Abdominal Pain + Diarrhea + Vomiting: Diagnosis & Management

Step 1 - Differential Diagnosis

Key red flag: If peritoneal signs (rebound, guarding, rigidity) are present - do NOT label as gastroenteritis. Pursue surgical workup urgently. - Tintinalli's Emergency Medicine

Step 2 - History & Physical Exam Focus

• Onset, duration, frequency of stools, presence of blood/mucus
• Associated fever (suggests bacterial or invasive pathogen)
• Recent food intake (timing matters: 1-6 h = preformed toxin; 8-24 h = bacterial; >24 h = viral/parasitic)
• Travel history (traveler's diarrhea - ETEC most common cause)
• Antibiotic use (C. difficile risk)
• Contact with sick individuals, day care, institutionalized settings
• Immunocompromised state (HIV, transplant, steroids)

Step 3 - Investigations

Step 4 - Management

A. Rehydration (First Priority)

• Use hypotonic ORS (WHO-modified 245 mOsm solution)
• Mild dehydration: 50 mL/kg over 4 hours
• Moderate dehydration: 100 mL/kg over 4 hours
• IV fluids (isotonic, e.g., Lactated Ringer's): reserved for severe dehydration, intractable vomiting, or shock - give 20 mL/kg bolus
• Replace ongoing losses: 5-10 mL/kg per loose stool

B. Antiemetics

• Ondansetron (Zofran): 0.15 mg/kg (max 8 mg) PO or IV - safe, reduces IV fluid needs and hospitalization
• Mechanism: blocks 5-HT3 receptors on intestinal vagal afferents
• Reduces vomiting and improves tolerance of ORT

C. Diet

• Continue feeding - fasting worsens bowel absorptive capacity
• Restart age-appropriate diet as soon as tolerated (BRAT diet no longer recommended as it has low nutritional value)
• Continue breastfeeding in infants
• Avoid hyperosmolar sports drinks (worsen osmotic diarrhea)

D. Antimotility Agents

• Loperamide: can be used in adults with mild-moderate watery diarrhea (no fever/blood)
• Avoid in fever, bloody stools, suspected Shiga toxin-producing E. coli (increases HUS/TTP risk), or children
• If used with fever/bloody stools, must combine with antibiotics

E. Antibiotics - Pathogen-Specific

Step 5 - Admission vs. Discharge

• Moderate-severe dehydration not responding to ORT
• Intractable or bilious vomiting
• Suspected surgical condition (peritoneal signs)
• Significant laboratory abnormalities, neurologic changes (seizures, lethargy)
• Extremes of age (infants <3 months, elderly)
• Immunocompromised patients
• C. difficile with toxic megacolon features

• Mild/no dehydration, tolerating ORT
• No red flags on history or exam
• Adequate home support; give written instructions to return if unable to tolerate fluids, bilious vomiting, worsening dehydration

Step 6 - Common Pathogens Summary

Management of Acute Gastroenteritis (Short)

1. Rehydration

• Mild-Moderate: Oral Rehydration Solution (ORS) - WHO 245 mOsm
• Severe/intractable vomiting: IV Lactated Ringer's or Normal Saline 20 mL/kg bolus
• Replace ongoing losses: 5-10 mL/kg per loose stool

2. Antiemetics

• Ondansetron 0.15 mg/kg (max 8 mg) PO/IV

3. Diet

• Continue feeding early - do NOT fast
• Continue breastfeeding in infants
• Avoid sugary drinks/fruit juice

4. Antimotility (adults only)

• Loperamide - only for watery diarrhea, no fever, no blood
• Avoid in children and suspected STEC (E. coli O157:H7)

5. Antibiotics (selective, not routine)

6. Admit if:

• Severe dehydration, bilious vomiting, peritoneal signs
• Infants <3 months, elderly, immunocompromised
• Unable to tolerate ORT at home

7. Discharge if:

• Mild dehydration, tolerating ORS, no red flags
• Give written instructions to return if worsening

Inj. EELD-VIT-12 - What It Is & How to Use

What Is It?

What Is It Used For?

How to Use (Step by Step)

1. Mix the contents of Part 1 (yellow ampoule - Vitamin C) with Part 2 (red/brown ampoule - B12 + Folic acid + Nicotinamide) in one syringe
2. Check the solution - do NOT use if particles are visible or solution is cloudy
3. Administer by:
   • IM injection - usually given in the deltoid (upper arm) or gluteus muscle
   • IV drip - diluted and administered slowly
4. Dose: As directed by the physician (label states "as directed by physician")

Important Cautions

• Must be given by a qualified healthcare professional (doctor or nurse) - not for self-injection
• Do not use if the solution has visible particles or discoloration
• Store in a cool, dark place - away from sunlight (light degrades B12 and Vitamin C)
• Keep out of reach of children
• Prescription only - do not use without medical advice

Relevance to Your Gastroenteritis Patient

• Vomiting and diarrhea deplete water-soluble vitamins (B12, C, folate)
• Helps in recovery and nutritional rehabilitation
• Vitamin C supports immune function and tissue repair

Management of Gastro-Duodenitis

Step 1 - Investigations (First)

Note: H. pylori is present in up to 90% of duodenal/antral disease cases. All positive patients must be treated. - Current Surgical Therapy 14e

Step 2 - Medical Management

A. Acid Suppression (Mandatory)

PPI is the backbone of treatment - heals mucosal oedema and inflammation

B. Antacid (Symptomatic Relief)

• Syrup Antacid (Magnesium hydroxide + Aluminium hydroxide) - 10 mL, 3 times/day after meals + at bedtime
• Or Sucralfate 1 g, 3-4 times/day - coats and protects the inflamed mucosa

C. Antiemetic (for nausea/vomiting)

• Ondansetron 4-8 mg PO/IV 8-hourly as needed
• Or Domperidone 10 mg before meals (also improves gastric motility)

D. Antispasmodic (for abdominal cramps)

• Dicyclomine (Mebeverine) 10-20 mg, 3 times/day
• Or Hyoscine butylbromide (Buscopan) 10 mg, 3 times/day

Step 3 - If H. pylori Positive: Eradication Therapy

• PPI + Bismuth subcitrate + Tetracycline + Metronidazole for 10-14 days

Confirm eradication with urea breath test or stool antigen test 4 weeks after completing antibiotics - Current Surgical Therapy 14e

Step 4 - Lifestyle & Diet Advice

Step 5 - Vitamins / Supportive

• This is appropriate to correct any nutritional deficiency from poor intake/vomiting
• Continue Multivitamin + B-complex tablet orally once daily for 4-6 weeks

Step 6 - Red Flags - Refer/Admit If:

• Severe pain, unable to eat/drink
• Hematemesis (vomiting blood) or melaena (black stools)
• Signs of perforation (rigid abdomen, peritoneal signs)
• No improvement after 2 weeks of treatment
• Weight loss, anemia - consider upper GI endoscopy urgently

Summary Prescription (Short)

How to Give Inj. EELD-VIT-12

Route

Equipment Needed

• 2 ampoules (Part 1 - yellow/orange + Part 2 - red/brown)
• 1 sterile syringe (3-5 mL)
• 2 needles (drawing needle + injection needle 21-23G)
• Alcohol swabs
• Gloves

Step-by-Step for IM Injection

Step 1 - Prepare

• Wash hands thoroughly
• Wear gloves
• Check expiry date (this one: EXP 04/2027 - valid)
• Check both ampoules for particles or discoloration - do NOT use if cloudy or particles visible

Step 2 - Mix the Two Ampoules

1. Tap both ampoules gently to bring liquid to the bottom
2. Score and snap open Part 1 (yellow ampoule - Vitamin C, 1.5 mL)
3. Draw all 1.5 mL into the syringe
4. Score and snap open Part 2 (red/brown ampoule - B12 + Folic Acid, 1 mL)
5. Draw all 1 mL into the same syringe
6. Total volume = 2.5 mL - mix gently by rolling syringe between palms
7. Check mixed solution - it should be clear, no particles

Step 3 - Choose Injection Site

• Deltoid muscle (upper outer arm) - for small volumes
• Gluteus medius (upper outer quadrant of buttock) - preferred for 2.5 mL
• Vastus lateralis (outer thigh) - alternative

For 2.5 mL volume, gluteal (buttock) site is preferred

Step 4 - Clean the Site

• Clean with alcohol swab in a circular motion
• Wait 20-30 seconds to dry

Step 5 - Inject

• Stretch the skin (for lean patients) or use Z-track method (pinch)
• Insert needle at 90° angle firmly
• Aspirate - pull back plunger slightly; if blood appears, withdraw and change site
• If no blood - inject slowly and steadily
• Withdraw needle quickly, apply gentle pressure with swab
• Do NOT massage (may cause irritation)

Step 6 - Dispose

• Cap needle and discard in sharps container
• Document time, site, and patient response

Frequency / Dose

• As directed by the physician (label states this)
• Typically: Once daily or alternate days for 5-10 days (for deficiency/recovery)

Important Cautions

This injection must be given by a trained nurse or doctor. Do not attempt to self-administer at home without proper training.

Which IV Drip to Use for Inj. EELD-VIT-12

Compatible IV Fluids

Preferred Method

Normal Saline 100 mL + EELD-VIT-12 (both ampoules mixed)

How to Set Up the IV Drip

Step 1 - Prepare

• Take Normal Saline 100 mL IV bag/bottle
• Mix Part 1 + Part 2 of EELD-VIT-12 into a syringe (total 2.5 mL)

Step 2 - Add to Drip

• Clean the rubber port of the NS bag with alcohol swab
• Inject the 2.5 mL of mixed EELD-VIT-12 into the NS 100 mL bag through the port
• Gently invert the bag 2-3 times to mix

Step 3 - Administer

• Connect IV line, run over 30-60 minutes (slow drip)
• Do NOT give as IV bolus/push - must be diluted and given slowly
• Monitor patient during infusion for any reaction

Infusion Rate

Important Points

• Protect from light during infusion - Vitamin B12 and Vitamin C are light-sensitive; cover the bag with dark cloth/foil if possible
• Do not mix with alkaline solutions (e.g., Sodium Bicarbonate)
• Do not mix with aminophylline or furosemide in the same drip
• Give fresh - do not store after mixing
• Watch for: redness at IV site, rash, flushing - stop if any reaction occurs

Injections for Abdominal Pain Relief in Gastro-Duodenitis

1. Antispasmodic (First Choice - Safest)

Inj. Hyoscine Butylbromide (Buscopan)

• Dose: 20 mg IM or slow IV
• Route: IM or diluted in 100 mL NS slow IV
• Frequency: 3 times/day as needed
• Action: Relaxes smooth muscle spasm in stomach/intestine
• Best for: Crampy, colicky abdominal pain
• Safe: No ulcer risk, no gastric side effects ✅

Inj. Dicyclomine (Cyclopam)

• Dose: 10 mg IM
• Route: IM only
• Frequency: 8-hourly as needed
• Action: Anticholinergic - reduces intestinal spasm
• Best for: Stomach cramps, colic pain ✅

2. Analgesic + Antispasmodic Combination

Inj. Diclofenac + Pitofenone (Spasmonil/Baralgan)

• Dose: 2 mL IM or slow IV in 100 mL NS
• Route: IM or IV drip
• Caution: ⚠️ Avoid if gastric ulcer suspected - NSAID component may worsen gastritis

3. Non-NSAID Analgesic

Inj. Paracetamol (Perfalgan) 1000 mg / 100 mL

• Dose: 1000 mg (1 vial = 100 mL) slow IV over 15 minutes
• Frequency: Every 6-8 hours
• Safe for stomach: Yes - no gastric irritation ✅
• Best for: Moderate pain, when NSAIDs are contraindicated

Inj. Tramadol 50-100 mg

• Dose: 50-100 mg diluted in 100 mL NS, slow IV over 30 min
• Route: IM or slow IV
• Frequency: 8-12 hourly
• Use: Moderate to severe pain
• Caution: May cause nausea/vomiting ⚠️

4. Antiemetic + Pain (Combined benefit)

Inj. Metoclopramide (Perinorm) 10 mg

• Dose: 10 mg IM or slow IV
• Frequency: 8-hourly
• Action: Reduces nausea + improves gastric motility
• Useful: When pain is with nausea/vomiting ✅

Inj. Ondansetron 4 mg

• Dose: 4 mg slow IV
• Frequency: 8-hourly
• Best for: Nausea and vomiting with pain ✅

5. PPI Injection (Reduces Acid = Reduces Pain)

Inj. Pantoprazole 40 mg

• Dose: 40 mg in 100 mL NS, IV over 15-30 minutes
• Frequency: Once or twice daily
• Action: Suppresses acid - directly reduces burning/pain from gastro-duodenitis ✅
• Most important injection for this condition

Recommended Protocol for This Patient (Gastro-Duodenitis)

⚠️ Avoid in Gastritis/Gastro-Duodenitis

Drotaverine vs Dicyclomine - Comparison

Inj. Drotaverine - How to Use

Available Forms

• Inj. Drotaverine 40 mg/2 mL ampoule (most common in India)

Dose

How to Give IV Drip

• Mix 40-80 mg Drotaverine in 100 mL Normal Saline
• Give over 30 minutes as slow IV drip
• Never give as IV bolus - may cause hypotension

Can You Combine with Other Drugs in Same Drip?

Recommended Protocol (Updated) for This Patient

Bottom Line

Drotaverine is preferred over Dicyclomine for GI spasm because it is:

• More effective at relaxing gut smooth muscle
• Has far fewer side effects (no anticholinergic effects)
• Safer in most patients including elderly, pregnant women, and those with glaucoma/BPH
• Very commonly used in India for abdominal colic and gastro-duodenitis