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Treatment of Chronic Diarrhea

If diarrhea continues for more than 4 weeks, it is considered as chronic diarrhea. Chronic diarrhea requires evaluation to rule out underlying pathology. Compared to causes of acute diarrhea, most of the causes of chronic diarrhea are noninfectious.

Principle of treatment of chronic diarrhea:

Treatment of chronic diarrhea depends on the specific cause of diarrhea and it is directed towards the cause of diarrhea, which may be curative, suppressive, or empirical. If the cause can be removed or eradicated, the treatment of chronic diarrhea is curative as with resection of a colorectal cancer, antibiotic administration for Whipple’s disease, or discontinuation of a drug (if any drug is the cause of chronic diarrhea).

For many chronic conditions, diarrhea can be controlled by suppression of the underlying mechanism which is causing the chronic diarrhea. Examples are elimination of dietary lactose for lactase deficiency or gluten (gluten free diet) for celiac sprue, use of glucocorticoids or other anti-inflammatory agents for idiopathic IBDs (inflammatory bowel diseases), adsorptive agents such as cholestyramine for ileal bile acid malabsorption etc. Other examples are use of proton pump inhibitors such as omeprazole for the gastric hypersecretion of gastrinomas, somatostatin analogues such as octreotide for malignant carcinoid syndrome, prostaglandin inhibitors such as indomethacin for medullary carcinoma of the thyroid, and pancreatic enzyme replacement if there is any pancreatic insufficiency.

But if the specific cause or mechanism of chronic diarrhea can not be pinpointed, empirical therapy may be beneficial. For example loperamide, is often helpful in mild or moderate watery diarrhea. For those with more severe diarrhea, codeine or tincture of opium may be beneficial. Such antimotility agents should be avoided with IBD, as there may be precipitation of toxic megacolon. Clonidine, an alpha-2 adrenergic agonist, may allow control of diabetic diarrhea.

General measures:

Fluid and electrolyte replacement is an important and essential component of management for all cases of chronic diarrhea. Replacement of fat-soluble vitamins may also be necessary in patients with chronic steatorrhea (lipids can not be absorbed or fat malabsorption).

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Posted by - July 19, 2009 at 9:34 am

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Treatment of Acute Diarrhea

Diarrhea is loosely defined as passage of abnormally liquid or unformed stools at an increased frequency and with a typical Western diet stool weight of more than 200 grams can be considered as diarrhea. 

Principle of treatment of acute diarrhea:

In acute diarrhea the most important part of treatment is the replacement of lost fluid and electrolytes. Fluid replacement should be gradual and over a period of time. In mild cases of acute diarrhea fluid replacement is all that may be required. Oral sugar-electrolyte solutions used in sports as drinks or designed formulations should be started promptly with severe diarrhea to limit dehydration, as severe ehydration is the major cause of death in severe diarrhea. If dehydration is very severe, especially infants and the elderly, require IV (intravenous) re-hydration for maintaining patients’ health.

If the dehydration is moderate as seen in non-febrile and non-bloody diarrhea, anti-motility and anti-secretory agents such as loperamide can be used. But drugs like loperamide should be avoided if the diarrhea patient is suffering from febrile dysentery, which may cause prolongation of diarrhea.

Role of antibiotics in acute diarrhea:

Use of antibiotics may sometimes reduce the severity and duration of diarrhea in some selected cases. Ciprofloxacin (500 mg twice a day for 3 to 5 days) is used by many doctors’ for treatment of severely ill patients with febrile dysentery empirically without diagnostic evaluation. If the cause of diarrhea is suspected to be due to giardiasis, metronidazole (250 mg 4 times a day for 7 days) can be used successfully. Antibiotic coverage has to be given whether or not a causative organism is discovered in patients who are immune deficient, have mechanical heart valves or recent vascular grafts, or are elderly.

Antibiotic prophylaxis should be given for certain patients traveling to high-risk countries in whom the likelihood or seriousness of acquired diarrhea would be especially high, including those with immunocompromise, IBD (inflammatory bowel disease e.g. ulcerative colitis), hemochromatosis, or gastric achlorhydria (absence of acid in stomach). For prophylaxis the use of trimethoprim/sulfamethoxazole (Bactrim), ciprofloxacin, or rifaximin (rifaximin not be suitable for invasive disease) may reduce bacterial diarrhea in such travelers by 90%. Finally, physicians should be vigilant to identify if an outbreak of diarrheal illness is occurring and to alert the public health authorities promptly, which may reduce the ultimate size of the diarrhea affected population.  

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Posted by - July 17, 2009 at 11:44 am

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Management of peptic ulcer

The aim of treatment:

The main aim of treatment of peptic ulcer is to provide symptomatic relief to the patient in the short term, induce ulcer healing and to prevent relapse in the long run. If H. pylori are found, attempt should be made to eradicate with appropriate antibiotic therapy

General measures:

 General measures for management of peptic ulcer are avoidance of smoking as it has a causative role in peptic ulcer and also smoking cause delay in ulcer healing. So smoking should be strongly discouraged. Aspirin and other NSAIDs (non-steroidal anti inflammatory drugs) should be avoided as far as possible because of the injurious effect they have on gastric and duodenal mucosa. If NSAIDs are required for pain relief of some other pain like toothache, a selective COX2-inhibitor NSAID (e.g. valdecoxib, celecoxib etc.) should be given or they can be given with proton pump inhibitor drugs (e.g. omeprazole, pantoprazole etc.) or with prostaglandin analogues like misoprostol. Alcohol should be avoided (although alcohol in moderation does no harm) as well as excess tea and coffee.

Medical Management:

Short term management of peptic ulcer is done with H2-receptor antagonist (e.g. ranitidine, famotidine etc.), proton pump inhibitor drugs (e.g. omeprazole, pantoprazole, rabeprazole, etc.), sucralfate, and prostaglandin analogues (e.g. misoprostol) or with antacids. All the above mentioned medications are equally effective in treatment of peptic ulcer.

Maintenance therapy is done with proton pump inhibitor drugs (e.g. omeprazole) or with H2-receptor antagonist like ranitidine (either of the group of drugs is safe and effective in long term maintenance).

Eradication of H. pylori is important if found in biopsy. For eradication of H. pylori 14 day treatment is given with omeprazole 20 mg, metronidazole (or tinidazole) 400 mg and clarithromycine 250 mg (available as kit which contains all 3 medicines). One kit is to be taken 2 times a day for 14 days. Other combination kits are also available where clarithromycine is replaced with amoxicillin 750 mg.

Surgical treatment:

If none of the above mentioned treatment regimens including eradication of H. pylori fails, surgical treatment should be considered. Indication of surgical intervention is strengthened by the younger age of the patient, complications like hemorrhage or perforation of intestine, strong family history of peptic ulcer, frequent relapses, if ulcer is causing obstruction to gastric outflow or produced an hour glass stomach due to fibrosis. There are also patients who do not comply with prolonged medical management, can be treated with elective surgical intervention. But in case of elderly patients surgical operation should be avoided.

Finally every ulcer should be viewed with seriousness, especially long standing gastric ulcer as it can turn malignant although rarely. As peptic ulcer is a common problem in the modern life, it should be appropriately treated and doctor’s advice followed strictly.   

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Posted by - May 21, 2009 at 12:59 am

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Treatment of Fever at Home

Fever or pyrexia can be defined as body temperature higher than normal body temperature. According to studies on many healthy individuals 18 to 40 years of age, the mean oral temperature is 36.8° ± 0.4° Centigrade (98.2° ± 0.7° Fahrenheit). Low levels are seen at 6 A.M. and the maximum normal oral temperature at 6 A.M. is 37.2°C (98.9°F). Higher levels of body temperature are seen at 4 to 6 P.M. and the maximum normal oral temperature at 4 to 6 P.M. is 37.7°C (99.9°F). These values define the 99th percentile for healthy individuals. So according to these studies, an A.M. temperature of more than 37.2°C (98.9°F) or a P.M. temperature of more than 37.7°C (99.9°F) could be defined as fever.

For checking the body temperature, always take oral temperature with a thermometer. Keep the thermometer just below tongue for about 2-3 minutes to get the best result. If the patient of fever is a baby and can not cooperate to take oral temperature, you can take temperature from axilla (keep the thermometer for 2-3 minutes in axilla).

The most of the fevers in an individual is due to self limiting infections, such as common viral diseases (e.g. common cold or flu). In these types of common viral infections temperature is usually very close to 100°F (little more than 100°F or little less).

If the fever is less than 100°F it can be tried at home first, by giving cold sponging (wipe the body or the lower and upper limbs with cold water every few minutes till temperature comes down to normal). This simple measure will bring down the temperature to normal in maximum cases with out any medication. If the temperature do not come down with cold sponging for 30 minutes or more than you can give paracetamol (acetaminophen) at the dose of 10 mg/kg body weight orally either tablet or as liquid. This will bring down temperature to normal. If there no reduction in fever, you should consult your doctor. You should also not try to treat fever at home if it is more than 100°F (see your doctor for that).

If you have fever you should drink plenty of fluids as there is evaporation of water through lungs and sweat, which you should replace by drinking plenty of oral fluid (water, fruit juice etc.). 

 

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Posted by - April 7, 2009 at 12:58 pm

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Non Typhoid Salmonella Infection: Treatment

Treatment of non typhoid Salmonella infection is different from typhoid infection due to Salmonella Typhi. In the treatment of non typhoid Salmonella infection antibiotic should not be used routinely as used in typhoid. Antibiotics should only be used if required, as most of the infections of non typhoid Salmonella are self limiting type and the duration of diarrhea and fever are not much affected by use of antibiotics. Additionally antibiotic therapy can increase relapse of the infection and also prolong the duration of gastrointestinal carrier state.

The main treatment should be aimed at correcting dehydration that may arise due to prolonged diarrhea, by fluid and electrolyte replacement.

Preemptive antibiotic treatment is required in case of neonates (up to 3 months of age), persons with age of more than 50 years with suspected atherosclerosis, patients with immunosuppression, cardiac valvular disease, endovascular abnormalities, significant joint disease etc. The preemptive treatment of non typhoid Salmonella infection should be done by oral or intra venous (IV) administration of antibiotics (Ciprofloxacin 500 mg twice a day; Trimethoprim-sulfamethoxazole 160/800 mg twice a day; Ceftriaxone 2000 mg/day; Amoxicillin 100 mg three times a day or Ampicillin 2000 mg every 4 hourly) for 2 to 3 days (48 to 72 hours) or till fever subsides. If patient is immunocompromised treatment may have to be continued for 1 to 2 weeks. Due to high incidences of antibiotic resistance, a third generation cephalosporin (Ceftriaxone) antibiotic or a fluoroquinolone (Ciprofloxacin) should be included in the empirical therapy for life-threatening NTS bacteremia or focal NTS infection. If a patient is suffering from non typhoid Salmonella infection with bacteremia (bacteria in blood) and AIDS, he/she should be treated for 1 to 2 weeks of intravenous antibiotics and followed by 4 weeks of treatment with oral Ciprofloxacin. If there is relapse of the infection, after the therapy (in AIDS patients) than the patient should be given long term suppressive therapy with a fluoroquinolone or trimethoprim-sulfamethoxazole (after doing culture and sensitivity test).

If patient has endocarditis or arteritis the treatment is by intravenous beta-lactum antibiotics like ceftriaxone or ampicillin. Surgical intervention is recommended where required.

For extraintestinal nonvascular non typhoid Salmonella infections, a 2 to 4 weeks course of antibiotic therapy (depending on the infection site) is recommended. In case of chronic osteomyelitis, abscess, urinary infection or hepatobiliary (liver and gall bladder) infection associated with anatomic abnormalities, surgical resection or drainage may be required in addition to prolonged antibiotic therapy for eradication of infection.    

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Posted by - March 14, 2009 at 3:44 pm

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