definisi: passage of abnormally liquid or unformed stools at an increased freque

ncy
- for adults on typical western diet: >200 gram per hari
- akut <2 minggu, persisten 2-4 minggu, kronik >4 minggu
- pseudodiare: sering tapi sedikit: rectal urgency, bisa jg IBS atau proctitis
- fecal incontinence: neuromuskular
- overflow diarrhea: krna impaksi fekal yg teraba pada RT
-----------------------
Diare akut
Ex:
1. Infectious agents (90%)
- ggn flora usus krna antibiotik: Clostridium difficile
- 5 high risk group:
a. traveler:
+ amerika latin, afrika, asia: ETEC, EAEC, campylobacter, shigella, aeromonas
, norovirus, coronavirus, salmonella
+ russia: giardia
+ nepal: cyclospora
+ campers, backpackers, swimmers: giardia
+ cruise ships: norovirus
b. consumers of certain foods
+ picnic, banquet, restaurant: salmonella, campylobacter, shigella from chick
en
+ undercooked hamburger: EHEC
+ fried rice or reheated food: Bacillus cereus
+ mayonnaise or creams: staph aureus, salmonella
+ eggs: salmonella
+ uncooked foods or soft cheese: listeria
+ seafood, esp raw: vibrio species, salmonella, hep A
c. Imunodef
i. primary imunodef: IgA deficiency, hipogamaglobulinemia, kronik granulomato
us disease
ii. secondary immunodef: AIDS, senescence, supresi obat2
+ enteric patogen: mikobakterium, virus (CMV, adenovir, herpes simp), protozo
a (cryptosporid, isospora belli, microsporodia, blastocystis hominis)
+ per rectum venereally: gonore, treponema palidum, klamidia: proctitis
+ hemokromatosis: jauhi ikan mentah: vibrio, yersinia
d. daycare attendees and family members: shigella, giardia, cryptosporid, rota
virus
e. institutionalized person: C. difficile (pada pengguna antibiotik dan yg buk
an -> acquired dari community)
DD:
- profuse, watery (hipersekresi small bowel): toksin bakteri, bakteri produksi
enterotoksin, patogen enteroaderen
- with vomiting:
+ less vomitnig
+ more cramping or bloating, fever is higher => cytotoxin producing and invasi
ve micro
- bloody diarrhea: invasive bact and E. histolytica
- yersinia:
+ terminal ileal & proximal colon -> nyeri perut dan nyeri tekan (mirip app)
+ bisa jg jadi: autoimmune type tiroiditis, perikarditis, GNA
- salmonella, campylobacter, shigella, yersinia: reactive arthritis, arthritis,
urethritis, conjunctivitis
- EHEC, shigella -> HUS
2. Other cause
- medications: AB, cardiac antidisritmik, anti hpt, NSAID, dll
 - occlusive or nonocclusive ischemic collitis
+ >50 thn
+ awalnya nyeri perut bawah -> diare cair -> diare berdarah
+ lanjut dgn perubahan inflamasi sigmoid or left colon, sparing the rectum
- divertikulitis dan graft-versus-host disease
- toxins: organofosfat insektisida, amanita dan jamur lain, arsenic, toksin di
seafood (cigatera dan scombroid)
- anafilaktik
- penyebab2 diare kronik: IBD, dll
---------------------
Approach:
- biasanya self limiting
- nanti evaluasi kalo:
+ dehidrasi
+ >38.5 deg
+ >48 jam tanpa perubahan
+ penggunaan antibiotik belakangan ini
+ wabah
+ nyeri perut hebat pada pasien >50 thn
+ lansia (>70 thn) atau imunokompromis
1. An dan PF: infeksi or non infeksi
a likely non infeksi: evaluasi dan tangani
b likely infeksi: no. 2
2. gejala?
a mild: observasi
+ resolves
+ persists*: stool microbiology studies
b moderate (aktivitas terhambat): >38.5? berdarah? leukosit feses? imunokomp/el
derly?
i. no: antidiare
+ resolves
+ persists*: stool microbiology studies
ii. yes: stool microbiology studies
c. severe: stool microbiology studies
- ada patogen: specific treatment $
- tdk ada patogen: empiric treatment + further evaluation
*: tambah metro
$: tambah kuinolon
Pemeriksaan:
- kultur bakteri/viral
- direct inspection for ova and parasites
- imunoassay: toksin bakteri tttu (C. dificile), antigen virus (rotavirus), ant
igen protozoa (giardia, E. histolitika)
- sigmoidoscopy dan biopsi + endoskopi duodenal, aspirasi dan biopsi: diare per
sisten yg stool studies unrevealing
- exclude IBD, colitis, diverticulitis, partial bowel obstr: sigmoidoskopi, kol
onoskopi, CT abdomen (or other imaging)
Diare persisten:
- biasanya giardia
- C. difficile, E. histolytica, cryptosporidium, campylobacter
-----------------------------
Tx:
 - cairan dan elektrolit
- antimotilitas dan antisekretorik (loperamid): moderately severe nonfebrile an
d nonbloody
- vomiting and diarrhea: bismuth subsalicylate (not to imunokompromis or renal
impairment: bismuthencepalopathy)
- AB:
+ empirik: sipro 2x500 mg 3-5 hari; metro 4x250 mg 7 hari
+ spesifik
+ tdk ditemukan patogen pada stool: beri pada imunokompromise, mechanical hear
t valves or recent vascular graft or elderly
===================
===================
Kronik
Ex:
1. Secretory: watery, large volume output, painless, persist with fasting (no ma
labsorbed solute -> osmolalitas feses no fecal osmotic gap)
- laksatif stimulan eksogen
- ingestion etanol kronik -> injury enterosit + impaired sodium and water abs,
rapid transit, dll
- laksatif endogen (dihydroxy bile acids)
- idiopathic secretory diarrhea:
+ ileitis Crohn's or resection of <1 m terminal ileum: dihydroxy bile acid lol
os dari absorbsi -> cholorrheic diarrhea
- certain bacterial inf
- bowel resection, disease or fistula (^ absorption):
+ tdk ada surface yg cukup utk reabsorbsi cairan dan elektrolit yg tersekresi
+ worsen with eating
- partial bowel obstruction or fecal impaction
+ paradoxically hipersekresi fluid
- hormone producing tumors
+ carcinoid: pelepasan sekretagog poten intestine (serotonin, histamin, PG, br
bgai kinin)
= metastatic GI ca tumor
= primary bronchial carcinoid: watery diare alone or + flushing, wheezing, di
spnea, right sided valvular heart disease
+ pellagra-liike skin lession: overproduksi serotonin dan deplesi niasin
+ VIPoma: tumor sel non-Beta pankreas
= volume diare >3 L/hari-20 L
= pancreatic cholera: hypokalemia, akloridria syndrome
+ ca medula tiroid:
= ec kalsitonin, other secretory peptide atau prostaglandin
= prominent diare -> biasanya sdh ada metastasis, dan prognosis jelek
+ colorectal villous adenoma: mediated by prostaglandin
= bisa diinhibisi NSAID
+ sistemik mastositosis
= berhubungan dgn urtikaria pigmentosa
- mediated by histamin or inflamasi krna infiltrasi sel mast
+ gastrinoma
= ulkus peptik refrakter
= diare 10% gejala
- addison's disease
- congenital electrolyte absorption defects
+ defek pertukaran Cl/HCO3 (congenital kloridorrhea) + alkalosis (mutasi gen d
own regulated in adenoma [DRA])
+ defek pertukaran Na/H (congenital sodium diarrhea (mutasi gen NHE3) -> asido
sis
2. Osmotic: tarik cairan ke kolon -> tdk bisa reabsorbsi; berkurang dengan fasti
ng, or with discontinuation of causative agent
- laksatif osmotik (Mg, PO4, SO4)
- defisiensi laktase dan disakarida lainnya
+ penyebab diare kronik 3/4 non white worldwide, 5-30% di US
+ hindari susu -> tdk perlu suplementasi enzim
- karbohidrat non absorbable (sorbitol, laktulosa, polietilen glikol)
3. Steatore: > 7g lemak di feses/hari, rapid transit >14 g/hari, intestinal dise
ase: daily fecal fat 15-25 g, insuf eksokrin pankreas >32 g
- maldigestion intraluminal
+ insufisiensi eksokrin pankreas (pankreatitis kronis -> etanol abuse, cystic
firosis, obstruksi duktus pankreatikus, somatostatinoma)
+ bacterial overgrowth:
= dekonjugasi bile acids -> alter micelle formation
= occurs with stasis from blind loop, small bowel diverticulum or dismotility
+ bariatric surgery, liver dis
- malabsorbsi mukosa
+ celiac disease: gluten sensitive enteropathy (~1% populasi)
= villous atrophy and crypt hyperplasia di proximal small bowel
= multiple nutritonal deficiency of varying severity
+ tropical sprue: mirip celiac disease tapi pasien biasanya dari daerah tropis
+ whipple's disease: bacilus Tropheryma whipplei
= infiltrasi mukosa small bowel
= biasanya young or middle age men
= ada artralgia, fever, limfadenopati, extreme fatigue
= bisa jg kena CNS dan endokardium
= gejala klinis dan PA mirip mikobakterium avium-intraselular pada pasien AID
S
+ abetalipoproteinemia (gangguan pembentukan kilomikron dan malabsorbsi lemak
pd anak)
= akantositik eritrosit, ataxia, retinitis pigmentosa
+ giardia, obat2an (kolkisin, kolestiramin, neomisin), amiloidosis, iskemia kr
onik
- postmucosal obst (1 deg or 2 deg lymphatic obst)
+ congenital intestinal lymphangiectasia
+ acquired lymphatic obstruction (tumor, trauma, cardiac disease, infection)
4. Inflammatory: nyeri, demam, berdarah/eksudat, gejala2 radang lainnya; ada leu
kosit atau protein leukocyte-derive (calprotectin)
- idiopatic IBD (crohn's, ulcerative colitis)
- kolitis limfositik, and collagenous
- immune related mucosal disease (1 deg or 2 deg immunodef, alergi makanan, gas
troenteritis eosinofilik, graft-vs-host disease)
- infeksi (bakteri, parasit, Brainerd)
- Behct's syndrome, Cronkhite-canada syndrome
- radiasi injury, GI malignancies
5. Dismotil cause: feses sekretori, tapi ada mild steatore up to 14 g fat per da
y
- IBS (termasuk postinfectious IBS)
- visceral neuromyopathies
- hipertiroid
- drugs, postvagotomi
6. Factitial cause
- Munchausen
- eating disorders
7. Iatrogenik
- kolesistektomi
- ileal resection
- bariatric surgery
- vagotomi, fundoplication
Approach
1. Anamnesa
- onset, durasi, pola, memperberat, mmemperingan
- fecal innkontinens, demam, peV BB, exposure (travel, medication, kontak dgn p
asien lain)
- extraintestinal manif (skin changes, artralgia, oral aphthous ulcers)
- riw IBD keluarga
2. PF
- general: malabsorpsi/IBD: anemia, dermatitis herpetiformis, edema, clubbing?
- autonomic neuropathy or collagen-vascular disease in pupil, ortostasis, skin,
hands, joints?
- masa/nyeri perut?
- RT: mukosa rektal, defek rektal (fistul, etc), ggn fungsi spingter anal?
- masa tiroid, wheezing, murmur jantung, limfadenopati, hematomegali?
3. PP
- leukosit, LED, CRP
- anemia reflects blood loss or nutrisi def
- eosinofil: parasit, neoplasia, collagen-vascular disease, allergy, gastroente
ritis eosinofilik
- elektrolit, fungsi hati, ggn metabolik lain
- antibodi transglutaminase jaringan -> celiac disease
- quantitative stool, occult blood, fat quantitation, laxative screen
- secretory:
+ fecal bacterial cultures
+ small bowel bact overgrowth:
= aspirasi intestine with quantitative cultures
= lactulose breath test (breath hydrogen, methane, other metabolite) -> dipen
garuhi waktu transit usus
- hormon2: serum gastrin, VIP, calcitonin, tiroid, TSH, 5-hidroksiindolasetik a
cid urin, histamin
- tes utk lactose intolerance (lactose breath testing, ekslkusi laktosa, lactos
e challenge, pH feses rendah)
- laxative screen: fecal magnesium ^, laxative levels ^ => konsul psikiatri
- insufisiensi eksokrin pankreas: secretin-cholecystokinin stimulation test
Algorithm
A. Initial management
1. Perdarahan per rektum? kolonoskopi + biopsi
2. suggest malabsorbsi? small bowel imaging, biopsi, aspirate
3. lebih nyeri sblm bowel mvts, relieved stlh bowel mvts, incomplete evac? susp
ek IBS
-> limited screen for organic disease
hasil flexible sigmoidoscopy, biopsi: normal: edukasi, antispasmodik, antidiar
e, bulk agent, anxiolytics, or antidepressant
4. tdk ada darah, tdk ada tanda2 malabsorbsi? mgkn diare fungsional, coba ekskl
usi diet (laktosa, sorbitol)
-> limited screen for organi disease
B. Evaluasi dari Limited screen of organic disease
1. Hb V, alb V; MCV MCH abnormal, lemak berlebih di feses
- kolonoskopi + biopsi
- small bowel imaging, biopsi, aspirasi; lemak feses 48 jam
+ stool fat >20 g/hari, fungsi pankreas
+ normal and stool fat <14 g/hari -> full gut transit -> titrate Rx to speed
of transit
2. Low K: stool vol, osm, pH; laxative screen; hormonal screen
3. Skrining lain normal
- opioid Rx + follow up --> persistent chronic diarrhea
Tx:
Terapi cairan dan elektrolit (seperti terapi akut)
1. sesuai penyebab
- Ca colorectal: reseksi
- whipple's disease or tropical sprue: AB
- lactose intolerant: eliminasi dietary lactose
- celiac sprue: eliminasi gluten
- IBD idiopatik: glukokortiko ato anti inflamasi lain
- bile acid malabsorption: kolestiramin (adsorptive agent)
- malignant carcinoid synd: somatostatin analog (ocreotide)
- medullary ca tiroid: prostaglandin inhibitor (indometasin)
- insufisiensi pankreas: pancreatic enzyme replacement
2. Tdk tau penyebab: terapi empirik
- mild-moderate watery diare: opiat ringan: difenoxylate/loperamide
- severe diare: codeine or tincture of opium
- hindari antimotility agents
- diabetic diarrhea: clonidine
- steatore kronik: fat soluble vitamin (ADEK)