Rosen & Barkin's 5-Minute Emergency Medicine Consult (46 page)

• Metronidazole: 500–750 mg (peds: 30–50 mg/kg/24 h) PO/IV q8h for 5–10 d
  
• Tinidazole: 2 g/d (peds: 50–60 mg/kg/d) PO for 3–6 d. For children older than 3 yr
  

• Chloroquine: 1,000 mg/d PO for 2 d then 500 mg/d PO for 14 d; or 200 mg IM for 10–12 d
  
• Erythromycin: 250–500 mg (peds: 30–50 mg/kg/24 h) PO q6h for 10–14 d
  
• Iodoquinol: 650 mg PO q8h for 20 d
  
• Nitazoxanide: 500 mg PO q12. for 3 d (10 d if liver abscess) for children >12 yr
  
• Paromomycin: 500 mg (peds: 25–30 mg/kg/24 h) PO q8h for 5–10 d
  
• Tetracycline: 250–500 mg (peds[>12 yr]: 25–50 mg/kg/24 h) PO q6h for 10 d
  

• Chloroquine and iodoquinol are contraindicated.
  
• Tetracycline contraindicated in children <8 yr
  

Use erythromycin or nitazoxanide only.

FOLLOW-UP

• Shock, sepsis, or peritonitis
  
• Hypotension or tachycardia unresponsive to IV fluids
  
• Children with >10% dehydration
  
• Severe electrolyte imbalance
  
• Patients unable to maintain adequate oral hydration:
  
  • Extremes of age, cognitive impairment, significant comorbid illness
    
• Fulminant colitis or toxic megacolon
  
• Bowel obstruction
  
• Extraintestinal abscesses
  
• Failure of outpatient regimen
  

• Nontoxic presentation of acute or chronic dysentery
  
• Able to maintain adequate oral hydration and medication compliance
  
• Dehydration responsive to IV fluids
  

Consult surgery if evidence of peritonitis, toxic megacolon, colonic perforation, or liver abscess.

• Gastroenterology and infectious disease follow-up in 7 days for repeat serology and possible endoscopic evaluation.
  
• Physical exam in 14 days to assess for treatment effectiveness and for development of complications or extraintestinal disease.
  

• Avoid antidiarrheal medications
  
• Always give double therapy with both a systemic amebicidal (metronidazole, tinidazole, or chloroquine) plus an intestinal amebicidal (erythromycin, iodoquinol, nitazoxanide, paromomycin, or tetracycline) unless contraindicated.
  
• Always be vigilant for high-mortality complications such as fulminant colitis or extraintestinal disease.
  

• Chavez-Tapia NC, Hernandez-Calleros J, Tellez-Avila FI, et al. Image-guided percutaneous procedure plus metronidazole versus metronidazole alone for uncomplicated amoebic liver abscess.
  Cochrane Database Syst Rev
  . 2009;1:CD004886. doi:10.1002/14651858.CD004886.pub2.
  
• Escobedo AA, Almirall P, Alfonso M, et al. Treatment of intestinal protozoan infections in children.
  Arch Dis Child
  . 2009;94:478–482.
  
• Fotedar R, Stark D, Beebe N, et al. Laboratory diagnostic techniques for
  Entamoeba
  species.
  Clin Microbiol Rev
  . 2007;20:511–532.
  
• Gonzalez MLM, Dans LF, Martinez EG. Antiamoebic drugs for treating amoebic colitis.
  Cochrane Database Syst Rev
  . 2009;2:CD006085. doi:10.1002/14651858.CD006085.pub2.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Diarrhea
  
• Gastroenteritis
  

CODES

• 006.0 Acute amebic dysentery without mention of abscess
  
• 006.1 Chronic intestinal amebiasis without mention of abscess
  
• 006.9 Amebiasis, unspecified
  

BASICS

• Absence of menstruation
  
• Primary amenorrhea:
  
  • No spontaneous uterine bleeding by age 16 yr or within 5 yr of breast development, which should occur by age 13.
    
• Secondary amenorrhea:
  
  • Absence of uterine bleeding for 3 mo in a woman with prior regular menses or for 9 mo in a woman with prior oligomenorrhea
    
  • More common than primary amenorrhea
    
  • Pregnancy is the most common cause.
    

• Primary:
  
  • Gonadal failure
    
  • Hypothalamic-pituitary disorder
    
  • Chromosomal abnormalities
    
  • Imperforate hymen
    
  • Turner syndrome
    
• Secondary:
  
  • Pregnancy, breast-feeding, or postpartum
    
  • Asherman syndrome (intrauterine adhesions)
    
  • Dysfunction of the hypothalamic-pituitary-ovarian axis
    
  • Polycystic ovarian syndrome (PCOS)
    
  • Endocrinopathies
    
  • Obesity, starvation, anorexia nervosa, or intense exercise
    
  • Drugs:
    
    • Oral contraceptives
      
    • Antipsychotics
      
    • Antidepressants
      
    • Calcium channel blockers
      
    • Chemotherapeutic agents
      
    • Digitalis
      
    • Marijuana
      
  • Autoimmune disorders
    
  • Ovarian failure
    
  • Menopause
    

DIAGNOSIS

• Menarche and menstrual history
  
• Sexual activity
  
• Exercise, weight loss
  
• Chronic illness
  
• Medications
  
• Previous CNS radiation or chemotherapy
  
• Family history
  
• Infertility
  

• Low estrogen:
  
  • Atrophic vaginal mucosa
    
  • Mood swings, irritability
    
• High androgen:
  
  • Truncal obesity
    
  • Hirsutism
    
  • Acne
    
  • Male-pattern baldness
    
• Thyroid exam
  
• Pelvic/genital exam
  
• Tanner staging
  

Pregnancy test

• If pregnancy test is negative, no further testing is needed emergently.
  
• May send TSH, prolactin, LH, FSH for follow-up by gynecology or primary care physician
  

None needed emergently unless concern for ectopic pregnancy or other emergency as directed by patient’s presentation

None needed emergently

Pregnancy

TREATMENT

If amenorrhea is the result of pregnancy, stabilize patient as appropriate for pregnancy.

Reassurance and referral for follow-up

Defer for gynecology evaluation.

FOLLOW-UP