Page 158 - Medicine and Surgery

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154 Chapter 4: Gastrointestinal system

Management pylorus and the ileocaecal valve, which is most com-
This depends on disease severity. Assessment of hypo- monly affected. Caseating granulomas and fibrosis may
volaemia may be made using clinical indices such as the result in stricture formation and obstructions. Tubercu-
difference between lying and standing blood pressure, lousperitonitismayresultfromreactivationofTBwithin
the heart rate, skin turgor, urine output and urea and an abdominal lymph node.
electrolyte measurement. A postural drop of 15 mmHg
or more suggests volume depletion. Clinical features
In significant volume depletion intravenous saline The presentation depends on the site of infection and

should be administered. The fluid input and out- often has an insidious onset. Patients may present with
put should be documented hourly and reviewed with diarrhoea, abdominal pain, alteration of bowel habit,
care. blood in stool and systemic features of anorexia and
In mild cases oral rehydration is the treatment of weight loss. Gastric outflow obstruction may result in

choice using a solution containing sodium, potas- vomiting and a succussion splash on examination. There
sium, chloride and citrate. Traditional solutions use may be a palpable abdominal mass. Clinically gastroin-
glucose to facilitate absorption, rice-based polymers testinal tuberculosis may be difficult to distinguish from
have been used in place of glucose with some evi- Crohn’s disease.
denceofbenefitinreducingdurationofdiarrhoea(see
Table 4.3). Investigations
Tetracycline or ciprofloxacin can be used to shorten Abdominal ultrasound may demonstrate mesenteric

duration and reduce severity of illness. thickening and lymph node enlargement. In patients
with vomiting an upper gastrointestinal endoscopy is
performed. Diagnosis may be made using histology,
Tuberculosis and the GI tract
culture or PCR of tissue obtained at laparoscopy or
Definition colonoscopy (particularly from the ileocaecal valve and
Infection of the gastrointestinal tract or the peritoneum terminal ileum). See also Tuberculosis (page 102).
by Mycobacterium tuberculosis (see also page 102).
Management
Treatment with a combination of rifampicin, isoniazid,
Aetiology/pathophysiology
Infections are most common in the immunosuppressed pyrazinamideandethambutolifresistanceislikely.Ther-
and are more common due to HIV. Sources of gastroin- apy should continue for 1 year in gut infections and
2years in peritonitis. Surgical resection of a strictured
testinal tuberculous infections:
bowel may be required for obstruction and to exclude a
Reactivation of primary tuberculosis.

caecal carcinoma.
Bovine TB infections from unpasteurised milk.

Self-infection may occur due to swallowing of infected

sputum.
Intestinal tuberculosis occurs at any point of turbulence, Disorders of the abdominal wall
e.g. the oesophagus at the indentation of the aorta, the
Abdominal hernias
Table 4.3 WHO oral rehydration salts (ORS) formula 2002
Definition
mmol/L Ahernia is the abnormal protrusion of an organ or tissue
outside its normal body cavity or constraining sheath
Sodium 75
Chloride 65 (see Fig. 4.3).
Glucose, anhydrous 75
Potassium 20 Incidence
Citrate 10 85% occur in males, with a lifetime risk of 1 in 4 males,
Total Osmolarity 245
but less than 1 in 20 females. They increase with age.