10.2.1 Peptic Ulcer Disease
Refers to acid related peptic ulceration involving the lower esophagus; stomach and duodenum as a result of active inflammation induced by acid –pepsin leading to disruption of the mucosal integrity causing local defect or excavation
10.2.1.1 Gastroesophageal Reflux Disease (GERD)
It is a disorder resulting from gastric acid-pepsin activity and other gastric contents into the esophagus due to incompetent barriers at the gastroesophageal junction leading to active inflammation of the distal third of the esophagus.
Diagnostic Features
- Heartburn and regurgitation are cardinal symptoms.
- Odynophagia, dysphagia, weight loss and bleeding
- Chronic cough, laryngitis, pharyngitis
- Chronic bronchitis, asthma, COPD, pneumonia, chronic sinusitis and dental decay PLUS
- Endoscopic evidence mucosal ulceration OR
- Histological evidence of chronic active inflammation OR
- PositSive finding with a gold standard 24-hours esophageal pH testing.
Pharmacological Treatment:
A: Omeprazole (PO) 20mg once daily for 8 weeks
OR
S: Esomeprazole (PO) 20mg once daily for 8 weeks.
| Note: | |
| | For refractory cases acid suppression therapy may require continuation up to 6 months. |
| | Life style modification and avoidance of triggers diet is important including avoidance of smoking, alcohol and NSAID use. |
| | Refer to next level centre with adequate expertise and facility for refractory cases or cases with alarming symptoms (red flags) such as bleeding, dysphagia or weight loss |
10.2.1.2 Gastroduodenal Ulcers (PUD)
This is a disorder resulting from breakdown of mucosal defense mechanisms against hydrochloric acid and proteolytic enzymes, most commonly secondary to H.Pylori infection or NSAID use.
Diagnostic Criteria
- Burning epigastric abdominal pains, usually relived by antacids.
- Anorexia, early satiety, bloating,
- Hematemesis or melena stools
- Weight loss PLUS
- Endoscopic evidence of gastric or duodenal mucosal ulceration
Pharmacological Treatment
A: Omeprazole (PO) 20mg once daily for 8 weeks
OR
D: Esomeprazole (PO) 20mg once daily for 8 weeks
OR
D: Pantoprazole (PO) 40mg once daily for 8 weeks.
10.2.1.3 Helicobacter Pylori Related Peptic Ulcer Disease
Diagnostic Features
As above in cap 10.2.1.2 together with evidence of
- Positive stool antigen test OR
- Positive urease breath test OR
- Positive urease test on endoscopic biopsy sample OR
- Identification of the pathogen by histopathology examination
Pharmacological Treatment
Triple therapy is indicated for complete eradication of the organism
A: Omeprazole (PO) 20mg twice daily Plus amoxycillin (PO) 1000mg twice daily
AND
A: Metronidazole (PO) 400mg twice daily for 10–14 days
OR
C: Lansoprazole (PO) 30mg twice daily
AND
D: Clarithromycin (PO) 500mg twice
AND
B: Tinidazole (PO) 500mg twice daily for 10–14 days
OR
Any combination of PPI + 2 antibiotics active for H. pylori
| Note: | |
| | H.pylori diagnostic tests should be repeated 3 months after 2weeks of triple therapy to confirm eradication. |
| | Refer to next level of care with adequate expertise and facility for cases refractory to conventional triple therapy or persistent of symptoms or new onset complications |
10.2.2 Ulcer Related Conditions
10.2.2.1 Non-ulcer Dyspepsia (Functional Dyspepsia)
It is a chronic recurrent dyspeptic disorder characterized by epigastrtic pain syndrome and post prandial distress syndrome without any organic, systemic or metabolic disease to explain its presence6.
Diagnostic Criteria
Dyspeptic symptoms present for last 3 months and onset at least months prior to diagnosis and must include one or more of the following 6
- Bothersome post prandial fullness.
- Early satiation.
- Epigastric pains
- Epigastric burning PLUS
- Lack of evidence of structural disease by upper endoscopic examination.
Pharmacological Treament
A: Omeprazole (PO) 20mg daily
AND
C: Metoclopramide 10mg 8 hourly (bloating and nausea symptoms)
OR
D: Domperidone (PO) 10mg 8 hourly or to alleviate bloating and nausea symptoms.
10.2.2.2 Gastritis
This is an inflammatory mucosal response to injury from variety of agents and mechanisms including infections, drugs, alcohol, acute stress, radiation, allergy, acid and bile, ischemia or direct trauma. The inflammation may involve the entire stomach (pangastritis) or a region of the stomach (antral gastritis) while the severity of inflammation may be erosive or non erosive.
Diagnostic Criteria
- Nausea, vomiting, loss of appetite, belching, and bloating
- Acute abdominal pain or abdominal discomfort
- Fever, chills, and hiccups also may be present PLUS
- Endoscopic evidence of gastric mucosal inflammation OR
- Histologic evidence of chronic active inflammation of biopsy specimen.
Non-Pharmacological Treatment
- Reduce the use of drugs known to cause gastritis (eg, NSAIDs, alcohol)
- Stop smoking
- Reduce fatty, spicy and deep fried foods
Pharmacological Treatment:
- Triple therapy for pylori eradication if confirmed present.
- Administer fluids and electrolytes as required, particularly if the patient is vomiting.
- Omeprazole or Pantoprazole and Metoclopramide (for cases presenting with intractable vomiting) in order to relieve symptoms.
Referral:
Refer to next level service with adequate expertise and facilities for complicated case with alarm features (anemia, vomiting blood and weight loss).
10.2.3 Inflammatory Bowel Diseases
Inflammatory bowel disease (IBD) is an idiopathic disease involving an immune reaction of the body to its own intestinal tract. The 2 major types of IBD are ulcerative colitis (UC) and Crohn disease (CD). Pathologically, ulcerative colitis is limited to the colon while Crohn disease can involve any segment of the gastrointestinal (GI) tract from the mouth to the anus.
10.2.3.1 Ulcerative Colitis (UC)
Inflammatory condition that involves the rectum and extends proximally to affect a variable extent of the colon up to the caecum
Diagnostic Criteria
- Diarrhoea
- Rectal bleeding
- Tenesmus, passage of mucus
- Crampy abdominal pain
- Fevers and chills PLUS
- Endoscopic evidence of diffuse and continuous colonic mucosal inflammation with friability and loss of mucosal vascularity. characteristic cobble stone appearance AND
- Histologic evidence of abnormal crypt architecture and superficial inflammation typical of UC.
Pharmacological Treatment
D: Sulphasalazine (PO) 1000mg four times a day for acute disease, reducing to
1000mg once daily for maintenance
OR
S: Mesalazine (PO) 1.5g–4g/day in divided and reduced to 0.75–2g g/day in divided doses for maintenance
PLUS
B: Prednisolone (PO) 30–60mg once daily for severe, acute and extensive disease; tapering gradually after induction of remission.
| Note: | |
| | Complication of UC may present with massive haemorrhage, toxic mega colon, AND perforation with features of peritonitis. |
| | Correction of fluid deficit and/or blood is important in acute severe forms which may necessitates hospitalization |
| | Lifelong follow up is required due to risk of bowel cancer Use steroids only when the disease is confirmed and for induction of remission only. |
| | Refer to next level of care with adequate expertise and facilities for all suspected cases for initial evaluation and management and cases presenting with acute complications |
10.2.3.2 Chrohn’s Disease
Crohn disease is an idiopathic, chronic, transmural inflammatory process of the bowel that often leads to fibrosis and obstructive symptoms and can affect any part of the gastrointestinal tract from the mouth to the anus.
Diagnostic Criteria
- Abdominal pain, diarrhea, weight loss, anorexia and fever
- Gross rectal bleeding or acute hemorrhage is uncommon
- Anemia due to illeal disease involvement
- Small bowel obstruction, due to stricturing
- Perianal disease associated with fistulization
- Gastroduodenal ulceration PLUS
- Endoscopic evidence of rectal sparing skip lesions, cobble stoning with linear ulceration appearance with,
- Histological evidence of transmural disease, apthous ulcers, and non caseating granulomas
Pharmacological Treatment
S: Methotrexate (PO) 7.5–15mg weekly
OR
S: Azathioprine (PO) 50mg once daily for maintenance of remission.
PLUS
B: Prednisolone (PO) 1–2mg/kg for induction of remission only.
PLUS
A: Metronidazole (PO) 400mg 8hourly for 7–10 days
OR
A: Ciprofloxacin (PO) 500mg 12 hourly for 7–10 days – can be added in presence of perianal disease or evident septic complications.
| Note: | |
| | Resuscitative and supportive management should be instituted as for UC section note above |
| | Refer to next level of care with adequate expertise and facilities for all suspected cases for initial evaluation and management and cases presenting with acute complications. |
10.2.3.3 Pseudomembrenous Colitis
This condition is caused by Clostridium difficile a gram positive, anaerobic bacteria causing antibiotic associated diarrhoea as a result of altered bacterial flora and release of enterotoxins.
Diagnostic Criteria
- Bloody Diarrhea
- Abdominal cramps and tenderness
- Nausea, fever, dehydration
- Lower endoscopic pathognomic findings of pseudomembranous yellowish plaques overlying the ulcerated and friable rectal sigmoid colon mucosa PLUS
- Laboratory evidence of difficile toxin A-B isolation from cultured stool samples (Toxin B) OR ELISA assay (ToxinA)
Pharmacological Treatment:
Stop the causative antibiotics
A: Metronidazole (PO) 400mg 8 hourly for 7 days
OR
D: Vancomycin (PO) Adults, 125mg–500mg 6 hourly for 5–10 days
| Note: | |
| | Resuscitative and supportive management should be instituted as for UC section note above |
| | Refer to next level of care with adequate expertise and facilities for all suspected cases for initial evaluation and management and cases presenting with acute complications such as Toxic megacolon |
10.2.4 Irritable Bowel syndrome
Irritable bowel syndrome (IBS) is a functional GI disorder characterized by abdominal pain and altered bowel habits in the absence of specific and unique organic pathology.
Diagnostic Criteria
Recurrent abdominal pains or discomfort at least 3 days per month in the last 3 months associated with two or more of the following
- Improvement with defecation
- Onset associated with a change in frequency of stools
- Onset associated with a change in form of stool
- Bloating or feeling of abdominal fullness
Non-Pharmacological Treatment
- Counseling on compelling psycho –social factors, life style modification, avoidance of trigger factors, and reassurance are corner stone of long term management strategy. Plus supportive therapies such as:
- High fibre diet and eating a healthy diet.
Pharmacological Treatment
A: Hyoscine butyl bromide (PO) 10mg 6hourly per day as needed
OR
D: Mebeverine (PO) 135mg 8 hourly per day as needed
Plus
C: Diazepam (PO) 5–10 mg 8 hourly (as needed for relief of anxiety)
Plus
C: Lactulose (PO) 20mls 12 hourly (as needed for constipation)
Plus
B: Loperamide (PO) 4mg stat, for diarrhoea followed by 2mg 8 hourly or after each unformed stool until diarrhoea is controlled.
10.2.5 Pancreatitis
Pancreatitis is an inflammatory process in which pancreatic enzymes auto digest the pancreatic gland leading to functional and morphologic loss of the gland.
10.2.5.1 Acute Pancreatitis
It is due to sudden inflammation of the pancreas due to pancreatic enzymes auto digestion. Common risk factors which trigger the acute episode are presence of gallstones and alcohol intake.
Diagnostic Criteria
- Severe, unremitting epigastric pain, radiating to the back
- Nausea and vomiting
- Signs of shock may be present
- Ileus is also common
- Local complications: inflammatory mass, obstructive jaundice, gastric outlet obstruction
- Systemic complication: sepsis, acute respiratory distress syndrome, acute renal failure PLUS
- Raised Serum levels for lipase and amylase greater than 3 times the upper limit of normal ULN and,
- Radiological evidence of inflamed and/or necrotizing pancreatitis.
Pharmacological Treatment
- Principles of management include supportive therapies.
- Intravascular volume expansion (colloids/crystalloid)
- Opiates analgesia usually required (follow WHO analgesic ladder)
- Enteral feeding, (only in absence of illeus) start within 72 hours
- Correction of electrolytes and metabolic deficit accordingly
- Give Ceftriaxone (IV) 1 g 12 hourly AND Metronidazole (IV) 500mg 8 hourly for 7 days
- ERCP + Sphincterotomy may be needed.
- Refer unstable cases to next level of care with adequate expertise and facility.
10.2.5.2 Chronic Pancreatitis
Chronic pancreatitis is long-term (chronic) inflammation of the pancreas that leads to permanent loss of function and morphology of the gland.
Diagnostic Criteria
- Chronic upper abdominal pain associated with nausea, vomiting and loss of appetite.
- Malabsorption diarrhoea
- Weight loss
- Diabetes PLUS
- Radiological evidence pancreatic calcification and atrophy.
Pharmacological Treatment
Supportive therapies with
B: Tramadol (PO) 50mg 12 hourly as need for chronic pain relief.
PLUS
S: Pancreatin (PO) 1–3 tablet once daily to supplement digestive enzyme and improve food absorption.
PLUS
A: Metformin (PO) 500mg 12 hourly
OR
B: Insulin 0.5mg/kg/day in two divided doses (SC) for control of hyperglycaemia.
10.2.6 Hemorrhoids
Hemorrhoid disease is due to enlargement or thrombosis of the veins in the external or internal hemorrhoidal plexus.
Diagnostic Criteria
- Painless anal rectal piles
- Painless bleeding –post defecation
- Pain
- Pruritus
- Prolapse PLUS
- Endoscopy (Anoscopy, or proctosigmoidoscopy) for evidence of characteristic anal recta piles.
Treatment
Depends on severity of the disease
- Grade I hemorrhoids are treated with conservative medical therapy and avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs) and spicy or fatty foods
- Grade II or III hemorrhoids are initially treated with nonsurgical procedures (sclerotherapy, band ligation
- Very symptomatic grade III and grade IV hemorrhoids are best treated with surgical hemorrhoidectomy
Pharmacological Treatment:
B: Benzyl benzoate 1.25%, bismuth oxide 0.875%, bismuth subgallate
2.25%, hydrocortisone acetate 0.25%, Peru balsam 1.875%, zinc oxide
10.75% (PR) suppository one or twice a day
OR
Any compound hemorrhoid preparation containing corticosteroid, soothing agent and local anesthetics (PR) suppository one or twice a day
10.2.7 Anal Fissures
These are painful linear ulcers in the anal canal. Young and middle aged adults most commonly affected. Primary fissure occur in the posterior midline. It can also be secondary to Chrohn’s disease, anal cancer, or infection such as syphilis, TB in which case they occur more lateral. Passage of hard stools is a common predisposition to primary fissures.
Diagnostic Criteria
- Severe sharp pain during and after defecation with/out bright red bleeding.
PLUS - Evidence of linear anal rectal ulceration on protoscopy examination
Non-Pharmacological Treatment
- Ensure high fluid intake
- Use non stimulant osmotic laxatives
Pharmacological Treatment
- Topical anaesthetics and frequent seat baths can reduce sphincter spasm
Surgical sphicterotomy is definitive treatment.
