Cancer

2. ACKNOWLEDGEMENTS
The first edition of the Nigerian Standard Treatment Guidelines is a product of the support,
recommendations and contributions of the following:
Prof. Eyitayo Lambo
Prof. Adenike Grange
Mr. R.K. Omotayo mni
Mr. J.E. B. Adagadzu
Dr Peter Eriki
Dr Mohammed Belhocine
Dr. Olaokun Soyinka
Dr Ogori Taylor
Federal Ministry Of Health
World Health Organization
Expert Committee Members
Prof. Abdu-Aguye, I.
Prof. Adelowo, F.
Prof. Bayeroju-Agbeja, A.
Prof. Borodo, M.
Prof. Danbauchi, S.S
Prof. Gureje, O.
Prof. Idoko, J.
Prof. Isah, A.O.
Prof. Mabadeje, A.F.B.
Prof. Mbonu, O.
Prof. Ogisi, F.
Prof. Ohwovoriole, A.
Prof. Olumide, M.
Prof. Ojogwu, L.I.
Prof. Okonofua, F.
Prof. Oruamabo, R.
Prof. Oviawe, O
Dr. Ameh, E.
Dr. Abosede, Y.
Dr. Akoria, O.
Dr. Irhibhogbe, P.
Dr. Kehinde, M.
Dr. Mero-Asagba, G.
Dr. Okpapi, J.U.
Dr. Savage, S.
Dr. Taylor, O.
Mr. Obiaga, G.O.
International Network for Rational Use of
Drugs (INRUD) - Nigerian Core Group
Editorial Team
Prof. Abdu-Aguye, I.
Prof. Isah, A.O.
Prof. Mabadeje, A.F.B.
Dr. Abosede, O.A.
Dr. Aina, B.A.
Dr. Akinyede, A.
Dr. Akoria, O.A.
Dr. Asalu, A.F.
Dr. Akinlekan, J.
Mr. Obiaga, G.
Dr. Obodo, J.O.
Mr. Okoko, O.O.
Dr. Oparah, A.
Dr. Olayemi, S.O.
Dr. Oreagba, I.
Mr. Otahabru, B.
Dr. Mero-Asagba, G.
Dr. Taylor, O.
Prof. Abdu-Aguye, I.
Prof. Isah, A.O.
Dr. Akoria, O.A.
Dr. Mero-Asagba, G.
Mr. Obiaga, G.O.
Mrs. Okpeseyi, M.I.
Mr. Fagbemiro, L.O.
Mr. Otahabru, B.
Dr. Olaokun Soyinka
Dr. Taylor, O.
European Commission
For funding the programme
© 2008 Federal Ministry of Health, Nigeria
All rights reserved. No part of this publication may be reproduced, stored in retrieval
system or transmitted in any form or by any means, electronic, mechanical,
photocopying, recording and/or otherwise, without prior written permission of the
Federal Ministry of Health, Nigeria.
For all enquiries or comments, write to the publishers:
The Honourable Minister,
Federal Ministry of Health,
Federal Secretariat Complex,
Shehu Shagari Way,
P.M.B. 080 Garki,
Abuja.
Nigeria
Printed in Nigeria.

3. FOREWORD
I am indeed very pleased to write the foreword to this maiden edition of the
Standard Treatment Guidelines (STG) for the Nigerian health care system. I am
aware that the process of its production began in 2005 involving contributions and
recommendationsofvariousexpertsandstakeholdersinthehealthcaresector.
The STG is an important tool for the attainment of comprehensive and effective
health care delivery services thereby achieving the goals of the National Drug
Policy, which inter alia are: the availability of safe, efficacious and affordable
medicines to satisfy the healthcare needs of the majority of the population and
ensure the rational use of drugs. The fulfillment of the above mentioned goals is
part of the strategic thrust of the Health Sector Reform Programme aimed at the
reduction of disease burden and the improvement of access to quality health
services. It is expected that the STG will become a major reference document for all
healthworkers bothinthepublicandprivatesectors.
It is instructive to note that the development of the STG followed due process with
wide consultations and meetings involving various stakeholders and interest
groups. The document that has come out of this process is a reflection of the quality
of the inputs that went into its development. In my opinion, this maiden edition of
the STG has been produced and serialized in such a way as to assist health care
providers especially doctors in the effective discharge of their duties as prescribers.
It will also ensure discipline as only those medicines recommended will be
prescribedforpatientswithinagivenhealthfacility.
I commend all those who worked tirelessly towards the completion of this maiden
edition STG. Special mention and gratitude must go to the World Health
Organization (WHO) for sponsoring and providing sustained technical support to
the committee. Without this support, this STG would not have seen the light of the
day.
Finally, let me quickly add that this STG must be widely circulated and
disseminated. Everything possible must be done to ensure that practitioners
maximize the benefit of such a useful document. If it has worked in other parts of
the world, it should also work in Nigeria. It must also be subjected to regular
reviewsinviewofthedynamicnatureofhealthcaremanagement.
Dr.Hassan MuhammedLawal,CON
SupervisingMinisterofHealth

5. SECTION A
Chapter 1: Alimentary Tract
Chapter 2: Blood And Blood-forming Organs
Chapter 3: Cardiovascular System
Gastrointestinal Disorders ...................................1
Amoebiasis ..........................................................1
Bacillary Dysentry ................................................1
Cholera ................................................................2
Constipation .........................................................2
Diarrhoea (acute) .................................................3
Gastritis ................................................................4
Giardiasis .............................................................4
Haemorrhoids ......................................................5
Pancreatitis ..........................................................5
Peptic Ulcer Disease ...........................................6
Upper Gastrointestinal Bleedin ............................6
Hepatic And Biliary Disorders ............................. 7
Hepatitis.. .............................................................7
Hepatic Encephalopathy ......................................8
Jaundice ..............................................................9
Liver Cirrhosis ......................................................9
Nutritional Disorders ..........................................10
Kwashiokor And Marasmus ...............................10
Micronutrient Deficiencies ..................................10
Obesity................................................................11
Anaemias ...........................................................13
Blood Transfusion ..............................................14
Haemostasis And Bleeding Disorders ...............16
Leukaemias .......................................................16
Lymphomas .......................................................19
Sickle Cell Disease.............................................20
Angina Pectoris..................................................23
Cardiac Arrhythmias ..........................................23
Congenital Heart Disease .................................24
Deep Venous Thrombosis .................................24
Heart Failure .....................................................25
Hyperlipidaemia ................................................26
Hypertension .....................................................26
Infective Endocarditis ........................................27
Myocardial Infarction..........................................29
Myocarditis ........................................................30
Paediatric Cardiac Disorders.............................30
Pericarditis ........................................................30
Pulmonary Embolism ........................................31
Pulmonary Oedema ..........................................32
Rheumatic Fever ..............................................32
Rheumatic Heart Disease .................................33
Standard Treatment Guidelines for Nigeria 2008
i
PREFACE
This first edition of Standard Treatment Guidelines (STG) for the Nigerian health
practitioner is coming relatively later than those of many other countries. It is indeed a
welcome development.
The standard of medical practice and the wage bill of health services are usually
remarkably improved by health personnel putting to use STG. This among other
benefits can only lead to improved health of the community.
In Nigeria our health indices are among the worst in the world. Our country Nigeria
does not lack the manpower or the necessary infrastructure to turn things around. What
appears to be lacking is the organization of health services required to put both to
optimal use. Efforts such as the actualization of our own national STG and the various
health reforms currently in progress will definitely improve our situation.
It is therefore my pleasure and privilege to write the preface to this maiden edition of
the STG. This is the outcome of a long journey that started several years ago. The
previous chairmen of the National Formulary and Essential Drugs Review Committees
made efforts to start the project but were unsuccessful due to lack of funds.
The current committee had the luck of being assisted by the country office of the World
Health Organization (WHO) in not only this endeavor but in the preparation and
printing of the last edition of the Nigerian Essential Medicines List. The desk officer,
Dr Ogori Taylor showed great commitment to the project and the country owes a debt
of gratitude to WHO.
In preparing this document every effort was made to ensure that the stakeholders own
the project so that it is not seen as an imposition. Accordingly, the major contributions
came from various practitioners and their associations as well as from many
practitioners whose input were judged crucial to the success of the project. We also
adopted the acceptable practices in the field that were in use by special health projects
such as HIV/AIDS, Malaria, TB/Leprosy programmes etc. The academia was also
involved. There were several fora where the contributions were discussed openly with
the stakeholders and consensus arrived at.
It is my hope therefore that this document will be widely used by Nigerian health
practitioners. I salute the contributors and those that helped in one way or the other.
The committee of course accepts responsibility for any lapses but also hopes that these
would be brought to our attention for correction in subsequent editions.
Professor Ibrahim Abdu-Aguye,MBBS; FMCP;SFIAM; FIICA;D. Sc (Hon)
Chairman, National Formulary and Essential Drugs Review Committee.
Chapter 4: Central Nervous System
Chapter 5: Dental And Oral Disorders
Chapter 6: Dermatology
Non-psychiatric Disorders ..................................34
Dizziness ............................................................34
Headaches..........................................................35
Meningitis ...........................................................36
Migraine ..............................................................37
Parkinsonism.......................................................38
Seizures/epilepsies .............................................39
Stroke .................................................................41
Syncope ............................................................42
The Unconscious Patient ....................................42
Psychiatric Disorders ..........................................43
Alcoholism (alcohol Dependence) ......................43
Anxiety Disorder .................................................44
Bipolar Disorders ................................................44
Delirium...............................................................45
Depression .........................................................46
Insomnia..............................................................47
Panic Disorder.....................................................47
Schizophrenia......................................................48
Acute Necrotizing Ulcerative Gingivitis................49
Acute Periapical Abscess ...................................49
Alveolar Osteitis ..................................................50
Cellulitis...............................................................50
Dental Caries ......................................................50
Gingivitis .............................................................51
Neoplasms Of The Oral Cavity ...........................51
Oral Thrush (candidiasis) ...................................51
Pericoronitis ........................................................52
Periodontitis.........................................................52
Pulpitis ................................................................53
Salivary Gland Diseases ....................................54
Temporo-mandibular Joint Disorders...................54
Bacterial Infections .............................................56
Cellulitis ..............................................................56
Furunculosis (boils) ............................................56
Impetigo Contagiosa ..........................................57
Dermatitis And Eczema ......................................58
Atopic Dermatitis (atopic Eczema)......................58
Contact Dermatitis ..............................................59
Exfoliative Dermatitis (erythroderma)..................59
Parasitic Dermatoses .........................................60
Cutaneous Larva Migrans (creeping
Eruption).............................................................61
TABLE OF CONTENTS

6. Guinea Worm Disease (dracunculiasis)..............61
Myiasis ...............................................................62
Onchocerciasis (river Blindness) .......................62
Pediculosis (lice) ................................................63
Scabies ..............................................................64
Papulosquamous Disorders ..............................65
Lichen Planus ....................................................65
Pityriasis Rosea .................................................66
Psoriasis ............................................................67
Superficial Fungal Infections ..............................69
Dermatophyte Infections (tinea) .........................69
Pityriasis Versicolor (tinea Versicolor ) ...............70
Viral Infections ...................................................71
Herpes Zoster ....................................................71
Molluscum Contagiosum ...................................72
Varicella (chickenpox) ........................................72
Viral Warts (verrucae) ........................................73
Miscellaneous Disorders ....................................74
Acne Vulgaris (pimples) .....................................74
Pruritus ..............................................................76
Urticaria And Angioedema .................................78
Vitiligo ................................................................80
Acute Otitis Media...............................................81
Adenoid Disease ................................................82
Chronic Otitis Media ...........................................82
Epistaxis .............................................................83
Foreign Bodies In The Airways ..........................83
Foreign Bodies In The Ear .................................84
Foreign Bodies In The Nose And Rhinoliths.......84
Mastoiditis...........................................................84
Nasal Allergy ......................................................85
Otitis Externa ......................................................86
Peritonsillar Abscess (quinsy) ............................86
Pharyngitis (sore Throat) ...................................86
Sinusitis ..............................................................87
Tonsillitis .............................................................88
Tracheostomy ....................................................89
Wax In The Ear ..................................................89
Diabetes Mellitus ................................................90
Hyperthyroidism (thyrotoxicosis) ........................97
Hypothyroidism (myxoedema) ...........................99
Acute Anterior Uveitis (iritis) .............................100
Acute Keratitis ..................................................100
Allergic Conjunctivitis .......................................101
Eye Injuries ......................................................101
Foreign Bodies In The Eye ...............................102
Infective Conjunctivitis ......................................103
Ophthalmia Neonatorum ..................................103
Scleritis / Episcelitis .........................................104
Stye (hordeolum) .............................................104
Chapter .7: Ear, Nose And Throat
Chapter 8: Endocrine System
Chapter 9: Eye Disorders
Chapter 13: Obstetrics And Gynaecology
Chapter 14: Respiratory System
Chapter 15: Injuries And Acute Trauma
Chapter 16: Surgical Care And Associated
Disorders
Chapter 17: Paediatric Perspectives
Abortion ..........................................................149
Antenatal Care ................................................150
Anaemia In Pregnancy ...................................152
Cancer Of The Cervix .....................................153
Cardiac Disease In Pregnancy .......................154
Eclampsia .......................................................156
Ectopic Pregnancy ..........................................158
Hyperemesis Gravidarum ...............................159
Immunization Schedules .................................160
Jaundice In Pregnancy ...................................160
Pelvic Inflammatory Disease ..........................162
Rape ................................................................163
Acute Epiglottitis ..............................................165
Acute Laryngo-tracheo-bronchitis (croup) .......165
Acute Rhinitis (common Cold) ........................166
Bronchial Asthma ...........................................166
Bronchiectasis ................................................167
Chest Pain ......................................................168
Chronic Obstructive Airways Disease(coad) ....168
Cough .............................................................169
Dyspnoea .......................................................170
Lung Abscess .................................................170
Pneumonia .....................................................171
Pulmonary Embolism .....................................172
Bites And Stings ..............................................173
Burns ..............................................................175
Disaster Plan ..................................................176
Head Injury .....................................................177
Multiple Injuries ...............................................180
Acute Abdomen ..............................................182
Antimicrobial Prophylaxis In Surgery ...............184
Intestinal Obstruction ......................................184
Preoperative Evaluation and
Postoperative Care ..........................................186
Use Of Blood Transfusion In Surgery ..............189
Measles (rubeola) ............................................190
Poliomyelitis .....................................................191
Vitamin A Deficiency .......................................193
Section B
Standard Treatment Guidelines for Nigeria 2008 Standard Treatment Guidelines for Nigeria 2008
ii iii
The Red Eye ....................................................104
Trachoma..........................................................105
Xerophthalmia ..................................................105
Nephrology ......................................................106
Acute Renal Failure..........................................106
Chronic Kidney Disease ..................................106
Nephrotic Syndrome ........................................107
Sexually Transmitted Infections ......................108
Bacterial Vaginosis ..........................................108
Chancroid (ulcus Molle, Soft Chancre) ............109
Chlamydial Infection ........................................110
Gonorrhoea .....................................................111
Granuloma Inguinale (donovanosis;
Granuloma Venereum)......................................113
Lymphogranuloma Venereum ..........................114
Syphilis ............................................................115
Trichomoniasis ................................................116
Vulvo-vaginal Candidiasis ...............................117
Urology ............................................................118
Benign Prostatic Hyperplasia ..........................118
Carcinoma Of The Prostate ............................118
Erectile Dysfunction (impotence) ....................119
Male Infertility ..................................................120
Posterior Urethral Valves ................................120
Priapism ........................................................121
Prostatitis ........................................................121
Scrotal Masses ...............................................122
Torsion Of The Testis ......................................122
Urethral Stricture ............................................123
Urinary Schistosomiasis .................................123
Urinary Tract Calculi .......................................124
Fevers: Management Approach ......................125
Food Poisoning ...............................................125
Helminthiasis ..................................................127
Human Immunodeficiency Virus Infection ......129
Malaria ............................................................135
Rabies...............................................................137
Tetanus ...........................................................138
Trypanosomiasis (sleeping Sickness) .............140
Tuberculosis ....................................................140
Typhoid Fever .................................................142
Back Pain ........................................................143
Gout ................................................................144
Osteoarthritis ..................................................145
Rheumatoid Arthritis .......................................146
Septic Arthritis .................................................147
Systemic Lupus Erythematosus .....................148
Chapter 10: Genito-urinary System
Chapter 11: Infectious Diseases /
infestations
Chapter 12: Musculoskeletal System
Section C
Chapter 18: Emergencies
Chapter 19: Therapeutics
Chapter 20: Notifiable Diseases ....................209
Acute Left Ventricular Failure ...........................195
Cardiac Arrest ..................................................196
Drowning And Near-drowning ..........................197
Electrolyte Abnormalities .................................198
Hypertensive Emergencies ...............................200
Hypoglycemia ...................................................200
Myxoedema Coma ..........................................201
Thyroid Storm (thyrotoxic Crisis) .....................201
Poisoning .........................................................202
Prescription Writing .........................................206
Adverse Drug Reactions ..................................208
APPENDICES
Appendix I
Appendix II:
Appendix III
Appendix IV:
Appendix V:
Appendix VI:
WHO clinical staging of HIV for infants and
children with established HIV infection............211
WHO new antenatal care model classifying
form 2001.........................................................212
Calculation of dosage requirements in
children............................................................214
Medicines with teratogenic potential................215
Medicines that could cause harm when
administered to breastfeeding mothers.............215
NAFDAC Adverse Drug Reaction Reporting
form ................................................................217

7. CHAPTER 1: ALIMENTARY TRACT
Amoebicdysentery
Amoebicabscess
ChronicCarriers
Amoebicdysentery
Amoebicliverabscess
GASTROINTESTINAL DISORDERS
A common parasitic infection of the gastrointestinal
systemcausedbytheprotozoan
Itmaypresentas:
Fever/chills
Liverabscess: swelling,painintherightsub-costalarea
Intracranialspace-occupyinglesion
Lungs:coughandbloodstainedsputum
Amoeboma:swellinganywhereintheabdomen
Anal ulceration: may occur by direct extension from the
intestinalinfection
Symptom-free
Bacillarydysentery
Any othercauseofbloodydiarrhoea
Canceroftheliver
Othercausesofliverenlargement
Ruptureofabscessintothelungs,peritoneum
Space-occupyinglesioninthebrain
Rightinguinalmass
Stool: microscopy for cysts and motile organisms
(amoebicdysentery)
FullBloodCount
Chestradiograph(inamoebicliverabscess)
AbdominalUltrasoundScan
Rehydrateadequately
Eradicatetheprotozoa
Correctdehydration(seesectiononrehydration)
Metronidazole
800mg8hourlyfor5days
30mg/kg/dayin3divideddoses for5days
Metronidazole
800mg8hourlyfor10days
50mg/kg/dayin3divideddoses for7-10days
Aspiration is indicated to prevent spontaneous rupture of
abscesses.
AMOEBIASIS
Introduction
Clinicalfeatures
Differentialdiagnoses
Complications
Investigations
Treatmentobjectives
Drug treatment
Non-drug treatment
Entamoebahistolytica
Adult:
Child:
Adult:
Child:
Acquiredthroughfaeco-oraltransmission.
Persistentmucoid/bloodydiarrhoea
Abdominalpain
This can occur in any of the following forms as a result of
spreadviathebloodstream:
diarrhoeas resulting from bacterial infection are usually
self-limiting. Appropriate systemic antibiotics are
howeverrequiredwhensystemicinfectionsoccur.
- Amoxicillin500mg8hourlyfor5days
Or:
- Cotrimoxazole960mg12hourlyfor3-5days
Or:
- Ciprofloxacin500mg-1gorally12hourlyfor5days
- Azithromycin 500 mg daily for 3 days for resistant
strains
Ciprofloxacin may induce tendinitis especially in
children.
Ciprofloxacin is not recommended for use in children
lessthan18years.
Antidiarrhoealmedicinesarenotadvised.
Safedrinkingwater
Sanitarydisposalofhumanwastematerial
An acute severe diarrhoeal illness of worldwide
importance;endemicinmanydevelopingcountries.
Caused by bacilli (classical and
species)
Excessive secretion of fluid is mediated by the release
of enterotoxin (released by the bacilli), which acts on the
enterocytesofthesmallintestineviacyclicAMP.
Highlyinfectious;spreadbyfaeco-oralroute.
Mildwaterydiarrhoea
Severe life-threatening diarrhoea leading to
hypovolaemicshockifuntreated
Occasionally,vomiting
Hypovolaemic shock with multiple end organ failure
leadingtodeath
Hypoglycaemia
Paralyticileus
Stoolmicroscopy,cultureandsensitivity
FullBloodCount
Urea,ElectrolytesandCreatinine
Rehydrateadequatelyandrapidly
Eradicatetheinfectiveorganism
Preventspreadoftheinfection
IntravenousRinger's lactate/Darrow's solutions
OralRehydrationTherapy
Antibiotictherapy
Tetracycline:
500mgorallyevery6hours for5days
Notableadversedrug reactions
Precaution
Prevention
CHOLERA
Introduction
Clinicalfeatures
Complications
Investigations
Treatmentobjectives
Drug treatment
Vibrio cholerae El Tor
.
Adult:
Consultasurgeon.
Treatcystcarrierifpatientisafoodhandler:
Diloxanidefuroate
500mgevery8hours for10days
20 mg/kg orally every 8 hours for 10
days
Metronidazoleiscontraindicatedinpregnancy.
Avoid alcohol during treatment and at least 48 hours after
treatment.
Provisionofsafedrinkingwater
Sanitarydisposaloffaeces
Regular examination of food handlers and appropriate
treatmentwherenecessary.
An important cause of colonic diarrhoea in developing
countries.
Caused by pathogenic species of Shigella A-D
( )
Transmittedviathefaeco-oralroute.
Mucoid bloody diarrhoea associated with severe central
andlowerabdominalpain
Tenesmus
Moderate-gradepyrexia
Sometimes only a mild, self-limiting diarrhoea lasting 2-
3days
Articularfeaturesoccasionally
Septicaemic spread with multi-system involvement
occasionally.
Amoebicdysentery
Idiopathicenterocolits(ulcerative)
infection
Colorectalcancer
Septicaemia/bacteraemia
Severerectalbleeding
Intestinalperforation
Reiter's syndrome
Stoolmicroscopy,cultureandsensitivity
FullBloodCount
Urea,ElectrolytesandCreatinine
Adequaterehydration
Eradicatebacterialpathogens
Oral Rehydration Therapy (see rehydration under
diarrhoea)
Parenteral hydration therapy (see rehydratrion under
diarrhoea)
Antibacterial drugs are not usually necessary: even
Asymptomatic cystcarriers
Adult:
Child over 25 kg:
dysenteri,flexneri,boydiiandsonnei .
Campylobacterjejuni
Notableadversedrug reactions,caution
Prevention
BACILLARYDYSENTRY
Introduction
Clinicalfeatures
Differentialdiagnoses
Complications
Investigations
Treatmentobjectives
Drug treatment
Or:
Doxycycline:
:200mgorallyoncedailyfor5days
12 - 18 years, 200 mg on first day, then 100 mg
daily
- Severeinfections,200mgorallydaily
Erythromycin:
: 250 - 500 mg orally every 6
hours for5daysor500mg-1gevery12hours
125 mg every 6 hours; 2 - 8 years: 250
mgevery6hours
- Doses doubledinsevereinfection
Or:
Sulfamethoxazole-trimethroprim(Co-trimoxazole)
960mgorallyevery12hours for5days
6 weeks - 6 months 120 mg 12 hourly; 6 months - 6
years 240 mg; 6 - 12 years 480 mg; 12 - 18 years 960 mg
orallyevery12hours for5days
Monitor fluid intake and output (vomitus, urine and
stool)
Provideaccesstosafedrinkingwater
Food hygiene
Safedisposalofhumanwaste
Choleravaccine
A clinical condition characterized by infrequent bowel
openingand/orpassageofhardstools.
Inadequatefibreindiet(simpleconstipation)
Drugs e.g.antidepressants,narcoticanalgesics,etc
Diseases of the anus, rectum and colon e.g. fissures,
haemorrhoids,cancer
Functional:irritablebowelsyndrome
Metabolicdiseasese.g.hypothyroidism,hypercalcaemia
Stoolsareoftenhard
Abdominalbloating
Excessiveflatulence
Relevant associated history to determine aetiology
shouldbevigorouslypursued
Physical examination should be thorough, and must
includearectalexamination
Megacolon
Analfissures/tears
Haemorrhoids
Rectal bleeding
Stoolexaminationincludingmicroscopy
Proctoscopy/sigmoidoscopy
Adult
Child:
Adult and child over 8 years
Child up to 2 years:
Adult:
Child:
Supportivemeasures
Prevention
CONSTIPATION
Introduction
Aetiology
Clinicalfeatures
Complications
Investigations
1 2
Chapter 1: Alimentary Tract Standard Treatment Guidelines for Nigeria 2008
SECTION A

8. Barium enema
Serum hormonal levels e.g. thyroxine, triiodotyronine,
thyroidstimulatinghormonetoexcludehypothyroidism
Identifyandeliminatecause(s)
Evacuatehardfaecalmatter
Situations where straining will exacerbate pre-existing
medical/surgicalconditions
- Angina
- Riskofrectalbleeding
- Increasedriskofanaltear
Other indications
- Drug-inducedconstipation
- To clear the alimentary tract before surgery or
radiologicalprocedures
Avoid precipitants
Highfibrediet(includingfruitsandvegetables)
Adequatefluid intake
Stimulant laxatives
- Senna7.5mgtablet(assennosideB)
2-4tabletsatnight
6 - 12 years 1 - 2 tablets at night (or in the morning
ifpreferred)
12-18years:2-4tabletsatnight
Or:
Bisacodyl tablets 10 mg orally at night; suppositories
10mgperrectumatnight
Laxatives should generally be avoided. Most times
thesedrugs areneededforonlyafewdays
A very common clinical problem the world over,
particularlyindevelopingcountries.
Accounts for significant morbidity and mortality,
especiallyinchildren.
Infective agents are recognized in about 70% of cases
andaretransmittedbythefaeco-oralroute.
Viruses (particularly Rotavirus) are responsible for
over70%ofdiarrhoeasinchildrenbelow2years.
Many bacteria and some parasites are also important
aetiologicagents,particularlyinadolescentsandadults.
Endemicandepidemicpresentationscanoccur.
Contamination of food and water by bacterial toxins can
also lead to acute diarrhoea, sometimes with associated
vomiting (i.e. food poisoning). This is usually self-
limiting.
Treatmentobjectives
Non-drug treatment
Drug treatment
Caution
DIARRHOEA(Acute)
Introduction
Indicationsforuseoflaxatives
Megacolon:
Saline enema
Surgical:resectionoflargebowel
Adult:
Child :
Personalhygiene:hand-washing,careinfood-handling
Inflammationofthegastricmucosa.
Canbeacuteorchronic.
The most important risk factors for acute gastritis
includeuseofdrugs (NSAIDs inparticular)andalcohol.
H. infection is the most important risk factor for
chronicgastritis
All agents of gastritis work through the common path of
disruptingtheprotectivemucosalbarrierofthestomach.
Acute gastritis may evoke pain that mimics peptic ulcer
disease; chronic gastritis is a precursor of peptic ulcer
disease (type B gastritis) and gastric cancer (type A
gastritis).
Chronicgastritisisessentiallyasymptomatic
Acute gastritis evokes acute abdominal pain that mimics
pepticulcerdisease(seepepticulcerdisease)
Occasionally acute gastritis may be haemorrhagic with
melaenalstoolsorrarelyhaematemesis
Acutegastritis: haemorrhage
Chronicgastritis:pepticulcerdisease;gastriccancer
Pepticulcerdisease(acutegastritis)
Endoscopy(macroscopicdiagnosis)
Histologyofgastricbiopsyfordefinitivediagnosis
Eliminatepain(acutegastritis)
Prevent progression to peptic ulcer disease or gastric
cancer
Re-establishnormalhistology
AcuteGastritis:
Antacids
- Magnesium trisilicate 1 - 2 tablets or suspension 10 mL
orallythreetimesdailyor asrequired
Or:
H receptorantagonist
- Ranitidine150mgorallyoncedailyasrequired
Or:
ProtonPumpInhibitors
- Omeprazole20mgorallyoncedailyasrequired
TypeAgastritis:
Endoscopic surveillance every 2 - 3 years for early
detectionofcancer
TypeBgastritis:
EradicationofH. usingtripletherapywith
- Clarithromycin500mgorallytwicedailyfor7days
Plus:
- Amoxicillin1gorallyevery12hours for7days
Plus:
GASTRITIS
Introduction
Clinicalfeatures
Complications
Differentialdiagnosis
Investigations
Treatmentobjectives
Drug treatment
pylori
.
pylori
2
Clinicalfeatures
Complications
Differentialdiagnoses
Investigations
Treatmentobjectives
Drug treatment
Supportivemeasures
Notableadversedrug reactions
Prevention
Watery diarrhoea of varying volumes, sometimes with
vomiting: this is the commonest presentation, and
suggests pathologyinthesmallintestine.
Bloodymucoidstools:suggests diseaseinthecolon
Fever,abdominalpainanddehydration
Fast and small volume pulse with low blood pressure:
indicatessignificantfluidloss
Hypovolaemicshockwithmultipleorganfailure
Septicaemia
Intestinalperforation
Gastro-intestinalbleeding
Paralytic ileus
Non-infectiousdiarrhoeae.g.drug-induced
Gutallergy(e.g.gluten)
Psychogenic stress
Metabolic and endocrine causes (e.g. thyrotoxicosis,
uraemia,diabetesmellitus)
Stool examination including microscopy, culture and
sensitivity
FullBloodCount
Urea,ElectrolytesandCreatinine
Serology(e.g.Widaltest)
Achieveadequate hydration
Eliminateinfectiousagent(wherepossible)
Treatcomplications
Rehydratewith:
Oral Rehydration Therapy - ORT (low osmolarity) for
mildtomoderatedehydration
- 500mLorallyover2-3hours, 3-4timesdaily
Intravenoussodiumchloride0.9%
- 1litre2-6hourlyformoderate-to-severedehydration
- Alternate with Darrow's solution depending on serum
potassium
Children:
Use ofzincsupplementation
- 20mgperdayfor10-14days
- Under6monthsold:10mgperday
Specific anti-infective agents for infectious diarrhoeas
e.g.metronidazoleforamoebiasis,giardiasis
Monitorfluidintake/output
Heartfailure:fromoverhydration
Initial increase in diarrhoea with ORT: this is self
limiting
Hyperkalaemia: from excessive use of potassium-
containingfluids
Provideaccesstosafedrinkingwater
Sanitarydisposalofhumanwaste
- Omeprazole20mgorally for7days
Or:
- Metronidazole400mgorallyevery8hours for7days
Plus:
- Amoxicillin500mgorallyevery8hours for7days
Plus:
- Omeprazole20mgorally for7days
Avoidriskfactors(NSAIDs, alcohol,etc)
Aparasiticinfectioncausedby
Worldwide in distribution but more common in
developingcountries.
Spreadbythefaeco-oralroute.
Invasion of the upper small intestine by the parasite
evokes inflammation, leading to progressive villous
atrophy.
Acute disease: watery diarrhoea with abdominal
bloating
Chronic disease: diarrhoea, steatorrhoea and weight
loss from malabsorption syndrome- with lactose
intolerance, xylose malabsorption and vitamin B
deficiency
DiseasesrelatedtoVitaminB deficiency
Other causes of upper gastrointestinal malabsorption
suchascoeliacdiseaseandtropicalsprue
Fullbloodcount
Stoolmicroscopyandfaecalfatassessment
Jejunalbiopsy
Rehydrate adequately
Eradicate parasite
Replacemalabsorbed(deficient)nutrients
Metronidazole
2 g orally daily for 3 days or 400 mg 8 hourly for 5
days
1 - 3 years 500 mg orally daily; 3 - 7 years 600 -
800mgdaily;7-10years1gdailyfor3days
Tinidazole
40 mg/kg orally as a single dose; repeat after 1
week
50 to 75 mg/kg as a single dose; repeat after 1
week
VitaminB supplementation
Avoidanceofmilk
every12hours
every12hours
Prevention
GIARDIASIS
Introduction
Pathogenesis
Clinicalfeatures
Complications
Differentialdiagnoses
Investigations
Treatmentobjectives
Drug treatment
Supportive
Giardialamblia.
Adult:
Child:
Adult:
Child:
12
12
12
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9. Notableadversedrug reactions
Prevention
HAEMORRHOIDS
Introduction
Clinicalfeatures
Differentialdiagnoses
Complications
Investigations
Treatmentobjectives
Non-drug treatment
Drug treatment
Surgery
Caution
PANCREATITIS
Introduction
Metallictasteandvomitingfrommetronidazole
Good sanitaryhabits
Uncontaminatedwaterandfoodsupplies
Enlarged or varicose veins of the tissues at the anus or
rectaloutlet.
Engorgement of the vascular complex or thrombus
oftenleadstothesymptomsofdisease.
The pathophysiologic mechanisms are complex and
varywiththesubject.
Maybeexternalorinternal.
Internal haemorrhoids: typically painless but present
withbrightredrectalbleeding
May become thrombosed and protrude into the anal
canal
External haemorrhoids when thrombosed cause acute
perinealpainwithorwithoutnecrosisandbleeding
Fibrosedexternalhaemorrhoidspresentasanaltags
Colorectalcancer
Adenomatouspolyps
Inflammatoryboweldisease
Bleeding,necrosis,perinealsepsis, mucusdischarge
Anoscopy
Fullbloodcountincludingbloodfilm
Relieve pain
Prevent complications
Increasefibreinfoods
Increasefluidintake
Avoidfoods thatcauseconstipation
Stool softeners
Regular exercise
Suppositories/ointments of preparations containing
hydrocortisone acetate with or without lidocaine
hydrochlorideplusastringent(s)
Elasticbandligation
Sclerosis, photocoagulaton, cryosurgery, excisional
haemorrhoidectomy
Eachdrugtreatmentcourseshouldnotexceed7days
A state of inflammation of the pancreas, which can be
Nasogastrictubesuctioning
Decreasepancreaticinflammation
Prevent,identifyandtreatcomplications
Caution
Prevention
PEPTICULCERDISEASE
Introduction
Aetiology/Predisposingfactors
Clinicalfeatures
Complications
Investigations
Differentialdiagnoses
Treatmentobjectives
Avoid narcotic analgesics which may cause spasm of
thesphincterofOddiandworsen pancreatitis
Controlalcoholingestion
Caused by peptic ulceration that involves the stomach,
duodenumandloweroesophagus.
An increasingly common problem in developing
countries.
Most ulcersareduodenal
. gutinfection
Use ofNSAIDs
Smoking
Recurrentepigastricpain
- Oftenradiatingtotheback
- Worseat night
- Improvedbyantacids
- May be made worse by some food types (generally
betterwithblanddiet)
Uppergastrointestinalbleeding
Perforation
Penetration
Gastricoutletobstruction
Gastriccancer
FullBloodCount
LiverFunctionTests
Urea,ElectrolytesandCreatinine
Occultbloodtest
Stool microscopy
Endoscopy
Doublecontrastbariummeal
Direct/indirect detection of (by CLO test or by
CO breathtest)
Gastritis
Duodenitis
Non-UlcerDyspepsia
Gastro-duodenalmalignancy
Oesophagitis
Gallbladderdiseases
Relieve pain
Promotehealingofulcers
Eradicate
Prevent/reduce recurrence
H pylori
H. pylori
H. pylori
2
acuteorchronic.
Varied,butmostimportantare:
Gallstones
Alcoholingestion
Abdominaltrauma
Infections
Idiopathicinasmanyas20-30%cases
Occurrence is worldwide, but commoner in areas of the
world where gallstones and alcohol ingestion are
common.
Autolysis of pancreatic tissue by pancreatic enzymes as
a result of “secretory block” in the pancreatic bed (often
causedbystones).
Acutepancreatitis:
Epigastric pain: may radiate to the back in over 50% of
cases
Nausea,vomiting,abdominaldistension
Severe abdominal tenderness with features of
hypovolaemiainseverecases
Pepticulcerdisease
Cholecystitis
Serumamylase:raisedin80%ofacutecases
Serum lipase: if raised is more specific than serum
amylase
Alanine aminotransferase: a rise above 3-fold suggests
pancreatitisofgallstoneorigin
CTscan
Abdominalultrasound:leastusefulinacutepancreatitis
Hypovolaemic shock
Acuterenalandrespiratoryfailure
Phlegmos
Gastrointestinal bleeding
Electrolyteimbalance(hypo&hypercalcaemia)
Pancreatic pseudocysts
Relieve pain
Preventcomplications
Renalfailure:haemodialysis
Respiratoryfailure:mechanicalventilation
Gallstones: Endoscopic Retrograde Cholangio
Pancreatography(ERCP)withsphincterotomy
Pancreaticpseudocyst:surgery
Analgesics
Treat specific complications
Aetiology
Pathophysiology
Clinicalfeatures
Differentialdiagnoses
Investigations
Complications
Treatmentobjectives
Non-drug treatment
Drug treatment
Supportivemeasures
Bedrest
Monitorvitalsigns;fluidintaket/output
Drug treatment
Adjunct therapy
Supportivetherapy
Notableadversedrug reactions
Treatmentofcomplications
UPPERGASTROINTESTINALBLEEDING
Introduction
Symptomatic treatment with antacids may be used prior
toconfirmingthediagnosisofpepticulcerdisease
Tripletherapywith:
- Metronidazole400mgorallyevery8hours for7days
Plus:
- Amoxicillin500mgorally for7days
Plus:
- Omeprazole20mgorallyevery12hours for7days
Or:
- Clarithromycin 500 mg orally for 7
days
Plus:
- Amoxicillin1gorally for7days
Plus:
- Omeprazole20mgorally for7days
Magnesium trisilicate suspension 15 mL orally three
timesdailyasrequired
Regular meals
Avoidance of provocative factors (NSAIDs, alcohol,
spicyfoods etc.)
Gastricirritation,diarrhoeafromtripletherapy
Diarrhoea/constipationfromadjuncttherapy
Intravenous omeprazole 20 mg 12 hourly for 5 days then
standardtripletherapy
Interventionalendoscopictreatment
Blood transfusion
Surgery
Surgery
Restthegut
Surgery
Bleeding from the lower oesophagus, stomach or
duodenumuptothelevelofligamentofTreitz.
Occurs worldwide and is responsible for significant
mortalityandmorbidity.
Majorcausesincludebleedingfrom:
- Pepticulcerdisease
- Oesophagealandgastricvarices
- Mallory-Weisstear
- NSAID-relatedmucosalbleeding
- Neoplasia
Bleeding is either from rupture of engorged varices or
from disruption of the oesophageal or gastro-duodenal
H. pylorieradication
Milduppergastrointestinalbleeding
Severeuppergastrointestinalbleeding
Perforation
Gastricoutletobstruction
every8hours
every 12 hours
every12hours
every12hours
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10. mucosa with ulceration or erosion into an underlying
vessel.
Depends on whether the bleeding is acute or chronic,
mildorsevere
Variouspresentations
- Haemetemesis
- Melaena
- Haematochezia
- Hypovolaemia
- Irondeficiencyanaemia(withitsassociated
symptoms)
Blackstoolsfromingestionofirontablets
Haematemesis/melaena from previously swallowed
blood(fromtheupperrespiratorytractandoralcavity)
Hypovalaemicshock
Congestiveheartfailurefromchronicsevereanaemia
Upper gastrointestinal endoscopy: picks up lesions in
90%ofcases
Upper gastrointestinal barium radiography: 80%
detectionrate
Selectivemesentericarteriography
Radioisotopescanning
Stool-occultbloodtest
FullBloodCount
Restoreandmaintainhaemodynamicstatus
Control bleeding
Preventrecurrenceofbleeding
Carefully monitor vital signs (pulse, blood pressure,
respiration and temperature) as frequently as
necessitatedbythepatient's condition
Insert a nasogastric tube to aspirate gastric contents
and/ortointroduceagentstoconstrictthebloodvessels
Blood transfusion: whole blood (acute bleeding) or
packed cells (chronic) bleeding. Up to 5 - 6 pints of blood
maybeneededinseverecases
- Plasmaexpandersintheabsenceofblood
ContinuousCentralVenousPressure (CVP) monitoring
ProtonPumpInhibitors
- Omeprazole20mgorallyoncedailyfor4weeks
Or:
- Omeprazole 40 mg by slow intravenous injection over
5minutesoncedailyuntilpatientcantakeorally
Anti therapysetabove.
Endoscopic treatment for actively bleeding ulcer or
visiblenon-bleedingvessel
- Injection therapy with 98% alcohol (total volume less
than1mL)
Or:
Clinicalfeatures
Differentialdiagnoses
Complications
Investigations
Treatmentobjectives
Non-drug treatment
Drug treatment
Bleedingpepticulcers/erosions
Helicobacterpylori
Aetiology
Importantrisk factors
Clinicalfeatures
Differentialdiagnoses
Complications
Investigations
Treatmentobjectives
Non-drug treatment
Drug treatment
Varies,dependingongeographicalregion:
Viruses, alcohol and drugs are the commonest aetiologic
agents
Familyhistory
Alcoholingestion
Previousbloodtransfusion
Contaminationoffoodandwaterbysewage
Drug ingestion
Sexualcontact
Acutehepatitis:
Mild-to-moderate jaundice
Vagueupperquadrantdiscomfort
Withorwithoutmildfever
There may be enlargement of the liver below the costal
margin with varying consistency (depending on the stage
oftheliverdisease)
Chronichepatitis:
Re-occurenceofjaundicemaysuggestachronicillness
Liver abscess
Metabolicliverdisease/disorder
Fulminanthepaticfailure
Bleeding tendencies
Liver FunctionTests
SerologicmarkersofHepatitisA,B,C,D andE
Abdominalultrasonography
Providesupportivemeasures
Preventprogressiontochronicphase
Highcarbohydrateandlowproteindiet
Discontinuationofhepatotoxicmedication
Bedrest
Self-limitingdisease.No specificdrugtreatment
Acute:
Self-limitingtofulminant
Treatment is supportive
Chronic:
Interferon alfa -2b: 10 million units subcutaneously
threetimesweeklyfor4months
Lamivudine:100mgorallydailyfor1year
Liver transplant
ChronicHepatitisC:
Interferonalfa-2b
- 3 million units subcutaneously 3 times weekly for 4
months
Ribavirin
- 400 mg orally twice daily for adults with body weight
HepatitisA
HepatitisB
- Injection therapy with epinephrine (1:10,000) up to
1mL
Or:
- Thermalcoagulationwithheatprobe
Or:
- Laser therapy
Intravenous vasopressin 20 units over 20 minutes bolus
theninfusionof0.1-0.5units/min
Plus:
Intravenous nitroglycerin 40 microgram/min (titrated
upward to maintain systolic blood pressure above 90
mmHg)
Endoscopic treatment
Injection sclerotherapy: equal volume mixture of 3%
sodium tetradecyl sulfate, 98% ethanol, sodium chloride
0.9%injection(2-5mL/site;maximum50mL)
Varicealband ligation
Radiologic therapy
Venousembolization
TransjugularIntrahepaticPortosystemicShunt(TIPS)
Oesophagealtransectionanddevascularization
Liver transplant
Surgicalrepairorresectionasappropriate
Monitor vital signs and urine output to detect early
featuresofhypovolaemicshock
Lookoutforfeaturesofhepaticencephalopathy
Vasopressin can cause abdominal cramps. It lowers
blood pressure drastically and could worsen ischaemic
heartdisease
Avoid NSAIDs.
Treat infection
blockers (propranolol 40 mg orally 12 hourly and
titrateupto160mgdependingontheheartrate)
Maintenance sclerotherapy
Inflammation of the liver that can be caused by
infectiveagents,drugs andothertoxins
The most predominant and important presentation of
liverdiseaseworldwide
The suffixes acute, chronic, viral, autoimmune,
alcoholic etc. define the agents causing hepatic injury or
theirdurationasthecasemaybe
Bleedingvarices
Pepticulcers/erosions/tumours
Peptic ulcers/erosions related upper gastrointestinal
bleeding
Oesophagealvarices
Supportive
Notableadversedrug reactions
Prevention
HEPATITIS
Introduction
H. pylori
β
HEPATICAND BILIARYDISORDERS
less than 65 kg; 400 mg in the morning and 600 mg in the
evening for adults weighing 65-85 kg; 600 mg twice daily
foradultsweighingover85kg
Interferon alfa -2b: 3 million units subcutaneously 3
timesweeklyfor4months
Plus:
Lamivudine:100mgorallyoncedailyfor4months
Largelysupportive
Interferon alpha 2b and Ribavirin haematopoietic
toxicity
Flu-like illness
Leucopenia
Psychiatric-like symptoms
Development of early resistance if therepy exceeds 1
year
Preventionoffaecalcontaminationoffoodandwater
Screen blood and blood products for hepatotrophic
viruses
ImmunizationagainsthepatitisA, B
Reductionofdrugmisuse/abuse
Pre-exposure prophylaxis(asforNPI/EPI)
Post-exposure prophylaxis
Astate of disturbed central nervous system function as a
resultofhepaticinsufficiency
Characterized by changes in personality, cognition,
motorfunction,levelofconsciousness
One-yearsurvivalrateis40%
Nitrogenous substances, particularly ammonia, reach
the brain via portosystemic shunts leading to alteration of
neurotransmission
Reducedbloodsupplytotheliver
Infectionoftheliver
Bleedingintothegut
Electrolyte imbalance (hypokalaemia and
hypomagnesaemia)
Poor bowelevacuation
Cognitive abnormalities: may be mild and recognizable
only with psychometric testing but may be severe with
frank confusion,alteredlevelofconsciousnessandcoma
Hyper-reflexia
Fetorhepaticus
Insomnia
Flappingtremor(asterixis)
Intracranial lesions (haemorrhage, tumour, abscess
etc.)
HepatitisD
HepatitisE
Notableadversedrug reactions
Prevention
HEPATICENCEPHALOPATHY
Introduction
Predisposingfactors
Clinicalfeatures
Differentialdiagnoses
7 8
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11. CNS infections(encephalitis,meningitis)
Other metabolic encephalopathies (uraemia,
hyper/hypoglycaemiaetc.)
Hypertensive encephalopathy
Alcoholintoxication
Drug toxicitye.g.sedatives,heavymetals
As appropriatetoidentifypossibleprecipitatingfactors
FullBloodCount
Urea,ElectrolytesandCreatinine,
Blood sugar
Microscopyandcultureofthestoolandblood
Reverseneuropsychiatricsymptoms
Minimizenitrogenoussubstances
Treatprecipitatingfactors
Lactulosesyrup (10g/15mL)
- Initially 30 - 45 mL orally three times daily titrated to
either the resolution of symptoms or production of three
softstoolsperday
Or:
- As rectal retention enema 300 mL in 1 litre water
retainedfor1hour; durationusuallyfordaysorweeks
Or:
Metronidazole800mgorally12hourly
Treat underlying cause(s) e.g hypokalaemia, anaemia,
infection
Lactulose:excessgas,diarrheoa
Metronidazole:peripheralneuropathy,dysgeusia
Avoid precipitatingfactors
Acommonclinicalstateofvaryingaetiologies
Classifiedashaemolytic,hepaticorobstructive
Clinical jaundice occurs when the level of serum
bilirubinexceeds2.5mg/dL
The bilirubin may be conjugated, unconjugated or
mixed
Diseasesoftheliverandthebiliarytract
Conditions that cause excessive red cells haemolysis:
infections,haemoglobinopathies
Discolouration of the sclerae and other mucus
membranes
With or without pruritus (especially with cholestatic
jaundice)
Investigations
Treatmentobjectives
Drug treatment
Notableadversedrug reactions
Prevention
JAUNDICE
Introduction
Importantcauses
Clinicalfeatures
Supportivemeasures
Highcarbohydrate,lowproteindiet
Adequatehydration
Rectalwash out
Hepato-renal syndrome
LFTs
PT,PTTK,Serumalbumin
Liver biopsy
Ultrasoundexaminationoftheliver
Screening for aetiologic factors in chronic liver disease
e.g. viral markers for hepatotrophic viruses (e.g.
HepatitisB&C)
Preventfurtherliverdamage
Preventdeteriorationofliverfunction
Symptomaticrelieffromanaemia,fatigueandoedema
Encouragehighfibreandlowsaltdiet
Enhanceopeningofbowel
Correctionofanaemia
Reduce oedemaandascites
Spironolactonetablets25-100mgorally12hourly
Furosemide20-80mgorally12hourly
Salt-pooralbuminforintractableascites
Propranolol40-80mgorallydaily
Livertransplant
Lactulose30mLorallytwicedaily
- Doses to be titrated upward until at least 3 bowel
motionsdailyareachieved
Salinerectalenema
ImmunizationagainsthepatitisB,C
Abstinencefrom alcohol
Adequate nutrition is the intake and utilization of
energy-giving and body building foods and nutrients, to
maintainwell-being,andproductivity.
“Malnutrition” includes generalized malnutrition that
manifests as stunting, underweight, wasting
(kwashiorkor and marasmus), obesity as well as
deficienciesofmicronutrients.
Kwashiorkor isprotein-energymalnutrition.
Marasmus is malnutrition resulting from inadequate
calorieintake.
Obesity is a commonly nutritional disorder (results from
excessiveintakeofcalories).
Investigations
Treatmentobjectives
Non-drug treatment
Drug treatment
Prevention
KWASHIOKORAND MARASMUS
Introduction
Epidemiology
Ascitesandpedaloedema
Preventionofvaricealbleeding
Replacementofdamagedliver
Preventionofencephalopathy
NUTRITIONALDISORDERS
Associatedfeaturesoftheunderlyingdisease
LFTs: determine levels and nature of bilirubin, liver
enzymes(AST,ALT,Alkalinephosphotase)
Abdominal ultrasound scan: look out for canalicular
dilatations,biliarystones
Treatunderlying cause
Prevent complications
Specifictreatmentdependsontheidentifiedcause
Colestyramine
- 3-6g orally6hourlyinsevereobstructivejaundice
Phenobarbitalinneonataljaundice
- 5-8mg/kgorallydaily
Colestyramine:diarrhoea
Phenobarbital may cause dose-dependent respiratory
depression
ERCPsphincterotomywithstoneremoval
Stent insertion
Pancreatichead/duodenalheadrealignment
An advanced stage of chronic liver disease associated
with permanent distortion of the liver architecture and
replacement of some destroyed hepatocytes with fibrous
tissue
Accompanied by some loss of liver function leading to
certainrecognizedsymptomsandsigns
Similartosomecausesofacuteliverdiseases
No known aetiologyinupto30%ofcases
Varieswiththeextentofliverdamage:
Fatigue
Ascites
Pedal oedema
Haematemesis
Liver may be shrunken or enlarged below the costal
margin;itistypicallyfirm
Granulomatouslesionoftheliver
Primaryorsecondaryneoplasmsoftheliver
Intractable oedema
Uppergastrointestinaltractbleeding
Coagulopathy
Hepatic encephalopathy
Investigations
Treatmentobjectives
Drug treatment
Notableadversedrug reactions
Surgicaltreatment
LIVERCIRRHOSIS
Introduction
Aetiology
Clinicalfeatures
Differentialdiagnoses
Complications
Obstructivejaundice
Supportivemeasures
Reassuranceandmonitoring
Phototherapyinneonataljaundice
High percentages in under-developed countries,
especiallysub-SaharanAfrica
Kwashiorkor:
Growth retardation
Muscle wasting
Anaemia
Apathy
Moon face
Lack-luster skin
Easilyplucked hair
Pedal oedema
Hypo-pigmentedskinpatches
Exfoliation,
Diarrhoea
Marasmus:
Thin;protrudingbones
Hungry-looking
'old-looking face’
Whimperingcry
FullBloodCount,ESR
Stool microscopy
Urinalysis
Serum proteins
Chest radiograph
Mantoux test
Nutritional counselling
Adequate nutrient intake: may require assistance and
specialpreparationse.g.nasogastricfeeding,etc.
Periodicgrowthmonitoring
May be indicated where there are specific
infections/infestations
Deficiencies of minerals (iron, iodine, zinc, calcium,
phosphorus, magnesium, copper, potassium, sodium,
chloride,fluorideetc);folicacidandvitamins
Inadequatedietaryintake
Increased requirements
Increasedloss (e.g.worminfestation)
Global; high percentages in under-developed countries,
especiallysub-SaharanAfrica
Iron:anaemia
Iodine:goitre
Zinc, copper: manifestations of enzyme and insulin
deficiencies
Calcium:rickets,osteomalacia
Phosphorus andfluoride:teethandboneabnormalities
Clinicalfeatures
Investigations
Non-drug treatment
Drug treatment
MICRONUTRIENT DEFICIENCIES
Definition
Aetiology
Epidemiology
Clinicalfeatures
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12. Vitamins:
- A:keratomalacia,cornealxerosis,nightblindness
- B (thiamine):beri-beri
- B (riboflavin): scrotal and vulval dermatoses, angular
stomatitis,scars,magentatongue,cheilosis
- B (niacin):scarletanddrytongue,pellagra
- Ascorbic acid: scurvy, petechiae and musculo-skeletal
haemorrhages
- D: rickets, epiphyseal enlargement, muscle wasting,
bossing of skull bone, 'thoracic rosary', persistently open
anteriorfontanelle,genuvalgumorvarum
Blood,urineandstooltests
Otherinvestigationsasappropriate
Correctnutrientdeficiencies
Ensureadequateintake
Prevent complications
Administration of specific nutrients (as concentrates in
foods)
Food supplementation
Treatunderlying diseases
Nutritional counselling
Optimal breastfeeding and appropriate weaning
practices
Adequateintakeoflocallyavailable,nutritiousfoods
Personal/food/waterhygiene
Prophylactictherapiesformalaria
Amajorcomponentofthemetabolicsyndrome.
Being overweight or obese significantly increases the
risk of morbidity and mortality from Type 2 diabetes and
itsco-morbidities.
Successful weight reduction has a positive impact on
morbidityandmortalityoutcomes.
Constititional obesity is a result largely of diet and
lifestyle.
Bodymassindex(BMI):calculationforoverallobesity
Waist circumference: determination of central fat
distribution
BMI iscalculatedasfollows
BMI = weight in kg divided by height in m , expressed as
kg/m
Underweight:<18.5kg/m
Normalweight:18.5-24.9kg/m
Overweight:25-29.9kg/m
Obesity(Class1):30-34.9kg/m
Obesity(Class2):35-39.9kg/m
Extremeobesity(Class3):>40kg/m
BMI representsoveralladiposity
1
2
6
Investigations
Treatmentobjectives
Treatment
Prevention
OBESITY
Introduction
Measurementsforevaluation
ClassificationofBMI
2
2
2
2
2
2
2
2
Prevent complications
Assess dietary intake, level of physical activity, BMI
(total body fat) and waist circumference (abdominal fat)
onpresentationandatregularmonitoring
Assess efficacyofweightloss measures
Integrate weight control measures into the overall
managementofdiabetesmellitusandco-morbiditiesif
- BMI is>25
- Waist circumference is more than 102 cm and 88 cm in
menandwomenrespectively
Educatepatientsandotherfamilymembers
Setrealisticgoals
Use amulti-disciplinaryapproachtoweightcontrol
Dietary changes and increased level of physical activity
arethemosteconomicalmeanstolooseweight
Maintain records of goals, instructions and weight
progress charts
Surgicalinterventionmayberequiredinextremecases
Management
The pattern of distribution of fat in the body (whether
mostly peripheral or central) is assessed by the use of the
waist/hipratio(WHR)
Waist/Hip ratio=Waist circumference (in cm) divided by
Hipcircumference(incm)
Waist circumference: measure midway between the
lowerribmarginandtheiliaccrests
Hipcircumference:thelargestcircumferenceofthehip
Waist circumference better depicts central or upper
bodyobesitythanwaist/hipratio
- Upper limits: 102 cm and 88 cm in men and women
respectively
Non-specific
- Always bear in mind the possibility of an underlying
cause: although these may not be common, specific
therapymaybeavailable
- Clinical presentation may therefore require specific
investigationstoexcludeconditionssuchas
Hypothyroidism
Hypercortisolism
Male hypogonadism
Insulinoma
CNS diseasethataffectshypothalamicfunction
Cardiovascular:
Coronary disease
Stroke
Congestiveheartfailure
Pulmonary:
Obstructivesleepapnoea
'Obesityhypoventilationsyndrome'
Endocrine:
Insulinresistanceandtype2diabetesmellitus
Hepatobiliary:
Gallstones
Reproductive:
Male hypogonadism
Menstrual abnormalities
Infertility
Cancers:
In males, higher mortality from cancer of the colon,
rectumandprostate
In females, higher mortality from cancer of the gall
bladder, bile ducts, breasts, endometrium, cervix and
ovaries
Bone,jointandcutaneousdisease:
Osteoarthritis
Gout
Acanthosisnigricans
Increasedriskoffungalandyeastinfections
Venousstasis
Toeducatepatientandcaregivers
Achieveanidealbodyweight
Investigations
Complications
Treatmentobjectives
CHAPTER 2: BLOOD AND BLOOD-FORMING
ORGANS
ANAEMIAS
Introduction
Morphologicalclassification
Classificationbasedon aetiologyand pathogenesis
Anaemia is a reduction in the haemoglobin
concentration in the peripheral blood below the normal
rangeexpectedfortheageandsexofanindividual
The determination of haemoglobin concentration
should always take the state of hydration and altitude of
residenceoftheindividualintoconsideration
It can be classified on the basis of red cell morphology
andaetiology/pathogenesis
Macrocytic
Megaloblastic
- Folicaciddeficiency
- VitaminB deficiency
- InheriteddisordersofDNAsynthesis
Non-megaloblastic
- Acceleratederythropoiesis
- Increasedmembranesurfacearea
- Obscure
Hypochromic-microcytic
Iron deficiency
Disorders ofglobinsynthesis
Otherdisordersofironmetabolism
Normochromic-normocytic
Recentbloodloss
Haemolytic anaemias
Hypoplastic bonemarrow
Infiltratedbone marrow
Endocrine abnormality
Chronic disorders
- Renal disease
- Liver disease
BloodLoss:
Acute
Chronic(leadstoirondeficiency)
Increasedredcelldestruction(haemolyticanaemias):
Corpuscular defects (intracorpuscular or intrinsic
abnormality)
Disorders of the membrane e.g elliptocytosis,
spherocytosis
Disorders of metabolism e.g Glucose-6-Phosphate
Dehydrogenasedeficiency
Haemoglobinopathye.gsicklecelldisease
ParoxysmalNocturnalHaemoglobinuria
Abnormal haemolytic mechanisms (extra-corpuscular or
intrinsicabnormality):
Autoimmune
Rhesus-incompatibility,mismatchedtransfusion
Hypersplenism
Infectionse.gmalaria,
Drugs andtoxins
12
Clostridiumwelchii
11 12
Chapter 1: Alimentary Tract Standard Treatment Guidelines for Nigeria 2008

13. Otherse.g.burns
Decreasedredcellproduction:
Nutritional (due to deficiencies of substances essential
forerythropoiesis)
- Iron
- Folate
- VitaminB
- Variousdeficiencies e.g.protein,ascorbicacid
Bonemarrowstemcellfailure:
Primary(idiopathic):
- Aplasticanaemia
- Pureredcellaplasia
Secondary:
- Drugs (phenylbutazone,cytotoxicagents,etc)
- Chemicals
- Irradiation
Anaemiasassociatedwithsystemicdisorders:
Infection
Liver disease
Renal disease
Connectivetissuedisease
Cancer(includingleukaemia)
Marrow infiltration
Thyroidorpituitarydisease
Depend on the degree of anaemia, severity of the
causativedisorderandageofthepatient
The clinical effects of anaemia are due to anaemia itself
andthedisorder(s)causingit
Common:
Tiredness
Lassitude
Weakness
Dyspnoeaonexertion
Palpitations
Pallor
Lesscommon:
Anginaof effort
Faintness
Giddiness
Headache
Ringingintheears
Highoutputstate
Congestivecardiacfailure
Cardiac failure
Respiratory failure
Cardiac failure
Death
Haematologic:
Haematocrit;haemoglobinconcentration
Redcellindices
Reticulocyte count
Totalleukocyteanddifferentialcounts
12
Clinicalfeatures
Differentialdiagnoses
Complications
Investigations
Notnecessaryunlessthereisintolerancetooraliron
Indicationsforparenteraliron:
Anaemiadiagnosedinlatepregnancy
Correction of anaemia just before an operative
procedure
Haemorrhageexpectedtocontinueunabated
Ironpreparations:
Irondextrangivenas“totaldose" infusion
Dose in mL (of 50 mg/mL preparations) = [Patient's wt.
inkgX (14 Hb ing/dL)] 10
Oralironpreparations:
Nausea, epigastric pain, diarrhoea, constipation, skin
eruptions
Reduce dosage and frequency of administration to
reducetheseeffects
Parenteraliron:
Localreactions:phlebitisandlymphadenopathy
Systemic reactions: may be early or late- headache,
fever, vomiting; general aches and pains, backache,
chestpain,dyspnoea,syncope;deathfromanaphylaxis
A test dose should be administered: 25 mg
intramuscularly or by intravenous infusion over 5 to 10
minutes
Total-dose infusion should be avoided in patients with
historyofallergy
Response to therapy is satisfactory if administered
doseislimitedtotheminimaldailyrequirement
Treatment with vitamin B (cobalamin) to replace
bodystores
- Six-1000 micrograms intramuscular injections of
hydroxocobalamingivenat3-7dayintervals
Maintenance therapy: patients will need to take
vitaminB forlife
- 1000 micrograms hydroxocobalamin intramuscularly
onceevery3months
Toxic reactions are very rare and are usually not due to
cobalaminitself
Pharmacologic doses of folic acid produce
haematological response in vitamin B -deficient
patientsbutworsen theneurologicalcomplications
Large doses of vitamin B also give haematological
responseinfolate-deficientpatients
Balanced diet
Prompttreatmentofallillnesses
Blood transfusion is the administration of blood for
therapy.
It is potentially hazardous: blood should be given only
if the dangers of not transfusing outweigh those of
÷
Notableadversedrug reactions,caution
Notableadversedrug reactions,caution
Prevention
BLOOD TRANSFUSION
Introduction
Megaloblasticanaemia
12
12
12
12
Platelet count
Erythrocytesedimentationrate
Bloodfilmexaminationformorphologyofcells
Thickandthinfilmsformalariaparasites
Urineanalysis:
Colour,pH, clarity,specificgravity
Microscopicexaminationoffreshurinespecimen
Protein
Glucose
Occult blood
Stool:
Colour,consistency
Examinationforovaandparasites
Occult blood
Plasma:
Blood Urea Nitrogen(BUN)
Totalproteinandalbumin
Bilirubin
Creatinine(if BUN isabnormal)
Others:
Coombstestforthepresenceofantibodiestoredcells
Ham's test(acidifiedserumtest)
Bonemarrowaspirationandtrephinebiopsy
Haemoglobin electrophoresis
Sicklingtest(metabisulphiteandsolubility)
Family studies
Restorehaemoglobin concentrationtonormallevels
Prevent/treat complications
Bed rest in severe cases: initially necessary, especially
whencardiovascularsymptomsareprominent
Treatcardiacfailurebystandardmeasures
Balanceddietwithadequateproteinandvitamins
Correctdietarydeficiencies(e.g.iron,folicacid)
Blood transfusion: a very important measure in the
treatment of anaemia, but should not be used as a
substitute for investigation, or specific treatment of the
cause
Arrest bloodloss
Treatanyunderlyingsystemicdisorder
Removeanytoxicchemicalagentordrug
Correctanatomicalgastro-intestinalabnormalities
Haematinicse.g.iron,vitaminB folicacid
Thespecifichaematinicindicatedshouldbegivenalone
Response to adequate treatment is important in
confirmingdiagnosis
Oralirontherapy:
- Ferrous sulfate 200 mg (containing 65 mg of iron) 1
tablet2-3timesdaily
Treat for 3- 6 months to correct deficits in haemoglobin
andinstores
Parenteraltherapy:
Treatmentobjectives
Supportivemeasures
Drug treatment
12,
Irondeficiency
transfusion.
Indication(s)mustbeclearlyestablished.
Transfusion of whole blood or red cell concentrates is
important in the treatment of acute blood loss and of
anaemia.
Red cells can be stored at 4ºC for 5 weeks in media that
are specially designed to maintain the physical and
biochemical integrity of the erythrocytes and which
maintaintheirviabilityaftertransfusion.
Citrate Phosphate Dextrose with Adenine (CPDA) is
commonlyusedforcollectionsofwholeblood.
The use of whole blood as a therapeutic agent has been
almost completely replaced by the use of blood
fractions.
Autologousbloodtransfusion:
Transfusionofthepatient's own bloodtohim/her
- Safestbloodforpatients
Thethreemaintypesare:
- Pre-depositautologoustransfusion
- Immediate pre-operative phlebotomy with
haemodilution
- Intra-operativebloodsalvage
Exchangetransfusion:
To remove deleterious material from the blood, for
example, in severe jaundice resulting from haemolytic
diseaseofthenewborn
Alternativestoredcelltransfusion:
PerfluorochemicalssuchasFluosol-DA
Polymerised haemoglobin solutions with good
intravascularrecovery
Symptomatic anaemias:
- Recurrent haemorrhage
- Haemolysis
- Bonestemcellfailure
- Pureredcellaplasia
- Severeanaemiaofchronicdisorders
- Haematological malignancies (e.g. leukaemia,
lymphoma)
- Chemotherapycomplicatedbyanaemia
Inneonates:
- Severeacutehaemorrhage
- Haemolyticdiseaseofthenewborn
- Septicaemia
- Prematurity
Bleeding disorders:
- Congenitale.g.haemophilia
- Acquirede.g.disseminatedintravascularcoagulopathy
Preventionortreatmentofshock:
- Clinical situations in which there is need to restore
and/or maintain circulatory volume e.g. trauma,
haemorrhage
To maintain the circulation (as in extracorporeal or
cardiacby-pass shunts)
Typesofbloodtransfusion
Indicationsfor bloodtransfusion
Wholebloodpreparations
13 14
Chapter 2: Blood and Blood-Forming Organs Standard Treatment Guidelines for Nigeria 2008

14. Should be limited to correction or prevention of
hypovolaemiainpatientswithsevereacutebloodloss
Justified by the recognition that there is a relatively
rapid loss of platelets, leucocytes and some coagulation
factors with liquid storage. There is also progressive
increase in the levels of undesirable products such as
potassium,ammonia,andhydrogenions
Four typesareincommonuse:
- Packedredbloodcells
- Washedredbloodcells
- Leucocyte-reducedredbloodcells
- Frozenredbloodcells
Obtained from liquid-stored blood by saline washing
using a continuous-flow cell separator or from frozen
erythrocytes extensively washed to remove the
cytoprotectiveagents
Best prepared by passing whole blood or packed cells
throughspecificallydesignedfilters.
Three main reasons for the use of leucocyte-reduced
redbloodcells:
- To prevent non-haemolytic febrile reactions to white
cell and platelet antibodies in recipients exposed to
previoustransfusionsorpregnancies
- To prevent sensitization of patients with aplastic
anaemia who may be candidates for bone marrow
transplantation
- To minimize risk of transmission of viruses such as
HIVorcytomegalovirus
Informed consent should be obtained from patients
exceptinlife-threateningemergencies
The risks and benefits of the proposed transfusion
therapy should be discussed with the patient and
documentedinthepatient's medicalrecords
There may be no time available to type, select and
cross-matchcompatibleblood
Arareoccurrence,exceptfor
- Trauma
- Unexpectedintra-operativehaemorrhage
- Massivegastro-intestinalbleeding
- Ruptured aneurysm
Uncross-matched or partially cross-matched blood is
administered; routine cross-match should be carried out
retrospectivelytoidentifyanyincompatibility
Immunological:
Sensitizationtoredcellantigens
Haemolytictransfusionreactions
- Immediate
- Delayed
Reactionsduetowhitecellandplateletantibodies
Fresh Blood
Erythrocytepreparations
Washedredbloodcells
Leucocyte-reducedredbloodcells
Bloodforemergencies
Transfusion therapy
Complicationsofbloodtransfusion
Prompt treatment of illnesses that could be complictated
byanaemia
Regularmedicalcheck-ups
A heterogeneous group of diseases characterized by
infiltration of the blood, bone marrow and other tissues
byneoplasticcellsofthehaematopoieticsystem
Two main types
- Myeloidleukaemia
- Lymphoid leukaemia
Eachisfurtherdividedintoacuteandchronic
Acute leukaemias are defined pathologically as blast
cell leukaemias or malignancies of immature
haematopoietic cells. The bone marrow shows > 30%
blastcells
Two maingroups ofacuteleukaemias
- Acutemyeloidleukaemia(AML)
- Acutelymphoblasticleukaemia(ALL)
Childhoodleukaemias:patientsaged<15years
Adultleukaemias:patientsaged>15years
Leukaemias in adults aged > 60 years: an important
groupbecause
- Their responses to current treatment protocols both for
ALLandAMLareinferior
- These patients are not usually considered for more
radical treatment approaches such as autologous or
allogeneicbonemarrowtransplantation
80%ofadultcases:AML
Morecommoninindustrializedthanruralareas
Environmental agents implicated in the induction of
certaintypesofleukaemia:
Ionisingradiation:X-rays andotherionizingrays
Chemical carcinogens
- Benzeneandotherpetroleumderivatives
- Alkylatingagents
Host susceptibilitye.g.geneticdisorders:
Bloom's syndrome
Fanconi's anaemia(AML)
Ataxiatelangiectasia(ALL)
Down's syndrome
Blast transformation in pre-existing myeloproliferative
disoders:
Aplasticanaemia(ALL)
Oncogenicviruses:
HTLV-1 (Human T-cell Lymphotropic virus 1):
implicatedinadultTcellleukaemia/lymphoma
HAEMOSTASIS AND BLEEDING DISORDERS -
referfor specialistcare
LEUKAEMIAS
Introduction
Epidemiology/predisposingconditions
Acute lymphoblastic leukaemia (ALL) and Acute
myeloidleukaemia(AML)
- Febriletransfusionreactions
- Post-transfusion purpura
Reactions due to white cell and plasma protein
antibodies
- Urticaria
- Anaphylaxis
Non-immunological:
Transmissionof disease
Reactionsduetobacteriaandbacterialpyrogens
Circulatory overload
Thrombophlebitis
Airembolism
Transfusionhaemosiderosis
Complicationsofmassivetransfusion
A minimum of three major procedures must be carried
out:
- Determinetherecipient'sABO andRhesus groups
- Selectcompatibledonorblood
- Cross-matchdonorcellsagainstrecipient's serum
Donor blood should be screened for infective agents:
HIV,hepatitisB,andCviruses
Haemoglobin concentration
Haematocrit
Redcellindices:MCH, MCV,MCHC
Totalleucocyteanddifferentialcounts
Reticulocyte count
Erythrocytesedimentationrate
Plateletcount
To raise haemoglobin concentration and other blood
parameterstonormallevels
Topreventbloodtransfusioncomplications
Transfusion of red blood cells, platelet concentrates or
plateletrichplasmaasrequired
Provision of fresh frozen plasma or other blood
productsasnecessary
Furosemide 40 mg on administration of one unit of
blood
In the event of transfusion reactions, stop the transfusion
immediatelyandadministerthefollowing:
Promethazine25mgintramuscularlyorintravenously
Epinephrine 0.5 mL of 1:1000 solutions to be
administeredsubcutaneously
Hydrocortisonesodiumsuccinate100mginjection
Appropriatenutrition
Adequatehydration
Furosemide:dehydrationandhypersensitivity
Promethazine:drowsiness, hypersensitivity
Avoid/prevent accidents
TestsofCompatibility
Other investigations
Treatmentobjectives
Non-drug treatment
Drug treatment
Supportivemeasures
Notableadversedrug reactions,caution
Prevention
Clinicalfeatures
Differentialdiagnoses
Complications
Investigations
Treatmentobjectives
Non-drug treatment
Generalsymptomsofanaemia
Bleeding
Infections
Anorexia
Weightloss
Lymphadenopathy (not common in AML except in the
monocyticvariant)
Skin:
Macules,papules,vesicles
Pyoderma gangrenosum
Neutrophilic dermatitis
Leukaemic cutis
Granulocytic sarcoma
Septicaemia
Miliary tuberculosis
Malignant histiocytosis
Worseningill-health
FullbloodcountwithESR,reticulocytecount
Coomb's test
Bonemarrowexamination
Biochemical tests: serum electrolytes, urea, creatinine,
uricacid
Liverfunctiontests
Prothrombintime,partialthromboplasnime
HumanLeucocyteAntigentyping
HIVIandII
Cytochemical tests
- Peroxidase
- SudanBlackB
- Non-specificesterasereactione.g.alphanapthyl
acetateesterase
Bonemarrowcultures
Cytogenetic studies
Electron microscopy
Cell markers e.g. using a panel of antibodies combined
with flow cytometric analysis or the alkaline phosphase-
antialkaline phosphate (APAAP) technique to classify
theblastcellsintolymphoidormyeloidlineages
Abdominalultrasound/CTscans
Immunological classification
Terminal deoxynucleotidyl transferase demonstration
innucleiofBandTlymphocytes
Induceremissiontoachievecompleteremission
Maintaindisease-freestate
Appropriatenutrition
Adequatehydration(atleast3litres/24hours)
Erythrocytetransfusionasrequired
Plateletconcentratetransfusionasrequired
Maintainelectrolytebalance
15 16
Chapter 2: Blood and Blood-Forming Organs Standard Treatment Guidelines for Nigeria 2008

15. Drug treatment
Acutelymphoblasticleukaemia
Acutemyeloblasticleukaemia
Allopurinol300mgdailyorally
Daunorubicin 30 mg/m intravenously on days 8, 15, 22
and29
Vincristine 1.4 mg/m to a maximum of 2 mg
intravenouslyondays8,15,22and29
Prednisolone60mgorallyoncedailyfromday1-28
L-asparaginase 1000 IU/m intravenously on days 12,
15,18,21,24,27,30and33
Or:
Cyclophosphamide 650 mg/m intravenously on days 1
and8;14and22
Vincristine 1.4 mg/m intravenously to a maximum of 2
mg:days1and8;14and22
Cytosine Arabinoside 50 mg/ m subcutaneously 12
hourly for 12 days or bolus intravenous injection 100
mg/m dailyfor7days
Prednisolone40mg/m oralfor14days
- Drugs aregivenevery28daysfor3courses
Nervous systemprophylaxis
- Methotrexate 12.5 mg/m intrathecally twice weekly to
amaximumof15mgi.e.5doses over3weeks.
Tobegivenonday29
COAPregime to be given once provided WBC count is
=1x10 /Landplateletcountis=100x10 /L
6-Mercaptopurine75mg/m orallydaily
Methotrexate20mg/m orallyweekly
- For 3 years if remission is maintained, otherwise re-
assessment
Tobegivenevery3monthswith
- Vincristine 1.4 mg/ m to a maximum of 2 mg weekly
ondays1and8
EitherTAD orCOAPasshown below:
Cytarabine 100 mg/m (continuous infusion) on days 1
and 2, and 100 mg/m by intravenous
infusionover30minutesondays 3 -8
Thioguanine 100 mg/m orally on days
3-9
Daunorubicin 60 mg/m by intravenous infusion over
onehourondays3 -5
Or:
Cyclophosphamide 650 mg/m intravenously on days 1
and8
Vincristine 1.4 mg/m intravenously to a maximum of 2
mgondays1and8
Cytarabine 50 mg/m subcutaneously
DVPRegime
COAPRegime
Consolidation
Maintenance
Pulsetherapy(Intensification)
TAD
COAP
2
2
2
2
2
2
2
2
2
9 9
2
2
2
2
2
2
2
2
2
2
every 12 hours
every 12 hours
every 12 hours
Clinicalfeatures
Complications
Investigations
Treatmentobjectives
Non-drug treatment
Drug treatment
Notableadversedrug reactions caution
Asymptomatic
Abdominalswelling/pain
Lethargy
Shortness ofbreathonexertion
Weightloss
Unexplained haemorrhage at various sites e.g. gums,
intestinal/urinarytracts
Increasedsweating
Visualdisturbances
Gout
Priapism
Splenomegaly
Anaemia
Haemorrhage
Fever
Lymphadenopathy(rareinchronicphase)
Blastictransformation
Death
As aboveforacuteleukaemiaplus:
DeterminationofPhiladelphiachromosome
Lacticdehydrogenase
Serumcalcium
Induceremissiontoachievecompleteremission
Maintaindisease-freestate
AchieveabsenceofPhiladelphiachromosome
Appropriatenutrition
Adequatehydration
Electrolyte balance
Hydroxycarbamide(hydroxyurea)
20-30 mg/kg orally daily or 80 mg/kg every third
day
Notrecommended
Interferon alpha
9 million units subcutaneously or intravenously
thriceweeklyfor6-12 months
Or:
Imatinib mesylate
- 400mgorallydaily
,
The above drugs (except the steroids) all cause profound
myelosuppression
Profound nausea, vomiting, diarrhoea and abdominal
discomfort
Secondary malignancies
Steroids: Cushing's syndrome, hypertension, diabetes
mellitus,immunosuppression,infections
Vincristine:neurotoxicity
Cylophosphamide:alopecia,haemorrhagiccystitis
Daunorubicin: myelosuppression, alopecia,
Adult:
Child:
Adult:
- Tobeusedstrictlyunderspecialistsupervision
for7days
Prednisolone40mg/m orallyfor14days
- Nervous systemprophylaxisisnotrequired
- Assess forremissionafter3courses
COAPevery6weeksfor2years
Intrathecal treatment as forALLif there is CNS disease
ofthemonocytictype
Also Chronic Myelogenous Leukaemia; Chronic
GranulocyticLeukaemia(CGL)
A clonal disease that results from acquired genetic
changeinapluri-potentialhaematopoieticstemcell
Altered stem cell proliferation generates a population of
differented cells, and a greatly expanded total myeloid
mass
Majority of patients have relatively homogenous
diseasecharacterizedby:
- Splenomegaly
- Leucocytosis
- Presence of Philadelphia (Ph) chromosone in all
leukaemiacells
Minority of patients have less typical disease (atypical
CML)
- ThesevariantslackPh chromosome.Examples:
- Chronic myelomonocyticleukaemia
- Chronic neutrophilicleukeamia
- Juvenilechronicmyeloidleukaemia
Rare below the age of 20 years but occurs in all age
groups
Increased risk of developing CMLwith exposure to high
doses ofirradiation
Abiphasic or triphasic disease, usually diagnosed in the
initial“chronic”orstablephase
Untreatedpatient:
- <12%blastcellsinbloodormarrow
Treatedpatient:
- Normal or near-normal blood count without immature
granulocytesinperipheralblood
Risingleucocytecountdespitetreatment
Rapidleucocytedoublingtime
Immaturegranulocytesinblood
Blastcells>5%but<30%inmarrow
Anaemia(Hb <10g/dL)notattributabletotreatment
Thrombocytosis(>1000x10 /L)
Acquisitionofspecificnewcytogeneticabnormalities
Increasingmarrowfibrosis
Morethan30%blasts
Or:
Blastspluspromyelocytesinbloodorbonemarrow
2
9
Maintenance
DistinguishingfeaturesbetweenphasesofCGL
Chronicphase
Acceleratedphase
Blastictransformation
ChronicMyeloidLeukaemia(CML)
Classification
Epidemiology,aetiologyand natural history
cardiotoxicity
All are contraindicated in patients with history of
hypersensitivityreactionstotherespectivemedicines
Avoidexposuretoionizingradiation
Earlydetectionandtreatment
Neoplasticproliferationsofmaturelymphocytes
The diseases involve the blood bone marrow and other
tissues
Characterized by accumulation of small mature-looking
CD5+ B lymphocytes in the blood, marrow and
lymphoidtissues
B-celldisordersaremorecommon
B-cellCLLismorecommoninmalesthanfemales
- Accountsfor60%ofcases
- Rarelydiagnosedbelowtheageof40years
Asymptomatic(30%ofcases)
Symptomsofanaemia
Lymphnodeenlargement(painless)
Rare:pyrexia,sweatingorweightloss
Severechestinfection/pneumonia
Splenomegaly(50%ofcases)
Hepatomegaly(notfrequent)
Low grade non-Hodgkin's lymphomas with frequent
blood and bone marrow involvement (leukaemia /
lymphomasyndromes)
Tuberculosis
Viralinfections
Toxoplasmosis
Richter transformation
Progression ofdisease
Cellmorphology:
Size
Nuclear:cytoplasmic(N:C)ratio
Regularityorirregularityofthenuclearoutline
Characteristics of the cytoplasm (presence and length or
absenceofazurophilgranules)
Degree of nuclear chromatin condensation and its
pattern
Prominence, frequency and localization of the
nucleolus
As foranaemiaandotherleukaemias
Induceremissiontoachievecompleteremission
Maintaindisease-freestate
Appropriatenutrition
Adequatehydration
Maintenanceofelectrolytebalance
Bonemarrowtransplant
Prevention
Clinicalfeatures
Differentialdiagnoses
Complications
Investigations
Investigations
Treatmentobjectives
Non-drug treatment
ChronicLymphocyticLeukaemia
17 18
Chapter 2: Blood and Blood-Forming Organs Standard Treatment Guidelines for Nigeria 2008

16. Redcellandplateletconcentratetransfusionasrequired
Allopurinol100mgorally every8hours
Chlorambucil5mg/m orallyondays1to3
Prednisolone 75 mg orally on day 1; 50 mg orally on
day2and25mgorallyonday3
- Repeatevery2weeks
Or:
Fludarabine 25 - 30 mg intravenously over 30 minutes
ondays1-5
- Repeatevery4weeks
Or:
Combination chemotherapy
- Cyclophosphamide400mg/m
- Vincristine1.4mg/m
- Prednisolone100mgorallydays 1 -5
Repeatevery3weeks
Or:
Fludarabine 30 mg/m intravenously over 30 minutes
ondays1-3
Cyclophosphamide 250 - 300 mg/m intravenously
over30minutesondays 1 -3
- Repeatevery4weeks
Appropriatenutrition
Adequatehydration
Sameasforotherleukaemias
Avoidchemicalsonbody(e.gbenzene)
Avoidionizingradiation(X rays)
Earlydetectionandtreatment
Solid neoplasms that originate in lymph nodes or
otherlymphatictissuesofthebody
Aheterogeneousgroupofdisorders
- Canariseatvirtuallyanysite
- More often occurs in regions with large
concentrations of lymphoid tissues, e.g. lymph
nodes,tonsils,spleenandbonemarrow
Two maingroups:
- Hodgkin's disease
- Non-Hodgkin's lymphomas
Hodgkin's disease is characterized by Reed-
Sternberg cells (large binucleate cells with vesicular
nucleiandprominenteosinophilicnucleoli)
- Reed-Sternberg cells are occasionally found in
other clinical conditions e.g. hyperplastic or
inflammatorylesionsoflymphnodes
Non-Hodgkin's lymphomas: a heterogeneous
collectionoflymphoproliferativemalignancies
Drug treatment
Supportivemeasures
Notableadversedrug reactions,caution
Prevention
LYMPHOMAS
Introduction
ChronicLymphocyticLeukaemia
2
2
2
2
2
Vincristine 1.4 mg/m (maximum 2 mg) on days 1
and8
Prednisolone100mgorallyondays1-8
Mechlorethamine 6 mg/m intravenously on days 1
and8
Vincristine 1.4 mg/m (maximum 2 mg)
intravenouslyondays1and8
Procarbazine100mg/m orallyondays14
Prednisolone40mgorallyondays1-14
Chlorambucil6mg/m orallyondays1and14
Vinblastine 6 mg/m (maximum 10 mg)
intravenouslyondays1and18
Procarbazine100mg/m orallyondays1and14
Prednisolone40mgorallyondays1-14
Appropriatenutrition
Adequatehydration
All the drugs are contraindicated in patients with
hypersensitivity reactions to the respective
medicines
Profound nausea, vomiting, diarrhoea and
abdominaldiscomfort
Secondary malignancies
Myelosuppression(exceptthesteroids)
Steroids (prednisolone) may cause Cushing's
syndrome,hypertension,diabetesmellitus,
suppression ofimmunity,infections
Vincristine:neurotoxic
Cyclophosphamide: alopecia and haemorrhagic
cystitis
Doxorubicin:cardiotoxic
Avoid unnecessary exposure to irradiation and
chemicals
Agroupofconditionswithpathologicalprocesses
resultingfromthepresenceofHaemoglobinS
Usuallyinheritedfromtheparentswho have
themselvesinheritedhaemoglobinS
Theprincipalgenotypesinclude:
- Homozygoussicklecelldisease(SS)
- Sicklecell-haemoglobinCdisease(SC)
- Sicklecell-ßthalassaemia(Sß thal)
Sickle cell-ß+ thalassaemia Type I (Sß+thal.Type
I)
Sicklecell-ß+thalassaemia.TypeII.(Sß+thal.
TypeII)
2
2
2
2
2
2
2
Hodgkin'slymphoma
MOPP
ChIVPP
Supportivemeasures
Notableadversedrug reactions,caution
Prevention
SICKLE CELLDISEASE
Introduction
- Vary widely according to histological subtype,
stageandbulkofdisease
Full Blood Count (i.e. haemoglobin, haematocrit,
leucocyte and differential counts; red cell indices,
reticulocytecount)
Erythrocytesedimentationrate
Coombs test
Bonemarrowaspirationandneedlebiopsy
SerumUrea,Electrolytes
SerumUricacid
Liver Function Tests: transaminases-ALT, AST,
ALP; bilirubin;serumproteins
HIVscreening
Immunoglobulins
ChestX- ray
Examinationofpost-nasalspace
Serumcopperlevel
Neutrophilalkalinephosphatase
Tomogramsoflungormediastinum
SkeletalX-ray
Abdominal ultrasoundscans
Intravenous pyelography
CTscansofchestandabdomen
Supplementarynodebiopsy
Induce remission
Restorepatienttodisease-freestate
Maintainstateofwellbeing
Appropriatenutrition
Adequatehydration
Red cell and platelet concentrate transfusions as
required
Malariaprophylaxis:proguanil200mgorallydaily
Antibioticsasindicated
Allopurinol 300 mg orally daily (when uric acid is
high)
(3weekly):
Cyclophosphamide 750 mg/m intravenously on
day1
Doxorubicin50mg/m intravenouslyonday1
Vincristine 1.4 mg/m (maximum of 2 mg)
intravenouslyonday1
Prednisolone100mgorallyondays1-5
(4weekly):
Cyclophosphamide 750 mg/m intravenously on
days1and8
Doxorubicin 25 mg/m intravenously on days 1 and
8
Investigations
Treatmentobjectives
Non-drug treatment
Drug treatment
Mandatory
Optional
Non-Hodgkin'slymphomas
CHOP
CHOP
2
2
2
2
2
Sicklecell-ß+thalassaemia.TypeIII.(Sß+thal.
TypeIII)
Inheritance of one normal gene controlling
formation of ß Haemoglobin (HbA), and a sickle
gene(HbS)
Totalhaemoglobin AismorethanhaemoglobinS
NormalhaemoglobinF
Inheritance of two abnormal allelemorphic genes
controlling formation of ß chains of haemoglobin, at
leastoneofwhichisthesicklegene
Polymerization of the sickle haemoglobin may
leadtovaso-occlusion
Red cells have reduced deformability and easily
adhere to vascular endothelium, increasing the
potential for decreased blood flow and vascular
obstruction.
Abnormalities in coagulation, leucocytes, vascular
endothelium, and damage to the membranes of red
cellscontributetosickling
Haemolyticanaemiaandvasculopathyarethe
resultofthevariouspathophysiologicprocesses
Organdamageison-goingandisoftensilentuntil
faradvanced
Thecourseofthediseaseispunctuatedbyepisodes
ofpain
Varywidelyfromonepatienttoanother:
Persistent anaemia/pallor
Growth retardation(variable)
Jaundice(variable)
Bonepains(recurrent)
Prominent facial bones due to increased bone
marrowactivity
Leanerbodybuildandlessweight(onaverage)
Some fingers are shortened as a result of infarction
(destructionduetoblockageofbloodsupply)
Hand-foot syndrome (painful and swollen hands
andfeet)inchildhood
Lifespanonaverageshorterthannormal
Sexual development is delayed in both sexes:
menarche occurs at a mean age of 15.5 years (range
12 - 20 years) compared to non-sicklers (mean
13.2years)
Impotencecanoccurfromprolongedpriapism
Highfoetalloss inpregnancy
Patient has acute symptoms/signs attributable
directlytosicklecelldisease
Two maintypes:
Pain(vaso-occlusive)crisis
Anaemiacrisis
Sicklecelltrait
Sicklecelldisease
Sicklecellcrises
Vaso-occlusivecrises
Pathophysiology
Clinicalfeatures
19 20
Chapter 2: Blood and Blood-Forming Organs Standard Treatment Guidelines for Nigeria 2008

17. Painful
Painless
Tender,swollenbones
Acutehepatopathy
Acutechest syndrome
Priapism
Haematuria
Cerebrovascular disease (accident) - in descending
orderofprevalence
- Thrombotic stroke
- Seizures
- Haemorrhage
Retinopathy(commonestinSC patients)
Acutesplenic(orhepatic)sequestration
Hyper-haemolytic(e.g.precipitatedbymalaria)
Megaloblastic(folicaciddeficiency)
Hypoplastic(duetoinfectionorrenalfailure)
Aplastic(e.g.duetoepidemicparvovirusB19)
Connective tissue disorders e.g. rheumatoid
arthritis
Liver disease
Othercausesoffailuretothrive
Kidneys:
- Hyposthenuria(reducedabilitytoconcentrate
urine/conservebodyfluids)
- Haematuria
- Albuminuria
- Reducedkidneyfunction
Leg ulcers:
- Occuraroundankles
- Healslowlyandtendtorecur
BonesandJoints
- Osteomyelitis
- Avascular necrosis
Thesemaycause:
- Hip pain
- Limping gait
- Kyphoscoliosis when necrosis affects spinal
vertebralbones
Infections:
- Salmonella osteomyelitis
- Pneumococcal pneumonia
- Pneumoccoccalmeningitis(rareinadolescents
andadults)
- Tonsillitisand pharyngitis
Brainandnerves:
- Strokes,seizures(notcommoninadults)
- Meningitis(notcommoninadults)
- Cerebral haemorrhage
- Mentalneuropathy(rare)
Cardiovascular/respiratory:
- Heart failure
Anaemiccrises
Differentialdiagnoses
Complications
- Emotional stress
Bloodtransfusion(especiallyredcelltransfusion)
Anti-pneumococcalvaccine
(when patient is well with no
complaints):
Proguanil
200mgorallydaily
under 1 year 25 mg daily;1 - 4 years 50 mg; 5 -
8years100mg;9-14years150mgorallydaily
Plus:
Folicacid5mgorallydaily
Paracetamol
1 g, every 4 - 6 hours to a maximum of 4 g
daily
1 - 5 years 120 - 250 mg; 6 -12 years 250 - 500
mg; 12 -18 years 500 mg every 4 - 6 hours
(maximum4doses in24hours)
Or:
Aspirin (acetylsalicylic acid) 600 mg orally every 8
hours daily
- Notrecommendedforchildrenunder16years
Or:
Ibuprofen 200 mg every 8 hours daily (or other
non-steroidalanti-inflammatorydrugs)
- Notrecommendedforchildrenunder16years
Parenteraltherapy:
Diclofenacsodium
75 mg or 100 mg intramuscularly (as
necessary)
- Notrecommendedforchildren
Oraltherapy:
Paracetamol
1 - 5 years 20 mg/kg every 6 hours (maximum
90 mg/kg daily in divided doses) for 48 hours or
longer if necessary and if adverse effects are ruled
out
Then:
15mg/kgevery6hours (maintenance)
6 - 12 years: 20 mg/kg (maximum 1 g) 6 hourly
(maximum 90 mg/kg daily in divided doses, not to
exceed 4 g for 48 hours or longer if necessary and if
adverseeffectsareruledout
Then:
15mg/kgevery6hours (maximum4gdaily)
12-18years:500mg-1g every 4 - 6 hour
(maximum4doses in24hours)
Diclofenacpotassium50mgevery12hours daily
Or:
Diclofenacsodium100mgoncedaily
Or:
Morphine15mgevery8-12hours daily
Adjuncttreatment
Drug treatment
Steady state
Paincrises
Adult:
Child:
Adult:
Child:
Adult:
Child:
s
Mildpain
Moderate-to-severepainfulcrises
- Pulmonary hypertension
- Acute chest syndrome
Full Blood Count (haemoglobin, haematocrit, total
leucocyte count and differential counts, platelet
counts)
Erythrocytesedimentationrate
Redcellindices(MCH, MCHC, MCV)
Reticulocyte count
Sicklingtests:solubilitytest;metabisulphitetest
Haemoglobin electrophoresis
- Using cellulose acetate paper at pH 8.4 (alkaline)
orcitrateagargelatpH 5.6(acidic)
SerumElectrolytes,UreaandCreatinine
Liver function tests (transaminases, bilirubin,
serum albumin, alkaline phosphatase and
prothrombintime)
Urinalysis;microscopy,cultureandsensitivity:
Sputum
- AcidFastBacilli
- Microscopy,cultureandsensitivity
Stool:
- Ovaandparasites
- Occultblood
Ultrasound scan:
- Abdominalultrasound scan
- TranscranialDopplerultrasonography
Chest radiograph
Maintain(orrestore)asteadystateofhealth
Preventandtreatcomplications
Provide accurate diagnosis, relevant health
education and genetic counselling to patients,
relativesandheterozygotes
Improvequalityoflife
Provideapositiveself-imageinaffectedpersons
Counsellingandhealtheducation
Encouragingmembershipofsupportgroups
Providing infection prophylaxis (antimalarial; anti-
pneumococcal,hepatitisBvirusvaccines)
Providingfolatesupplementation
Avoiding pain-inducingconditions
Providingprompttreatmentofsymptoms
Advisingon contraception
Supervisingpregnancy/Labour
Providingregularhealthchecks
Limitingfamilysize
Balanced diet
Adequatefluidintake(atleast3litres/24hours)
Avoidanceofpain-inducingconditions
- Strenousphysicalexertionorstress
- Dehydration
- Suddenexposuretoextremesoftemperature
- Infectionse.g.malaria
Investigations
Treatmentobjectives
Treatmentstrategies
Non-drug treatment
Antimalarials
Artemisinin-based combination therapy (see
sectiononmalaria)
Counsellingandhealtheducation
Membershipofsupportgroup
Regularhealthchecks
Paracetamolshouldbeusedwithcautionin
patientswithhepaticimpairment
Opioid analgesics cause varying degrees of
respiratorydepressionandhypotension
- They should be avoided when intracranial pressure
issuspectedtoberaised
Advice on the risks involved in marriages between
carriers,andbetweensicklers
Anti-pneumococcalvaccine
Supportivemeasures
Notableadversedrug reactions,cautionand
contraindications
Prevention
21 22
Chapter 2: Blood and Blood-Forming Organs Standard Treatment Guidelines for Nigeria 2008

18. CHAPTER 3: CARDIOVASCULAR SYSTEM
ANGINAPECTORIS
Introduction
Clinicalfeatures
Differentialdiagnoses
Complications
Investigations
Treatmentobjectives
Non-drug treatment
A symptom complex characterised by chest pain or
discomfort caused by transient myocardial ischaemia
usuallyduetocoronaryheartdisease
Less common in this environment though current
studiesshow increasingprevalence
In90%(ormore)ofcasesthereisahereditaryfactor
Majorriskfactors:
Hypertension
Diabetes mellitus
Hypercholesterolemia
Smoking
Obesity
Male sex
Age
Stable angina (chest discomfort on exertion and
relievedbyrest)
Unstableangina(discomfortonexertionandatrest)
Myocardial infarction (chest pain or discomfort that
lasts more than 30 minutes; may be associated with
symptomsofcardiacfailure,shock,arrhythmias)
Myalgia
Pericarditis
Aorticdissection
Pleurisy
Cardiac failure
Myocardial infarction
Arrhythmias
Sudden death
FullBloodCountanddifferentials
Urea,ElectrolytesandCreatinine
Fastingblood glucose
Urinalysis;urinemicroscopy
Electrocardiograph:resting,treadmillexercise
Echocardiography(resting/exercise)
Radionuclidestudies
Cardiacenzymes(CK-MB)
Coronaryangiography
Relieve discomfort
Improvequalityoflife
Prevent complications
Relievetheobstruction
Address theriskfactorspresent
Dietarymanipulation(lowsalt,lowcholesteroldiet)
Exercise
Stop smoking
Reducealcoholconsumption
Differentialdiagnoses
Complications
Investigations
Treatmentobjectives
Non-drug treatment
Drug treatment
Supportivemeasures
Notableadversedrug reactions
Prevention
CONGENITALHEARTDISEASE
Introduction
Clinicalfeatures
Sinus arrhythmias
Anxiety
Cardiacfailure
Stroke
Peripheralembolicphenomena
Sudden death
Electrocardiograph (resting, 24 hour Holter, 1 month
Holtermonitoring)
Urea,ElectrolytesandCreatinine
Echocardiography
Electrophysiology
Abolishthe arrhythmias
Treatcomplications
Preventfurtherarrhythmias
Pacemaker insertion
Ablation(electrophysiology)
Cardioversion:acutearrhythmias
Dependsonthetypeofarrythmia
Refertoaspecialistforappropriatemanagement
Patient education
Efficientsystemstofacilitatepatientrecovery
Allanti-arrhythmiasarepro-arrhythmicsthemselves
Cardiacfailure(allanti-arrhythmics)
Blindness(amiodarone)
Prevention of conditions such as hypertension,
rheumatic heart disease, diabetes mellitus, ischaemic
heartdisease,congenitalheartdiseasesetc
A heart defect that occurs during the formation of the
heartinutero
Could be fatal (i.e. causes intrauterine death, or death at
anytimeafterwards)
- An importantcauseofperinatalmorbidity/mortality
Classifiedas
Cyanotic
Acyanotic
Willdependonthetypeofthedefect:
Milddefectsgounnoticed
Stuntedgrowth
Cyanosis
Failuretothrive
Heartmurmurs
Drug treatment
Other measures
Notable adverse drug reactions caution and
contraindications
Prevention
CARDIACARRHYTHMIAS
Introduction
Clinicalfeatures
ß blockers
- Atenolol50-100mgdaily
Nitrates
- Glyceryl trinitrate 0.3 - 1 mg sublingually, repeated as
required
Or:
- Isosorbide dinitrate 30 - 120 mg orally daily (up to 240
mg)
Calciumchannelantagonists
- Verapamil80-120mgorally8hourly
Anti-platelets
- Aspirin(acetylsalicylicacid)75mgorallydaily
Treatasforacutemyocardialinfarction
Angioplasty(PTCA)
Coronaryarterybypass graft(CABG)
Treat/reduceriskfactors
Patienteducation(veryimportant)
,
ß blockers
- Bradycardia
- Caution in asthmatics and patients with chronic
obstructive airways disease because of
bronchoconstriction.
Nitrates:hypotension
Calciumchannelantagonists:hypotension
Aspirin,thrombolytics:bleeding
- Avoid in recent stroke and in upper gastrointestinal
bleeding
Avoidconcurrentuseofß-blockerswithverapamil
Nutrition education
Address risk factors
Healthy living
Conditionsinwhichcardiacrhythmsbecomeabnormal
Usually complicate acquired and congenital heart
diseases
- Abnormal arrangements of the cardiac impulse fibres
orfibrosisaffecttheconductionfibres
Mildarrhythmiasmightgounnoticed
Maypresentwith:
Palpitations
Sudden collapse
Dizziness
Syncope
Near-syncope
- Maybecomplicatedbycardiacfailure,stroke,etc
Unstableangina
Differentialdiagnoses
Complications
Investigations
Treatmentobjectives
Non-drug treatment
Drug treatment
Supportivemeasures
Prevention
DEEPVENOUS THROMBOSIS
Introduction
Clinicalfeatures
Differentialdiagnoses
Complications
Investigations
Rheumaticheartdisease
Endomyocardialfibrosis
Embolic phenomena
Cardiac failure
FullBloodCountanddifferentials
Urea,ElectrolytesandCreatinine
Chest radiograph
Electrocardiograhy
Foetal echocardiography
Angiography
Relieve symptoms
Treatthedefinitivedefect(s)
Lowsaltdiet
Treatmentofcardiacfailureifpresent
- Digoxin,diureticsandpotassiumsupplements
Oxygen
Counselling
Pre-conceptionnutritioneducation
Antenatalcare
Genetic counselling
Formation of blood clot(s) in the deep veins of the calf
musclesorpelvis
It has the potential of being dislodged to the lungs,
causingpulmonaryembolism
Broughtaboutby:
Hyper-coagulable states
Long periods of immobilization e.g. cardiac failure,
followingsurgery,long-distancetravel,etc
Malignancies
Couldbeasymptomatic
Painandswellingoftheleg(calfmuscles)
Cellulitis
Infarctivecrisisinsicklers
Abscess (myositis)
Pulmonary embolism
FullBloodCountanddifferentials
Prothrombinetime
KCCT
Doppleroftheleg/pelvicvessels(veins)
23 24
Chapter 3: Cardiovascular System Standard Treatment Guidelines for Nigeria 2008