Ma
l
ab
sorption foo
d
Hea
lth pro
b
l
e
ms
Ma
l
ab
sor
b
si is
a
situ
a
tion in th
e
pro
ce
ss of th
e
pro
ce
ss
Ab
sorption
a
n
d d
ig
e
stion norm
a
lly on on
e
or mor
e
nutrition
.
O
n th
e
g
e
n
e
r
a
lly p
a
ti
e
nts
c
om
e
with
d
i
a
rrh
ea
so som
e
tim
e
s it
'
s h
a
r
d
to
d
istinguish
D
i
d d
i
a
rrh
ea ca
us
ed b
y m
a
l
ab
sor
b
si or oth
e
r r
ea
sons
.
Be
si
de
s th
a
t som
e
tim
e
s
th
e ca
us
e
of th
e d
i
a
rrh
ea
ov
e
rl
a
ps
be
tw
ee
n on
e
r
ea
son with
ca
us
e
oth
e
rs in
c
lu
de
thos
e ca
us
ed b
y
Ma
l
ab
sor
b
si
.
Va
rious things
a
n
d c
ir
c
umst
a
n
ce
s
ca
n
ca
us
e
m
a
ll
ab
sor
b
si
a
n
d
m
a
l
d
ig
e
sty
to som
e
on
e
.
Ma
l
ab
sor
b
si
a
n
d
m
a
l
d
ig
e
sty
ca
n
be ca
us
ed b
y
e
nzym
e de
fi
c
i
e
n
c
y or
d
isruption to th
e
int
e
stin
a
l mu
c
os
a
pl
ace ab
sor
b
ing
a
n
d
t
e
st
ed
th
e
su
b
st
a
n
ce
.
A
n
a
mn
e
sis
(
su
b
j
ec
tiv
e
)
r
e
sults
A c
ompl
a
int
Pa
ti
e
nts with m
a
l
ab
sor
b
si usu
a
lly
c
om
e
with
c
ompl
a
ints of
c
hroni
c d
i
a
rrh
ea
,
usu
a
lly th
e
form of liqui
d
f
ece
s r
e
m
e
m
be
rs th
e d
isruption in th
e
sm
a
ll int
e
stin
e
d
o
e
s not
e
xist
N
utrition
a
l su
b
st
a
n
ce
s
a
r
e ab
sor
bed
so th
a
t f
ece
s
a
r
e
not sh
a
p
ed
.
I
f
a
pro
b
l
e
m
th
e
p
a
ti
e
nt
beca
us
e
of f
a
t m
a
l
ab
sor
b
si
,
th
e
p
a
ti
e
nt will
c
ompl
a
in of th
e
f
ece
s
O
ily
(
st
a
tor
e
).
T
h
e
right
a
n
a
mn
e
sis
ab
out possi
b
l
e ca
us
e
s
a
n
d
trips
d
is
ea
s
e
is import
a
nt to
de
t
e
rmin
e
wh
a
t h
a
pp
e
ns
m
a
l
ab
sor
b
si
.
R
isk f
ac
tor
: -
S
impl
e
physi
ca
l
a
n
d
supporting r
e
sults
(
o
b
j
ec
tiv
e
)
P
hysi
ca
l
e
x
a
min
a
tion
O
n physi
ca
l
e
x
a
min
a
tion it
ca
n
be
foun
d a
n
e
mi
a
sign
(
d
u
e
to iron
de
fi
c
i
e
n
c
y
,
F
oli
c ac
i
d
,
a
n
d B
12
):
A
n
e
mi
c c
onjun
c
tiv
a
,
p
a
l
e
skin
,
l
ac
k of nutrition
a
l st
a
tus
.
L
ook
for
S
p
ec
ifi
c
signs
a
n
d
symptoms
de
p
e
n
d
on th
e ca
us
e
.
S
upport
1
.
c
ompl
e
t
e
p
e
riph
e
r
a
l
b
loo
d
:
hypo
c
hrom
e
mi
c
ro
c
yti
c a
n
e
mi
a d
u
e
to iron
de
fi
c
i
e
n
c
y
or m
ac
ro
c
yti
c a
n
e
mi
a beca
us
e
of foli
c ac
i
d de
fi
c
i
e
n
c
y
a
n
d
vit
a
min
B
12
.
2
.
Rad
iology
:
pl
a
in photo
abd
om
e
n
D
i
a
gnosti
c E
nfor
ce
m
e
nt
(
A
ss
e
ssm
e
nt
)
C
lini
ca
l
d
i
a
gnosis
T
h
e d
i
a
gnosis is
e
nfor
ced ba
s
ed
on
a
n
a
mn
e
sis
,
physi
ca
l
e
x
a
min
a
tion
,
a
n
d
support
.
D
i
a
gnosis of
A
pp
ea
l
1
.
Pa
n
c
r
ea
tititis
2
.
CHRONS DISEASES IN ILLEUM TERMINALIS
3
.
Ce
li
ac S
pru
e
4
.
W
hippl
e d
is
ea
s
e
5
.
A
myloi
d
osis
6
.
Lac
t
a
s
e de
fi
c
i
e
n
c
y
7
.
Z
olling
e
r
-
E
llison
S
yn
d
rom
e
8
.
P
ost
-
g
a
st
e
r
ec
tomy
d
isor
de
rs
,
fin
e
int
e
stin
a
l r
e
s
ec
tion or
c
olon
C
ompli
ca
tions
De
hy
d
r
a
tion
C
ompr
e
h
e
nsiv
e Ma
n
a
g
e
m
e
nt
(
P
l
a
n
)
Ma
n
a
g
e
m
e
nt of
Need
to
c
onsult
a
sp
ec
i
a
list in int
e
rn
a
l m
ed
i
c
in
e
to s
ea
r
c
h
T
h
e ca
us
e
of th
e Maa
l
ab
sor
b
si is th
e
n m
a
n
a
g
ed acc
or
d
ing to th
e ca
us
e
.
1
.
Ma
n
a
g
e
m
e
nt
de
p
e
n
d
s on th
e ca
us
e
s of m
a
l
ab
sor
b
si
2
.
Ce
rt
a
in nutrition
a
l r
e
stri
c
tions
3
.
V
it
a
min
a
n
d M
in
e
r
a
l
S
uppl
e
m
e
nts
4
.
d
ig
e
stiv
e e
nzym
e
suppl
e
m
e
nts
5
.
G
ov
e
rn
a
n
ce
of
P
h
a
rm
ac
ology
:
A
nti
b
ioti
c
s
a
r
e
giv
e
n if
Ma
l
ab
sor
b
si is
c
onn
ec
t
ed
b
y
O
v
e
rrowth
E
nt
e
rotoxig
e
ni
c Bac
t
e
ri
a
:
E
.
C
olli
,
K
.
pn
e
umoni
ae a
n
d
E
nt
e
rro
bac
t
e
r
c
lo
acae
.
F
ollow up pl
a
n
I
t n
eed
s to
be
monitor
ed b
y th
e
su
cce
ss of th
e d
i
e
t or th
e
r
a
py giv
e
n to th
e
p
a
ti
e
nt
.
C
ouns
e
ling
a
n
d ed
u
ca
tion
P
rovi
de ed
u
ca
tion to f
a
mily to h
e
lp in t
e
rms of r
e
stri
c
tions
ce
rt
a
in nutri
e
nts in p
a
ti
e
nts
a
n
d
o
b
s
e
rv
e
p
a
ti
e
nts
d
uring
tr
ea
tm
e
nt
.
Re
f
e
r
e
n
ce c
rit
e
ri
a
Need
to
c
onsult
a
sp
ec
i
a
list in int
e
rn
a
l m
ed
i
c
in
e
to s
ea
r
c
h
T
h
e ca
us
e
of th
e Maa
l
ab
sor
b
si is th
e
n m
a
n
a
g
ed acc
or
d
ing to th
e ca
us
e
.
E
quipm
e
nt
S
impl
e
l
ab
or
a
tory for
c
ompl
e
t
e
p
e
riph
e
r
a
l
b
loo
d c
h
ec
ks
.
P
rognosis
T
h
e
prognosis is v
e
ry
de
p
e
n
de
nt on th
e
p
a
ti
e
nt
'
s
c
on
d
ition wh
e
n
c
oming
,
c
ompli
ca
tions
,
a
n
d
tr
ea
tm
e
nt
.
I
n g
e
n
e
r
a
l
,
th
e
prognosis
d
o
e
s not thr
ea
t
e
n th
e
soul
,
how
e
v
e
r
T
h
e
fun
c
tion
a
m
a
n
d
s
a
n
a
tion
a
m
a
r
e D
u
b
i
a Ad B
on
a
m
.
T
yphoi
d
f
e
v
e
r
Hea
lth pro
b
l
e
ms
T
ypoi
d
f
e
v
e
r is foun
d
in ur
ba
n so
c
i
e
ty
a
n
d a
t
c
ountrysi
de
.
T
his
d
is
ea
s
e
is
c
los
e
ly r
e
l
a
t
ed
to th
e
qu
a
lity of p
e
rson
a
l hygi
e
n
e a
n
d
Sa
nit
a
tion
e
nvironm
e
nt th
a
t is not goo
d
.
I
n
I
n
d
on
e
si
a
it is
e
n
de
mi
c a
n
d
I
s
a
pu
b
li
c
h
ea
lth pro
b
l
e
m
.
F
rom th
e ca
s
e
of
ca
s
e
s in th
e
hospit
a
l
b
ig in
I
n
d
on
e
si
a
,
th
e
susp
ec
t typhoi
d
f
e
v
e
r shows
a
t
e
n
de
n
c
y
in
c
r
ea
s
ed
from y
ea
r to y
ea
r with
a
n
a
v
e
r
a
g
e
in
e
quitis
e
of
500
/
100
,
000
Re
si
de
nts
a
n
d
mort
a
lity r
a
t
e
s
be
tw
ee
n
0
.
6
-
5
%
(
KMK
,
2006
).
Be
si
de
s l
e
v
e
l
high in
c
i
de
nt
,
typhoi
d
f
e
v
e
r r
e
l
a
t
ed
to v
a
rious
a
sp
ec
ts of th
e
pro
b
l
e
m
oth
e
rs
,
for
e
x
a
mpl
e
:
acc
ur
ac
y of
d
i
a
gnosis
,
a
nti
b
ioti
c
r
e
sist
a
n
ce a
n
d
still low
T
yphoi
d
f
e
v
e
r v
acc
in
a
tion
c
ov
e
r
a
g
e
.
A
n
a
mn
e
sis
(
su
b
j
ec
tiv
e
)
r
e
sults
A c
ompl
a
int
1
.
Fe
v
e
r go
e
s up
e
sp
ec
i
a
lly in th
e a
ft
e
rnoon
a
n
d e
v
e
ning with
a
n int
e
rmitt
e
nt
p
a
tt
e
rn
a
n
d
th
e
in
c
r
ea
s
e
in st
e
p
-
l
adde
r t
e
mp
e
r
a
tur
e
.
H
igh f
e
v
e
r
ca
n
be c
ontinuous
(
C
ontinuous f
e
v
e
r
)
until th
e
s
ec
on
d
w
ee
k
.
2
.
Headac
h
e
(
d
izzin
e
ss
)
th
a
t is oft
e
n f
e
lt in th
e
front
a
l
a
r
ea
3
.
Ga
stroint
e
stin
a
l
d
isor
de
rs in th
e
form of
c
onstip
a
tion
a
n
d
m
e
t
e
orismus or
d
i
a
rrh
ea
,
n
a
us
ea
,
vomiting
,
abd
omin
a
l p
a
in
a
n
d b
loo
d
y
c
h
a
pt
e
r
4
.
O
th
e
r
c
ompoun
d
ing symptoms
,
su
c
h
a
s mus
c
l
e
p
a
in
a
n
d ac
h
e
s
,
c
ough
,
a
nor
e
xi
a
,
insomni
a
5
.
I
n s
e
v
e
r
e
typhoi
d
f
e
v
e
r
,
it
ca
n
be
foun
d a dec
r
ea
s
e
in
c
ons
c
iousn
e
ss or
s
e
izur
e
s
.
R
isk f
ac
tor
1
.
H
ygi
e
n
e
p
e
rson
a
l is not goo
d
,
e
sp
ec
i
a
lly r
a
r
e
ly w
a
sh h
a
n
d
s
.
2
.
H
ygi
e
n
e
foo
d a
n
d d
rinks
a
r
e
not goo
d
,
for
e
x
a
mpl
e
foo
d
Wa
sh
ed
with
c
ont
a
min
a
t
ed
w
a
t
e
r
,
v
e
g
e
t
ab
l
e
s f
e
rtiliz
ed
with
hum
a
n stool
,
d
ust pollut
ed
foo
d
or g
a
r
ba
g
e
or s
e
iz
ed
fly
.
3
.
Sa
nit
a
tion
e
nvironm
e
nt is not goo
d
.
4
.
T
h
e e
xist
e
n
ce
of out
b
r
ea
k typhoi
d
f
e
v
e
r
a
roun
d e
v
e
ry
da
y r
e
si
de
n
ce
.
5
.
T
h
e
r
e
is
a
typhoi
d ca
rri
e
r
a
roun
d
th
e
p
a
ti
e
nt
.
6
.
I
mmuno
de
fi
c
i
e
n
c
y
c
on
d
itions
.
S
impl
e
physi
ca
l
a
n
d
supporting r
e
sults
(
o
b
j
ec
tiv
e
)
P
hysi
ca
l
e
x
a
min
a
tion
1
.
Ge
n
e
r
a
l
c
on
d
itions usu
a
lly s
ee
m si
c
k or s
e
riously ill
.
2
.
A
w
a
r
e
n
e
ss
:
ca
n
c
ompos m
e
ntis or
dec
r
ea
s
e a
w
a
r
e
n
e
ss
(
st
a
rting from
th
e
lightw
e
ight
,
lik
e a
p
a
thy
,
somnol
e
n
,
to th
e
h
ea
vy for
e
x
a
mpl
e de
lirium
or
c
omm
a
)
3
.
Fe
v
e
r
,
Te
mp
e
r
a
tur
e
>
37
.
5
o
C
.
4
.
Ca
n
be
foun
d
r
e
l
a
tiv
e b
r
ad
y
ca
r
d
i
a
,
n
a
m
e
ly th
e dec
r
ea
s
e
in th
e
fr
e
qu
e
n
c
y of th
e
puls
e
A
tot
a
l of
8
bea
ts p
e
r minut
e eac
h in
c
r
ea
s
e
of
1
o
C
.
5
.
I
ku
6
.
O
r
a
l
c
h
ec
k
:
T
yphoi
d T
ongu
e
,
T
ongu
e T
r
e
mor
,
Ha
litosis
7
.
Abd
omin
a
l
e
x
a
min
a
tion
:
p
a
in
(
e
sp
ec
i
a
lly
e
pig
a
stri
c
r
e
gion
),
h
e
p
a
tospl
e
nom
e
g
a
li
8
.
De
lirium in
a
h
ea
vy
ca
s
e
P
hysi
ca
l
e
x
a
min
a
tion in
ad
v
a
n
ced
situ
a
tion
1
.
Dec
r
ea
s
ed
light
a
w
a
r
e
n
e
ss oft
e
n o
cc
urs in th
e
form of
a
p
a
thy with
A
w
a
r
e
n
e
ss lik
e
foggy
.
I
f
c
lini
ca
lly s
e
v
e
r
e
ly
,
th
e
p
a
ti
e
nt
ca
n
bec
om
e
somnol
e
n
a
n
d c
omm
a
s or with symptoms of psy
c
hosis
(
org
a
ni
c b
r
a
in
syn
d
rom
e
).
2
.
I
n suff
e
r
e
rs with toxi
c
,
de
lirium symptoms
a
r
e
mor
e
promin
e
nt
.
3
.
Abd
omin
a
l p
a
in with
ac
ut
e abd
omin
a
l signs
S
upport
1
.
c
ompl
e
t
e
p
e
riph
e
r
a
l
b
loo
d a
long with th
e ca
l
c
ul
a
tion of l
e
ukosis
Ca
n show
:
l
e
ukop
e
ni
a
/
l
e
uko
c
ytosis
/
norm
a
l l
e
uko
c
yt
e
,
r
e
l
a
tiv
e
lympho
c
ytosis
,
mono
c
ytosis
,
throm
b
o
c
ytop
e
ni
a
(
usu
a
lly mil
d
),
a
n
e
mi
a
.
2
.
Se
rology
a
.
I
gm
A
ntig
e
n
O
9
Sa
lmon
e
ll
a T
hypi
(
T
u
be
x
-
TF
)
®
Ca
n only
de
t
ec
t th
e I
g
M
s
a
lmon
e
ll
a
typhi
a
nti
b
o
d
y
Ca
n
be d
on
e a
t th
e
first
4
-
5
da
ys of f
e
v
e
r
b
r
ea
kf
a
st
.
E
nzym
e I
mmuno
a
ss
a
y
Te
st
(
T
yphi
d
ot
®
)
1
.
Ca
n
de
t
ec
t
I
g
M a
n
d I
g
G
s
a
lmon
e
ll
a
typhi
2
.
Ca
n
be d
on
e
on th
e
first
4
-
5
da
ys of f
e
v
e
r
C
..
W
i
da
l t
e
sts
a
r
e
not r
ec
omm
e
n
ded
D
i
d a
ft
e
r
a
f
e
v
e
r l
a
st
7
da
ys
.
I
nt
e
rpr
e
t
a
tion of positiv
e
r
e
sults wh
e
n th
e
tit
e
rs
a
glutinin o minimum
1
/
320
or
th
e
r
e
is
a
tit
e
r in
c
r
ea
s
e
up to
4
tim
e
s on
a
r
e
-
e
x
a
min
a
tion
with int
e
rv
a
ls of
5
-
7
da
ys
.
T
h
e
r
e
sults of f
a
ls
e
positiv
e
positiv
e
wi
da
l
e
x
a
min
a
tions oft
e
n o
cc
ur
beca
us
e
c
ross r
eac
tion with
non
-
typhoi
da
l s
a
lmon
e
ll
a
,
E
nt
e
ro
bac
t
e
ri
aceae
,
e
n
de
mi
c
r
e
gions of
de
ngu
e a
n
d
m
a
l
a
ri
a
inf
ec
tions
,
history of typhoi
d
immuniz
a
tion
a
n
d c
omm
e
r
c
i
a
l
a
ntig
e
n pr
e
p
a
r
a
tions
v
a
ri
e
s
a
n
d
st
a
n
da
r
d
iz
a
tion is not goo
d
.
T
h
e
r
e
for
e
,
W
i
da
l
e
x
a
min
a
tion is not r
ec
omm
e
n
ded
if only from
1
tim
e
ac
ut
e
s
e
rum
e
x
a
min
a
tion
beca
us
e
of th
e
high f
a
ls
e
positiv
e
s
Ca
n l
ead
to ov
e
r
-
d
i
a
gnosis
a
n
d
ov
e
r
-
tr
ea
tm
e
nt
.
3
.
Sa
lmon
e
ll
a T
yphi
c
ultur
e
(
G
ol
d S
t
a
n
da
r
d
)
Ca
n
be d
on
e
on sp
ec
im
e
ns
:
a
.
B
loo
d
:
I
n th
e
first w
ee
k until th
e e
n
d
of th
e
s
ec
on
d
w
ee
k of illn
e
ss
,
d
uring
a
f
e
v
e
r
th
e
high
b
r
ea
kf
a
st
.
Fe
z
e
s
:
O
n th
e
s
ec
on
d
w
ee
k of illn
e
ss
C
..
U
rin
e
:
in th
e
s
ec
on
d
or thir
d
w
ee
k of illn
e
ss
d
.
B
il
e
liqui
d
:
A
t
a
n
ad
v
a
n
ced
st
a
g
e
of
d
is
ea
s
e
,
to
de
t
ec
t
ca
rri
e
rtyphoi
d
4
.
O
th
e
r supporting
e
x
a
min
a
tions
a
r
e
in
acc
or
da
n
ce
with
c
lini
ca
l in
d
i
ca
tions
,
for
e
x
a
mpl
e
:
SGOT
/
SGPT
,
L
ip
a
s
e a
n
d A
myl
a
s
e
l
e
v
e
ls
A
tt
ac
hm
e
nt
D
i
a
gnosis
(
A
ss
e
ssm
e
nt
)
S
usp
e
k
T
yphoi
d Fe
v
e
r
(
S
usp
ec
t
Ca
s
e
)
F
rom
A
n
a
mn
e
sis
a
n
d P
hysi
ca
l
E
x
a
min
a
tion
S
ymptoms of
Fe
v
e
r
,
D
isor
de
rs
d
ig
e
stiv
e
tr
ac
t
a
n
d a
r
b
it
e
r
a
w
a
r
e
n
e
ss
d
isor
de
rs
.
T
ifoi
d S
usp
ec
t
D
i
a
gnosis
O
nly m
ade
in prim
a
ry h
ea
lth s
e
rvi
ce
s
.
C
lini
ca
l
T
ifoi
d Fe
v
e
r
(
P
ro
bab
l
e Ca
s
e
)
S
usp
ec
t
ed
typhoi
d
f
e
v
e
r is support
ed b
y
a
pi
c
tur
e
of
a
l
ab
or
a
tory
S
hows typhoi
d
.
D
i
a
gnosis of
A
pp
ea
l
De
ngu
e
h
e
morrh
a
gi
c
f
e
v
e
r
,
m
a
l
a
ri
a
,
l
e
ptospirosis
,
urin
a
ry tr
ac
t inf
ec
tion
,
He
p
a
titis
A
,
Se
psis
,
T
u
be
r
c
ulosis
M
ili
e
r
,
I
nf
ec
tiv
e E
n
d
o
ca
r
d
itis
,
R
h
e
um
a
ti
c Fe
v
e
r
Ac
ut
e
,
I
nn
e
r
ab
s
ce
ss
,
f
e
v
e
r r
e
l
a
t
ed
to
HIV
inf
ec
tion
.
C
ompli
ca
tions
U
su
a
lly o
cc
urs in th
e
s
ec
on
d
w
ee
k
a
n
d
thir
d
f
e
v
e
r
.
C
ompli
ca
tion
A
noth
e
r
b
l
eed
ing
,
int
e
stin
a
l p
e
rfor
a
tion
,
s
e
psis
,
e
n
ce
ph
a
lop
a
thy
,
a
n
d
oth
e
r org
a
ns
inf
ec
tions
.
1
.
T
ifoi
d
toxi
c
(
typhoi
d e
n
ce
ph
a
lop
a
thy
)
S
uff
e
r
e
rs with tifoi
d
f
e
v
e
r syn
d
rom
e
with high h
ea
t
acc
omp
a
ni
ed
W
ith gr
ea
t m
e
nt
a
l
c
h
a
os
,
c
ons
c
iousn
e
ss
dec
r
ea
s
e
s
,
r
a
nging from
de
lirium
U
ntil
c
om
a
.
2
.
s
e
pti
c
sho
c
k
S
uff
e
r
e
rs with typhoi
d
f
e
v
e
r
,
high h
ea
t
a
n
d
tox
e
mi
c
symptoms
Hea
vy
.
I
n
add
ition
,
th
e
r
e a
r
e
symptoms of h
e
mo
d
yn
a
mi
c d
isor
de
rs su
c
h
a
s
b
loo
d
pr
e
ssur
e d
own
,
smooth
a
n
d
f
a
st puls
e
,
c
ol
d a
n
d
w
e
ll sw
ea
t
c
ol
d
.
3
.
B
l
eed
ing
a
n
d I
nt
e
stin
a
l
Pe
rfor
a
tions
(
Pe
ritonitis
)
C
ompli
ca
tions of
b
l
eed
ing
a
r
e
m
a
rk
ed b
y m
e
m
e
m
a
tos
c
h
e
zi
a
.
T
oo
K
nown
b
y th
e e
x
a
min
a
tion of th
e Fee
s
(
Occ
ult
B
loo
d Te
st
).
T
his
c
ompli
ca
tion
Ma
rk
ed b
y
ac
ut
e
symptoms of
abd
omin
a
l
a
n
d
p
e
ritonitis
.
O
n pl
a
in photos
Abd
om
e
n
3
positions
a
n
d c
lini
ca
l
e
x
a
min
a
tions of surgi
ca
l g
a
s o
b
t
a
in
ed
fr
ee
g
a
s
I
n th
e abd
omin
a
l
ca
vity
.
4
.
He
p
a
titis
T
ifos
a
Ab
norm
a
liti
e
s in th
e
form of j
a
un
d
i
ce
,
h
e
p
a
tom
e
g
a
ly
,
a
n
d
liv
e
r fun
c
tion t
e
st
ab
norm
a
liti
e
s
.
5
.
T
ypos
a Pa
n
c
r
ea
titis
T
h
e
r
e
is
a
sign of
ac
ut
e
p
a
n
c
r
ea
titis with in
c
r
ea
s
ed
lip
a
s
e e
nzym
e a
n
d
a
myl
a
s
e
.
T
his sign
ca
n
be
h
e
lp
ed
with ultr
a
soun
d
or
CT
s
ca
n
.
6
.
P
n
e
umoni
a
Ob
t
a
in
ed a
pn
e
umoni
a
sign th
a
t w
a
s
d
i
a
gnos
ed
with
a
photo
T
or
a
xi
c
pl
a
in
C
ompr
e
h
e
nsiv
e Ma
n
a
g
e
m
e
nt
(
P
l
a
n
)
Ma
n
a
g
e
m
e
nt of
1
.
S
upportiv
e
th
e
r
a
py
ca
n
be d
on
e b
y
:
a
.
B
r
ea
k
bed
r
e
st
a
n
d
s
e
t th
e
st
a
g
e
s of mo
b
iliz
a
tion
b
r
ea
kf
a
st
.
Ma
int
a
in
ade
qu
a
t
e
flui
d
int
a
k
e
,
whi
c
h
ca
n
be
giv
e
n or
a
lly
a
n
d
p
a
r
e
nt
e
r
a
l
.
C
..
Ba
l
a
n
ced
nutritious
d
i
e
t
,
soft
c
onsist
e
n
c
y
,
quit
e ca
lori
e
s
a
n
d
prot
e
in
,
L
ow fi
be
r
.
d
.
Re
gul
a
r
a
n
d c
ompl
e
t
e d
rug
c
onsumption
He
y
.
C
ontrol
a
n
d
monitor vit
a
l signs
(
b
loo
d
pr
e
ssur
e
,
puls
e
,
t
e
mp
e
r
a
tur
e
,
a
w
a
r
e
n
e
ss
),
th
e
n w
e
ll r
ec
or
ded
in th
e
p
a
ti
e
nt m
ed
i
ca
l r
ec
or
d
2
.
S
imptom
a
ti
c
th
e
r
a
py to r
ed
u
ce
f
e
v
e
r
(
a
ntipyr
e
ti
c
s
)
a
n
d
Red
u
c
ing g
a
stroint
e
stin
a
l
c
ompl
a
ints
.
3
.
De
finiv
e
th
e
r
a
py with
a
nti
b
ioti
c
s
.
F
irst lin
e a
nti
b
ioti
c
for
T
yphoi
d
f
e
v
e
r is
c
hlor
a
mph
e
ni
c
ol
,
a
mpi
c
illin or
a
moxi
c
illin
(
s
a
f
e
F
or p
a
ti
e
nts who
a
r
e
pr
e
gn
a
nt
),
or trim
e
troprim
-
sulf
a
m
e
tox
a
zol
e
(
C
otrimox
a
zol
e
).
4
.
I
f th
e ad
ministr
a
tion of on
e
of th
e
first lin
e a
nti
b
ioti
c
s is
c
onsi
de
r
ed
in
e
ff
ec
tiv
e
,
it
ca
n
r
e
pl
aced
with oth
e
r
a
nti
b
ioti
c
s or s
e
l
ec
t
ed
s
ec
on
d
-
lin
e a
nti
b
ioti
c
s
,
n
a
m
e
ly
Se
ftri
a
kson
,
Se
fiksim
,
K
uinolon
e
(
not r
ec
omm
e
n
ded
for
c
hil
d
r
e
n
<
18
y
ea
rs
Beca
us
e
it is
c
onsi
de
r
ed
to int
e
rf
e
r
e
with
b
on
e
growth
).
F
ollow up pl
a
n
1
.
I
f th
e
p
a
ti
e
nt is tr
ea
t
ed a
t hom
e
,
a d
o
c
tor or nurs
e ca
n
d
o
F
ollow up visits
e
v
e
ry
da
y
a
ft
e
r th
e
st
a
rt of th
e
m
a
n
a
g
e
m
e
nt
.
2
.
C
lini
ca
l r
e
spons
e
to
a
nti
b
ioti
c
s is
a
ss
e
ss
ed a
ft
e
r its us
e
for
1
w
ee
ks
.
H
om
e Ca
r
e I
n
d
i
ca
tions
1
.
Re
quir
e
m
e
nts for p
a
ti
e
nts
a
.
M
il
d c
lini
ca
l symptoms
,
no signs of
c
ompli
ca
tions or
c
omor
b
i
d
Da
ng
e
rous
.
b
r
ea
kf
a
st
.
G
oo
d a
w
a
r
e
n
e
ss
.
C
..
Ca
n
ea
t
a
n
d d
rink w
e
ll
.
d
.
Fa
mily
e
nough to un
de
rst
a
n
d
how to
ca
r
e
for
a
n
d
signs of
da
ng
e
r
whi
c
h will
a
ris
e
from typhoi
d
.
He
y
.
H
ous
e
hol
d
p
a
ti
e
nts h
a
v
e a
n
d
impl
e
m
e
nt th
e
syst
e
m
E
x
ec
ut
e d
ispos
a
l
(
f
ece
s
,
urin
e
,
vomiting liqui
d
)
th
a
t m
ee
ts
Hea
lth
Re
quir
e
m
e
nts
.
f
.
T
h
e
p
a
ti
e
nt
'
s f
a
mily is
ab
l
e
to un
de
rgo
a
goo
d
m
a
n
a
g
e
m
e
nt pl
a
n
.
2
.
Re
quir
e
m
e
nts for h
ea
lth work
e
rs
a
.
T
h
e e
xist
e
n
ce
of
1
d
o
c
tor
a
n
d
p
e
rm
a
n
e
nt nurs
e
is fully r
e
sponsi
b
l
e
a
g
a
inst p
a
ti
e
nt m
a
n
a
g
e
m
e
nt
.
b
r
ea
kf
a
st
.
T
h
e d
o
c
tor
c
onfirms th
a
t th
e
p
a
ti
e
nt
d
o
e
s not h
a
v
e
signs
whi
c
h h
a
s th
e
pot
e
nti
a
l to
ca
us
e c
ompli
ca
tions
.
C
..
A
ll
Ac
tiviti
e
s of
Ma
n
a
g
e
m
e
nt
(
D
i
e
t
,
L
iqui
d
,
Bed Re
st
,
T
r
ea
tm
e
nt
)
Ca
n
be ca
rri
ed
out prop
e
rly
a
t hom
e
.
d
.
D
o
c
tors
a
n
d
/
or nurs
e
s follow up p
a
ti
e
nts
e
v
e
ry
da
y
.
He
y
.
D
o
c
tors
a
n
d
/
or nurs
e
s
ca
n
c
ommuni
ca
t
e
smoothly with
Fa
mili
e
s of p
a
ti
e
nts throughout th
e
m
a
n
a
g
e
m
e
nt of m
a
n
a
g
e
m
e
nt
.
C
ouns
e
ling
a
n
d ed
u
ca
tion
Pa
ti
e
nt
ed
u
ca
tion
ab
out pro
ced
ur
e
s
:
1
.
T
r
ea
tm
e
nt
a
n
d ca
r
e a
n
d
oth
e
r
a
sp
ec
ts of typhoi
d
f
e
v
e
r th
a
t must
be
K
nown p
a
ti
e
nts
a
n
d
th
e
ir f
a
mili
e
s
.
2
.
D
i
e
t
,
a
mount of liqui
d
n
eeded
,
ph
a
sing mo
b
iliz
a
tion
,
a
n
d c
onsumption
m
ed
i
c
in
e
shoul
d be c
onsi
de
r
ed
or s
ee
n
d
ir
ec
tly
b
y th
e d
o
c
tor
,
a
n
d
T
h
e
p
a
ti
e
nt
'
s f
a
mily un
de
rst
a
n
d
s
a
n
d
is
ab
l
e
to impl
e
m
e
nt
.
3
.
T
h
e a
rt of
e
m
e
rging must
be
notifi
ed
to th
e
p
a
ti
e
nt
a
n
d
f
a
mily
I
n or
de
r to
be
t
a
k
e
n imm
ed
i
a
t
e
ly to th
e
n
ea
r
e
st hospit
a
l for tr
ea
tm
e
nt
.
C
ommunity
O
ri
e
nt
ed A
ppro
ac
h
D
o
c
ouns
e
ling or
ed
u
ca
tion on th
e c
ommunity
ab
out
a
sp
ec
ts
P
r
e
v
e
ntion
a
n
d c
ontrol of typhoi
d
f
e
v
e
r
,
through
:
1
.
E
nvironm
e
nt
a
l s
a
nit
a
tion improv
e
m
e
nts
2
.
I
n
c
r
ea
s
ed
foo
d a
n
d be
v
e
r
a
g
e
hygi
e
n
e
3
.
I
n
c
r
ea
s
ed
in
d
ivi
d
u
a
l hygi
e
n
e
4
.
P
r
e
v
e
ntion with immuniz
a
tion
Re
f
e
r
e
n
ce c
rit
e
ri
a
1
.
T
yphoi
d
f
e
v
e
r with
a
h
ea
vy g
e
n
e
r
a
l
c
on
d
ition
(
toxi
c
typhoi
d
).
2
.
T
yphoi
d
with
c
ompli
ca
tions
.
3
.
T
yphoi
d
with
a
h
ea
vy
c
omor
b
i
d
.
4
.
Ha
s r
ece
iv
ed
th
e
r
a
py for
5
da
ys
b
ut h
a
s not y
e
t
bee
n r
e
p
a
ir
ed
.
E
quipm
e
nt
P
oly
c
lini
c
s
e
ts
a
n
d
l
ab
or
a
tory
e
quipm
e
nt to
ca
rry out
b
loo
d c
h
ec
ks
R
outin
e a
n
d
s
e
rology
.
P
rognosis
T
h
e
prognosis is
b
on
a
m
,
b
ut
ad
s
a
n
a
tion
a
l
d
u
b
i
a ad b
on
a
m
,
beca
us
e
D
is
ea
s
e
s
ca
n o
cc
ur r
e
p
ea
t
.
Ga
stro
e
nt
e
ritis
(
c
hol
e
r
a a
n
d
gi
a
r
d
i
a
sis
)
Hea
lth pro
b
l
e
ms
Ga
stro
e
nt
e
ritis
(
GE
)
is th
e
infl
a
mm
a
tion of th
e
stom
ac
h
a
n
d
sm
a
ll int
e
stin
a
l mu
c
os
a
whi
c
h is
c
h
a
r
ac
t
e
riz
ed b
y
d
i
a
rrh
ea
with
a
fr
e
qu
e
n
c
y
3
tim
e
s or mor
e
in
24
hours
.
I
f
d
i
a
rrh
ea
>
30
da
ys
a
r
e ca
ll
ed c
hroni
c
.
WHO
(
W
orl
d Hea
lth
O
rg
a
niz
a
tion
)
de
fin
e ac
ut
e d
i
a
rrh
ea a
s
d
i
a
rrh
ea
whi
c
h usu
a
lly l
a
sts
3
-
7
da
ys
b
ut it
ca
n
a
lso l
a
st up to
14
da
ys
.
Pe
rsist
e
nt
d
i
a
rrh
ea
is
th
e e
piso
de
of
d
i
a
rrh
ea
whi
c
h is
e
stim
a
t
ed
to
ca
us
e
inf
ec
tion
a
n
d
st
a
rt
a
s
ac
ut
e d
i
a
rrh
ea b
ut it
e
n
d
s mor
e
th
a
n
14
da
ys
,
a
n
d
this
c
on
d
ition
ca
using m
a
lnutrition
a
n
d
high risk
ca
using
dea
th
Ga
stro
e
nt
e
ritis is mor
e c
ommon in
c
hil
d
r
e
n
beca
us
e
of th
e e
n
d
ur
a
n
ce
W
hi
c
h is not optim
a
l
.
D
i
a
rrh
ea
is on
e
of th
e ca
us
e
s of mor
b
i
d
ity
a
n
d
high mort
a
lity in
c
hil
d
r
e
n un
de
r fiv
e
y
ea
rs throughout
T
h
e
worl
d
,
whi
c
h r
eac
h
e
s
1
b
illion in p
a
in
a
n
d
3
million
dea
ths p
e
r y
ea
r
.
Ca
us
e
s of g
a
stro
e
nt
e
ritis in
c
lu
de
inf
ec
tion
,
m
a
l
ab
sor
b
si
,
poisoning or
foo
d a
ll
e
rgi
e
s
a
n
d
psy
c
hologi
ca
l p
a
ti
e
nts
.
I
nf
ec
tion th
a
t
ca
us
e
s
GE d
u
e
to
e
nt
a
mo
eba
histolyti
ca ca
ll
ed d
ys
e
nt
e
ry
,
I
f
ca
us
ed b
y
G
i
a
r
d
i
a La
mpli
a
is
ca
ll
ed
gi
a
r
d
i
a
sis
,
wh
e
r
ea
s if
Ca
us
ed b
y
V
i
b
rio
C
hol
e
r
a ca
ll
ed c
hol
e
r
a
.
A
n
a
mn
e
sis
(
su
b
j
ec
tiv
e
)
r
e
sults
A c
ompl
a
int
T
h
e
p
a
ti
e
nt
c
om
e
s to th
e d
o
c
tor
beca
us
e
of th
e
l
a
t
e
or liqui
d c
h
a
pt
e
r
(
c
h
a
pt
e
r
),
ca
n
mix
ed b
loo
d
or mu
c
us
,
with fr
e
qu
e
n
c
y
3
tim
e
s or mor
e
in tim
e
24
hours
.
Ca
n
be acc
omp
a
ni
ed b
y un
c
omfort
ab
l
e
t
a
st
e
in th
e
stom
ac
h
(
p
a
in or
b
lo
a
ting
),
n
a
us
ea
a
n
d
vomiting
a
n
d Te
n
e
smus
.
E
v
e
ry tim
e d
i
a
rrh
ea
,
th
e c
h
a
pt
e
r
ca
n pro
d
u
ce a
l
a
rg
e
volum
e
(
a
s long
a
s it is from
th
e
int
e
stin
e
S
m
a
ll
)
or sm
a
ll volum
e
(
origin of th
e
l
a
rg
e
int
e
stin
e
).
I
f
d
i
a
rrh
ea
is
acc
omp
a
ni
ed b
y
a
f
e
v
e
r
S
o it is
a
ll
e
g
ed
ly inf
ec
tion
.
I
f th
e d
i
a
rrh
ea
o
cc
urr
e
n
ce
is pr
eceded b
y
ea
ting or
d
rinking from th
e
sour
ce
Le
ss hygi
e
n
e
,
GE ca
n
be ca
us
ed b
y inf
ec
tion
.
H
istory of tr
a
v
e
ling to
r
e
gions with
d
i
a
rrh
ea
out
b
r
ea
ks
,
history of l
ac
tos
e
intol
e
r
a
n
ce
(
e
sp
ec
i
a
lly in inf
a
nts
),
C
onsumption of irrit
a
tiv
e
foo
d
,
d
rinking h
e
r
ba
l m
ed
i
c
in
e
,
c
ol
a d
i
e
t
,
or
ea
t m
ed
i
c
in
e
su
c
h
a
s l
a
x
a
tiv
e
s
,
m
a
gn
e
sium hy
d
ro
c
hlori
de
,
m
a
gn
e
sium
c
itr
a
t
e
,
h
ea
rt r
e
m
ed
y
quini
d
in
e
,
gout m
ed
i
c
in
e
(
kolki
c
in
),
d
iur
e
ti
c
s
(
furos
e
mi
d
,
ti
a
zi
d
),
tox
e
ni
c
(
a
rs
e
ni
c
,
org
a
nophosph
a
t
e
),
ins
ec
ti
c
i
de
,
ca
ff
e
in
e
,
m
e
thyl x
a
ntin
e
,
e
n
d
o
c
rin
e a
g
e
nt
(
pr
e
p
a
r
a
tion
thyroi
d
m
ed
i
a
),
misoprostol
,
m
e
s
a
l
a
min
,
a
nti
c
holin
e
st
e
r
a
s
e a
n
d d
rugs
D
i
e
ts n
eed
to
be
known
.
I
n
add
ition
,
immuno
c
omprom
a
ti
c c
on
d
itions
(
HIV
/
AIDS
)
a
n
d
tifoi
d
f
e
v
e
r n
eed
i
de
ntifi
ed
.
I
n th
e
p
a
ti
e
nt
,
th
e c
hil
d
is
c
l
ea
rly
a
sk
ed b
y th
e
symptom of
d
i
a
rrh
ea
:
1
.
T
r
a
v
e
l
d
i
a
rrh
ea
is th
e d
ur
a
tion of
d
i
a
rrh
ea
,
wh
e
n
d
i
a
rrh
ea
a
pp
ea
rs
(
d
uring n
e
on
a
t
e
s
,
bab
i
e
s
,
or
c
hil
d
r
e
n
)
to know
,
is it
in
c
lu
d
ing
c
ong
e
nit
a
l
d
i
a
rrh
ea
or o
b
t
a
in
ed
,
c
h
a
pt
e
r fr
e
qu
e
n
c
y
,
c
onsist
e
n
c
y from
f
ece
s
,
th
e
r
e
is no
b
loo
d
in f
ece
s
2
.
L
ooking for risk f
ac
tors th
a
t
ca
us
e d
i
a
rrh
ea
3
.
S
ymptoms of
acc
omp
a
nying
:
abd
omin
a
l p
a
in
,
b
lo
a
ting
,
a
lot of g
a
s
,
f
a
iling to
grow
.
4
.
T
h
e
tr
a
v
e
l history
,
living in
a c
hil
d ca
r
e ce
nt
e
r is
a
risk
for th
e
inf
ec
tion
.
R
isk f
ac
tor
1
.
Pe
rson
a
l hygi
e
n
e a
n
d
l
ac
k of
e
nvironm
e
nt
a
l s
a
nit
a
tion
.
2
.
H
istory of l
ac
tos
e
intol
e
r
a
n
ce
,
d
rug
a
ll
e
rgy history
.
3
.
HIV
inf
ec
tion or s
e
xu
a
lly tr
a
nsmitt
ed
inf
ec
tions
.
S
impl
e
physi
ca
l
a
n
d
supporting r
e
sults
(
o
b
j
ec
tiv
e
)
P
hysi
ca
l
e
x
a
min
a
tion
1
.
O
n
a
physi
ca
l
e
x
a
min
a
tion it shoul
d be c
h
ec
k
ed
:
w
e
ight
,
b
o
d
y t
e
mp
e
r
a
tur
e
,
fr
e
qu
e
n
c
y
Hea
rt r
a
t
e a
n
d b
r
ea
thing
a
n
d b
loo
d
pr
e
ssur
e
.
2
.
L
ook for th
e
m
a
in signs of
de
hy
d
r
a
tion
:
a
w
a
r
e
n
e
ss
,
thirst
,
a
n
d
turgor
Abd
omin
a
l skin
a
n
d
oth
e
r
add
ition
a
l signs
:
l
a
rg
e c
rowns
sunk
e
n or not
,
e
y
e
s
:
sunk
e
n or not
,
th
e
r
e
or
ab
s
e
n
ce
of t
ea
rs
,
L
ips
,
mouth mu
c
os
a a
n
d
tongu
e d
ry or w
e
t
.
3
.
Re
spir
a
tion th
a
t is f
a
st in
d
i
ca
tion of m
e
t
ab
oli
c ac
i
d
osis
.
4
.
T
h
e
noisy of th
e
int
e
stin
e
is w
ea
k or not th
e
r
e
if th
e
r
e
is hypok
a
l
e
mi
a
.
5
.
E
x
a
min
a
tion of
e
xtr
e
miti
e
s n
ece
ss
a
ry
beca
us
e
of p
e
rfusion
a
n
d ca
pill
a
ry r
e
fill
ca
n
de
t
e
rmin
e
th
e de
gr
ee
of
de
hy
d
r
a
tion th
a
t o
cc
urs
.
6
.
A
ss
e
ssm
e
nt of th
e
w
e
ight or
de
gr
ee
of
de
hy
d
r
a
tion
ca
n
be de
t
e
rmin
ed b
y
:
o
b
j
ec
tiv
e
ly
,
b
y
c
omp
a
ring w
e
ight
be
for
e a
n
d d
uring
d
i
a
rrh
ea
.
S
u
b
j
ec
tiv
e
ly using
c
rit
e
ri
a
.
O
n
c
hil
d
r
e
n us
e
WHO
1995
c
rit
e
ri
a
.
A
tt
ac
hm
e
nt
D
i
a
gnosis
(
A
ss
e
ssm
e
nt
)
C
lini
ca
l
d
i
a
gnosis
D
i
a
gnosis is
e
nfor
ced b
y
A
n
a
mn
e
sis
(
C
h
a
pt
e
r
L
iqui
d M
or
e
th
a
n
3
tim
e
s
a da
y
)
a
n
d
physi
ca
l
e
x
a
min
a
tion
(
foun
d
hypovol
e
mi
c
signs
a
n
d
C
h
ec
k th
e c
onsist
e
n
c
y of th
e c
h
a
pt
e
r
).
F
or
de
f
e
nitiv
e d
i
a
gnosis is
d
on
e
S
upporting
e
x
a
min
a
tion
.
D
i
a
gnosis of
A
pp
ea
l
T
ifoi
d
f
e
v
e
r
,
c
ryptospori
d
i
a
(
in
HIV
suff
e
r
e
rs
),
ps
e
u
d
om
e
m
b
r
a
n
e c
olitis
C
ompli
ca
tions
:
H
ypovol
e
mi
c S
ho
c
k
C
ompr
e
h
e
nsiv
e Ma
n
a
g
e
m
e
nt
(
P
l
a
n
)
Ma
n
a
g
e
m
e
nt in
ad
ult p
a
ti
e
nts
I
n g
e
n
e
r
a
l
ac
ut
e d
i
a
rrh
ea
is light
a
n
d
h
ea
l
ed
qui
c
kly with
its
e
lf through r
e
hy
d
r
a
tion
a
n
d a
nti
d
i
a
rr
e d
rugs
,
so it is r
a
r
e
ly n
eeded
furth
e
r
e
v
a
lu
a
tion
.
T
h
e
r
a
py
ca
n
be
provi
ded
with
1
.
P
rovi
d
ing
ade
qu
a
t
e
liqui
d
s
a
n
d d
i
e
ts
a
.
T
h
e
p
a
ti
e
nt is not f
a
st
ed a
n
d
giv
e
n
ade
qu
a
t
e
flui
d
for
r
e
hy
d
r
a
tion
.
b
r
ea
kf
a
st
.
A
voi
d c
ow
'
s milk
beca
us
e
th
e
r
e
is
a
tr
a
nsi
e
nt l
ac
t
a
s
e de
fi
c
i
e
n
c
y
.
C
..
A
voi
d d
rinks th
a
t
c
ont
a
in
a
l
c
ohol or
ca
ff
e
in
e
,
beca
us
e
ca
n in
c
r
ea
s
e
motility
a
n
d
int
e
stin
a
l s
ec
r
e
tion
.
d
.
F
oo
d c
onsum
ed
shoul
d
not
c
ont
a
in g
a
s
,
a
n
d ea
sy to
d
ig
e
st
.
2
.
De
hy
d
r
a
t
ed d
i
a
rrh
ea
p
a
ti
e
nts
ca
n
be
giv
e
n
a
nti
d
i
a
rrh
ea
l
d
rugs for
Red
u
c
ing symptoms
a
n
d a
ntimi
c
ro
b
i
a
ls for
de
finitiv
e
th
e
r
a
py
.
Ad
ministr
a
tion of
e
mpiri
ca
l
a
ntimi
c
ro
b
i
a
l th
e
r
a
py is in
d
i
ca
t
ed
in p
a
ti
e
nts who
a
ll
e
g
ed
ly
e
xp
e
ri
e
n
c
ing inv
a
siv
e bac
t
e
ri
a
l inf
ec
tions
,
tr
a
v
e
l
e
r
'
s
d
i
a
rrh
ea
,
a
n
d
immunosuppr
e
ssion
.
A
ntimi
c
ro
b
i
a
l
:
I
n
GE d
u
e
to inf
ec
tion giv
e
n
a
nti
b
ioti
c
s or
A
ntip
a
r
a
sit
e
,
or
a
ntifung
a
l
de
p
e
n
d
s on th
e ca
us
e
.
A
nti
d
i
a
rr
e d
rugs
,
a
mong oth
e
rs
:
1
.
De
riv
a
tiv
e
s of
O
pioi
d
s
:
L
op
e
r
a
mi
d
,
D
ryph
e
noxyl
A
tropin
,
O
pium
T
in
c
tur
e
.
2
.
T
his
d
rug shoul
d
not
be
giv
e
n to p
a
ti
e
nts with th
e d
ys
e
nt
e
ry
acc
omp
a
ni
ed b
y f
e
v
e
r
,
a
n
d
its us
e
must
be
stopp
ed
if
d
i
a
rrh
ea
T
h
e
h
ea
vi
e
r
e
v
e
n though th
e
r
a
py is giv
e
n
.
3
.
BISMUT S
u
b
s
a
lissyl
a
t
e
,
be ca
r
e
ful in immuno
c
omprom
a
ti
c
p
a
ti
e
nts
,
su
c
h
a
s
HIV
,
Beca
us
e
it
ca
n in
c
r
ea
s
e
th
e
risk of
b
ismuth
e
n
ce
ph
a
lop
a
thy
.
4
.
D
rugs th
a
t
a
r
e
h
a
r
de
n
b
y stools
:
R
oofing
4
x
2
t
ab
l
e
ts
/
da
y or
S
m
ec
tit
e
3
x
1
Sac
h
e
t is giv
e
n
e
v
e
ry
d
ilut
e c
h
a
pt
e
r until th
e
stop
d
i
a
rrh
ea
.
5
.
A
nti
-
s
ec
r
e
tory or
a
nti
-
e
n
c
h
e
f
a
lin
a
g
e d
rugs
:
Racecad
otril
3
x
1
A
ntimi
c
ro
b
i
a
l
,
a
mong oth
e
rs
:
1
.
T
h
e
quinoloqu
e
s of th
e c
iproflox
a
sin
2
x
500
mg
/
da
y for
5
-
7
da
ys
,
or
2
.
T
rim
e
trroprim
/
sulf
a
m
e
tox
a
zol
e
160
/
800 2
x
1
t
ab
l
e
t
/
da
y
.
3
.
I
f
d
i
a
rrh
ea
is thought to
be ca
us
ed b
y
G
i
a
r
d
i
a
,
m
e
troni
da
zol
e ca
n
U
s
ed
with
a d
os
e
of
3
x
500
mg
/
da
y for
7
da
ys
.
4
.
I
f th
e e
tiology is known from
ac
ut
e d
i
a
rrh
ea
,
th
e
r
a
py is
ad
just
ed
to
e
tiology
.
I
f
de
hy
d
r
a
tion o
cc
urs
,
a
ft
e
r
de
t
e
rmining th
e de
gr
ee
of
de
hy
d
r
a
tion
,
th
e
p
a
ti
e
nt
dea
lt with th
e
following st
e
ps
:
1
.
De
t
e
rmin
e
th
e
typ
e
of liqui
d
to
be
us
ed
I
n lightw
e
ight initi
a
l
ac
ut
e d
i
a
rrh
ea
,
th
e
r
e
is
a
hypotoni
c
or
a
l liqui
d
W
ith
a c
omposition of
29
gr glu
c
os
e
,
3
.
5
gr
NaC
l
,
2
.
5
gr so
d
ium
b
i
ca
r
b
on
a
t
e
a
n
d
1
.
5
KC
l
e
v
e
ry lit
e
r
.
T
his liqui
d
is giv
e
n or
a
lly or through
a
hos
e
n
a
sog
a
strik
.
O
th
e
r liqui
d
s
a
r
e
l
ac
t
a
t
e
ring
e
r liqui
d a
n
d
0
.
9
%
NaC
l
intr
a
v
e
nously giv
e
n
.
2
.
De
t
e
rmin
e
th
e a
mount of liqui
d
to
be
giv
e
n
T
h
e
prin
c
ipl
e
in
de
t
e
rmining th
e a
mount of th
e
liqui
dITICIAL
n
eeded
is
:
BJ
P
l
a
sm
a
with
a
formul
a
:
F
lui
d de
fi
c
it
:
BJ
pl
a
sm
a
-
1
,
025
x
b
o
d
y w
e
ight x
4
ml
0
,
001
L
iqui
d
r
e
quir
e
m
e
nts
=
s
c
or
e
x
10
%
x kg
bb
x
1
lit
e
r
15
3
.
De
t
e
rmining th
e
gr
a
nting of flui
d
s
:
a
.
T
h
e
first two hours
(
initi
a
l r
e
hy
d
r
a
tion st
a
g
e
):
T
ot
a
l
Need
s
L
iqui
d acc
or
d
ing to
BJ P
l
a
sm
a
or
Da
l
d
iyono
Sc
or
e
is giv
e
n
d
ir
ec
tly
I
n this
2
hours to
be ac
hi
e
v
ed
optim
a
lly r
e
hy
d
r
a
tion
a
s soon
a
s possi
b
l
e
.
b
r
ea
kf
a
st
.
O
n
e
n
e
xt hour
/
3
r
d
hour
(
2
st st
a
g
e
)
ad
ministr
a
tion giv
e
n
Ba
s
ed
on loss for
2
hours of
ad
ministr
a
tion of r
e
hy
d
r
a
tion flui
d
P
r
e
vious initi
a
ls
.
I
f th
e
r
e
is no sho
c
k or
Da
l
d
iyono is l
e
ss th
a
n
3
ca
n
be
r
e
pl
aced b
y or
a
l flui
d
s
.
C
..
T
h
e
n
e
xt hour of gr
a
nting th
e
liqui
d
is giv
e
n
ba
s
ed
on loss
flui
d
through f
ece
s
a
n
d
ins
e
nsi
b
l
e
w
a
t
e
r loss
.
C
on
d
itions th
a
t r
e
quir
e
furth
e
r
e
v
a
lu
a
tion in
ac
ut
e d
i
a
rrh
ea
if
foun
d
:
1
.
D
i
a
rrh
ea de
t
e
rior
a
t
e
s or s
e
ttl
e
s
a
ft
e
r
7
da
ys
,
f
ece
s must
be a
n
a
lyz
ed
mor
e
mor
e
2
.
Pa
ti
e
nts with toxi
c
signs
(
de
hy
d
r
a
tion
,
d
ys
e
nt
e
ry
,
f
e
v
e
r
≥
38
,
5
o
C
,
Hea
vy
abd
omin
a
l p
a
in in p
a
ti
e
nts
a
g
ed
ov
e
r
50
y
ea
rs
3
.
E
l
de
rly p
a
ti
e
nts
4
.
Pe
rsist
e
nt vomiting
5
.
Me
nt
a
l st
a
tus
c
h
a
ng
e
s su
c
h
a
s
Le
th
a
rgi
,
A
p
a
thy
,
I
rrit
ab
l
e
6
.
O
ut
b
r
ea
k in th
e c
ommunity
7
.
I
n immuno
c
omprom
a
ti
c
p
a
ti
e
nts
.
C
ouns
e
ling
a
n
d ed
u
ca
tion
I
n light
c
on
d
itions
,
ed
u
ca
tion is giv
e
n to th
e
f
a
mily to h
e
lp
flui
d
int
a
k
e
.
Ed
u
ca
tion is
a
lso giv
e
n to pr
e
v
e
nt
GE a
n
d
P
r
e
v
e
nt tr
a
nsmission
.
Re
f
e
r
e
n
ce c
rit
e
ri
a
1
.
S
ign of h
ea
vy
de
hy
d
r
a
tion
2
.
T
h
e
r
e
is
a dec
r
ea
s
e
in
a
w
a
r
e
n
e
ss
3
.
S
ignifi
ca
nt
abd
omin
a
l p
a
in
4
.
T
h
e
p
a
ti
e
nt
ca
nnot
d
rink or
a
l
5
.
T
h
e
r
e
is no
INTITION SET a
n
d
infusion flui
d
in s
e
rvi
ce
f
ac
iliti
e
s
Ma
n
a
g
e
m
e
nt in p
ed
i
a
tri
c
p
a
ti
e
nts
Acc
or
d
ing to th
e I
n
d
on
e
si
a
n
M
inistry of
Hea
lth
(
2011
),
th
e
prin
c
ipl
e
of
d
i
a
rrh
ea
'
s
m
a
n
a
g
e
m
e
nt in to
dd
l
e
rs is
C
ross
d
i
a
rrh
ea
(
fiv
e
st
e
ps to
c
ompl
e
t
e d
i
a
rrh
ea
),
whi
c
h is support
ed b
y
b
on
d
s
I
n
d
on
e
si
a
n p
ed
i
a
tri
c
i
a
n with
WHO
r
ec
omm
e
n
da
tions
.
Re
hy
d
r
a
tion is not th
e
only
Sa
tu
a
tus
w
a
ys to ov
e
r
c
om
e d
i
a
rrh
ea b
ut improv
e
th
e c
on
d
ition of th
e
int
e
stin
e a
n
d
sp
eed
up h
ea
ling
/
stop
d
i
a
rrh
ea a
n
d
pr
e
v
e
nt
c
hil
d
r
e
n
N
utrition
a
l
de
fi
c
i
e
n
c
y
d
u
e
to
d
i
a
rrh
ea
is
a
lso
a
w
a
y to tr
ea
t
d
i
a
rrh
ea
.
T
h
e c
ross
-
d
i
a
rrh
ea
progr
a
m is
:
1
.
Re
hy
d
r
a
tion using low
O
smol
a
lity
ORALIT
T
o pr
e
v
e
nt
de
hy
d
r
a
tion
ca
n
be d
on
e
st
a
rting from hom
e
th
e
st
a
irs
b
y giving low
O
smol
a
rity or if th
e
y
d
on
'
t
A
v
a
il
ab
l
e
giving hous
e
hol
d
flui
d
s su
c
h
a
s s
a
lt w
a
t
e
r solutions
.
A
r
a
l wh
e
n
this is
c
ir
c
ul
a
ting on th
e
m
a
rk
e
t
a
lr
ead
y n
e
w
ORTAN
with osmol
a
rity
L
ow
,
whi
c
h
ca
n r
ed
u
ce
n
a
us
ea a
n
d
vomiting
.
ORS
is th
e be
st liqui
d
for
d
i
a
rrh
ea
p
a
ti
e
nts to r
e
pl
ace
L
ost liqui
d
.
I
f th
e
p
a
ti
e
nt
ca
nnot
d
rink it must
be b
rought imm
ed
i
a
t
e
ly
to h
ea
lth f
ac
iliti
e
s to g
e
t liqui
d
h
e
lp through infusion
.
O
r
a
l giving is
ba
s
ed
on
de
gr
ee
s of
de
hy
d
r
a
tion
(
Ke
m
e
nk
e
s
RI
,
2011
).
a
.
D
i
a
rrh
ea
without
de
hy
d
r
a
tion
A
g
e
<
1
y
ea
r
: ¼ - ½
c
ups
e
v
e
ry tim
e a c
hil
d d
i
a
rrh
ea
(
50
-
100
ml
)
A
g
e
1
-
4
y
ea
rs
:
1
/
2
-
1
gl
a
ss
e
v
e
ry tim
e a c
hil
d d
i
a
rrh
ea
(
100
-
200
ml
)
A
g
e
ov
e
r
5
y
ea
rs
:
1
-
1
½
c
ups
e
v
e
ry tim
e a c
hil
d d
i
a
rrh
ea
(
200
-
300
ml
)
b
r
ea
kf
a
st
.
D
i
a
rrh
ea
with m
ed
ium lightw
e
ight
de
hy
d
r
a
tion
T
h
e d
os
e
of th
e ORAIT
is giv
e
n in th
e
first
3
hours
75
ml
/
kg
bb a
n
d
th
e
n forw
a
r
ded b
y giving or
a
l lik
e d
i
a
rrh
ea
without
de
hy
d
r
a
tion
.
C
..
D
i
a
rrh
ea
with h
ea
vy
de
hy
d
r
a
tion
D
i
a
rrh
ea
suff
e
r
e
rs who
ca
nnot
d
rink must
be
imm
ed
i
a
t
e
ly r
e
f
e
rr
ed
to
P
usk
e
sm
a
s for infusion
.
F
or
c
hil
d
r
e
n un
de
r th
e a
g
e
of
2
y
ea
rs th
e
liqui
d
must
be
giv
e
n with
a
spoon
B
y m
ea
ns of
1
t
ab
l
e
spoon
e
v
e
ry
1
to
2
minut
e
s
.
G
ift with
a b
ottl
e
m
a
y not
be d
on
e
.
B
igg
e
r
c
hil
d
r
e
n
ca
n
d
rink
d
ir
ec
tly from
th
e
gl
a
ss
.
I
f th
e
r
e
is
a
vomiting stop it for
10
minut
e
s l
a
t
e
r st
a
rt
a
g
a
in slowly for
e
x
a
mpl
e
1
t
ab
l
e
spoon
e
v
e
ry
2
-
3
minut
e
s
.
F
lui
d
T
his
c
ontinu
e
s until
d
i
a
rrh
ea
stops
.
2
.
Z
in
c
is giv
e
n for
10
c
ons
ec
utiv
e da
ys
G
iving zin
c d
uring
d
i
a
rrh
ea
h
a
s
bee
n prov
e
n to r
ed
u
ce
long
a
n
d
l
e
v
e
l
D
i
a
rh
ea
s
e
v
e
rity
,
r
ed
u
c
ing th
e
fr
e
qu
e
n
c
y of
de
f
eca
tion
,
r
ed
u
c
ing
th
e
volum
e
of f
ece
s
,
a
n
d
r
ed
u
ced
th
e
r
ec
urr
e
n
ce
of th
e
in
c
i
de
n
ce
of
d
i
a
rrh
ea
in
3
months
th
e
n
e
xt
.
Ba
s
ed
on this
e
vi
de
n
ce a
ll
d
i
a
rrh
ea c
hil
d
r
e
n must
be
giv
e
n zin
c
I
mm
ed
i
a
t
e
ly wh
e
n
c
hil
d
r
e
n
e
xp
e
ri
e
n
ce d
i
a
rrh
ea
.
D
os
a
g
e
giving zin
c
in to
dd
l
e
rs
:
A
g
e
<
6
months
: ½
t
ab
l
e
t
(
10
mg
)
p
e
r
da
y for
10
da
ys
.
A
g
e
>
6
months
:
1
t
ab
l
e
t
(
20
mg
)
p
e
r
da
y for
10
da
ys
.
Z
in
c
is still giv
e
n for
10
da
ys
e
v
e
n though
d
i
a
rrh
ea
h
a
s stopp
ed
.
H
ow to
P
rovi
de Z
in
c Tab
l
e
ts
:
D
issolv
e
t
ab
l
e
ts in
1
t
ab
l
e
spoon of w
a
t
e
r
Ma
tur
e
or
b
r
ea
st milk
,
a
ft
e
r
d
issolving giving to
d
i
a
rrh
ea
.
3
.
C
ontinu
e b
r
ea
stf
eed
ing
a
n
d
foo
d
Feed
ing
d
uring
d
i
a
rrh
ea a
ims to giv
e
nutrition
suff
e
r
e
rs
e
sp
ec
i
a
lly in
c
hil
d
r
e
n to r
e
m
a
in strong
a
n
d
grow
a
n
d
P
r
e
v
e
nt r
ed
u
ced
w
e
ight
.
C
hil
d
r
e
n who still
d
rink
b
r
ea
st milk must
mor
e
oft
e
n
b
r
ea
stf
ed
.
C
hil
d
r
e
n who
d
rink formul
a
milk
a
r
e a
lso giv
e
n mor
e
O
ft
e
n th
a
n usu
a
l
.
C
hil
d
r
e
n
a
g
ed
6
months or mor
e
in
c
lu
d
ing
bab
i
e
s
h
a
v
e
got soli
d
foo
d
s must
be
giv
e
n
ea
sy foo
d
d
ig
e
st
ed a
n
d
giv
e
n
a
littl
e
l
e
ss
a
n
d
mor
e
oft
e
n
.
A
ft
e
r
d
i
a
rrh
ea
S
top
,
ad
ministr
a
tion of
e
xtr
a
foo
d
is forw
a
r
ded
for
2
w
ee
ks for
He
lp th
e
r
e
stor
a
tion
4
.
Se
l
ec
tiv
e a
nti
b
ioti
c
s
A
nti
b
ioti
c
s shoul
d
not
be
us
ed
r
e
gul
a
rly
beca
us
e
of th
e
sm
a
ll in
c
i
de
n
ce
d
i
a
rrh
ea
in to
dd
l
e
rs
ca
us
ed b
y
bac
t
e
ri
a
.
A
nti
b
ioti
c
s only
us
e
ful in
d
i
a
rrh
ea
with
b
loo
d
(
mostly
beca
us
e
S
hig
e
llosis
)
a
n
d
susp
ec
t
ed c
hol
e
r
a
A
nti
-
d
i
a
rrh
ea
m
ed
i
c
in
e
s shoul
d
not
be
giv
e
n to
c
hil
d
r
e
n
suff
e
r from
d
i
a
rrh
ea beca
us
e
it is prov
e
n to
be
us
e
ful
.
N
o
a
nti
-
vomiting
d
rug
I
t is r
ec
omm
e
n
ded e
x
ce
pt
a
h
ea
vy vomiting
.
T
h
e
s
e d
rugs
d
o not pr
e
v
e
nt
de
hy
d
r
a
tion
or improv
e c
hil
d
nutrition
a
l st
a
tus
,
e
v
e
n mostly
ca
us
e
s h
a
rmful si
de e
ff
ec
ts
a
n
d ca
n
be
f
a
t
a
l
.
D
rug
a
nti
-
protozo
a
is us
ed
if prov
e
n
d
i
a
rrh
ea
is
ca
us
ed b
y p
a
r
a
sit
e
s
(
A
mo
eba
,
G
i
a
r
d
i
a
).
5
.
Ad
vi
ce
to p
a
r
e
nts
/
ca
r
e
giv
e
rs
M
oth
e
r or
ca
r
e
giv
e
rs who
a
r
e c
los
e
ly r
e
l
a
t
ed
to to
dd
l
e
rs must
be
giv
e
n
Ad
vi
ce ab
out
:
a
.
H
ow to provi
de
flui
d a
n
d
m
ed
i
c
in
e a
t hom
e
b
r
ea
kf
a
st
.
W
h
e
n to
b
ring
bac
k to
dd
l
e
rs to h
ea
lth work
e
rs if
:
D
i
a
rrh
ea
mor
e
oft
e
n
Re
p
ea
t vomiting
Ve
ry thirsty
Ea
t
/
d
rink
a
littl
e
Fe
v
e
r
B
loo
d
y stool
I
t
d
o
e
sn
'
t improv
e
in
3
da
ys
.
C
ouns
e
ling
a
n
d ed
u
ca
tion
P
r
e
v
e
ntion of
d
i
a
rrh
ea acc
or
d
ing to th
e Ma
n
a
g
e
m
e
nt
G
ui
de
lin
e
s for
D
i
a
rh
ea MDI
(
2006
)
a
r
e a
s follows
:
1
.
b
r
ea
stf
eed
ing
2
.
P
rovision of
ASI c
omp
a
nion foo
d
3
.
U
s
e e
nough
c
l
ea
n w
a
t
e
r
4
.
Wa
sh h
a
n
d
s
5
.
U
s
e
l
a
trin
e
s
6
.
D
ispos
e
of
bab
y f
ece
s
c
orr
ec
tly
7
.
G
iving m
ea
sl
e
s immuniz
a
tion
Re
f
e
r
e
n
ce c
rit
e
ri
a
1
.
C
hil
d
r
e
n
d
i
a
rrh
ea
with s
e
v
e
r
e de
hy
d
r
a
tion
a
n
d
no inp
a
ti
e
nt f
ac
iliti
e
s
a
n
d
I
ntr
a
v
e
nous inst
a
ll
a
tion
.
2
.
I
f r
e
hy
d
r
a
tion
ca
nnot
be d
on
e
or
ac
hi
e
v
ed
in th
e
first
3
hours
h
a
n
d
ling
.
3
.
C
hil
d
r
e
n with p
e
rsist
e
nt
d
i
a
rrh
ea
4
.
C
hil
d
r
e
n with hypovol
e
mi
c
sho
c
k
E
quipm
e
nt
I
nfusion s
e
t
,
intr
a
v
e
nous flui
d
,
l
ab
or
a
tory
e
quipm
e
nt for
b
loo
d
t
e
sts
R
outin
e
,
Fee
s
a
n
d W
i
da
l
P
rognosis
T
h
e
prognosis is v
e
ry
de
p
e
n
de
nt on th
e
p
a
ti
e
nt
'
s
c
on
d
ition wh
e
n it
c
om
e
s
,
th
e
r
e
/
ab
s
e
n
ce
c
ompli
ca
tions
,
a
n
d
tr
ea
tm
e
nt
,
so g
e
n
e
r
a
lly th
e
prognosis is
D
u
b
i
a
Ad B
on
a
m
.
I
f
c
on
d
itions wh
e
n
c
oming with h
ea
vy
de
hy
d
r
a
tion
,
prognosis
ca
n
Bec
om
e D
u
b
i
a Ad N
ight
.
