CHAPTER Abnormal Uterine Bleeding (AUB) The normal menstrual cycle is 21 to 35 days in length. Bleeding normally lasts for 3 to 7 days ah consists of 30 to 40 ml of blood. Cycles that are longer than 35days, cycles that are shorter than days, and bleeding that lasts more than 7 days should be considered abnormal, particula first 2 years from the onset of menarche, Nearly 30% of all gynecological attendance are constitute a significant portion of attendance in family practice. Table 1.1 [eau Normal menstruation - regular cyclic uterine blood flow at an in to 7 days with a typical blood loss of 30 to 80 mL re Menorrhagia - cyclic uterine bleeding at regular intervals, the bleedi amount (more than 80 mL) or duration (more than 7 days) a = Metrorrhagia - acyclic uterine bleeding at irregular intervals (occurs between ovulat = Menometrorrhagia - acyclic uterine bleeding at irregulalr intervals, the bleeding is eith in amount (more than 80 mL) or duration (more than 7 days) eee Polymenorrhea - cyclic uterine bleeding at intervals of less than 21 days. jomenorrhea - cyclic uterine bleeding at intervals of more than 35 days. Intermenstrual bleeding - bleeding at any time during menstrual cycle other than durin menstruation. Cee |ERAL PRACTICE_] Amenorrhea - uterine bleeding is absebnt for 6 months or more, in non-menopausal wom: iT OF SYMPTOMS IN GEN F The Normal Menstrual Sycle | The menstrual cycle is divided into 2 phases-follicular phase before ovulation and luteal phase after Z| ovulation, Ovulation occurs on 14th day in a 28 days menstrual cycle. During the follicular phase, | release of gonadotropin-releasing hormone (GnRH) from the hypothalamus stimulates the pituitary to secrete luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which then stimulate ovarian estrogen secretion. Ovulation occurs 12 hours after the midcycle surge in LH. The luteal phase follows ovulation, and the corpus luteum secretes progesterone and estrogen. Progesterone inhibits endometrial Proliferation and induces glandular changes. Without fertilization, progesterone and estradiol levelsf <-almormal Uterine seeding (U5) EIR decrease and sloughing of the endometrium occurs after 14 days. In anovulatory cycles, the follicular growth occurs with the stimulation from FSH; however, due to lack of LH surge, ovulation fails to occur. Consequently, no corpus luteum is formed and no progesterone is secreted. The endometrium continues its proliferative phase excessively. When the follicle involutes, estrogen levels drop and estrogen withdrawal bleeding occurs. Inca emu nee ue Dysfunctional uterine bleeding (DUB) Fibroid uterus Adenomyosis Chronic tubo-ovarian mass nee eee ceae) DUB -usually during adolescence, following childbirth and abortion and preceding menopause Submucous fibroid Uterine polyp Carcinoma cervix and endometrial carcinoma Ci once Urethral caruncle Ovular bleeding Breakthrough bleeding in pill use IUCD in utero Contact bleeding - carcinoma cervix, cervicitis, Ginetta ‘Age related ~ during adolescence and preceding menopause Weight related - obesity Stress and exercise related Endocrine disorders - PCOS (most common), hyperprolactinemia, hyperthyroidism ‘Androgen producing tumors - ovarian, adrenal Tubercular endometritis - late cases Drugs ~ phenothiazines, cimetidine, methyldopa COMMON CONDITIONS CAUSING ABNORMAL UTERINE BLEEDING |. Polycystic ovary syndrome (PCOS) isa common cause of abnormal uterine bleeding. of reproductive age most frequently seek attention because of irregular menses, hitsutis Patient is obese with abdominal fat distribution, PCOS is associated with metabolic abnormalities (eg. dysli - insulin resistance, glucose intolerance), Most women deny childhood obesity and deseribe normal weight unt after menarche, Significant weight gain occurs in the adolescent age ‘Young women sm, or infertilitySUNN secrion 1: wason symproms g g g é Z & & g z 2 5 = 8 z s 3 \2| 5 = . Infections: Chlamydia infections and Manifestations of androgen excess include acne and hirsutism. Most patients with PCOS have oligo/ amenorthea, Often the menstrual formula (.., 3 to 5 days of menstrual flow every 28 to 35 days) occurs forthe first one to two years after menarche (which occurs at the normal age), but menses then become less frequent. The patient may be diabetic or may have hyperinsulinaemia, USG shows cystie follicles in the ovarie The diagnostic criteria for PCOS include at least two of the following: = Menstrual irregularity due to oligomenorrhea or anovulation, Signs of androgen excess on physical examination (e.g., hirsutism, acne) Laboratory testing (e.g., elevated testosterone). « Evidence of polycystic ovaries by ultrasound. Hyperprolactinemia is a pituitary cause of amenorrhea in the presence of normal puberty. Hyperprolactinemia can occur as a consequence of breastfeeding, microadenomas of the pituitary, and psychoactive medications (e.g., haloperidol, phenothiazines, amitriptyline, benzodiazepines, cocaine, and marijuana). Bleeding disorders: An underlying bleeding disorder should be considered when a patient has any of the following Menorrhagia since menarche Family history of bleeding disorders Personal history of one or more of the following: Notable bruising without known injury, bleeding of oral cavity or gastrointestinal tract without obvious lesion, epistaxis more than 10 minutes duration (possibly necessitating packing or cautery), . Contraception related: Treatment with oral contraceptives, progestin-only preparations, or Postmenopausal hormone replacement therapy might be associated with iatrogenically induced uterine bleeding. Progesterone breakthrough bleeding occurs in the presence of an unfavorably high ratio of progestin to estrogen. Intermittent bleeding of variable duration can occur with progestin- only oral contraceptives, depo-medroxyprogesterone, and depo-levonorgestrel. IUCD can cause menorthagia with dysmenorrhoea and dyspareunia, Pregnancy-related bleeding: The possibility of pregnancy must be considered when a woman in reproductive age group (even an unmarried adolescent), seeks treatment for abnormal bleeding. Bleeding in pregnancy can be associated with a spontaneous abortion, ectopic pregnancy, or other Pregnancy-related complications, such as a hydatiform mole. Usually there is a history of missed period with bleeding and pelvic pain. Urine and/or serum HCG will be positive. gonorrhea can cause PID and cervicitis in sexually active women irregular or post-coital bleeding. Tuberculosis usually causes and cause polymenorthagia, menorthagia, amenorrhea or oligomenorthoea, A woman1-Abnormal Uterine Bleeding (AUB) 7. Dysfunctional uterine bleeding (DUB): Itis irregular uterine bleeding that occurs in the absence of local pathology or systemic medical illness. Its a type of AUB. It can be anovulatory, which is characterized by irregular unpredictable bleeding, or ovulatory, which is characterized by heavy but regular periods (i.e., polymenorthea, polymenorrhagia or menorthagia). Ovulatory DUB is seen in reproductive age group between 30-45yrs of age. Anovulatory DUB is seen few months preceding menopause or in adolescent age group. Anovulatory cycle is characterized by acyclical bleeding- a short period of amenorrhea followed by heavy bleeding lasting for 2-6 weeks, but is. painless. 8. Uterine fibroids and polyp: Abnormal bleeding is the most common symptom for women with uterine fibroids. Although the number of uterine fibroids and their size do not appear to influence the occurrence of abnormal bleeding, submucosal fibroids are most likely to cause menorthagia, esp. on 2nd and 3rd day of menses. Endometrial polyps are a cause of intermenstrual bleeding, irregular bleeding, and menorthagia. However, as with fibroids, most endometrial polyps are asymptomatic. The incidence of endometrial polyps increases with age throughout the reproductive years. 9. Thyroid disorders: Both hypothyroidism and hyperthyroidism can be associated with abnormal bleeding. With hypothyroidism, menstrual abnormalities including menorthagia are common. Hyperthyroidism can result in oligomenorrhoea or amenorrhea. The most common cause of hyperthyroidism in premenopausal women is Graves' disease. 10.Psychogenie causes: Emotional disturbances like changes in environment, marital or examination related stress can cause change in menstrual pattern-either excessive bleeding or oligomenorthoea. The abnormal menstrual pattern can be a delayed response and be seen months afier the crisis is over. Similarly chronic illness, excessive exercise as in athletes, eating disorders like anorexia nervosa can cause changes in menstrual pattern. New classification of AUB: The PALM COEIN classification Abnormal uterine bleeding patterns have been traditionally expressed by terms like menorrhagia, metrorthagia, polymenorthea and oligomenorrhea. In order to create an universally accepted nomenclature to describe AUB, International Federation of Gynecology and Obstetrics (FIGO) and American College of Obstetricians and Gynecologists (ACOG) introduced newer system of terminology to describe AUB. This newer classification system is known by the acronym PALM-COEIN (FIGO-2011) which classifies AUB on basis of etiology. Classification of AUB (FIGO-2011) Rtn) neers Polyp AU! Adenomyosis AUB-A Leiomyoma AUB-L Coagulopathy AUB-C eee dysfunction AUB-O ndometrial AUB“ Other myoma AUB-LO Not yet identified AUB. Malignancy and hyperplasia AUB-M e(GRRRRRER scion 1 mason symproms APPROACH TO A PATIENT OF ABNORMAL UTERINE BLEEDING ‘OMS IN GENERAL PRACTICE MANAGEMENT OF SYMPTI A.Mistory History of missed period before uterine b «Are there symptoms suggestive of premenstrual syndrome? DUB is ovulatory type. # Ivthe bleeding weyelivil, usually painless and heavy? DUB is anovulatory type. History of bleeding during previous surgery or easy bruising? Think of blood dyscrasia. # Is the patient obese, having, constipation, eaxy faligability? Think of hypothyroidism, Does the y menorthagia with pelvic pain and white PY discharge? Think of PID. » Does the patient have oligomenorrhoca with obesity, acne, and hirsutism? Think of PCOS, Does the patient have oligomenorrhoca with galactorthoea? Think of hyperprolactinemia # Does the patient have menorthagia with dyspareunia? Think of endometriosis or PID. # Docs the patient have menorshagia with dysmenorrhoca? Think of fibroid or adenomyosis. «Is the paticnt having irregular bleeding more after 35 yrs of age? Rule out uterine or cervical cancer by Pap smear and transvaginal USG. Jing? Rule out pregnaney. ent hav B. Physical examination On pelvic examination are there abnormal lesions on cervix? Think of cervicitis, cervical polyp, CA cervix. = Is the uterus enlarged on pelvic exa 1? Think of pregnancy or fibroids or adenomyosis. = Are the ovaries enlarged on PV exam? Think of ovarian cyst, tumor, and endometriosis. + Isthere uterine and adnexal tenderness on PV exam’ Think of PID, endometriosis, ectopic pregnancy. C. Investigations Is the urine pregnancy test or serum HCG test positive? Bleeding is pregnancy related- abortion, ectopic pregnancy or mole. Does the Pap smear show abnormal picture? Think of cervical or uterine carcinoma. Is the endometrial thickness on USG more than 12 mm (endometrial hyperplasia)? Do endometrial biopsy to rule out malignancy esp. in women>35 yrs of age. Does the USG show polycystic ovaries or ovarian cysts? Could be PCOS. Is the platelet count, BT, CT, PT, PTTK or coagulation profile abnormal? Cause is blood dyscrasia. conn vestigations in abnormal upT Pregnancy Haemogram ‘Anaemia PT,PTT Coagulopathy : Pap smear Cervical cancer especially in >35 yrs contd.FT Liver disease TSH Thyroid disease FSH,LH Ovarian/ hypothalamic function Prolactin Hyperprolactine RFT Renal disease a Symptoms of endocrinopathies: = Polycystic ovary disease - obesity, acne, hirsutism with oligomenorrhoea = Hyperprolactinemia- —oligomenorrhoea with galactorrhoea = Hypothyroidism- obesity with fatigue, constipation, and less or heavy menses Signs of anaemia like pallor, koilonychia Pelvic examination: = Inspection of the vagina and cervix for physical lesions (polyps, malignancy, cervicitis or discharge) = The size, shape, position, and firmness of the uterus and adnexia-tenderness, fullness in cul- de-sac = Signs of pregnancy SPECIAL INVESTIGATIONS IN A CASE OF ABNORMAL UTERINE BLEEDING 1. Uterine ultrasound, especially transvaginal ultrasonography (TV-US), can give information about suspected structural problems including fibroid tumors. Itis classically indicated when physical exam indicates abnormalities of uterus or ovaries. It provides information about endometrial thickness, evidence of ovulation, intramural polyps or submural fibroids, adenomyosis, ovarian pathologies like cysts, ete, An endometrial thickness measuring less than 5 mm is rarely associated with cancer, and endometrial sampling may not be necessary in such patients. Sonohysterography is a new technique that involves infusion of saline in uterine cavity during transvaginal sonography. It provides better visualization of uterine pathologies. Endometrial Biopsy (EMB) is the most commonly used diagnostic test. It provides an adequate evidence for diagnosis of endometrial problems in 90% to 100% of cases, but may fail to detect polyps and leiomyomas. Itis indicated in all women with menstrual problem who are 35 years of age or older, since their risk of developing malignancy is much higher. Any woman with amenorrhea for one year or longer who experiences uterine bleeding also should have an EMB. It provides evidence of ovulation or anovulation, endometritis, esp. tuberculosis, hyperplasia, malignancy, ete. 3. Hysteroscopy allows for direct visualization of the endometrial cavity. Endometrial biopsy can be done at the same time. Hysteroscopy is more sensitive than fractional D & C, especially at diagnosingGUNEENIM secrion 1: wason symeroms GENERAL PRAC [MANAGEMENT OF SYMPTOMS IN polyps and submucosal leiomyomas, but it may miss endometritis. When combi almost 100% accuracy in diagnosing endometrial dysplasia and cancer. Many small fibroids can be treated in the same setting, ined with EMB, i benign lesions like poly Dilatation and Curettage (D & C) allows more extensive sampling of the uterine cavity and has the advantage of being both diagnostic and therapeutic. It may be the treatment of choice when bleedi severe and necessitates blood transfusions. MANAGEMENT A) Medical treatment The choice of approach depends on the cause, severity of bleeding, patient's fertility status and need for contraception. Severe Acute Bleeding: Severe acute uterine bleeding usually occurs in one of three settings: the adolescent with a coagulopathy (most commonly Von Willebrand disease), the adult with submucous fibroids, or the adult taking anticoagulants, If the patient is hypovolumic or is haemodynamically unstable, hospitalize. The patient is given high-dose estrogen (orally or intravenously depending on severity of bleeding) and then a tapering schedule of oral contraceptives. One common oral contraceptive regimen is ethinyl estradiol 30 g/norgestrel 0.3 mg (e.g,, LoOvral) 1 pill 2 times daily for 2 days, followed by once daily for 3 weeks. The patient then stops the pill for I week and then cycles in the usual manner, 3 weeks on and | week off, for at least 3 months. Investigations into the cause of bleeding should be done. These include coagulation studies and transvaginal ultrasound (TVUS). ooee | oR = Medroxyprogesterone (Provera) 10 mg PO/day for 10 to 12 days = Depo-medroxyprogesterone (Depo-provera) 150 mg IM every 3 months : = Oral contraceptive pill for 5 to 7 days or until bleeding stops = Intravenous estrogen 25 mg every 4 hrs-- until bleeding stops till maximum 3 doses or = Oral conjugated estrogen (Premarin) divided doses up to 10 mg/day = Progesterone-containing IUD-(Mirena ) = NSAIDS like naproxen (Naprosyn) 500 mg bd, ibuprofen (Brufen) 400 mg tds, mefenamic acid (Meftal). £00 mg tds, tranexamic acid (Pause) 500mg tds, ethamsylate (Sylate) 500 mg qid = Danazol (Danocrine) 200 to 800 mg/day for 3 to 6 months * GnRH agonists Goserelin acetate (Zoladex), 3.6 mg SC every 28 days; leuprolide acetate (Lupron) or nafarelin acetate (Syneral) 2. Abnormal uterine bleedin; of medroxyprogesterone (P: is given. If patient is sexu "3. Abnormal ute 6 in pubertal age group: If bleeding is not severe, cyclic administration (14th -24th day of cycle) for 3-6 months n. rovera)10 mg orally for 10 days ally active, 0.C pills should be give e bleeding in reproductive age grow Patient requires contraception, O.C pills are a good choice. O.C pi i 0.6 .C pills with like metformin are given in PCOD patients for 3-6 months Soe contraindication to the use of O.C pills she may be given eye na pregnancy or has a1-Abnormal Uterine Bleeding (AUS) [ED of the cycle or medroxyprogesterone 10 mg od from 14th to 24th day of the cycle. If the patient does not Want hormonal therapy or bleeding is ovulatory type, various NSAIDs can be tried- mefenemic acid 500 mg tds. naproxen 500 mg bd, ibuprofen 400 mg tds ete, as given in box. Antifibrinolytic agents like tranexamic acid can also be given in dose of 500 mg tds or qid per day. Less commonly used drugs are danazol (expensive and cause androgenic side-effects), and gonadotropin releasing hormone (GnRH) analogues (expensive and causes osteoporosis). Progesterone release (Mirena) IUCD is costly but effective. +. Abnormal uterine bleeding in peri-menopausal age group: One should always rule out malignancy inthose above 35 yrs as a cause of uterine bleeding. USG with endometrial biopsy needs to be done. If normal, then treatment is with hormonal or non- hormonal drugs as in other patients. If there is any suspicion of pre-malignant condition, hysterectomy is preferred. Amenorrhoea or Oligomenorrhoea: Other than pregnancy, pubertal delay, anovulation, and chronic illness, most of the other disorders causing amenorthea may require referral to a specialist for treatment. Many of the treatments will require surgery or specific therapies. For the adolescent with normal secondary sexual characters and anovulatary cycles, the goal should be to restore ovulatory cycles, by giving estrogen-progestin therapy. B) Surgical treatment 1. Dilatation and curettage (D&C) may ameliorate DUB, as well as diagnose potential dysplasia or malignancy. It is avoided in adolescents because of concerns about possible infertility, Repeated procedures may result in intrauterine adhesions. Hysteroscopic ablation of endometrium can be done by using (Nd: YAG) laser, electrocautery by a resectoscope, or thermal uterine balloon. The goal is to ablate the endometrium and encourage endometrial adhesions resulting in hypo- or amenorrhea, Ablation is specially indicated in those who refuse hysterectomy and in those who are poor surgical risks. Advantages of ablation are a shorter recovery time and less morbidity. However symptoms can recur or persist, requiring hysterectomy. It is not recommended for patients with high risk of endometrial carcinoma. - (Nd: YAG) laser endometrial ablation is a new method of surgically treating the endometrium. It has a success rate of approximately 85% and is more effective in patients over the age of 35 years. There is some concern that cancers could be missed, since no tissue is available for histopathology study. Laser equipment is expensive and requires special safety precautions. ~ _ Hysteroscopic transcervical resection of the endometrium (TCRE) makes use of an electrocautery loop or ball to remove or coagulate the endometrium to stop DUB. The hysteroscope is considerably less expensive to buy and maintain than the laser but carries the risks of endometritis and uterine perforation - In thermal uterine balloon system hot water is circulated in a latex balloon inserted in uterine cavity. The treatment has been found to be as efficacious with fewer complications, 3. Hysterectomy remains the most absolute curative treatment for DUB that does not respond to hormonal therapy or other surgical management, It is best indicated for patients who do not desire fertility and have significant pelvic pathology in the form of polyp, fibroids, endometriosis or PID. It can be done as open surgery by vaginal or abdominal route, or laparoscopically.REND section 1 mason symptoms Hee MPTOMS IN GENERAL F MANAGEMENT OF svt Lindl eal ubiuneeicleeeatd f If the patient is In reproductive age group (even if unmarried) and gives even a short history of — amenorrhea before uterine bleeding- rule out pregnancy. If the patient has hypotension with severe acute bleeding- admit the patient to prevent — shock. 3 Ifa young girl presents with menorrhagia since menarche- always rule out blood dyscrasia, | If a women >35 yrs of age presents with Irregular bleeding- think of uterine or cervical - cancer. Lae hn as Below the age of 20 yrs, abnormal menstrual bleeding usually occurs without pelvic pathology and with a tendency of spontaneous cure. In the reproductive age group, an organic cause of bleeding (especially pregnancy related), is most likely. After the age of 40years, again DUB is common but investigations need to be done to rule out benign or malignant tumors. Irregular bleeding within 2 years of menarche is usually due to anovulation, secondary to an immature hypothalamic-pituitary-ovarian axis. Early periods and occasional missed periods are common in young women and may result from mental stress or iliness. Severe acute uterine bleeding in the nonpregnant patient usually occurs in one of three settings: the adolescent with a coagulopathy (most commonly Von Willebrand disease), the adult with submucous fibroids, or the adult taking anticoagulants. Missed periods and prolonged intervals are expected in peri-menopause. Intervals may also decrease in the peri-menopause, but repeated intervals less than 21 days or other irregular patterns require endometrial biopsy. In any reproductive-aged woman, a few days of premenstrual spotting, if it is immediately before the period can be a normal variant, but the total duration should be less than 8 days. A few days of postmenstrual spotting, if it is immediately after the period, can also be considered a normal variant. j Brief midcycle spotting can occur at the time of ovulation due to the normal dip in serum estrogen levels. However, this is not common and should prompt an endometrial biopsy in women more than 35 years old. Menorrhagia can often be managed without endometrial biopsy because regular bleeding, — even if heavy, is less likely to be caused by endometrial cancer. However, if the bleeding is prolonged (7 days) or does not respond to hormonal therapy as outlined above, further evaluation with TVUS or endometrial biopsy is indicated. Breakthrough bleeding occurs commonly with low dose oral contraceptive pills. In patients with an IUD, abnormal bleeding may be associated with endometritis. Contraindications to oral contraceptives include history of thromboembolic event or stroke, estrogen- dependent tumor, active liver disease, pregnancy, hypertriglyceridemia, and smoking more than 15 - cigarettes per day. Pelvic examination is unnecessary in oligomenorrheic patients who are not sexually active and are within 18 months of menarche. An endometrial thickness measurement of less than Smm is rarely associated with cancer, and endometrial biopsy may not be necessary in such patients.1-Abnormal Uterine Bleeding (AUB) UPT + ve UPT - ve Pregnancy Do USG, TSH, prolactin levels Manage v Prolactin increased v v Outlet Hyperthyroid/ = obstruction ) Hypothyroid PCOD J _Do MRI brain } Treat ui v ‘Normal Pituitary adenoma Refer tumour Y Rule out chronic disease like TB, eating Refer ) ‘order, athleticism or stress-advice lifestyle changesSECTION 1 : MAJOR SYMETONS J \GEMENT OF SYMPTOMS IN GENERAL PRACTICE MANAG ’ UPT + ve y een eee eed) l i = Y v Age > 35 years Refer Age < 35 years, . y heavy bleeding since Do Pap smear, USG + parener ees endometrial biopsy DoTSH, PT, _) Y vy PTTK, Pit count, USG Normal } Abnormal cae | aR ¥. Hormonal ) Refer therapy me) Pe Hypothyroidism/ | Coagulopathy | Fibroid/polyp) PID) All in 2 Hyperthyroidism nornae y Refer Ree?) CREE ‘Treat Treat with hor ‘or non-hot treatmer1-Abnormal Uterine Bleeding (AUB) Goce Amenorrhoea or oligomenorrhoea with PCOD (if ferti Tab. Metformin 500mg tds for 3-6months Tab. 0.C pills (LoOvral) 1 od from 3” day of cycle for 21 days. Tab. MPA (Divery) 10mg od 5® day to 25" day of cycle ity not desired) Severe acute uterine bleeding (Hospitalization not required) Tab. Premarin 2.5mg tds or gid and Tab. Promethazine 25 mg tds to qid (if vor Tab. LoOvral bd x 2 days, then od x 3 weeks. After 1 week of gap, Tab LoOvral 1 od for 21 days x 3 months (or) Tab Provera 10 mg from 14!™ day to 24 day for 3 months. ing) till bleeding lessens, then For acute uterine bleeding (alternative therapy) Tab Ovral L bd for 7 days then Tab Ovral L od for 14 days. Then after 7 days off Tab Ovral L od x 3 weeks Tab MPA (Provera) 10 mg tds till bleeding stops, then 1 od for 2 weeks. Irregular or heavy bleeding Tab. LoOvral from 5% to 25" day of menstrual cycle x 3 months,(if fertility not desired). Tab. Provera 10 mg from 15 -25% day for 3months (if fertility desired) If hormonal treatment not desired, Tab. Tranexamic acid (Pause) 500 mg 1-2 tabs tds (or) Tab. Mefenemic acid (Meftal) 500mg tds (or) Tab. Ibuprofen (Brufen) 400mg tds till bleeding stops. This chapter has been reviewed by Dr Girish Godbole (MD), Consultant Gynaecologist at Deenanath Mangeshkar Hospital, Pune.CHAPTER 2 Abnormal Vaginal Discharge Vaginal discharge is one of the most common gynaecological symptoms affecting women. Vaginal discharge may be physiological or pathological. Physiological discharge is usually clear or white, viscous in consistency, does not cause pruritus and is non-offensive. It consists of secretions from different structures in the reproductive tract like secretions from the Bartholin and Skene glands, transudate from the vaginal walls, exfoliated vaginal and cervical cells, cervical mucus, endometrial and fallopian tube fluids, and commensal micro- organisms. Therefore, phase of the menstrual cycle influences the quantity and quality of normal discharge, During the follicular phase, there isa gradual increase in vaginal fluid discharge, peaking at ovulation. After ovulation (luteal phase), the discharge becomes more viscous and thick. Leucor- thoea is a term used for excessive amount of normal discharge. Pathological discharge: A vaginal discharge is considered abnormal vaginal discharge if itis heavier and thicker than usual, pus-like, white an \d clumpy (like cheese), greenish, yellowish, blood-tinged, &} foul or fishy smelling, and accompanied by itching, burning, rash, or soreness. Although abnormal =| vaginal discharge gives a good opportunity to screen for sexu ENERAL PRACTICE |] 3 ally transmitted infections (STIs), it is | 2| poorly predictive of the presence of a STI. 3 = Causes of Increased Physiological Disc Cia CCud &| © Newborn |Z) = Puberty S| = Pregnancy [S| = Ovulation S| = Premenstrual (| © Sexual excitement Atrophic vaginitis2-Abnormal Vaginal Discharge Eigse 4 ive Causes EEE W CETTE IRI caeke ean Common Sexually transmitted infections = Trichomonas vaginitis = Chlamydia trachomatis = Neisseria gonorrhoea Other infections = Candida vulvovaginitis = Bacterial vaginosis Uncommon = Herpes simplex infection Human pa Mycoplasma genitalium Ureaplasma urealyticum Escherichia coli Note: Always rule out conditions like acute pelvic inflammatory disease, postoperative pelvic infec- tion, post-abortal sepsis, puerperal sepsis. SS eee en Chee e ees Atrophic vaginitis Vaginal tumours Cervical cancer and polyps Endometrial tumours Drug-induced: OC pills, antibiotics, steroids Foreign bodies—Condoms, tampons, IUCD Spermicides, vaginal creams, lubricants, douches and antiseptics Recto-vaginal fistula Allergy, €.g., soaps, condoms, etc Psychosomatic vaginitis COMMON CONDITIONS CAUSING ABNORMAL VAGINAL DISCHARGE 1. Increased Physiological Vaginal Discharge (Leucorrhoea) Newborn babies may have a mucoid vaginal discharge for 1-10 a . |-10 days. Leucorrhoea it srl during the few yearsbeforeand afer menarche, Vaginal discharges normally ieee paren aan and pre-menstrually. There is increase in Bartholin’s gland secretions iach ieel acstienrees a lation increased vaginal secretion. During pregnancy, hypertrophy ofthe vaginal epithelium lech er nt vaginal discharge, However, pregnancy may also predispose to infective conden eae vulvovaginitis. Hence, itis important to investigate an offensive, punulentor blocs on such as Candie with itching, burning, ete. : nt or bloody discharge ora discharge~ cones ace SE: ee, : . SECTION 1: MasoR syMPToms 2. Bacterial Vaginosis Bacterial vaginosis (BV) is the va most common cause of va initis. It is caused by an overgrowth of organisms such as Mycoplasma hominis, and Peptostreptococcus species. Risk facto include pregnancy, intrauterin (IUD) use, and frequent douching. BV causes offensive, fishy. smelling discharge, which is white to grey in colour, The discharge appears adhet ‘nt to the vaginal mucosa, The production of responsible for the “fishy” odour, which is characteristic of this condition. Irvitative symptoms like: soreness, or burning are absent. BV may be symptomatic or asymptomatic, may oceur at spisodically, may become persistent or may resolve spontaneously. As many as 50% of women with BY are asymptomatic. BV can cause complications like pelvic inflammatory disease, abnormal bleedin 2 endometritis, postoperative infections following pelvic surgery, and increased risk of transmission @ HIV infee Obstetric complications include preterm delivery, mid-trimester miscarriages, and intra and postpartum infections. initis, accounting for almost 50% of Jardnerella vaginalis, Mobiluncus s Pp Diagnosis The diagnosis is based on Amsel’s crite confirm the diagnosis of BV: |. A raised vaginal pH >4.5 Presence of a homogenous thin grey or white discharge coating the vaginal walls. Release of amines on mixing the discharge with 10% KOH—the ‘whiff test.’ Presence of >20% ‘clue cells’ on wet-mount microscopy of the vaginal fluid. a. Three of the following four criteria are necessary to Ben 3. Candida Vulvovaginitis Candida vulvovaginitis (CV) ranks as the second most common cause of vaginal infection. Approxi- mately 75% of women are estimated to have at least one episode of this infection during their repro. ductive life. It ean occur recurrently in women having predisposing factors like diabetes, HIV, and | patients on steroids, antibioties, OC pills, ete. About 90% of the infections are caused by Candida | albicans species, with the remainder being non-albicans species, mainly C. glabrata. It can be a normal asymptomatic colonization in the vagina. The presentation typically consists of vulvar pruritus, pain, terminal dysuria and a variable odourless vaginal discharge, ranging from thick. cheese, like to watery discharge. Pruritus is out of proportion to the discharge. Physical findings are of white plaques on the vaginal walls with minimal discharge and severe erythema with extensive valver involvement. There may be fissuring or “satellite lesions.” ENERAL PRACTICE S Mi INAGEMENT OF SYMPTOI Diagnosis Patients with symptomatic vaginitis can be readily diagnosed based on the microscopic examination of the discharge. A wet-mount preparation of the secretion mixed with 10% KOH, in addition to a | saline preparation is examined. The presence of branch-like pseudohyphae or budding yeasts is l diagnostic. The presence of large numbers of white cells would suggest a mixed infection, Vaginal pH reveals a normal pH (<4.5). Routine cultures (Sabouraud’s medium) are unnecessary and should ns be performed in recurrent candidial vaginitis. only2-abnormal Vaginal Oischorse ERE 4. Trichomonas vaginitis Trichomonas vaginalis (TV) is « unicellular flagellated protozoan, [Lis the third most common cause of infectious vaginitis. [Cis an anacrobie parasite that is responsible for 15-30% of all cases of vaginitis. Itis vainly transmitted (hrough sextial intercourse, although other routes of transmissions are known. Ithas been isolated trom toilet seats, baths, poorly chlorinated water, etc. There is concomitant BV infection in 60% of patients infected with TV, I can be asymptomatic in up to 50% of patients. A copious green or yellow frothy offensive vaginal discharge is the presenting complaint, Associated symptoms can include he soreness, pruritus, dysuria, dyspareunia, and frequency of micturition, Small punctate haemorrhages his “Strawberry cervix” is very specific with ulverations may be observed on the cervix on examination for Trichomonas int Diagnosis A vaginal pl 4.5 is found in 60% of cases of TY, Microscopic examination of a saline wet-mount ichomonads seen as small, pear-shaped organisms with highly motile Magellae, Increased numbers of Icucocytes are also seen, Organisms can be cultured using Diamond’s medium or Roiron medium, An effective, but more expensive test is monoclonal antibody testing and polymerase chain reaction (PCR) assay. preparation of the discharge shows 5. Chlamydia trachomatis Cervicitis C.trachomatiy is an intracellular organism, infecting the columnar epithelium of the endocervical canal and urethra. It is the most common bacterial sexually transmitted infection (STI). The infection is usually asymptomatic in 80% of women, Although it causes cervicitis and urethritis, women may present with a -2e due to the cervical discharge coming out ofthe vagina, Its non-itritant and non-odorous. There may be abnormal bleeding (postcoital or intermenstrual), lower abdominal pain, dyspareunia, or dysuria, Risk factors for C. trachomatis are: Age <25 years, a new sexual partner, or more than one partner in the last year, Clinical examination might reveal oedematous and reddened endocervix easily bleeding on touch, Diagnosis Diagnosis is confirmed by the presence of more than 10 polymorphs per high power field of microscopic examination of the cervical discharge. Endocervical cultures using ELISA, DNA probes can be used for the diagnosis of Chlamydia trachomatis. Because there is a high rate of concurrent infection, any woman being screened for Chlamydia should also be screened for gonorrhoea, It is a common cause of infertility. 6. Neisseria gonorrhoea Cervicitis N. gonorrhoeae is a gram-negative diplococcus causing cervicitis after sexual contact Up to 50% of women with N. gonorrhoea will complain of vaginal discharge. The discharge is due to cervicitis rather than vaginitis. Gonorrhoea is asymptomatic in 50% of cases.SECTION 1: MaJoR syMeTOMS 8 e z is 6 z 2 5 MANAGEMENT OF SYMPT( 2. Vaginitis due to foreign bodic Clinical Presentation The common symptoms are purulent vaginal discharge, postcoital or intermenstrual bleeding, d lower abdominal pain, and dyspareunia Clinical Examination This may reveal oedematous and reddened endocervix with yellow discharge from the opening 0 cervix and easily induced cervical bleeding. The Q-tip test has been described to test clinically mucopurulent cervicitis. The ectocervix is cleaned gently; a thin cotton swab stick is placed in 7. trophic Vaginitis Atrophic vaginitis isa symptomatic vaginal inflammatory condition caused by estrogen-deficient va epithelium. It mostly occurs in postmenopausal women. Symptoms include vaginal spotting, so1 external dysuria, pruritus, dyspareunia, and an increased vaginal discharge. Signs are thin, shiny, pale} vagina with loss of rugae with small ulcerations or bleeding points. Always consider a malignancy of genital tract in a woman who presents with a blood-stained discharge, especially in the case of women. A persistent vaginal discharge should also raise this suspicion. Non Infective causes of Vaginitis 1. Drug-induced vaginitis: Drugs may cause an allergic or inflammatory process in the vagina, Due to their estrogen activity, oral contraceptives can cause an increased discharge. Vaginitis can also caused by chemical allergy due toa vatiety of preparations; e.g., condoms, spermicides, vaginal lubricants, douches, and antiseptics. : An offensive, sometimes blood-stained vaginal discharge sho alert one to the possible presence of foreign bodies. Although most common in small childre can occur in any age group. Women are often too embarrassed to mention this, or may forgotten about it, The object usually leads to vaginal ulceration with secondary infection. Vay stenosis may occur if the foreign body remains in the vagina for a long time. It is important to and visualize the whole length of the vagina during examination. é Cervical erosion is a reddened area around the external cervical os. It commonly produces mucoid discharge, but may cause blood stained or mucopurulent discharge. It may cause post-coital bleeding. On per speculum examination, the erosion is soft and may bleed on touch. ; Neoplasm: Always consider a malignancy of the genital tract in a woman who presents with a blood-stained discharge, especially in the ease of elderly women. A persistent vaginal discharge should also raise this suspicion, Pelvic examination and regular cytological smears are both mandatory. Rectovaginal fistula: Presence of fecal matter in the discharge points toward fi istula, Although HSV and HPV cause ulcers and warts, respectively, they can cause increased vaginal discharge due to. ‘associated cervicitis.\ abnormal Vaginal Discharge ECE Preiaus Nature of discharge Colour Odour Consistency Associated irritation or discomfort Time scale Duration Variation in relation to menstrual cycle Coitus Factors associated with onset of the discharge Associated symptoms Lower abdominal pain Dyspareunia (superficial or deep) Associated inter-menstrual or post-coital bleed Vulvar lesions Urinary symptoms Sexual history New sexual partner, number of recent partners Symptoms in partner Previously diagnosed discharge Other factors Medications, e.g., hormonal drugs, antibiotics, steroids Personal hygiene practices, ¢.g., douching Surgical history, e.g., gynaecological procedure (MTP, post-partum) Diabetes Immunocompromised state like HIV/AIDS, chemotherapy APPROACH TO A PATIENT OF ABNORMAL VAGINAL DISCHARGE A.History «Is the woman <25 years with more than one sexual partner? If so, this is high risk for STI. = History of use of medications (¢.g., antibiotics, corticosteroids)? It could be candidiasis. = Is she diabetic or immunocompromised? Think of candidiasi Is she is postnatal, post-miscarriage, or post-abortion case? It could be gram -ve infection. Js she is within 3 weeks of insertion of intrauterine contraception? Could be secondary infection. «Is the discharge worse after menstruation and with pruritus? Think of trichomonal infection = Is the discharge very offensive? Think of bacterial vaginosis, foreign body, or neoplasm. = Is pruritus severe? Think of candidiasis and TV. «Is the patient with vaginal discharge pregnant? It could be physiological discharge or CV. Is she in the post menopausal age? Cause could be atrophic vaginitis or neoplasm. a Is the discharge blood stained? Think of cervical erosion or neoplasm. = Pelvic pain, dyspareunia, abnormal menses with discharge? It could be PID.(OUTED section 1 : mason symrroms MANAGEMENT OF SYMPTOMS IN GENERAL PRACTICE B. Physical Examination = Ina case of vaginal discharge, abdominal palpation (for pain or tenderness), inspection of if vulva (for obvious discharge, vulvitis). speculum examination (for inspection of vaginal i cervix: foreign bodies; amount, consistency, and colour of discharge), bimanual pelvic exa tion (adnexal and uterine tenderness, cervical motion tenderness), is must. , = Presence of a homogenous thin grey or white discharge coating the vaginal walls with fishy odow? Think of bacterial vaginosis. = Are there small punctate cervical and vaginal haemorrhages or “strawberry cervix"? Think of trichomonal vaginitis. = Is the cervix oedematous, reddened, and easily bleeding on touch? Think of chlamydial cervicitis, = Are there white plaques on the vaginal walls with minimal discharge and severe erythema with extensive vulvar involvement? Think of candidiasis. = Does P/S examination reveal oedematous and reddened endocervix with yellow discharge and easily induced cervical bleeding? It could be gonococcal infection. = Js the vagina thin, shiny, pale pink with loss of rugae and with small ulcerations or bleeding points? It could be atrophic vaginitis. «Is there reddened area around the cervical os which bleeds on touch? Probably cervical erosion. C. Investigations = Are there clue cells on saline mount (vide infra)? Bacterial vaginosis is the likely diagnosis. Is there budding veast or hyphae on saline mount? Could be candidiasis. Are there motile fusiform-shaped protozoan on saline mount? Think of trichomonal vaginitis. 4s the whiff test with potassium hydroxide (KOH) positive? Bacterial vaginosis is most likely. Js the vaginal pH more than 4.52 The diagnosis could be bacterial vaginosis or trichomonal vagini Saline wet mount: Vaginal discharge is placed on a slide with 1-2 drops of 0.9% isotonic sodium chloride solution and examined under high power (x 400). = BV: “Clue cells” are characteristic. These are vaginal epithelial cells covered with many vaginal rods and cocci bacteria, creating a stippled or granular appearance. A decreased number of lactobacilli are observed, and WBCs are absent. = Vaginal candidiasis: Hyphae and budding yeast forms are noted. = TV infection: 7- vaginalis is an oval-shaped or fusiform-shaped protozoan, which is 15-mm long with erratic, twitching motility. A large number of WBCs and epithelial cells are observed. KOH preparation: Vaginal discharge is placed on a slide with 10% KOH solution. Known as the whiff {esta positive finding is the release ofa fishy odour after addition of 10% KOH to discharge. «Vaginal candidiasis: Negative whifftest. = TC: Whiff test may be positive. + BV: Whiff testis one of the most specific tests for bacterial vaginosis and the least sensitive ;2-Abnormal Vaginal Discharge PH: Vaginal pH can be determined with litmus paper. A pH greater than 4.5 is often found in patients with Drichomonay infection or BY, 2 BV:pllis5.0-6.0. + Vaginal candidiasis: pH is <4.5, + TV intvetion: pH is 5.0-7.0. Cultures a Cultures have little use in diagnosing BV, = Cultures with Sabouraud’s medium should be performed in refractory or recurrent cases of vagi- nal candidiasis, = Culture using Diamond medium is the standard for detection of Trichomonads and should be used when infection is suspected but cannot be confirmed by other means. » Endocervical cultures using ELISA, DNA probes can be used for diagnosis of Chlamydia trachomatis. = Gonorrhoea can also be cultured in modified Thayer-Martin media or chocolate agar. Other tests: Nucleic acid based tests (NAAT) from the endocervical swab or urine sample are available for rapid diagnosis of Chlamydia trachomatis MANAGEMENT +The first step is to know whether vaginal discharge is normal or abnormal. Ifit is leucorrhoea (increased normal discharge), reassurance is all that is needed. + Ifthe patient is sexually active, risk of STIs is high. S7/ like gonorrhoea, trichomoniasis, Chlamy- dia, ete need partner notification and treatment, Barrier method or condom should be advised till the treatment of STI is completed and 7 days beyond. If the cause of STI is not clear, or even otherwise, a syndromie management approach is useful in the management of vaginal discharge. = Concurrent medications (e.g., antibiotics, corticosteroids, OC pills, UCD), medical conditions (e.g., diabetes, immunocompromised state) should be ruled in or out. = Consider non-infective causes of discharge (e.g., foreign body, cervical ectopy or polyps, genital tract malignancy). = Women presenting with vaginal discharge following abortion or miscarriage or in the puerperium should be fully investigated and treated for likely causal organisms while awaiting swab results. The possibility of retained products of conception should be considered. A heavy growth of coliforms be associated with infection in the presence of retained products. ‘ecurrent vaginal discharge, consideration should be given to underlying conditions causing BV or candida. = One must always rule out uncommon but sinister causes like foreign body or neoplasm. maQUE section: MAJOR SYMPTOMS ‘APTOMS IN GENERA reeer_evr/ OF sample Prescriptions Bacterial vaginosis x Tab Metronidazole (Flagyl) 400 mg twice daily for 7 days (or) Tab Tinidazole (Tini) 2 g oral single dose. Metronidazole (Flagyl) gel (0.75%):Apply at bed time for 5 days (or) Clindamycin cream (2%): Apply at bed time for 7 days. » Routine screening and treatment of male sexual partners not recommended. Trichomoniasis « Tab Metronidazole (Flagyl) 400 mg twice daily for 7 days or single 2 g dose (or) Tab Tinidazole (Tini) 2 g oral single dose. Metronidazole (Flagyl) gel (0.75%): Apply at bed time for 5 days (or) Clindamycin cream (2%): Apply at bed time for 7 days. «= Partner notification and treatment are recommended. Screen for other STIs. Candida 1 Tab Fluconazole: 150 mg single dose (or) Cap Itraconazole: 200 mg twice daily for 1 day. = Clotrimazole pessary: 500 mg single dose, 200 mg for 3 days or 100 mg for 6 days (or) Miconazole intravaginal cream (2%): Apply at bed time for 10-14 days or twice daily for 7 days. » Women can be advised to avoid douching and local irritants. Chlamydia = Tab Doxycycline (Doxy) 100 mg bd x 7 days (or) Azithromycin (Azee) 1g single dose. Gonorrhoea = Tab Ciprofloxacin (Ciplox) 500 mg single dose (or) Inj Ceftriaxone (C-Tri) 250-500 mg IM single dose. Syndromic management = Tab Ciprofloxacin (Ciplox) 500 mg + Tab Metronidazole (Flagyl) 2 el + Tab Doxycycline (Doxy) 100 mg bd daily for 7 days2-Abnormal Vaginal Discharge EERIE Cima Crem Bou Always consider malignancy of the genital tract in a woman who presents with a blood-stained discharge, especially in the case of elderly women. Many STIs can be asymptomatic. Physiological discharge is usually clear or white, viscous in consistency, does not cause pruri- tus and is non-offensive. Physical examination in a case of vaginal discharge should include abdominal palpation (for pain or tenderness), inspection of the vulva (for obvious discharge, vulvitis), speculum exami- nation (for inspection of: vaginal walls, cervix; foreign bodies and nature of discharge), bi- manual pelvic examination (for adnexal and uterine tenderness, cervical motion tenderness). Women are at higher risk of STIs with multiple sexual partners. In sexually active women, think of STI as the cause of vaginal discharge. BV: Thin, homogenous, malodorous white-to-grey vaginal discharge with no vaginal pain or vulvar irritation. Vaginal candidiasis: Pruritus is out of proportion to discharge. T. vaginalis infection: Profuse vaginal yellow or green discharge with dysuria, pruritus, and postcoital bleeding. Chlamydial trachomatis: Edematous and reddened endocervix easily bleeding on touch. Gonococcal cervicitis: Reddened endocervix with yellow discharge. Offensive discharge: Bacterial vaginosis, foreign body, or neoplasm. If you suspect STI and cause is not clear, give syndromic management. Red Flag Signs: Abnormal Vaginal Discharge Blood stained discharge: Rule out neoplasm. If not timely treted, STI can cause infertility, ectopic pregnancy, PID. In post menopausal woman, malignancy can be the cause of abnormal vaginal discharge. Recurrent vaginal discharge with pruritus: Rule out diabetes and HIV infection.MANAGEMENT OF SYMPTOMS IN GENERAL PRACTICE CHAPTER 3 Acute Diarrhoea Diarrhoea can be defined as too frequent passage of stools. Diarrhoea with blood and mucous is called dysentery. Diarthoea is very commonly seen in general practice, second only to upper respiratory tract infections Pseudo diarrhoea and fecal incontinence are ‘wo common conditions seen in general practice, which are likely to be confused with true diarrhoea. It is important to identify these conditions as therapeutic implications are different. Pseudo diarrhoea is passage of frequent small volume of stools scen in inflammatory bowel syndrome (IBS). Fecal incontinence is involuntary discharge of rectal contents seen in neuromuscular disorders or structural anorectal problems. More than 90% of cases of acute diarrhoea are infective. The rest are non infective and usually caused by drugs mainly antibiotics, antacids or laxatives. Broad Classification of Diarrhoea Broadly speaking diarthoca is produced by 2 different mechanisms. In the first, the organism releases toxins, which causes diarrhoea by acting on the secretary mechanism of the intestinal mucosa of the small intestine. This leads to profuse watery diarrhoea as there is no inflammation of the mucous membrane of the small intestine. This is called small bowel diarrhoea, The second mechanism by which other organisms act is by invading the large intestinal mucosa (colon), which causes inflammation and ulceration of the mucosa leading to diarrhoea with blood and mucous. This is called large howel diarrhoea. This distinction has clinical and management implications. In inflammatory large bowel diarrhoea, the illness can be resolved speedily only with the help of proper antibiotics. In small bowel diarrhoea, however, thanks to a built in local immune system (involving gut- or mucosa-associated lymphoid tissue, GALT/MALT). the organisms cannot cause inflammation or ulcerations, but causes secretary diarrhoea. Large amount of water. bicarbonates, chlorides, etc are lost in stools. The use of oral rehydration system (ORS) is designed to prevent dehydration, Antibiotics are not required as organ- isms are cleared by the body's own defense mechanism. The physician's main goal here is to replace the fluid and electrolyte lost and not institute antibiotics.\ 3-Acute Diarrhoea Cae atone ecrs Large bowel Shigella sp. Salmonella enteritidis Campylobacter jejuni Enterohaemorrhagic E. coli Enteroinvasive E. coli Enterotoxigenic E. coli Clostridium difficile Entamoeba histolytica Small bowel diarrhoea = Bacteria causing diarrhoea: Vibrio cholerae, Entertoxigenic E. coli (ETEC) = Bacteria causing food poisoning: Staphylococcus aureus, Bacillus cereus, Clostridium perfringens = Viral gastroenteritis: Rotavirus, Noro virus (Norwalk agent) = Opportunistic infections in AIDS: Isospora belli, Cryptosporidium, Microsporidium All the above organisms produce diarrhoea by different mechanisms. It is important to understand these mechanisms because this has clinical implications. So much also depends on the virulence of the organism. For example, in E.coli, Salmonella, V. cholerae infection, thousands of organisms must be ingested to produce diarrhoea. In shigella, even as few as ten bacteria can produce diarrhoea. SEUNTEIEIN Synopsis of causes of acute diarrhoea piper: Acute bacillary dysentery Cholera Amoebic dysentery "pseudomembranous colitis Giardiasis Diarrhoea in HIV ‘Acute gastroenteritis (usually virus) Henochschonlein purpura Bacterial food poisoning Ischaemic colitis Poisons Acute anxiety COMMON ACUTE DIARRHOEAL ILLNESSES SEEN IN GENERAL PRACTICE 1. Acute Bacillary Dysentery (ABD) ‘The principal causative organism of bacillary dysentery is Shigel/a species (dysenteriae, flexneri, boydii, and sonnei). Other organisms causing dysentery are listed above in the ‘synopsis of causes. Clinically, the patient suffers from small volume stools occurring about 10-20 times a day, containing blood, mucous and pus, abdominal cramps, fenesmus (due to involvement of the rectum), Fever may be moderate to high.|SREEEAN sections: maionsyproms SSS Treatment Mild-to-moderate cases of dysentery may resolve within a few days spontaneously, although antibioti shorten the duration of illness. But whenever possible, stool routine microscopy and culture sensitivit should be requested for. It can assist to decide about the need and proper choice of antibiotic. Howeve culture may not be practical and feasible in a general practice setup every time. Selecting an empiri antibiotic (depending on the local susceptibility pattern) may then be justified. Quinolones (ciprofloxae ofloxacin) are all effective against both Shigella and E. coli species, given for 5 days. However, ina fe areas resistance has developed to quinolones. Other antibiotics effective against shigella are furazolidor nalidixic acid, cefixime, and IV ceftriaxone. Dehydration should be corrected by ORS or by IV fluids, if required. 2. Amoebic Dysentery The causative organism is Entamoeba histolytica. It is caused by ingestion of cysts from faecally _ contaminated water or food. Trophozoites are released from the cysts into the intestines where the — are passively passed in stools. Cysts found in stool examination do not always indicate active infection: ‘About a month after ingestion of the cysts, symptoms of amoebic dysentery develop. These include lower abdominal pain, stools with blood and mucous, colic and tenesmus. High-grade fever is not a feature of amoebic dysentery (unlike bacillary dysentery), although it may be present in a minority of patients. 5) Treatment ACTICE] |) iodohydroxyquinolines (DIQ) and diloxanide furoate (DF) are poorly absorbed, remain in high concentra- ) tion in the lumen and can hence eradicate the cysts in the lumen. Tissue amoebicides like metronidazole, tinidazole, or ornidazole, penetrate the tissues where they reach high concentration. They are also absorbed into the systemic circulation and reach distant sites. These drugs are devoid of any side effects except metallic taste, nausea, vomiting, and disulfiram-like effect. As metronidazole does not eradicate cysts and hence cannot prevent transmission, all patients should receive a combination of a luminal and tissue amoebicide. 3. Giardiasis It is caused by Giardia lamblia, which is probably the most common parasite worldwide, as it is common both in developed and developing countries. Following ingestion of the cysts, many trophozoites are released in the duodenum and the proximal small intestine, where they reside, Clinically, a wide range of manifestations are seen ranging from the asymptomatic carrier to fulminant diarthoea. Symptoms may develop abruptly or gradually. In acute giardiasis, there is profuse watery diarthoea, abdominal pain, bloating, belching, nausea, and vomiting. In chronic giardiasis, intermittent watery, diarrhoea is present, but the upper gastrointestinal symptoms like belching, increased flatus, and bloating due to gases may predominate. Symptoms may be recurrent and chronic. IT OF SYMPTOMS IN GE [WANAGEMENS-Acute Diarrhoea ETA Treatment Metronidazole (400 mg tds for S~7 days) is the most commonly used drug for giardiasis infection. However it causes metallic taste in mouth. Tinidazole is as effective in a single dose of 2 gm. Nitazoxanide is a popular option in children as it is available in liquid form and needs to be taken only for 3 days. Other drugs which can be used are ornidazole and secnidazole. Sample Prescription: Acute Bacillary Dysentery Advice regarding oral intake: Initially only fluids for 24 hrs. Plenty of water, butter milk, black tea, coconut water, fruit juices, etc. Once the frequency of loose motions has decreased, allow overripe bananas, curds, soft rice, dal, ganji, etc. Cap Loperamide (Imosec) 2 caps stat then, 1 cap after each loose motion till they stop. Do ot exceed 8 caps in a day. Avoid in children. Tab Cyclopam 1 tds, if associated abdominal pain. Inj Metoclopramide 2 ml IM stat, if vomiting is present. Watch for extra-pyramidal reaction. In infective diarrhoea, use one of the following antibiotics: - Ciprofloxacin (Ciplox) 500 mg bd (or) = Norfloxacin (Norflox) 400 mg bd (or) = Nalidixic acid (Gramoneg) 500 mg tds (or) Cefixime (Zifi) 200 mg bd (or) Rifaximin (Rifagut) 400 or 550 mg bd (or) Inj Ceftriaxone (C-Tri) 1g bd 4, Acute Gastroenteritis (AGE, ‘Gastro’) Two distinct group of virus, the Rotavirus, which affects mainly children and the Norwalk virus, which causes diarrhoea in older children and adults, are important viruses that causes AGE. Although subclinical or mild infection caused by rotavirus is the most common, it can cause severe dehydration requiring hospitalization. Vomiting followed by profuse watery diarrhoea starts abruptly along with high-grade fever. Stool examination does not reveal pus or RBCs. Respiratory tract symptom may be present. The watery diarrhoea may lead to severe dehydration. ‘Norwalk virus causes sudden onset vomiting and diarrhoea in adults. Fever is usually low grade Mild headache, myalgia, cramps may be present. Illness resolves spontaneously within 1-2 days. 5. Bacterial Food Poisoning This should be suspected by history. If many people suddenly start vomiting and get loose motions after having ingested a common (contaminated) food item, food poisoning should be suspected. Staphylococcus aureus and Bacillus cereus produce an endotoxin in the food before it is ingested (preformed toxin) and hence the symptoms start within 1-6 hrs after ingestion of the contaminated food and lasts less than 12 hrs. In food poisoning, due to C. perfringens, toxins are produced after the food (usually undercooked food) is ingested and hence the symptoms start after 12 hrs and end within 24 hrs. Antibiotics are not required and efforts are to be directed toward correcting the dehydration.GMMERRNELN secriow 1: mason symrroms : (OF SYMPTOMS IN GENERAL PRA (MANAGEMENT LESS COMMON CLINICAL CONDITIONS «Cholera caused by Vibrio cholerae is not seen now frequently in general practice. Itis seen mainly = Pseudo membranous colitis is eaused by toxin produced by the overgrowth of Clostridium diffi in the bowel, which follows the use of broad-spectrum antibiotics. It is a potentially lethal cond tion seen mainly in the hospital 0 ’ = Henoch schonlein purpura is seen mainly in childhood. Bloody diarrhoea is accompanied by pain in abdomen, purpura, arthritis, and occasionally haematuria. 4 = Sudden onset of bloody stools with severe pain in the left iliac fossa usually in the elderly may b caused by occlusion of a branch of the inferior mesenteric artery causing ischaemic colitis. = Certain plants like mushrooms, berries, which are poisonous may be eaten by children or even” adults giving rise to diarrhoea, : = Finally, acute diarrhoea is known to be a manifestation of acute anxiety. This occurs because of overstimulation of the sympathetic nerves causing additional symptoms like sweating, palpitation, tachycardia, and frequency of micturition, 4 APPROACH TO A PATIENT OF ACUTE DIARRHOEA Viruses, bacteria, or amoeba are so common causes of acute diarthoea of abrupt onset that it should be thought of in any case of acute diarrhoea presenting in a previously healthy individual, In children, it necessary to rule out infection somewhere else in the body other than the gut (like urinary tract infection, respiratory tract infection) before concluding that it is the gut pathogens causing diarrhoea, Drugs, particularly antibiotics, are responsible for diarrhoea and history of drug intake should be sought. In antibiotic induced diarrhoea, there is no colic or pain in abdomen. Food poisoning is a rare cause and can be diagnosed on history taking. A. History 5 As in all branches of medicine, properly asked questions can narrow down the cause of diarrhoea on i which treatment depends 4 = Is there pain in the abdomen? Pain in the abdomen indicates inflammatory diarrhoea caused by shigella, amoeba, etc. Absence of pain indicates small bowel diarrhoea, = Has the patient taken any drugs? See the Box for a short list of drugs that cause diarrhoea. = Js there fullness of abdomen or bloating? Consider giardiasis, = What is the appearance of the stools? Blood and mucous indicates large bowel diarrhoea and watery stools suggests small bowel diarrhoea. Profuse ‘rice watery stools’ suggests cholera. = Js there pain in the rectum while defecating (tenesmus)? This indicates shigellosis, the most com mon cause of proctitis. = Js fever present? Fever indicates an invasive diarthoea, * Are many people in the family suffering from diarrhoea? Consider food poisoning,(MUNN) secon 1 : mason symeroms MANAGEMENT OF SYMPTOMS IN GENERAL PRACTICE] LESS COMMON CLINICAL CONDITIONS = Cholera caused by Vibrio cholerae is not seen now frequently in general practice, It is seen mainly epidemic diarrhoea in ‘melas,’ where adequate hygiene cannot be maintained and fecal contaminatiog of water is easy. Sporadic cases, however, are seen vomiting with profuse watery diarrhoe are not replaced rapidly. Treatment is doxycycline 100 mg bd for 5~7 days. = Pseudo membranous colitis is caused by toxin produced by the overgrowth of Clostridium diffill in the bowel, which follows the use of broad-spectrum antibiotics. It is a potentially lethal tion seen mainly in the hospitalized individuals and in elderly. Treatment is by oral vancomycin, * Henoch schonlein purpura is seen mainly in childhood, Bloody diarrhoea is accompanied by pain in abdomen, purpura, arthritis, and occasionally haematuria. = Sudden onset of bloody stools with severe pa caused by occlusion of a branch of the inferior mesenteric artery causing ischaemic colitis. = Certain plants like mushrooms, berries, which are poisonous may be eaten by children or even | adults giving rise to diarrhoea. = Finally, acute diarrhoea is known to be a manifestation of acute anxiety. This occurs because of overstimulation of the sympathetic nerves causing additional symptoms like sweating, palpitation, tachycardia, and frequency of micturition, : APPROACH TO A PATIENT OF ACUTE DIARRHOEA a Viruses, bacteria, or amoeba are so common causes of acute diarrhoea of abrupt onset that it should be | thought of in any case of acute diarrhoca presenting in a previously healthy individual. In children, itis necessary to rule out infection somewhere else in the body other than the gut (like urinary tract infection, respiratory tract infection) before concluding that it is the gut pathogens causing diarrhoea, Drugs, particularly antibiotics, are responsible for diarrhoea and history of drug intake should be sought. In antibiotic induced diarrhoea, there is no colic or pain in abdomen. Food poisoning is a rare cause and can be diagnosed on history taking. A.History As in all branches of medicine, properly asked questions can narrow down the cause of diarrhoea on which treatment depends, * Is there pain in the abdomen? Pain in the abdomen indicates inflammatory diarrhoea caused by shigella, amocba, etc, Absence of pain indicates small bowel diarrhoea, = Has the patient taken any druys? See the Box for a short list of drugs that cause diarrhoea. + Ss there fullness of abdomen or bloating? Consider giardias * What I the appearance of the stools? Blood and mucous indicates large bowel diarrhoea and Watery stools suggests small bowel diarrhoea, Profuse ‘rice watery stools’ suggests cholera. «Js there pain in the rectum while defecating (tenesmus)? This indicates shigellosis, the most com- mon cause of proctitin, # Is fever present) Vever indicates “A invasive diarrhoea, me many people in the family suffering. from diarrhoea? Consider food poisoning.