D
is
e
ntry
Ba
sil
e
r
a
n
d A
m
eba D
ys
e
nt
e
ry
Hea
lth pro
b
l
e
ms
D
ys
e
nt
e
ry is
a da
ng
e
rous typ
e
of
d
i
a
rrh
ea a
n
d
oft
e
n
ca
us
e
s
Dea
th
c
omp
a
r
ed
to oth
e
r typ
e
s of
ac
ut
e d
i
a
rrh
ea
.
T
his
d
is
ea
s
e ca
n
be ca
us
ed b
y th
e bac
t
e
ri
a
of th
e ba
sil
d
ys
e
nt
e
ry
ca
us
ed
b
y
S
hig
e
llosis
a
n
d A
mo
eba
(
D
is
e
ntry
A
mo
eba
).
A
n
a
mn
e
sis
(
su
b
j
ec
tiv
e
)
r
e
sults
A c
ompl
a
int
1
.
S
tom
ac
h p
a
in is m
a
inly l
e
ft
a
n
d de
f
eca
ting runny w
a
t
e
r
c
ontinuously
c
onst
a
ntly mix
ed
with mu
c
us
a
n
d b
loo
d
2
.
V
omiting
3
.
Headac
h
e
4
.
We
ight form
(
fulmin
a
ting
ca
s
e
s
)
is usu
a
lly
ca
us
ed b
y
S
.
D
ys
e
ntri
ae
with symptoms
a
ris
e
su
dde
nly
a
n
d
s
e
v
e
r
e
,
a
n
d ca
n
D
i
ed
if it w
a
sn
'
t h
e
lp
ed
qui
c
kly
.
R
isk f
ac
tor
Pe
rson
a
l hygi
e
n
e a
n
d
l
e
ss
e
nvironm
e
nt
a
l s
a
nit
a
tion
.
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
ca
n
be
foun
d
:
1
.
Feb
ris
2
.
Abd
omin
a
l p
a
in in th
e e
mph
a
sis on th
e
l
e
ft si
de
3
.
T
h
e
r
e a
r
e
signs of
de
hy
d
r
a
tion
4
.
Te
n
e
smus
S
upport
E
x
a
min
a
tion of th
e
stool
d
ir
ec
tly
a
g
a
inst th
e ca
us
e
of th
e ca
us
e
.
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 b
y
a
n
a
mn
e
sis
,
physi
ca
l
e
x
a
min
a
tion
,
a
n
d
S
upporting
e
x
a
min
a
tion
.
D
i
a
gnosis of
A
pp
ea
l
1
.
E
s
c
h
e
ri
c
i
ae c
oli inf
ec
tion
2
.
E
s
c
h
e
ri
c
hi
a C
oli
E
nt
e
roinv
a
siv
e
(
EIEC
)
inf
ec
tion
3
.
E
s
c
h
e
ri
c
hi
a C
oli
E
nt
e
roh
e
mor
a
gi
c I
nf
ec
tion
(
EHEC
)
C
ompli
ca
tions
1
.
Hae
molyti
c U
r
e
mi
c S
yn
d
rom
e
(
HUS
)
2
.
Hea
vy hypon
a
tr
e
mi
a
3
.
Hea
vy hypogly
ce
mi
a
4
.
I
nt
e
stin
a
l
c
ompli
ca
tions su
c
h
a
s toxi
c
m
e
g
a
kolon
,
r
ec
t
a
l prol
a
ps
,
p
e
ritonitis
a
n
d
p
e
rfor
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
1
.
P
r
e
v
e
nt
de
hy
d
r
a
tion
2
.
L
ooks on
bed
3
.
M
il
d
to mo
de
r
a
t
e de
hy
d
r
a
tion
ca
n
be c
orr
ec
t
ed
with r
e
hy
d
r
a
tion flui
d
or
a
l
4
.
I
f or
a
l r
e
hy
d
r
a
tion is insuffi
c
i
e
nt it
ca
n
be
giv
e
n flui
d
through th
e
infusion
5
.
D
i
e
t
,
giv
e
n soft foo
d
until th
e c
h
a
pt
e
r fr
e
qu
e
n
c
y is l
e
ss th
a
n
5
tim
e
s
/
da
y
,
th
e
n giv
e
n or
d
in
a
ry sn
ac
ks if th
e
r
e
is progr
e
ss
.
6
.
P
h
a
rm
ac
ologi
ca
l
:
a
.
Acc
or
d
ing to th
e WHO
gui
de
lin
e
s
,
if th
e
p
a
ti
e
nt
'
s
d
i
a
gnosis h
a
s
bee
n
d
i
a
gnos
ed
tr
ea
t
ed
with
a
nti
b
ioti
c
s
.
I
f
a
ft
e
r
2
da
ys tr
ea
tm
e
nt shows
Re
p
a
ir
,
th
e
r
a
py is
c
ontinu
ed
for
5
da
ys
.
I
f th
e
r
e a
r
e
no r
e
p
a
irs
,
A
nti
b
ioti
c
s
a
r
e
r
e
pl
aced
with oth
e
r typ
e
s
.
b
r
ea
kf
a
st
.
S
hort
-
t
e
rm us
e
with fluoroquinolon
e
singl
e d
os
e
s
lik
e
siproflox
a
sin or th
e
m
ac
roli
d a
zithromy
c
in turn
ed
out to work w
e
ll
for th
e
tr
ea
tm
e
nt of
ba
sil
d
ys
e
nt
e
ry
.
T
h
e c
iproflox
a
sin
d
os
e
us
ed
is
2
x
500
mg
/
da
y for
3
da
ys whil
e a
zithromy
c
in
giv
e
n
1
gr
a
m singl
e d
os
e a
n
d
s
e
fi
c
tion of
400
mg
/
da
y for
5
th
e da
y
.
Ad
ministr
a
tion of siproflox
a
sin is
a c
ontr
a
in
d
i
ca
tion of
C
hil
d
r
e
n
a
n
d
pr
e
gn
a
nt wom
e
n
.
C
..
I
n
de
v
e
loping
c
ountri
e
s wh
e
r
e
th
e
r
e
is
a
g
e
rms s
d
ys
e
ntri
ae
M
ulti
S
ist
e
n typ
e
1
on
d
rugs
,
giv
e
n n
a
li
d
iksy
ac
i
d
W
ith
a d
os
e
of
3
x
1
gr
a
m
/
da
y for
5
da
ys
.
N
o
a
nti
b
ioti
c
s
I
t is r
ec
omm
e
n
ded
in th
e
tr
ea
tm
e
nt of th
e ce
ntr
a
liz
ed ca
r
ee
r st
a
g
e
.
d
.
F
or
D
is
e
ntry
A
mo
BA
is giv
e
n m
e
troni
da
zol
e a
nti
b
ioti
c
s
500
mg
3
x
a da
y for
3
-
5
da
ys
F
ollow up pl
a
n
Pa
ti
e
nts n
eed
to
be
s
ee
n in th
e de
v
e
lopm
e
nt of th
e d
is
ea
s
e beca
us
e
it t
a
k
e
s tim
e
L
ong h
ea
ling
ba
s
ed
on th
e
w
e
ight of th
e d
is
ea
s
e
.
C
ouns
e
ling
a
n
d ed
u
ca
tion
1
.
T
r
a
nsmission of th
e D
ys
e
nt
e
ry
A
mo
BA a
n
d
th
e ba
sil
ca
n
be
pr
e
v
e
nt
ed a
n
d
r
ed
u
ced b
y
e
nvironm
e
nt
a
l
a
n
d c
l
ea
n s
e
lf
-
lik
e c
on
d
itions su
c
h
a
s
c
l
ea
ning h
a
n
d
s
with so
a
p
,
w
a
t
e
r supply is not
c
ontr
ac
ting
a
n
d
us
e
C
l
ea
n toil
e
tri
e
s
.
2
.
T
h
e
f
a
mily pl
a
ys
a
rol
e
in pr
e
v
e
nting tr
a
nsmission with
c
on
d
itions
e
nvironm
e
nt
a
n
d c
l
ea
n s
e
lf lik
e c
l
ea
ning h
a
n
d
s with
so
a
p
,
w
a
t
e
r supply th
a
t is not
c
ont
a
min
a
t
ed
,
th
e
us
e
of l
a
trin
e
s
c
l
ea
n
.
3
.
T
h
e
f
a
mily h
e
lps k
ee
p th
e d
i
e
t p
a
ti
e
nt giv
e
n soft foo
d
until
C
h
a
pt
e
r fr
e
qu
e
n
c
y is l
e
ss th
a
n
5
tim
e
s
/
da
y
,
th
e
n giv
e
n sn
ac
ks
O
r
d
in
a
ry if th
e
r
e
is progr
e
ss
.
Re
f
e
r
e
n
ce c
rit
e
ri
a
I
n p
a
ti
e
nts with s
e
v
e
r
e ca
s
e
s n
eed
to
be
tr
ea
t
ed
int
e
nsiv
e
ly
a
n
d c
onsult to
Sec
on
da
ry
Hea
lth
Se
rvi
ce
s
(
I
nn
e
r
D
is
ea
s
e S
p
ec
i
a
lists
).
E
quipm
e
nt
Lab
or
a
tory for
E
x
a
min
a
tion of
S
tools
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
.
I
n g
e
n
e
r
a
l
,
th
e
prognosis of
D
u
b
i
a Ad B
on
a
m
.
Ga
stroint
e
stin
a
l
b
l
eed
ing
a
.
B
l
eed
ing of th
e
top
d
ig
e
stion
Hea
lth pro
b
l
e
ms
Ma
nif
e
st
a
tion
b
l
eed
ing
c
h
a
nn
e
l
d
ig
e
stion
v
a
ri
ed
st
a
rting
with
a
pri
ce
of
a
soul th
a
t thr
ea
t
e
ns th
e
soul to v
a
gu
e b
l
eed
ing
whi
c
h is not f
e
lt
.
He
m
a
t
e
m
e
sis shows
b
l
eed
ing from th
e c
h
a
nn
e
l
T
h
e d
ig
e
st
a
tion of th
e
top
,
proxim
a
l of th
e
tr
e
itz lig
a
m
e
ntum
.
Ve
ntil
a
tion
th
e b
l
eed
ing of th
e
top
d
ig
e
stion
,
though
b
l
eed
ing from
T
h
e
sm
a
ll int
e
stin
e
or th
e
right
c
olon
,
ca
n
a
lso
ca
us
e
m
e
l
e
n
a
.
I
n
I
n
d
on
e
si
a b
l
eed
ing
beca
us
e
th
e
ruptur
e
of th
e Ga
stro
e
sof
a
gus v
a
ri
c
os
e
is
T
h
e
most
c
ommon
ca
us
e
is
a
roun
d
50
-
60
%
,
e
rosiv
e
g
a
stritis
a
roun
d
25
-
30
%
,
ul
ce
rs
Pe
pti
c
is
a
roun
d
10
-
15
%
a
n
d beca
us
e
of th
e
oth
e
r r
ea
son
<
5
%
.
M
ort
a
lity
O
v
e
r
a
ll still high is
a
roun
d
25
%
,
dea
th in p
e
opl
e
with ruptur
e
s
Va
ri
c
os
e
v
a
ri
c
os
e ca
n r
eac
h
60
%
whil
e dea
th in non
-
v
e
il
b
l
eed
ing
Ab
out
9
-
12
%
.
A
n
a
mn
e
sis
(
su
b
j
ec
tiv
e
)
r
e
sults
A c
ompl
a
int
Pa
ti
e
nts
ca
n
c
om
e
up with
c
ompl
a
ints of
b
l
ac
k
b
loo
d
vomiting lik
e
c
off
ee
pow
de
r
(
h
e
m
a
t
e
m
e
sis
)
or
b
l
ac
k
de
f
eca
tion lik
e
t
e
r
or
a
sph
a
lt
(
m
e
l
e
n
a
),
O
th
e
r
c
lini
ca
l symptoms
a
r
e
in
acc
or
da
n
ce
with
c
omor
b
i
d
,
su
c
h
a
s
c
hroni
c
liv
e
r
d
is
ea
s
e
,
L
ung
d
is
ea
s
e
,
h
ea
rt
d
is
ea
s
e
,
ki
d
n
e
y
d
is
ea
s
e e
t
c
.
I
n th
e a
n
a
mn
e
sis th
a
t n
eed
s to
be a
sk
ed
is
a
history of
c
hroni
c
liv
e
r
d
is
ea
s
e
,
D
isp
e
psi
a H
istory
,
H
istory of
C
onsuming
NSAID
s
,
R
h
e
um
a
ti
c Med
i
c
in
e
s
,
A
l
c
ohol
,
Ja
muj
a
mu
a
n
,
Med
i
ca
tion for
Hea
rt
D
is
ea
s
e
,
S
trok
e Med
i
ca
tion
,
H
istory of
K
i
d
n
e
y
D
is
ea
s
e
,
H
istory of lung
d
is
ea
s
e a
n
d
oth
e
r
b
l
eed
ing in pl
ace
.
H
istory
vomiting
be
for
e
th
e
o
cc
urr
e
n
ce
of h
e
m
a
t
e
m
e
sis is v
e
ry supportiv
e
T
h
e
possi
b
ility of
Ma
llory
We
iss
'
s syn
d
rom
e
.
R
isk f
ac
tor
C
onsumption of
NSAID d
rugs
P
r
ed
isposition f
ac
tor
H
istory of h
e
p
a
ti
c c
irrhosis
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
.
h
e
mo
d
yn
a
mi
c a
ss
e
ssm
e
nt
(
c
ir
c
ul
a
tion st
a
t
e
)
2
.
E
v
a
lu
a
t
e
th
e a
mount of
b
l
eed
ing
.
3
.
O
th
e
r physi
ca
l
e
x
a
min
a
tions
a
r
e
looking for stigm
a
t
a
of
c
hroni
c
liv
e
r
d
is
ea
s
e
(
I
kt
e
rus
,
S
pi
de
r
Ne
vi
,
A
stit
e
s
,
S
pl
e
nom
e
g
a
ly
,
E
rit
e
m
a Pa
lm
a
ris
,
Ede
m
a
l
e
gs
),
abd
omin
a
l m
a
ss
,
abd
omin
a
l p
a
in
,
p
e
riton
e
um stimul
a
tion
,
lung
d
is
ea
s
e
,
h
ea
rt
d
is
ea
s
e
,
rh
e
um
a
ti
c d
is
ea
s
e e
t
c
.
4
.
Rec
t
a
l
T
ou
c
h
e
r
5
.
I
n this
d
i
a
gnosis pro
ced
ur
e
it is import
a
nt to s
ee a
spir
a
t from
Na
so
Ga
stri
c
T
u
be
(
NGT
).
S
tir whit
e a
spir
a
t in
d
i
ca
t
e
s no
b
l
eed
ing
Ac
tiv
e
,
m
a
roon
a
spir
a
t
e
in
d
i
ca
t
e
s m
a
ssiv
e b
l
eed
ing
Ve
ry lik
e
ly
a
rt
e
ri
a
l
b
l
eed
ing
.
S
upporting
c
h
ec
ks in prim
a
ry h
ea
lth s
e
rvi
ce
s
1
.
C
ompl
e
t
e B
loo
d Lab
or
a
tory
2
.
x r
a
y thor
a
x
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
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
He
moptisis
,
He
m
a
tok
e
zi
a
C
ompli
ca
tions
H
ypovol
e
mi
a S
ho
c
k
,
P
n
e
umoni
a A
spir
a
tion
,
Ac
ut
e K
i
d
n
e
y
Fa
ilur
e
,
A
n
e
mi
a Beca
us
e
b
l
eed
ing
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
t
ab
iliz
e
h
e
mo
d
yn
a
mi
c
s
.
a
.
IV L
in
e I
nst
a
ll
a
tion
b
r
ea
kf
a
st
.
O
xyg
e
n hook
/
Ca
nul
a
C
..
Rec
or
d
th
e
output int
a
k
e
,
a
urin
e ca
th
e
t
e
r must
be
inst
a
ll
ed
d
.
M
onitor
b
loo
d
pr
e
ssur
e
,
puls
e
,
oxyg
e
n s
a
tur
a
tion
a
n
d
oth
e
r
c
ir
c
umst
a
n
ce
s
in
acc
or
da
n
ce
with
e
xisting
c
ommor
b
i
d
s
.
2
.
NGT
(
Na
sog
a
tri
c T
u
be
)
inst
a
ll
a
tion
R
ins
e
th
e
stom
ac
h to m
a
k
e
it
ea
si
e
r in th
e ac
tion of th
e e
n
d
os
c
op
e
.
3
.
BARING COURS
4
.
Fa
sting
/
D
i
e
t
Hea
rt
/
S
tom
ac
h
a
.
I
nj
ec
tion of
H
2
r
ece
ptor
a
nt
a
gonists or proton pump inhi
b
itors
(
PPI
)
b
r
ea
kf
a
st
.
S
itoprot
ec
tor
:
S
ukr
a
lf
a
t
3
-
4
x
1
gr
a
m
C
..
A
nt
ac
i
d
s
d
.
V
it
a
min
K
inj
ec
tion for p
a
ti
e
nts with
c
hroni
c
liv
e
r
d
is
ea
s
e
F
ollow up pl
a
n
E
v
e
n though th
e
p
a
ti
e
nt
'
s
e
n
d
os
c
op
e
th
e
r
a
py h
a
s
bee
n
d
on
e
E
xp
e
ri
e
n
ce a
r
e
-
r
e
n
e
w
a
l
.
T
h
e
r
e
for
e
th
e a
ss
e
ssm
e
nt n
eed
s to
be d
on
e
M
or
e acc
ur
a
t
e
to pr
ed
i
c
t r
e
-
b
l
eed
ing
a
n
d
mort
a
lity
.
C
ouns
e
ling
a
n
d ed
u
ca
tion
Fa
mili
e
s support to k
ee
p th
e
p
a
ti
e
nt
'
s
d
i
e
t
a
n
d
tr
ea
tm
e
nt
.
l
e
gs
),
abd
omin
a
l m
a
ss
,
abd
omin
a
l p
a
in
,
p
e
riton
e
um stimul
a
tion
,
lung
d
is
ea
s
e
,
h
ea
rt
d
is
ea
s
e
,
rh
e
um
a
ti
c d
is
ea
s
e e
t
c
.
4
.
Rec
t
a
l
T
ou
c
h
e
r
5
.
I
n this
d
i
a
gnosis pro
ced
ur
e
it is import
a
nt to s
ee a
spir
a
t from
Na
so
Ga
stri
c
T
u
be
(
NGT
).
S
tir whit
e a
spir
a
t in
d
i
ca
t
e
s no
b
l
eed
ing
Ac
tiv
e
,
m
a
roon
a
spir
a
t
e
in
d
i
ca
t
e
s m
a
ssiv
e b
l
eed
ing
Ve
ry lik
e
ly
a
rt
e
ri
a
l
b
l
eed
ing
.
S
upporting
c
h
ec
ks in prim
a
ry h
ea
lth s
e
rvi
ce
s
1
.
C
ompl
e
t
e B
loo
d Lab
or
a
tory
2
.
x r
a
y thor
a
x
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
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
He
moptisis
,
He
m
a
tok
e
zi
a
C
ompli
ca
tions
H
ypovol
e
mi
a S
ho
c
k
,
P
n
e
umoni
a A
spir
a
tion
,
Ac
ut
e K
i
d
n
e
y
Fa
ilur
e
,
A
n
e
mi
a Beca
us
e
b
l
eed
ing
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
t
ab
iliz
e
h
e
mo
d
yn
a
mi
c
s
.
a
.
IV L
in
e I
nst
a
ll
a
tion
b
r
ea
kf
a
st
.
O
xyg
e
n hook
/
Ca
nul
a
C
..
Rec
or
d
th
e
output int
a
k
e
,
a
urin
e ca
th
e
t
e
r must
be
inst
a
ll
ed
d
.
M
onitor
b
loo
d
pr
e
ssur
e
,
puls
e
,
oxyg
e
n s
a
tur
a
tion
a
n
d
oth
e
r
c
ir
c
umst
a
n
ce
s
in
acc
or
da
n
ce
with
e
xisting
c
ommor
b
i
d
s
.
2
.
NGT
(
Na
sog
a
tri
c T
u
be
)
inst
a
ll
a
tion
R
ins
e
th
e
stom
ac
h to m
a
k
e
it
ea
si
e
r in th
e ac
tion of th
e e
n
d
os
c
op
e
.
3
.
BARING COURS
4
.
Fa
sting
/
D
i
e
t
Hea
rt
/
S
tom
ac
h
a
.
I
nj
ec
tion of
H
2
r
ece
ptor
a
nt
a
gonists or proton pump inhi
b
itors
(
PPI
)
b
r
ea
kf
a
st
.
S
itoprot
ec
tor
:
S
ukr
a
lf
a
t
3
-
4
x
1
gr
a
m
C
..
A
nt
ac
i
d
s
d
.
V
it
a
min
K
inj
ec
tion for p
a
ti
e
nts with
c
hroni
c
liv
e
r
d
is
ea
s
e
F
ollow up pl
a
n
E
v
e
n though th
e
p
a
ti
e
nt
'
s
e
n
d
os
c
op
e
th
e
r
a
py h
a
s
bee
n
d
on
e
E
xp
e
ri
e
n
ce a
r
e
-
r
e
n
e
w
a
l
.
T
h
e
r
e
for
e
th
e a
ss
e
ssm
e
nt n
eed
s to
be d
on
e
M
or
e acc
ur
a
t
e
to pr
ed
i
c
t r
e
-
b
l
eed
ing
a
n
d
mort
a
lity
.
C
ouns
e
ling
a
n
d ed
u
ca
tion
Fa
mili
e
s support to k
ee
p th
e
p
a
ti
e
nt
'
s
d
i
e
t
a
n
d
tr
ea
tm
e
nt
.
Re
f
e
r
e
n
ce c
rit
e
ri
a
1
.
a
g
a
inst p
a
ti
e
nts who
a
r
e a
ll
e
g
ed
ly
d
u
e
to th
e e
soph
a
gus v
a
ri
c
os
e
ruptur
a a
t
Re
f
e
r to
Sec
on
da
ry
Hea
lth
Se
rvi
ce
s
2
.
I
f
b
l
eed
ing
d
o
e
s not stop with th
e
initi
a
l h
a
n
d
ling in th
e
prim
a
ry s
e
rvi
ce
3
.
I
f th
e
r
e
is
a
s
e
v
e
r
e a
n
e
mi
a
E
quipm
e
nt
1
.
Ka
nul
a O
n
e O
xyg
e
n
Se
n
d
ul
2
.
Na
so
Ga
stri
c T
u
be
(
NGT
)
3
.
G
lov
e
s
4
.
ECG
5
.
Lab
or
a
tory for
c
ompl
e
t
e b
loo
d
t
e
sts
,
liv
e
r fun
c
tion
,
a
n
d
fun
c
tion
ki
d
n
e
y
.
P
rognosis
T
h
e
prognosis for this
c
on
d
ition is
D
u
b
i
a
,
m
a
y not
be
thr
ea
t
e
ning
S
oul
,
b
ut
ad
fun
c
tion
,
a
n
d Sa
n
a
tion
a
m
a
r
e
g
e
n
e
r
a
lly
D
u
b
i
a Ad N
ight
.
b
r
ea
kf
a
st
.
B
l
eed
ing
b
l
eed
ing
b
ottom
Hea
lth pro
b
l
e
ms
B
ottom
d
ig
e
stion
b
l
eed
ing is g
e
n
e
r
a
lly
de
fin
ed a
s
B
l
eed
ing from th
e
int
e
stin
e
is un
de
r th
e
tr
e
itz lig
a
m
e
nt
.
He
m
a
tok
e
zi
a
int
e
rpr
e
t
ed
fr
e
sh
b
loo
d c
oming out through th
e a
nus
a
n
d
is
T
h
e
most
c
ommon m
a
nif
e
st
a
tion of th
e b
ottom
d
ig
e
stiv
e b
l
eed
ing
.
T
h
e
most
c
ommon
ca
us
e
of th
e b
ottom
d
ig
e
stiv
e
tr
ac
t in
c
lu
de
s
b
l
eed
ing
D
iv
e
rtik
e
l
c
olon
,
a
ngio
d
ispl
a
si
a a
n
d
is
c
h
e
mi
c c
olitis
.
B
l
eed
ing
c
h
a
nn
e
l
d
ig
e
stion
th
e b
ottom is
c
hroni
c a
n
d
r
e
p
ea
t
ed
usu
a
lly
c
om
e
s from h
e
morrhoi
d
s
a
n
d
C
olon n
e
opl
a
si
a
.
A
n
a
mn
e
sis
Re
sults
(
A
n
e
mn
e
sis
)
A c
ompl
a
int
1
.
T
h
e
p
a
ti
e
nt
c
om
e
s with fr
e
sh
b
loo
d c
ompl
a
ints
c
oming out through th
e a
nus
(
h
e
m
a
tok
e
zi
a
).
2
.
Ge
n
e
r
a
lly m
e
l
e
n
a
shows
b
l
eed
ing in th
e
upp
e
r
d
ig
e
stiv
e
tr
ac
t
or th
e
sm
a
ll int
e
stin
e
,
how
e
v
e
r
,
it
ca
n
a
lso
c
om
e
from
R
ight
c
olon
b
l
eed
ing with
a
slow
d
own of mo
b
ility
.
3
.
B
l
eed
ing from
d
iv
e
rti
c
ulum is usu
a
lly no p
a
in
.
S
tool usu
a
lly
Red
m
a
roon
,
som
e
tim
e
s it
ca
n
a
lso
be
r
ed
.
Ge
n
e
r
a
lly stopp
ed
spont
a
n
e
ously
a
n
d
not r
e
p
ea
t
ed
.
4
.
He
morrhoi
d
s
a
n
d F
isur
a A
ni usu
a
lly
ca
us
e b
l
eed
ing with
c
olor
F
r
e
sh r
ed b
ut not mix
ed
with f
aece
s
.
5
.
Pa
ti
e
nts with f
a
int
b
l
eed
ing
c
hroni
c d
ig
e
stion
c
h
a
nn
e
ls g
e
n
e
r
a
lly not
T
h
e
r
e a
r
e
symptoms or som
e
tim
e
s just f
ee
ling f
a
tigu
e d
u
e
to
a
n
e
mi
a
.
6
.
Va
lu
e
in th
e a
n
a
mn
e
sis wh
e
th
e
r mix
ed
with f
ece
s
(
lik
e
h
a
pp
e
ning
I
n
c
olitis or l
e
sions in th
e
proxim
a
l r
ec
tum
)
or s
e
p
a
r
a
t
e
/
d
ripping
(
un
e
xp
ec
t
ed
h
e
morrhoi
d
s
),
us
e
of
a
nti
c
o
a
gul
a
nts
,
or oth
e
r syst
e
mi
c
symptoms
L
ik
e
ol
d
f
e
v
e
r
(
typhoi
d
,
inf
ec
tion
c
olitis
),
dec
r
ea
s
e
s w
e
ight
(
Ca
n
ce
r
),
c
h
a
ng
e
s in th
e
p
a
tt
e
rn of
de
f
eca
tion
(
ca
n
ce
r
),
without p
a
in
(
h
e
morrhoi
d
s
int
e
mi
e
s
,
a
ngio
d
ispl
a
si
a
),
abd
omin
a
l p
a
in
(
c
olitis inf
ec
tion
,
m
e
sm
e
ri
a
i
a
l is
c
h
e
mi
a
),
TENESMUS ANI
(
FISURA
,
DISINTRI
).
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
.
A
t th
e
r
ec
t
a
l plug it is foun
d
fr
e
sh
b
loo
d
2
.
V
it
a
l sign v
a
lu
e
s
,
e
sp
ec
i
a
lly wh
e
th
e
r or not r
e
sist
a
n
ce
or postur
a
l hypot
e
nsion
(
T
ilt t
e
st
).
3
.
ABDOMEN
'
s physi
ca
l
e
x
a
min
a
tion to
a
ss
e
ss th
e
pr
e
s
e
n
ce
or
ab
s
e
n
ce
of
t
e
n
de
rn
e
ss
(
Me
s
e
nt
e
ri
a
l
I
s
c
h
e
mi
a
),
S
timul
a
n
Pe
riton
ea
l
(
D
iv
e
rti
c
ulitis
),
Ma
ss
a
I
ntr
aabd
om
e
n
(
C
olon
T
umor
,
A
mu
b
om
a
,
C
rohn
'
s
d
is
ea
s
e
).
S
upport
C
ompl
e
t
e
p
e
riph
e
r
a
l
b
loo
d e
x
a
min
a
tion
,
routin
e
f
ece
s
a
n
d
v
a
gu
e b
loo
d
t
e
sts
.
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
D
i
a
gnosis is
e
nfor
ced b
y
a
n
a
mn
e
sis
,
physi
ca
l
e
x
a
min
a
tion
a
n
d
S
upporting
e
x
a
min
a
tion
.
D
i
a
gnosis of
A
pp
ea
l
Hae
morhoi
d
,
infl
a
mm
a
tory int
e
stin
a
l
d
is
ea
s
e
,
d
iv
e
rti
c
ulosis
,
a
ngio
d
ispl
a
si
a
,
tumor
c
olon
C
ompli
ca
tions
1
.
H
ypovol
e
mi
c
sho
c
k
2
.
Ac
ut
e
ki
d
n
e
y f
a
ilur
e
3
.
A
n
e
mi
a d
u
e
to
b
l
eed
ing
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
t
ab
iliz
e
h
e
mo
d
yn
a
mi
c
s
a
.
IV L
in
e I
nst
a
ll
a
tion
b
r
ea
kf
a
st
.
O
xyg
e
n hook
/
Ca
nul
a
C
..
Rec
or
d
th
e
output int
a
k
e
,
a
urin
e ca
th
e
t
e
r must
be
inst
a
ll
ed
d
.
M
onitor
b
loo
d
pr
e
ssur
e
,
puls
e
,
oxyg
e
n s
a
tur
a
tion
a
n
d
oth
e
r
c
ir
c
umst
a
n
ce
s
in
acc
or
da
n
ce
with
e
xisting
c
ommor
b
i
d
s
.
2
.
S
om
e b
ottom
d
ig
e
stiv
e b
l
eed
ing
ca
n
be
tr
ea
t
ed
m
ed
i
ca
l
.
He
morrhoi
d
s of
F
isur
a A
ni
a
n
d S
olit
a
ry
Rec
t
a
l
U
l
ce
rs
ca
n
be
tr
ea
t
ed
W
ith
B
ulk
-
F
orming
A
g
e
nt
,
S
itz
Ba
ths
,
a
n
d a
voi
d
ing woun
d
ing
.
3
.
Va
gu
e b
loo
d
loss r
e
quir
e
s iron suppl
e
m
e
nt
a
tion
,
f
e
rrosulf
a
t
e
325
mg thr
ee
tim
e
s
a da
y
.
C
ouns
e
ling
a
n
d ed
u
ca
tion
Fa
mili
e
s support to k
ee
p th
e
p
a
ti
e
nt
'
s
d
i
e
t
a
n
d
tr
ea
tm
e
nt
.
Re
f
e
r
e
n
ce c
rit
e
ri
a
1
.
B
low
e
rn
b
l
eed
ing th
e b
ottom of th
e b
ottom
2
.
Re
f
e
r to s
ec
on
da
ry h
ea
lth s
e
rvi
ce
s for
de
finitiv
e d
i
a
gnosis if not
Ca
n
be e
nfor
ced
in prim
a
ry h
ea
lth s
e
rvi
ce
s
E
quipm
e
nt
1
.
Lab
or
a
tory for
c
ompl
e
t
e b
loo
d c
h
ec
ks
a
n
d
f
a
int
b
loo
d
f
ab
s
2
.
G
lov
e
s
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
.
He
morrhoi
d G
r
ade
1
-
2
Hea
lth pro
b
l
e
ms
He
morrhoi
d
s
a
r
e
wi
de
ning v
e
ins in th
e
h
e
moroi
da
l pl
e
xus
.
A
n
a
mn
e
sis
(
su
b
j
ec
tiv
e
)
r
e
sults
A c
ompl
a
int
1
.
B
l
eed
ing
a
t th
e
tim
e
of
de
f
eca
tion
,
b
loo
d
is fr
e
sh r
ed
.
B
loo
d
ca
n tri
c
kl
e
out of th
e a
nus
a
f
e
w mom
e
nts
a
ft
e
r
de
f
eca
tion
.
2
.
P
rol
a
ps
a
m
a
ss
a
t th
e
tim
e
of
de
f
eca
tion
.
T
his m
a
ss
ca
n first
be
bac
k spont
a
n
e
ously
a
ft
e
r
de
f
eca
tion
,
b
ut th
e
n it must
be
in
c
lu
ded
Ma
nu
a
lly
a
n
d
fin
a
lly it
ca
nnot
be
in
c
lu
ded a
g
a
in
.
3
.
M
u
c
us
e
xp
e
n
d
itur
e
.
4
.
I
rrit
a
tion in p
e
ri
a
n
a
l skin
.
5
.
A
n
e
mi
c
symptoms
(
su
c
h
a
s
:
d
izzin
e
ss
,
w
ea
k
,
p
a
l
e
).
R
isk f
ac
tor
1
.
A
ging
2
.
Wea
k
b
loo
d
v
e
ss
e
l w
a
lls
3
.
P
r
e
gn
a
nt wom
e
n
4
.
C
onstip
a
tion
5
.
C
onsumption of low
-
fi
be
r foo
d
s
6
.
I
n
c
r
ea
s
ed
intr
aabd
omin
a
l pr
e
ssur
e
7
.
C
hroni
c c
ough
8
.
O
ft
e
n
b
linking
9
.
U
s
e
of ling
e
ring toil
e
ts
(
for
e
x
a
mpl
e
:
sitting in th
a
t tim
e
long in th
e
toil
e
t
)
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
.
C
h
ec
k
a
n
e
mi
a
signs
2
.
C
h
ec
k th
e
st
a
tus of th
e
lok
a
lis
a
.
I
nsp
ec
tion
:
He
morrhoi
d de
gr
ee
1
,
d
o
e
s not in
d
i
ca
t
e a
n
ab
norm
a
lity
Re
gio
a
n
a
l
.
He
morrhoi
d de
gr
ee
s
2
,
th
e
r
e
is no mu
c
os
a
l lump th
a
t
c
om
e
s out
through th
e a
nus
,
b
ut th
e
h
e
morrhoi
d
p
a
rts
c
ov
e
r
ed
in th
e
skin
ca
n
looks
a
s sw
e
lling
.
He
morrhoi
d de
gr
ee
s
3
a
n
d
4
whi
c
h
a
r
e
l
a
rg
e
will soon
be
r
ec
ogniz
ed
with th
e e
xist
e
n
ce
of
a
promin
e
nt m
a
ss of th
e a
n
a
l hol
e
whi
c
h is p
a
rt
T
h
e
outsi
de
is
c
ov
e
r
ed
in th
e
skin
a
n
d
th
e
insi
de
of th
e
mu
c
os
a
purs
e
or r
ed
.
b
r
ea
kf
a
st
.
Pa
lp
a
tion
:
He
morrhoi
d
int
e
rn
a
l
a
t th
e
initi
a
l st
a
g
e
of m
e
rup
a
k
a
wi
de
ning v
e
ins
soft
a
n
d ea
sy
c
oll
a
ps
e
so it
ca
n
'
t
be de
t
ec
t
ed
with p
a
lp
a
tion
.
A
ft
e
r h
e
morrhoi
d
s l
a
st long
a
n
d
h
a
v
e bee
n prol
a
ps
,
c
onn
ec
tiv
e
tissu
e
mu
c
os
a e
xp
e
ri
e
n
ce
fi
b
rosis so h
e
morrhoi
d
s
ca
n
be
tou
c
h
ed
wh
e
n
T
h
e
fing
e
rs f
ee
l
a
roun
d
th
e
low
e
r r
ec
tum
.
S
upport
R
outin
e b
loo
d c
h
ec
ks
,
a
im to
de
t
e
rmin
e
th
e
pr
e
s
e
n
ce
of
a
n
e
mi
a a
n
d
inf
ec
tion
.
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
D
i
a
gnosis is
e
nfor
ced b
y
a
n
a
mn
e
sis
,
physi
ca
l
e
x
a
min
a
tion
a
n
d
S
upporting
e
x
a
min
a
tion
.
He
morrhoi
d c
l
a
ssifi
ca
tion
,
d
ivi
ded
into
:
1
.
I
nt
e
rn
a
l h
e
morrhoi
d
s
,
whi
c
h
c
om
e
from th
e
proxim
a
l p
a
rt of
De
nt
a
t
e L
in
e a
n
d
mu
c
os
a c
o
a
t
ed
I
nt
e
rn
a
l h
e
morrhoi
d
s
a
r
e d
ivi
ded
into
4
gr
ade
,
n
a
m
e
ly
:
a
.
G
r
ade
1
:
He
morrhoi
d
s r
eac
h
a
n
a
l
ca
n
a
l lum
e
n
b
r
ea
kf
a
st
.
G
r
ade
2
:
He
morrhoi
d
s r
eac
h
e
xt
e
rn
a
l sphin
c
t
e
r
a
n
d a
pp
ea
r
a
t th
e
tim
e
E
x
a
min
a
tion
b
ut
ca
n r
e
-
e
nt
e
r spont
a
n
e
ously
.
C
..
G
r
ade
3
:
He
morrhoi
d
s h
a
v
e c
om
e
out of
a
n
a
l
ca
n
a
l
a
n
d ca
n only
e
nt
e
r
Bac
k m
a
nu
a
lly
b
y th
e
p
a
ti
e
nt
.
d
.
G
r
ade
4
:
He
morrhoi
d
s
a
lw
a
ys
c
om
e
out
a
n
d ca
nnot
e
nt
e
r
a
n
a
l
ca
n
a
l
e
v
e
n though it is in
c
lu
ded
m
a
nu
a
lly
2
.
E
xt
e
rn
a
l h
e
morrhoi
d
s
,
c
om
e
from th
e De
nt
a
t
e L
in
e a
n
d c
o
a
t
ed b
y
th
e
mo
d
ifi
ed
mu
c
os
a
l
e
pith
e
lium
a
n
d
m
a
ny inn
e
rv
a
tion fi
be
rs
S
om
a
ti
c
p
a
in n
e
rv
e
s
.
D
i
a
gnosis of
A
pp
ea
l
A
kumin
a
t
a c
on
d
ylom
a
,
P
roxitis
,
Re
kt
a
l
P
rol
a
ps
C
ompli
ca
tions
A
n
e
mi
a
C
ompr
e
h
e
nsiv
e Ma
n
a
g
e
m
e
nt
(
P
l
a
n
)
He
morrhoi
d
m
a
n
a
g
e
m
e
nt
a
t prim
a
ry s
e
rvi
ce
only for h
e
morrhoi
d
gr
ade
1
with m
ed
i
ca
l
c
ons
e
rv
a
tiv
e
th
e
r
a
py
a
n
d a
voi
d a
nti
-
infl
a
mm
a
tory
d
rugs
non
-
st
e
roi
d
s
,
a
s w
e
ll
a
s spi
c
y or f
a
tty foo
d
s
.
A
noth
e
r thing th
a
t
ca
n
be d
on
e
is to r
ed
u
ce
p
a
in
a
n
d c
onstip
a
tion
I
n h
e
morrhoi
d
p
a
ti
e
nts
.
C
ouns
e
ling
a
n
d ed
u
ca
tion
Ed
u
ca
t
e
p
a
ti
e
nts in
a
n
e
ffort to pr
e
v
e
nt h
e
morrhoi
d
s
.
He
morrhoi
d
pr
e
v
e
ntion
ca
n
be d
on
e b
y
:
1
.
25
-
30
gr
a
m fi
be
r
c
onsumption p
e
r
da
y
.
T
his
a
ims to m
a
k
e
f
ece
s
bec
om
e
mor
e
mushy
a
n
d
l
a
rg
e
,
th
e
r
eb
y r
ed
u
c
ing th
e
pro
ce
ss
W
rinking
a
n
d
pr
e
ssur
e
on th
e a
nus v
e
in
.
2
.
D
rink
6
-
8
gl
a
ss
e
s of w
a
t
e
r
a da
y
.
3
.
C
h
a
ng
e
th
e
h
ab
it of
de
f
eca
tion
.
I
n
a
hurry to th
e ba
throom
Fee
ling to
de
f
eca
t
e
,
d
on
'
t
be a
rr
e
st
ed beca
us
e
it will work
f
ece
s
.
A
voi
d
filling
.
Re
f
e
r
e
n
ce c
rit
e
ri
a
:
He
morrhoi
d
int
e
rn
a
l gr
ade
2
,
3
,
a
n
d
4
a
n
d e
xt
e
rn
a
l h
e
morrhoi
d
s n
eed
Ma
n
a
g
e
m
e
nt in s
ec
on
da
ry h
ea
lth s
e
rvi
ce
s
.
E
quipm
e
nt
G
lov
e
P
rognosis
P
rognosis in g
e
n
e
r
a
l
b
on
a
m
He
p
a
titis
a
Hea
lth pro
b
l
e
ms
He
p
a
titis
A
is
a
n
ac
ut
e
inf
ec
tion in th
e
liv
e
r
ca
us
ed b
y h
e
p
a
titis
a
virus
(
Ha
v
),
a RNA
virus th
a
t is
d
istri
b
ut
ed
through or
a
l f
eca
l rout
e
s
.
M
or
e
th
a
n
75
%
of symptom
a
ti
c ad
ults
,
whil
e c
hil
d
r
e
n
<
6
y
ea
rs
70
%
a
symptom
a
ti
c
.
Le
ss th
a
n
1
%
of
ad
ult h
e
p
a
titis
A
suff
e
r
e
rs
de
v
e
lop
Bec
om
e a
fulmin
a
nt h
e
p
a
titis
.
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
2
.
Ye
llow
e
y
e
s
a
n
d
skin
3
.
Dec
r
ea
s
ed a
pp
e
tit
e
4
.
M
us
c
l
e a
n
d
joints
5
.
Wea
k
,
tir
ed
,
a
n
d
l
e
th
a
rgy
.
6
.
Na
us
ea a
n
d
vomiting
7
.
urin
e c
olor lik
e
t
ea
8
.
stools lik
e
putty
R
isk f
ac
tor
1
.
O
ft
e
n
c
onsuming foo
d
or
d
rinks th
a
t
a
r
e
not m
a
int
a
in
ed
s
a
nit
a
tion
.
2
.
U
sing th
e c
utl
e
ry
a
n
d d
rinking from h
e
p
a
titis suff
e
r
e
rs
.
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
.
Feb
ris
2
.
S
kl
e
r
a
ikt
e
rik
3
.
h
e
p
a
tom
e
g
a
ly
4
.
urin
e c
olor lik
e
t
ea
S
upport
1
.
urin
e
l
ab
or
a
tory t
e
st
(
b
iliru
b
in in urin
e
)
2
.
B
loo
d e
x
a
min
a
tion
:
I
n
c
r
ea
s
ed b
iliru
b
in l
e
v
e
ls in th
e b
loo
d
,
l
e
v
e
ls
SGOT a
n
d SGPT
≥
2
x th
e
high
e
st norm
a
l v
a
lu
e
,
d
on
e a
t th
e
f
ac
ility
M
or
e c
ompl
e
t
e
prim
e
rs
.
3
.
I
gm
a
nti
-
h
a
v
(
in s
ec
on
da
ry s
e
rvi
ce
)
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 b
y
a
n
a
mn
e
sis
,
physi
ca
l
e
x
a
min
a
tion
,
a
n
d
S
upporting
e
x
a
min
a
tion
.
D
i
a
gnosis of
A
pp
ea
l
Ob
stru
c
tiv
e
j
a
un
d
i
ce
,
h
e
p
a
titis
B a
n
d ac
ut
e
,
h
e
p
a
ti
c c
irrhosis
C
ompli
ca
tions
He
p
a
titis
A
fulmin
a
nt
,
h
e
p
a
tikum
e
n
ce
ph
a
lop
a
thy
,
c
o
a
gulop
a
thy
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
.
Ade
qu
a
t
e ca
lori
e a
n
d
liqui
d
int
a
k
e
2
.
L
ooks on
bed
3
.
S
imptom
a
ti
c
tr
ea
tm
e
nt
a
.
Fe
v
e
r
:
i
b
uprof
e
n
2
x
400
mg
/
da
y
.
b
r
ea
kf
a
st
.
Na
us
ea
:
a
nti
e
m
e
ti
c
s su
c
h
a
s m
e
to
c
lopr
a
mi
d
3
x
10
mg
/
da
y or
d
omp
e
ri
d
on
3
x
10
mg
/
da
y
.
C
..
S
tom
ac
h sor
e a
n
d b
lo
a
ting
:
h
2
b
lo
c
k
e
r
(
sim
e
ti
d
in
e
3
x
200
mg
/
da
y or
2
x r
a
niti
d
in
e
150
mg
/
da
y
)
or proton pump inhi
b
itor
(
om
e
pr
a
zol
e
1
x
20
mg
/
da
y
).
F
ollow up pl
a
n
Pe
rio
d
i
ca
lly
c
ontrols to
a
ss
e
ss th
e
r
e
sults of tr
ea
tm
e
nt
.
C
ouns
e
ling
a
n
d ed
u
ca
tion
1
.
Sa
nit
a
tion
a
n
d
hygi
e
n
e a
r
e ab
l
e
to pr
e
v
e
nt vir
a
l tr
a
nsmission
.
2
.
Vacc
in
a
tion of h
e
p
a
titis
A
is giv
e
n to high
-
risk p
e
opl
e
inf
ec
t
ed
.
3
.
T
h
e
f
a
mily h
e
lps m
a
int
a
in
ade
qu
a
t
e ca
lori
e
int
a
k
e
,
a
n
d
L
imit p
a
ti
e
nt physi
ca
l
ac
tivity
d
uring th
e ac
ut
e
ph
a
s
e
.
Re
f
e
r
e
n
ce c
rit
e
ri
a
1
.
A d
i
a
gnosis
e
nfor
ce
m
e
nt with
a
l
ab
or
a
tory support
c
h
ec
k
2
.
He
p
a
titis
A
suff
e
r
e
rs with
c
ompl
a
ints of high
-
l
e
v
e
l ikt
e
rik
acc
omp
a
ni
ed
O
th
e
r
c
ompl
a
ints
.
3
.
He
p
a
titis
A
suff
e
r
e
rs with
a dec
r
ea
s
e
in
a
w
a
r
e
n
e
ss with th
e
possi
b
ility
tow
a
r
d
s h
e
p
a
ti
c e
n
ce
ph
a
lop
a
thy
.
E
quipm
e
nt
R
outin
e b
loo
d
l
ab
or
a
tori
e
s
,
routin
e
urin
e a
n
d
h
ea
rt fun
c
tion
c
h
ec
ks
P
rognosis
T
h
e
prognosis is g
e
n
e
r
a
lly
b
on
a
m
He
p
a
titis
B
Ma
s
a
l
a
hk
e
s
e
h
a
t
a
n
He
p
a
titis
B
is
a
virus th
a
t
a
tt
ac
ks th
e
h
ea
rt
,
e
nt
e
rs
b
loo
d
or
b
o
d
y flui
d
s from som
e
on
e
inf
ec
t
ed
.
T
his virus is wi
de
spr
ead
throughout
T
h
e
worl
d
with
d
iff
e
r
e
nt in
c
i
de
n
ce
.
He
p
a
titis pr
e
v
a
l
e
n
ce
l
e
v
e
l
B
in
I
n
d
on
e
si
a
v
a
ri
e
s gr
ea
tly
b
y
2
.
5
%
in
Ba
nj
a
rm
a
sin to
25
.
61
%
in
K
up
a
ng
,
so it is in
c
lu
ded
in th
e
st
a
t
e
group with
e
n
de
mi
c
ity
m
ed
ium to high
.
He
p
a
titis
B
inf
ec
tion
ca
n
be
in th
e
form of
ac
ut
e c
on
d
itions with symptoms
l
a
st l
e
ss th
a
n
6
months
.
I
f th
e
journ
e
y of th
e d
is
ea
s
e
t
a
k
e
s pl
ace
M
or
e
th
a
n
6
months
,
w
e ca
ll
c
hroni
c
h
e
p
a
titis
(
5
%
).
He
p
a
titis
B
C
hroni
c
l
e
s
ca
n
de
v
e
lop into h
e
p
a
ti
c c
irrhosis
,
10
%
of
c
irrhosis
T
h
e
h
e
p
a
tis will
de
v
e
lop into
a
mom
a
.
A
n
a
mn
e
sis
(
su
b
j
ec
tiv
e
)
r
e
sults
A c
ompl
a
int
1
.
Ge
n
e
r
a
lly
d
o
e
s not
ca
us
e
symptoms
e
sp
ec
i
a
lly in
c
hil
d
r
e
n
.
2
.
S
ymptoms
a
ris
e
if som
e
on
e
h
a
s
bee
n inf
ec
t
ed
for
6
w
ee
ks
,
be
tw
ee
n
oth
e
rs
:
a
.
g
a
stroint
e
stin
a
l
d
isor
de
rs
,
su
c
h
a
s
:
m
a
l
a
is
e
,
a
nor
e
xi
a
,
n
a
us
ea a
n
d
vomiting
;
b
r
ea
kf
a
st
.
S
ymptoms of flu
:
c
ough
,
photofo
b
i
a
,
h
eadac
h
e
,
mi
a
lgi
a
.
3
.
P
ro
d
rom
a
l symptoms lik
e
th
e ab
ov
e
will
d
is
a
pp
ea
r wh
e
n y
e
llow
a
ris
e
,
B
ut th
e c
ompl
a
ints of
a
nor
e
xi
a
,
m
a
l
a
is
e
,
a
n
d
w
ea
kn
e
ss
ca
n s
e
ttl
e
.
4
.
T
h
e
j
a
un
d
i
ce
is pr
eceded b
y th
e a
pp
ea
r
a
n
ce
of
da
rk urin
e
.
P
ruritus
(
U
su
a
lly mil
d a
n
d
t
e
mpor
a
ry
)
ca
n
a
ris
e
wh
e
n th
e
j
a
un
d
i
ce
in
c
r
ea
s
e
s
.
W
h
e
n th
e
y
e
llow
b
o
d
y
,
it is usu
a
lly follow
ed b
y th
e e
nl
a
rg
ed
h
ea
rt
follow
ed b
y p
a
in wh
e
n pr
e
ss
ed
on th
e
upp
e
r right
abd
om
e
n
.
A
ft
e
r
T
h
e
s
e
symptoms will
a
ris
e
th
e
r
e
solution ph
a
s
e
.
R
isk f
ac
tor
1
.
Ha
ving
a
s
e
xu
a
l s
e
x with p
e
opl
e
who h
a
v
e a
lr
ead
y
I
nf
ec
t
ed
with
He
p
a
titis
B
.
2
.
us
e
syring
e
s
a
lt
e
rn
a
t
e
ly
e
sp
ec
i
a
lly to
Ab
sorption of inj
ec
tion
d
rugs
.
3
.
U
s
e
th
e
usu
a
l tools to hurt tog
e
th
e
r with
He
p
a
titis
B
.
4
.
Pe
opl
e
who work in pl
ace
s
e
xpos
ed
to
b
loo
d
hum
a
ns
.
5
.
Pe
opl
e
who h
a
v
e e
v
e
r r
ece
iv
ed b
loo
d
tr
a
nsfusions
be
for
e be
ing
d
on
e
S
orting
d
onors
.
6
.
Pa
ti
e
nts with ki
d
n
e
y f
a
ilur
e
un
de
rgoing h
e
mo
d
i
a
lysis
.
7
.
C
hil
d
r
e
n
b
orn
b
y moth
e
rs who suff
e
r from h
e
p
a
titis
B
.
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
.
c
onjun
c
tiv
a
ikt
e
rik
2
.
E
nl
a
rg
e
m
e
nt
a
n
d a
littl
e
t
e
n
de
rn
e
ss in th
e
h
ea
rt
3
.
S
pl
e
nom
e
g
a
ly
a
n
d
lymph
ade
nop
a
thy
a
t
15
-
20
%
of p
a
ti
e
nts
S
upport
1
.
urin
e
l
ab
or
a
tory t
e
st
(
b
iliru
b
in in urin
e
)
2
.
B
loo
d e
x
a
min
a
tion
:
I
n
c
r
ea
s
ed b
iliru
b
in l
e
v
e
ls in th
e b
loo
d
,
l
e
v
e
ls
SGOT a
n
d SGPT
≥
2
x th
e
high
e
st norm
a
l v
a
lu
e
,
ca
rri
ed
out on prim
a
ry f
ac
iliti
e
s
M
or
e c
ompl
e
t
e
.
3
.
Hb
s
a
g
(
in s
ec
on
da
ry h
ea
lth s
e
rvi
ce
s
)
Pe
ng
e
k
a
n
d
i
aG
nosti
c
(
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 b
y
a
n
a
mn
e
sis
,
physi
ca
l
e
x
a
min
a
tion
,
a
n
d
S
upporting
e
x
a
min
a
tion
.
D
i
a
gnosis of
A
pp
ea
l
Hea
rt
ed Feed
n
e
ss
,
L
iv
e
r
D
is
ea
s
e Beca
us
e
of th
e d
rug or toxin
,
h
e
p
a
titis
A
utoimmun
e
,
a
l
c
oholi
c
h
e
p
a
titis
,
ac
ut
e
o
b
stru
c
tion of th
e B
ili
a
ris tr
ac
t
C
ompli
ca
tions
L
iv
e
r
c
irrhosis
,
h
e
p
a
tom
a
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
.
Ade
qu
a
t
e ca
lori
e a
n
d
liqui
d
int
a
k
e
2
.
L
ooks on
bed
3
.
S
imptom
a
ti
c
tr
ea
tm
e
nt
a
.
Fe
v
e
r
:
i
b
uprof
e
n
2
x
400
mg
/
da
y
.
b
r
ea
kf
a
st
.
Na
us
ea
:
a
nti
e
m
e
ti
c
s su
c
h
a
s m
e
to
c
lopr
a
mi
d
3
x
10
mg
/
da
y or
d
omp
e
ri
d
on
3
x
10
mg
/
da
y
.
C
..
S
tom
ac
h sor
e a
n
d b
lo
a
ting
:
h
2
b
lo
c
k
e
r
(
sim
e
ti
d
in
e
3
x
200
mg
/
da
y or
2
x r
a
niti
d
in
e
150
mg
/
da
y
)
or proton pump inhi
b
itor
(
om
e
pr
a
zol
e
1
x
20
mg
/
da
y
).
F
ollow up pl
a
n
Pe
rio
d
i
ca
lly
c
ontrols to
a
ss
e
ss th
e
r
e
sults of tr
ea
tm
e
nt
.
Re
f
e
r
e
n
ce c
rit
e
ri
a
1
.
E
nfor
ce
m
e
nt
d
i
a
gnosis with
a
l
ab
or
a
tory support
c
h
ec
k
Sec
on
da
ry
Hea
lth
Se
rvi
ce
s
2
.
He
p
a
titis
B
suff
e
r
e
rs with
c
ompl
a
ints of highlings th
a
t s
e
ttl
ed acc
omp
a
ni
ed
O
th
e
r
c
ompl
a
ints
.
C
ouns
e
ling
a
n
d ed
u
ca
tion
1
.
G
iv
e ed
u
ca
tion to th
e
f
a
mily to support p
a
ti
e
nts to r
e
gul
a
rly
Ta
k
e
m
ed
i
ca
tion
d
u
e
to long
-
t
e
rm tr
ea
tm
e
nt
.
2
.
I
n th
e ac
ut
e
ph
a
s
e
,
th
e
f
a
mily p
a
rti
c
ip
a
t
e
s in m
a
int
a
ining
ca
lori
e
int
a
k
e a
n
d
flui
d
ade
qu
a
t
e
,
a
n
d
limit th
e
physi
ca
l
ac
tivity of th
e
p
a
ti
e
nt
.
3
.
P
r
e
v
e
ntion of tr
a
nsmission on f
a
mily m
e
m
be
rs with p
a
tt
e
rn mo
d
ifi
ca
tions
L
if
e
for pr
e
v
e
ntion of tr
a
nsmission
a
n
d
immuniz
a
tion
.
E
quipm
e
nt
R
outin
e b
loo
d
l
ab
or
a
tori
e
s
,
routin
e
urin
e a
n
d
insp
ec
tion of liv
e
r fun
c
tion
.
