Adapted from Dr. Brian D’Cruz’s Grand Round Lecture August 23, 2017
In addition to classical GI complaints such as giardia, tropical areas have the additional issues such as limited resources, lack of physicians, and potentially poorly treated water resources. Severe malnutrition and dehydration are common complaints.
Severe Acute Malnutrition
Classically, mortality edges on 50% without treatment. Diagnosed by the median upper arm circumference, Z-score (height and weight ratio), or unexplained lower extremity edema. Refeeding immediately can cause cardiac arrest due to heart failure, and can quickly become volume overloaded with IV fluids. Oral or NG tube hydration and low calorie, high nutrient feeds are the initial treatment of choice. F75 is a specialized low calorie milk which is typically the initial treatment of choice in resource limited setting. In addition to slowly introducing calories, patients should be tested for malaria, vaccinated for measles, and treated for potential parasitic infections with albendazole. Previously, antibiotics were given empirically, however recent data shows no change in outcomes. Children with malnutrition are at higher risk for vitamin A deficiency, which may present with xerophthalmia.
Water sources and sanitation are key to preventing gastroenteritis. Most gastroenteritis is viral, and the mainstay of treatment is oral rehydration. Those with bloody diarrhea is typically caused by Shigella, although campylobacter and E coli is also common. The addition of Zinc to oral rehydration improves outcomes, and IV fluids should only be used in those who fail oral rehydration.
Cholera is typically treated primarily with improved hygiene and oral fluids. Less severe cases may be difficult to diagnose.
Many patients are infested with worms; ascariasis, hookworm, strongyloides, and pinworms are all common and treated with albendazole for 1-3 days. Diagnosis is typically based on clinical suspicion as diagnostics are usually not available.
Ebola hemorrhagic fever & diarrhea.
Ebola patients frequently present with vomiting and diarrhea, while only 10% of patients have hemorrhage. Mortality is due in large part to nutritional losses and anorexia associated with the disease process.