Acute Diarrhoea

Acute Diarrhoea 

INV - 
Stool microscopy and bacterial culture. Hospitalized pts on abs - test stool sample for C. Difficile toxin, CBC for TC increase, Tempk > 38.5 C

Treatment 
A. Diet - Tea, Soft digestible foods. Give bowel rest by avoiding high fibre foods, fats, milk, alc, coffee

B. Rehydration - ORS 50 - 200 ml/ kg/ 24 hrs

C. Antidiur - CI - bloody diar, high fever, sys toxicity, 
Use - in mild to moderate diar, to decrease the stool number, liquidity and urgency
1. Loperamide - 4 mg initially, f/b 2 mg after each loose stool (max 8 mg/ day)
2. Bismuth salicylate (Pepto -bismol) - 2 tab / 30 ml orally qid 
3. Diphenoxlate and Atropine- CI as anti cholinergic - leads to toxic megacolon
4. Antobiotics - 
Emperic - FQ - CIpro 500, Oflox 400, Levo 500 od for 1-3 days.
Doxy 100 mg bd
Rifaximin 200 mg tid x 3 days, Azithro 500 mg tid x 3 days 
Specific - in Shigella , cholera

Chronic Diarrhoea

DIARRHOEA
Chronic - 

Causes
1. Medications

2. Osmotic Diarrhoea 
Osmotic gap between stool measured and estimated > 50
a. Carbohydrate malabsorption - chronic post - prandial dirrhoea, distension, bloating, flatulence - diary ( lactose), fruits ( fructose), artificial sweeteners ( sorbitol)
processed foods n soft drinks, alcohol. Resolve during fasting.
Inv - Elimination trial for 2-3 weeks / H2 breath test
b. Laxatives - Antacids

3. Secretory Diarrhoea
watery with normal anion gap. eg bile salt malabs

4. Inflammatory - IBD - but occurs with pain, fever, weight loss, hematochezia

5. Malabs syndromes - weight loss, diarrhoea, steatorrhoea

6. Chronic infns - Giardia

7. Metabolic - Thyroid, DM


CF - 
diarrhoea - continuous / intermittent, relation to meals, at night / fasting ( secretory and not malabs)


INV - 
1. Routine - CBC, SE, LFT, Calcium, Phosphorous, ALb, TSH, Vit A and D, ESR, CRP
2. Stool - Ova, Cyst, FOBT, Stool Antigen Assays, Fecal fat ( malabs)
3. Endoscopic exam and mucosal biopsy 
4. CT 


TR- 
1. Loperamide - 4mg initially, then 2mg after each loose stool ( max 8 mg / day)
2. Diphenoxylate with atropine - 1 tid / qid
3. Codeine 
4. Clonidine - 0.1 - 0.3 mg bd in secretory diarrhoea ( inhibits secretion) 
5. Octreotide - 50 - 250 mcg s/c tid
6. Bile salt binders - Cholestyramine 2- 4 mg od/ tid in bile salt diarrhoea 

PTRA Antibiotics.

PTRA Antibiotics.
2day vs 5 day Cephalexin 500 mg qid. Equal.
1 L NS irrigation, 
povidone iodine prep, 
Only skin sutures with simple 3-0, 4-0 Nylon.

Abdominal trauma 
Cefotaxime/ Cefoxitin/ Ampi + Aminogly + Clinda 
2nd gen Cephalosporin sufficient.

2nd gen Cephalosporin - Cefoxitin, Cefprozil (Refzil - O), Cefuroxime 500 mg bd (Ceftum)

.................
not known use in PTRA 

3rd generation - Cefixime ( Taxim - O)

Medications

dm, htn ckd
t. telmisarton 80 mg 1-0-0
t. cilacar-m 1-0-0
t. moxavas 0.2 mg 1-0-1
t. storvas 10 mg 0-0-1
t. cetapin xe 500 1-0-1
inj novarapid 10-10-10
inj lantus 0-0-28
t. ciplox 500 1-0-1
t. clinda 300 1-1-1

lympoedema
t. lympedium 10 mg 1-0-1
t. bidazen forte 1-0-1

ckd, htn, tb pleural effusion, dcm
t. amlong 5 mg 1-0-1
t. prazopress XL 5 mg 1-0-1
T. seloken XL 50 mg 1-0-0
t. Clopilet A 75-75 0-1-0
t. Arkamine 0.1 mg 1-1-1
t. oflox 200 mg 1-0-0
t. rifampicin 450 mg 1-0-0
inj. Epofit 5000 iu sc 2/week
t shelcal 500 mg 1-1-1
t. sodabicarb 2-2-2
c. becosule z 0-1-0
t. aztor 20 mg 0-0-1

t. thyronorm 125 mcg 1-0-0

povd, sciatic nerve injury
Vit d satchet 1/week
t. amitryptiline -eliwel 10 mg hs
t shelcal 500 mg 1-0-1
t. polybion 0-1-0
t. nexito 5 mg 0-0-1
t. atorva  10 mg hs
t. ecosprin 75 mg 0-1-0
t. stiloz 50 mg 1-0-1
 t. amlong 5 mg 1-0-1
t. librium 10 mg 1-0-1
iv emeset 4 mg 1-1-1
iv tramadol 50 mg 1-1-1
iv pan 40 mg 1-0-0
t. tolpa- d 1-0-1

HTN, ITP, BRONCHITIS
t. wYSOLONE 50 MG 1-0-0
T. Folicacid 5 mg 1-0-0
T. shelcal 500 mg 1-0-1
T. Telma 40 mg 1-0-0
In view of intolerance to higher  doses of steroids, T. Azoran 50 mg 1-0-1
All Danazol 200 mg  1-0-1
Splenectomy option explained and Inj. Peumovac 1 dose sc deltoid
Hep B vaccine 1st dose
tachycaardia in echo ->  T. Metolar XR 50 mg 1-0-0
DM developed -> T. Metformin SR 500 1-0-0
Also C.D360 2000 IU weekly once x 6 months


ulcer
t. cefadroxil 500 mg 1-0-1 x 5 days

chronic plaque psoriasis
propysalic NF lotion 0-0-z
protar K shampoo ( alt days)
Fucibet cream 0-0-z
T. Allegra 180 mg 0-0-1

HTN DM
T. Glycomet GP1 1-0-1
T. Aten 50 1-0-1 (w/h if PVD)
Wound- T. Zincovit 1-0-1 x 20 days

DVT hyperhomocystinuria APLAa Prottein C  defy
T. Homocheck 10 mg 1-0-0

Gasstric bleed
Inj. Pan 80 mg iv stat and 80 mg in 500 ml NS @ 50 cc/hr (8 mg /hr)
ABG, ECG, CBC, Inj Vitneurine 1 amp od
Inj VIT K 30 mg iv stat
CXR, AXR, USG abd, amylase, lipase
RT Wash -> OGD
K correction
Arrange blood
IVF NS @ 75 ml/hr
->
Abd distended and tender, AXR multiple air fluid levels, suspected mesentric ischaemia
NPO, CRTA, maintain O2 sat, Repeat AXR,
CT iv and angiogram, blood,
CT= SMV thrombosis + non enhancing bowel, likely ischaemic.
10/1/13-> jej r n A. for jej gangrene  due to smv  thrombosis
16/1/13 ->   tube duodenostomy + FJ
13/2 -> duodenostomy clamped earlier , removed on 16/2
continue acitrom
FJ removed on 22/2
Headache-> t . metoprolol XL 50 mg 1-0-1 x 1 month., T. Eliwel 10 mg hs

stasis dermtitis
Topisal 6% oint 0-0-1
Liquid parafin 1-0-1
T. Levocet 5 mg 0-0-1
Rv after 2 weeks

disseminated eczema - erythematous plaqyes with oozing pus
Cap. augmentin
Ta wysoone 0 mg -> 30 mg -> 20 mg
Topical liq parafin 1-0-1 x 3 weeks
diprovate RD cream 1-0-1 x 3 weeks
roller gauze wraps with saline compress
Tab teczine 5 mg hs
tab rantac
tab wysolone 10 mg 3-0-0 x 1 week -> 2-0-0 x 1 week -> 1-0-0 x 1 week.

homocystemia
tab. folic acid 5 mg 0d

NHU vaseline after bath
breathlessness
tab levoday 750 mg od
tab synasma 400 mg 0-01
syp. grillinctus BM 2-2-2
tiova MDI 2-0-0

fullness of stomach
t lesuride 10 mg  1-1-1
t neurobion forte 1-0-0

MDI airtec FB 2 puff bd.
Unicontin

Panc-jej

8 12
chevron incision
stomach greater curvature devascularised to open lesser sac.
immediately below stomach lay duodenum and a red mass (pancreas)
Duct palpated and aspirated to confirm.
Duct opened with diathermy with duct lifted up with right angle.
stones removed with artery or desjardens
Dj visualised and ligament of treitz seen clearly as a adhesion to a loop.
20 cm from dj. jejunim divided with linear stapler 55. stapled ends were closed with 3-0 silk interrupted stiches.
ring worm removed by enterotomy.  also rest of intestines run through for worms and could be palpated.
distal roux loop taken antecolic to pancreas and reversed and opened. then fixed full thickness to pancreas using 3-0 prolene or 3-0 pds. most imp are corner stitches.
 JJ: 2 loops held side by side and fixed with 3-0 silk.
2 small 1 cm enterotomies made transversely and opened with mosquitoes,
linear stapler 55 held for 1 min and fired.
2 enterotomies closed transversely with interrupted 3-0 vicryl.
lesser sac romovac 28 drain placed.

Lap chole

Lap umbilical hernia