1. GI on HADJ Payman Adibi,MD Professor, GI section, Dept. of Medicine, IUMS

2. Scope of problems Acute complaints Chronic diseases Emergencies

3. Acute dyspepsia Recent discomfort in epigatrum –Pain –Fullness –Early satiety –Pressure sensation –Nausea

4. ER referral Look for alarms that necessitate ER referral –Hematemesis or melena –Urine color darkening –Severe pain –Hx of CAD or high risk for CAD –Unstable vital signs

5. Symptom relief Pyrosis Antacid 5 spf Pain Antacid 5 spf + Lidocaine PPI + Antispasmodic Nausea PPI + prokinetic

6. Acute Diarrhea Mild symptoms –No fever –No blood –< 3 pass –No urgency –Bismuth –Antidiarrheal

7. Severe symptoms –Fever >37.8 –Pass >4 –Urgency –Dysentery –Antibiotics –Antidiarrheal

8. Bismuth Two tab/ hr up to 8 doses May be continued for longer time Not in pregnancy,milking Stool color turns dark Make ASA effect stronger (Salcylte form) May cause neurotoxicity

9. Antibiotics Ciprofloxacin 500 mg bid for 3 days Azithromycin 1000 mg STAT

10. Antidiarrheal Loperamide

11. Acute Constipation Prevent –Liquids 8 glass/day –Fiber-containing portions 5 servings –Reduce tea < 4 cups –Move

12. ER referral Obstipation Real fever Tender abdomen Fecal impaction

13. Treat Osmotic agents –Lactulose May cause gas and bloat –MOM Not in renal failure Short-term use in elderly cases –PEG Rapid acting May cause dyspepsia

14. Stimulants Senna –May cause colic –Safe to use in long-term –On-off use may be preferred

15. FGID Change in –Sleep pattern –Meal intake Composition Habit –Stressors Loneliness –Mobility

16. Limited amount of fluid in one time Never over feed Low tea consumption Reduce speed of intake Reduce liquids with meals Consider botanicals Consider Metronidazol/Bismuth in bloating

17. IBD Before travel –Travelers' diarrhea chemoprophylaxis Ciprofloxacin 500 mg bid –Increase maintenance dose if symptomatic –Start steroids if fully symptomatic –Transfuse if anemic

18. IBD On-trip Flare-up –Clinical >6 pass >2 nocturnal pass Fever Colic Anemia –S/E WBC>5 RBC>5

19. Flare-up control 5-ASA –Increase to full dose –Reduce gradually Metronidazol –250 tds for 1-2 weeks Steroid –Step down prednisolone 50 > 25 > 12.5

20. CHD HBV –Health precautions to reduce transmission Provide HBIG if possible for post-exposure control –No contraindication for activity –Do not use steroids –On treatment cases are as normal subjects

21. HCV –Health precautions to reduce transmission –No contraindication for activity –No contraindication for drug –On treatment cases May face infection if neutropenic on IFN May face fatigue if anemic on Ribaverin

22. Cirrhosis On diuretic case may face dehydration A case with history of encephalopathy must continue Lactulose forever Any infection may increase encephalopathy Any significant esophageal varix must be eradicated before flight

23. NSAID May cause complication more in : –Elder patients –Those with past history of ulcer –Cases using steroids –Cases using anticoagulants PPI as preventive mean and early treatment

24. MPBPR Red blood Minimal No vital sign change Mostly with perennial problems Mostly in constipated cases Mostly low-risk