gastrectomy is the standard treatment.

Cholecystectomy and choledochostomy.

Basketting and ECSWL.

Rapid and adequate fluid replacement

Formula for WHO-ORS (Electral sachet)

Antibiotics

Tab Doxycycline 300 mg single dose in adults.

             or

Tab tetracycline 500 mg (adults) or 12.5 mg/kg (children) 4 times a day for 3 days.

             or

Tab TMP 160 mg + SMX 800 mg (adults) or TMP 5 mg/kg + SMX 25 mg/kg (children) twice a day for 3 days.22

             or

In case of tetracycline resistance:

Tab Ciprofloxacin 500 mg bd for 3 days

             or

Tab Erythromycin 500 mg qid for 3 days

             or

Tab Azithromycin lg single dose

Cholecystectomy.

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

For achlorhydria 1 to 2 tsp 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 fiber 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 fecal matter; 3 gm acts in 30 minutes.

Naturolax or Igol or Ispaghula one tsp with water at night daily

             or

Tab Dulcolax 1-2 tablet at bed time.

             or

Cremaffin 2-3 teaspoonful after dinner.

For chronic constipation—Tablet Cisapride 10 mg twice a day.

Combination of Ciprofloxacin (or TMX–SMX) and Metronidazole

             or

Amoxicillin/clavulanic acid monotherapy.

Clear liquid diet.

If severe disease, patient may be hospitalized with bowel rest, IV fluids, and antibiotics. Combination of Ampicillin and Aminoglycosides with additional amebic coverage with Metronidazole or Clindamycin 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.

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 gel 2 tab or 2 teaspoon 2-3 hours after meals.

Aluminum 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 hypercalcemia (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 aluminum salts.

Omeprazole 20 mg od for 1 month.

             or28

Rabeprazole 20 mg od for 1 month.

             or

Pantoprazole 40 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.30

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.

Low roughage diet.

Regulation of bowel habit with mineral oil or stool softeners.

Warm sitz bath (hip bath) for 15 min, 2-3 times a day.

Soothing anal suppository 2 to 3 times daily.

Xylocaine 2 percent topical ointment before and after defecation.

Diasomin (150 mg) (Daflon) 2 cap twice daily to tds for 1 week.

Antibiotics preferably Ampicillin for 5 to 7 days to combat any infection if present.31

The use of heparin containing oint (Hirudoid) or Hydrocortisone ointment (Proctosedyl) are of value once acute pain and bleeding are controlled.

Control other precipitating/aggravating factors like obesity, chronic cough, portal hypertension, etc.

Injection of sclerosing agents but recurrence occurs in 5 percent cases.

Band ligation.

Excision.

Local Idoxuridine application or 5 percent Acyclovir cream (Zovirax).

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

Slow deep breathing.

Neo-octinum 30 drops in a glass of water every 4 hourly.

             or

Neo-octinum dragees 1 tds.

Tab Valium 2 mg tds.

       If no response then

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

Haloperidol in doses of 2-5 mg or Metoclopramide in a dose of 10 mg 8 hourly can be used.

Amylnitrate inhalation may be effective.

Antacids-Gelusil/Digene tab after each meal.

If it still persists

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

Intensive phase: 2 months of HRZE

Continuation phase: 4 months of HR

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.

It may be given in single dose or in 2 divided doses.

Ethambutol 25 mg/kg body weight as single dose.

Supplementary multivitamins and Pyridoxin 40 mg daily.

Low residue high protein diet.

Localized hypertrophic lesion.

Stenosis of bowel.

Perforation of tuberculous ulcer.

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 main complaint is of frequent, loose stools with urgency then

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.

Simple acute vomiting following dietary or alcoholic indiscretion or during morning sickness of early pregnancy do not require much of treatment.

If symptomatic

Injection Perinorm IM.

             or

Injection Stemetil 12.5 mg IM.

             or

Injection Metachlorpramide (Reglan) 10 mg IV or IM.

             or

Tablet Perinorm or Domperidone one tds

             or

Tablet Eskazine 1 mg tds.

Eradicate the cause

Diuretic like Frusemide.

Stop alcohol completely.

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

Iron and folic acid for correction of anemia.

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 hypokalemia and alkalosis.

In large ascites, paracentesis is done.

Injection Vitamin K, 10 mg IV for 3 days.

Injection Pitressin 20 CC diluted in 100 ml 5 percent Glucose over 10 minute.39

             or

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

             or

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 Varices is done at an 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 nasogastric 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.

Immediate hospitalization as there lies chance of hemorrhage, perforation, toxic megacolon, sepsis, etc. endangering life.

Stoppage of oral intake, IV fluids and electrolytes, nasogastric suction if colon is dilated.

Broad spectrum antibiotic singly or in combination as a prophylaxis against sepsis (Ampicillin, Chloramphenicol and Gentamicin).

Prednisolone 300 mg IV daily at 6 hourly interval.41

Surgery: If patient remains toxic and colonic dilatation does not improve within 8 to 12 hours colonic resection is indicated. Selective colectomy may be performed in those who fail to improve in the long run.

Hospitalization 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.

Topical mesalazine given by suppository.

Tab mesalazine 2 g per day.

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

Hydrocortisone enema 100 mg every night until lesion heals.42

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 ECG monitoring.

When conservative treatment fails, surgical decompression with enterostomy or cecostomy 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 paraesophageal ones requires surgical correction.

Ranitidine 150 mg twice daily for 4 to 6 weeks.

Omeprazole 20 mg od 4–6 weeks.

Ursodeoxycholic acid (UDCA) 10-15 mg/kg/day in 2-4 divided doses

Cholestyramine to relieve pruritus.

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

Corticosteroids and Azathioprine in selected cases.

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

Liver transplantation.

Simple polypectomy by avulsion.

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

For diarrhea.

Tab Diaphenoxylate or Loperamide.

For general malaise—Iron, vitamin B₁₂, and supplements of potassium and magnesium.47

Tab Salazopyrine 500 mg thrice daily.

Long-term mesalamine (800 mg tds) may delay clinical relapse.

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, leukocytosis and tender mass then

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

Removal of causative factors and symptomatic treatment.

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 diarrhea, anorexia, weight loss, glossitis, and anemia. Once acute symptoms subside patient can be maintained on folic acid 5 mg daily.

Antibiotics: Broad spectrum antibiotic tetracycline can be used for up to 6 months.

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 producing49 euphoria and increase appetite. For malabsorption and steatorrhea—Pancreatic enzymes-Merckenzyme tabs 2 with meals.

In fully sensitive cases, Ciprofloxacin 500 mg bd or Ofloxacin 200 mg bd for 5-7 days.50

In multidrug resistance cases, Cefixime 400 mg bd for 7-14 days or Azithromycin 1 g/day for 7 days.

In quinolone resistant cases, Azithromycin 1 g/day for 7 days or Injection Ceftriaxone 1-2 g/day IV for 10-14 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.

Metronidazole 200 mg tds × 5 days.

Cap Becosule 1 daily.

Alkaline mouthwash.

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 percent 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.

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 percent Phenol with Calamine lotion or Cholestyramine 4 gm daily to reduce itching.

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.

If unresponsive to drugs, surgical resection is advised.