MANAGEMENT OF AMOEBIASIS

ACUTE DIARRHEA

History and Physical Exam Likely NON- INFECTIOUS

Likely INFECTIOUS Evaluate and Treat

accordingly

Stool Microscopy

(-) E. histolytica trophozoite (+) E. histolytica trophozoite

Drug Therapy
Metronidazole 10mg/kg 3x a day X 5 days

ASSESSMENT OF DEHYDRATION

NO DEHYDRATION WITH SOME DEHYDRATION SEVERE DEHYDRATION

TREATMENT Plan A
Home therapy to prevent dehydration and malnutrition.
1. Give the child more fluids than usual, to prevent dehydration.
2. Give zinc supplements
10 mg/day in infants- < 6 mos for 10- 14 days
20 mg/day in children 6 mos- 5 years old for 10- 14 days
3. Continue feeding
4. When to return
 Assessment of Dehydration Status Estimate the fluid deficit

Objectives of Treatment:
1. Prevent dehydration, if there are no signs of dehydration.
2. Treat dehydration, when it is present.
3. Prevent nutritional damage, by feeding during and after diarrhoea.
4. Prevent spread of the enteropathogen
In select cases,
5. Determine the etiologic agent and provide specific therapy if indicated.
6. Reduce the duration and severity of diarrhoea, and the occurrence of future episodes, by giving
supplemental zinc.
Treatment Plan A:
1. Give the child more fluid than usual to prevent dehydration.
Most fluids that a child normally takes can be used. It is helpful to divide suitable fluids into two groups:
a. Fluids that normally contain salt, such as ORS solution, salted drinks, vegetable or chicken soup with salt.
b. Fluids that do not contain salt, such as: plain water, water in which a cereal has been cooked (e.g. unsalted rice
water), unsalted soup, yoghurt drinks without salt, green coconut water, weak tea (unsweetened) and unsweetened
fresh fruit juice.
How much fluid to give?
The general rule is: give as much fluid as the child wants until diarrhea stops. As a guide, after each loose
stool, give:
a. children under 2 years of age: 50-100 ml (a quarter to half a large cup) of fluid; give a teaspoon
every 1-2 mins
b. children aged 2 up to 10 years: 100-200 ml (a half to one large cup);
c. older children and adults: as much fluid as they want.
d. For an older child, give frequent sips from a cup
e. If the child vomits, wait for 10 mins. Then continue but more slowly ( e.g every 2-3 mins)
z Zinc Therapy
Zinc has been identified to play a critical role in metalloenzymes, polyribosomes, the cell
membrane, and cellular function, leading to the belief that it also plays a central role in cellular
growth and in the function of the immune system.
Intestinal zinc losses during diarrhea aggravate pre existing zinc deficiency.
z Take the child to a health worker if there are signs of dehydration or other problems.
The mother should take her child to a health worker if the child:
 a. starts to pass many watery stools;
b. has repeated vomiting;
c. becomes very thirsty;
d. is eating or drinking poorly;
e. develops a fever;
f. has blood in the stool; or
g. the child does not get better in three days

ORS Preparation
Treatment Plan B: Treat Some Dehydration with ORS
z Oral Rehydration Therapy should be given in a health facility
z Patients should also receive Zinc supplementation described in the treatment plan A

ORAL REHYDRATION THERAPY

Approximate Amount of ORS Solution to give in the first 4 hours
Age <4 mos 4- 11 mos 12- 23 mos 2- 4 yrs 5- 14 yrs >15 yrs
Weight <5 kg 5- 7.9 kg 8- 10.9 kg 11- 15.9 kg 16- 29.9 kg >30 kg
In ml 200- 400 400- 600 600- 800 800- 1,200 1,200- 2,200 2,200- 4,000
use the patients age only when the weight of the patient is unknown. Estimation of approximate amount of ORS can be calculated by
multiplying weight (kg) by 75ml
if the patient wants more ORS than shown above, give more.
Encourage the mother to continue breastfeeding.
If the patient is < 6mos who are not breastfed and if using the old WHO ORS solution containing 90 mmol/L of Na, also give 100-
200 ml of clean water during this period. However, if using the new (reduced) osmolarity ORS solution containing 75 mmol/L, it is not
necessary.

How to give ORS solution

Infant and young children: clean spoon or cup
Feeding bottles should NOT be used
Babies: dropper or syringe (w/o the needle)
Children < 2 years old: teaspoonful of ORS every 1- 2 mins
Older children or adult: may take frequent sips directly from the cup

VOMITING- often occurs after 1 hour or 2 of ORS treatment

- If the child vomits, wait for 5- 10 mins before giving the ORS solution but more slowly

MONITORING THE PROGRESS

Monitor if the child from time to time during rehydration to ensure that ORS solution is
being taken satisfactorily and the signs of dehydration are not worsening. If at any time the
child develops signs of severe dehydration, shift to the treatment plan C.
If the child still has signs of some dehydration, continue ORS therapy by repeating
Treatment Plan B and start to offer food, milk and other fluids.
If there are no sign of dehydration, the child should be considered fully rehydrated. When
rehydration is complete:
Skin pinch is normal (goes back quickly)
 Thirst have subsided
Urine is passed
the child becomes quiet, and is no longer irritable and often falls to sleep.

Giving Zinc supplement (as described in the Treatment Plan A)

Giving Food
Children continued on Treatment Plan B longer than 4 hours should be given some food
every 3- 4 hours.
Treatment Plan C: For patients with severe dehydration
z Preferred treatment treatment for children with severe dehydration is rapid IV rehydration
z If possible, the child should be admitted to hospital.
z Children who can drink, even poorly, should be given ORS solution by mouth until the IV drip is
running.
z In addition, all children should start to receive some ORS solution (about 5 ml/kg/hr) when they can
drink without difficulty, which is usually within 3- 4 hours (for infants) or 1-2 hours (for older patients)

Guidelines for IV treatment of children and adults with severe dehydration

Give 100 ml/kg Ringers Lactate solution divided as follows:

Age First give 30 ml/kg in: Then give 70 ml/kg in:

Infants (under 12 months) 1 hour 5 hours
Older 30 minutes 2 hours
Reassess the patient every 1- 2 hours. If hydration is not improving, give the IV drip more rapidly.
After 6 hours (infants) or 3 hours (older children), evaluate the patient using the assessment chart.
Then choose the Treatment Plan (A, B or C) to continue treatment.
MONITORIING THE PROGRESS OF IV REHYDRATION
Patient should be reassessed every 15- 30 minutes until a strong radial pulse is present. Thereafter,
they should be reassessed at least every hour to confirm that hydration is improving. If not, the IV
drip should be given more rapidly.
When the planned amount of IV fluid has been given for 6 hours (infants) or 3 hours (older children),
the childs hydration status should be reassessed fully;
Look and feel for all the signs of dehydration
o if signs of severe dehydration are still present, repeat the IV fluid infusion as outlined
in Treatment Plan C
o if the child is improving (able to drink) but still shows signs of some dehydration,
discontinue the IV infusion and give ORS solution for 4 hours as specified in
Treatment Plan B.
o if there are no signs of dehydration follow Treatment Plan A. If possible, observe the
child for at least 6 hours before discharge while the mother gives the child ORS
solution to confirm that she is able to maintain the childs hydration. Remember that
the child will require therapy of ORD until diarrhea stops.
References:
Nelson Textbook of Pediatrics 20th edition
THE TREATMENT OF DIARRHOEA- A manual for physicians and other senior health workers by WHO
Harrisons Principles of Internal Medicine, 19TH Edition