CASE : 2B

GROUP 8
TUTOR : dr. Zita
BLOK : GIT
FACULTY OF MEDICINE
TARUMANAGARA
UNIVERSITY

Tutor
: dr. Zita Group List
Leader
: Kevin Barnabas Malingkas
Secretary
: Nancy
Scriber
: Amelia Febriana Handjaja
Member:
- Megawati Lohanatha
- Anggelina Angkola
- Meida Astriani
- Johan Yap
- Anggi Zerlina Darwin
- Maria N.E. Bagul
- Marcelly Raymando Salyo
- Angelia
- Ahmad Farid Haryanto

Problem 2B (child)
A 3-year-old boy is brought to the emergency room with fever,
vimiting, and diarrhea for the past day. He has not been able to
keep anything down by mouth and has had profuse, very watery
stools. He attends day care, an several of his classmates have
been out sick recently as well. Not adult members of the
household have been ill. He has no significant past medical
history. On examination, vital sign : temperature 37,9C, heart
rate 120 bpm, blood pressure 70/50 mmHg and capillary refill is
more than 2 seconds. Current body weight is 12 kg. Two weeks
ago his body weight was 14 kg. Mucous membranes are dry, and
eyes appear somewhat sunken. Abdomen has active bowel
sounds and is non tender. Stool is watery and pale. The stool tests
negative for blood, possitive for fecal leucocytes and fungi.

Learning Objective

Able to explain about diarrhea in

children
Able to explain about fluid and
electrolite balance

DIARRHEA

Diarrhea
A. Definition :
Frequency of bowel movements.

Absolute diarrhea is having more bowel

movements than normal.
Thus, since among healthy individuals
the maximum number of daily bowel
movements is approximately three
Diarrhea can be defined as any
number of stools greater than three.
Relative diarrhea is having more bowel
movements than usual.

Consistency of stools

the consistency of stool can vary

considerably in healthy individuals
depending on their diets.
Stools that are liquid or watery are
always abnormal and considered
diarrheal..

Epidemiology
Most cases of acute
infectious diarrhea
are caused by
viruses
Bacterial pathogens
isolated in 1-6% of
cases
Limitation of hospital
based survey:
- 22% examined
- 5% submitted stool

RISK FACTOR
Nutrition

Hygiene
Sanitation

Social
Culture
Patient

Germ
caused
diarrhea

COMMUNITY

Human that
carier the
germ
Health
people

Compact
inhabitant

Social
Economi

Other
factor

ETIOLOGY

Viruses : Enterovirus, adenovirus, rotav

Enteral Infection

Infection

Bacteria : Vibrio, E. coli, Shigella,

Salmonella, Campylobactr,
Yersinia, Aeromonas
Protozoa : G. Lamblia, E.
Histolitica, Isospora belli
Parasites

Caused
of diare

Helmin : Ascaris,
Trichuris, Oxyyuris,
Strongyloides
Fungal : Candida albicans

Parenteral Infections : Tonsilofaringitis,

Bronkopneumonia,
Morbilli
Malabsorption
: Carbohydrate, Lipid, Protein
Food : out-of-date, poisonous
Allergic
Immunodeficiency
Phsycology : afraid,

Any number of viruses can

cause diarrhea,as well as
vomitting,abndominal
pain,fever an chills.

Pathophysiology
Viruses injure the absorptive surface of
mature villous cells,resulting in decreased
fluid absorption and dissacharidase
deficiency.
Bacteria produce intestinal injury by
directly invading the mucosa,damaging the
villous surface or releasing toxin.

Viral infectious
ROTAVIRUS
Most common cause of viral gastroenteritis.
Usually occurs between 3 months and 3yrs of age.
Although most common during wintermonths, it
may occur year round.
Clinical manifestations:

Diarrhea
Fever and vomiting.
Blood is not usually found in stools
Usually lasts for few days and up to 1 wk.

Detection of rotavirus antigen in stoolby enzyme

immunoassay is diagnostic.

Viral infectious
ADENOVIRUS
Adenoviruses may be associated with acute
gastroenteritis, especially in children <2 yrsof age.
Illness usually occurs during summer.
Diagnosed by: stool viral culture.

NORWALK-VIRUS
Usually cause epidemics in school-aged children or
adults.
Infection usually comes from contaminated wateror food.
Clinical manifestations: (usually last several days)
Cramping abdominal pain
vomiting,and low-grade fever
Diagnosed by: stool viral culture.

Bacteria can also responsible

for diarrhea.accompanied by
cramps,blood in his stool and
fever.

Bacterial infection

Parasitic can also cause

diarrhea.symptoms may
include gas,bloating and
greasy stools.

Entamoeba histolytica
Although many species of amoeba exist, only E.
histolytica is clearly pathogenic. Transmission
occurs by fecal contamination of food or water.
Infection is endemic throughout the world,
especially where poor sanitation exists.
Clinical manifestations :
Diarrhea (with blood & mucus)
Abdominal pain / acute colitis with abdominal cramps,

Diagnosis is usually made by identification of cysts

or trophozoites in stool. Serology also may be
helpful,particularly with diagnosis of extraintestinal
amebiasis and liverinvolvement.

Strongyloides stercoralis
This roundworm,2.5 mm in length, is endemic in
southern U.S. and common in tropicsand Asia.
Clinical manifestation:
Skin becomes red and pruritic after penetration by larvae,
which usually occurs on feet.
Diarrhea,
Vomiting
Abdominal pain
Cough and pneumonia after migration of larvae through
lung scan
Peripheral eosinophilia may occur.

Identification of larvae in stool isdiagnostic.

Ascaris lumbricoides
Clinical manifestations:

Can be asymptomatic
Mild diarrhea
Intermittent epigastric pain
Anorexia
Vomiting

Diagnosed: by identifying whitish-brown Ascaris

worm,2040 cm in length, or finding Ascaris eggs
on microscopic exam of stool is diagnostic.

Hookworm Infection
Adult hookworms (N. americanus and A.
duodenale)
Clinical manifestations:
Red, pruritic lesions on feetor between toes where larvae
penetrate.
Diarrhea
Vomiting
Abdominal pain
Anemia from GI blood loss
Peripheral eosinophilia.

Detecting hookworm eggs on stool smear is

diagnostic.

Trichuris trichiura
T. trichiura,4-cm long whipworm, occurs most
commonly in tropical areas but is also found in
subtropical areas (e.g., southern U.S.).
Clinical manifestations:

Most individuals are asymptomatic

Diarrhea
Tenesmus
Weight loss
Anemia
Peripheral eosinophilia

Diagnosed: by seeing eggs on microscopic stool

examis diagnostic.

Fungal infectious
Candida sp
C. albicans is most common cause of Candida
enteritis
Characterized by watery diarrhea and abdominal
pain.
Predisposing factors :prolonged antibiotic or
immunosuppressive therapy yeast forms are
ubiquitous and occur in fecal flora of normal
persons, their presence alone is not diagnostic.
Definitive diagnosis requires demonstration of
intestinal mucosal invasion by Candida on biopsy
or isolation of Candida from ulcerative lesions.

Types of diarrhea

Osmotic diarrhea
osmotic force that acts in the
lumen to drive water into the gut
(caused by hyperosmotic drugs
(MgSO4, Mg(OH)2), malabsorption,
defect in mucosal absorption
(disacharide deficiency,
glucose/galactose malabsorption)

Secretory diarrhea
increase in the active secretion
inhibition of absorption.
The most common cause of this type
of diarrhea is a cholera toxin that
stimulates the secretion of anions,
especially chloride ions.

Inflammatory and Infectious Diarrhea

The epithelium of the digestive tube is protected from insult by a
number of mechanisms constituting the gastrointestinal barrier, but
like many barriers, it can be breached. Disruption of the epithelium
of the intestine due to microbial or viral pathogens is a very common
cause of diarrhea in all species. Destruction of the epithelium results
not only in exudation of serum and blood into the lumen but often is
associated with widespread destruction of absorptive epithelium. In
such cases, absorption of water occurs very inefficiently and diarrhea
results. Examples of pathogens frequently associated with infectious
diarrhea include:
Bacteria: Salmonella, E. coli, Campylobacter
Viruses: rotaviruses, coronaviruses, parvoviruses (canine and feline),
norovirus
Protozoa: coccidia species, Cryptosporium, Giardia
The immune response to inflammatory conditions in the bowel
contributes substantively to development of diarrhea. Activation of
white blood cells leads them to secrete inflammatory mediators and
cytokines which can stimulate secretion, in effect imposing a
secretory component on top of an inflammatory diarrhea. Reactive
oxygen species from leukocytes can damage or kill intestinal
epithelial cells, which are replaced with immature cells that typically
are deficient in the brush border enyzmes and transporters
necessary for absorption of nutrients and water. In this way,
components of an osmotic (malabsorption) diarrhea are added to the
problem.

 Diarrhea Associated with Deranged Motility

In order for nutrients and water to be efficiently

absorbed, the intestinal contents must be
adequately exposed to the mucosal epithelium
and retained long enough to allow absorption.
Disorders in motility than accelerate transit time
could decrease absorption, resulting in diarrhea
even if the absorptive process per se was
proceeding properly.
Alterations in intestinal motility (usually increased
propulsion) are observed in many types of
diarrhea. What is not usally clear, and very
difficult to demonstrate, is whether primary
alterations in motility are actually the cause of
diarrhea or simply an effect.

Classsification : Organs
Stool
Characteristics

Small Bowel

Large Bowel

Appearance

Watery

Mucoid and/or
bloody

Volume

Large

Small

Frequency

Increased

Highly increased

Blood

Possibly positive
but never gross
blood

Commonly grossly
bloody

pH

Possibly <5.5

>5.5

Reducing
substances

Possibly positive

Negative

WBCs

<5/high power
field

Commonly
>10/high power
field

Sign and Symtomp

Inadult :
Your diarrhea persists beyond
three days
You become dehydrated as
evidenced by excessive thirst,
dry mouth or skin, little or no
urination, severe weakness,
dizziness or lightheadedness,
or dark-colored urine
You have severe abdominal or
rectal pain
You have bloody or black
stools
You have a temperature of
more than 102 F (39 C), or
signs of dehydration despite
drinking plenty of liquids

In children, particularly
young children, diarrhea
can quickly lead to
dehydration.
Hasn't had a wet diaper in
three or more hours
Has a fever of more than
102 F (39 C)
Has bloody or black stools
Has a dry mouth or cries
without tears
Is unusually sleepy, drowsy,
unresponsive or irritable
Has a sunken appearance to
the abdomen, eyes or
cheeks
Has skin that doesn't flatten
if pinched and released

Chronic diarrhea

Chronic diarrhea. With chronic diarrhea, the focus usually shifts from
dehydration and infection (with the exception of Giardia, which
occasionally causes chronic infections) to the diagnosis of non-infectious
causes of diarrhea. (See the prior discussion of common causes of chronic
diarrhea.)
This may require X-rays of the intestines (upper gastrointestinal series or
barium enema), or endoscopy (esophagogastroduodenoscopy or EGD, or
colonoscopy) with biopsies.

Fat malabsorption can be diagnosed by measuring the fat in a 72 hour

collection of stool.

Sugar malabsorption can be diagnosed by eliminating the offending sugar

from the diet or by performing a hydrogen breath test. Hydrogen breath
testing also can be used to diagnose bacterial overgrowth of the small
intestine.

Treatment For Diarrhea in

Child

WHO susgests some treatment for diarrhea

in child,such as:
a. Rehidration
b. Breast feeding while diarrhea and recovery
phase.
c. Do not use anti diarrhea drugs
antibiotics just given for patient with
cholera and dysentri caused by shigella, and
metronidazole given for patient with
giardiasis and amebiasis.

COMPLICATIONS
Diarrhea

Water
Dehydration
Potassium Hypokalaemia
Natrium Hyponatraemia
Bicarbonate Acidosis
Nutrient Hypoglycemia

Prevention

Breastfeeding
Improving food sapling
Using plenty of clean water
washing hands
Using a household toilet
How to dispose of feces is good and
right
Measles immunization

Complications

Kidney failure
Coma
Shock
Heat-related illnesses & associated complications
Electrolyte abnormalities
In dehydration, electrolyte abnormalities may occur since
important chemicals (like sodium and potassium) are lost
from the body through sweat.
If rehydration is done too slowly :
--> hypotensive & in shock for too long
If done too quickly :
--> water and electrolyte concentrations within organ cells
can be negatively affected --> causing cells to swell --> die.

FLUID AND ELECTROLITE

BALANCE

Total Body Fluid by

Compartment
Total Body
Water

Electrolyte Composition of Body Fluid

Compartments

HOMEOSTATIC REGULATION
ADH
Permeability TD

H2O

RBF

reabs h2o

RENIN
HOMEOSTATI
C
ANGIOTENSI
N

OSMOLALITY

ALDOSTERON
Reabs Na

Composition of Parenteral Fluids

(mEq/L)
Fluid

Na+

K+

Ca2+ Cl-

HCO3- pH

ECF

142

103

27

7.4

LR

130

2.7

109

28

6.5

.9% NaCl

154

154

4.5

.45% NaCl

77

77

4.5

.2% NaCl

30

30

4.5

3% NaCl

513

513

4.5

5% NaCl

855

855

4.5

5% Albumin

145

7.4

Composition of GI Fluids
(mEq/L)
Source
Saliva
Gastric

Daily Loss Na+

1000

K+

Cl-

HCO3-

30-80

20

70

30

1000-2000 60-80

15

100

Panc

1000

140

5-10

60-90

40-100

Bile

1000

140

5-10

100

40

SB

2000-5000

140

20

100

25-50

LB

200-1500

75

30

30

Sweat

200-1000

20-70

5-10

40-60

Dehydration
The body needs the correct amount of water
and electrolytes (salts) to function properly.
Diarrhea causes excess loss of fluids and
essential electrolytes from the body. When
fluid lost in the stools is not replaced,
diarrhea can lead to dehydration
(abnormally low water content in the body).
Dehydration can be a life-threatening
complication of diarrhea for some
individuals, especially infants, small children
and elderly people

Dehydration can be categorized according to

osmolarity and severity.
Serum sodium is a good surrogate marker of osmolarity
assuming the patient has a normal serum glucose.
Dehydration may be isonatremic (130-150 mEq/L),
hyponatremic (<130 mEq/L), or hypernatremic (>150
mEq/L).
Isonatremic dehydration is the most common (80%).
Hypernatremic and hyponatremic dehydration each
comprise 5-10% of cases.
Variations in serum sodium reflect the composition of
the fluids lost and have different pathophysiologic effects.

 Isonatremic (isotonic) dehydration occurs when the lost fluid

is similar in sodium concentration to the blood. Sodium and
water losses are of the same relative magnitude in both the
intravascular and extravascular fluid compartments.
Hyponatremic (hypotonic) dehydration occurs when the lost
fluid contains more sodium than the blood (loss of hypertonic
fluid). Relatively more sodium than water is lost. Because the
serum sodium is low, intravascular water shifts to the
extravascular space, exaggerating intravascular volume
depletion for a given amount of total body water loss.
Hypernatremic (hypertonic) dehydration occurs when the
lost fluid contains less sodium than the blood (loss of
hypotonic fluid). Relatively less sodium than water is lost.
Because the serum sodium is high, extravascular water shifts
to the intravascular space, minimizing intravascular volume
depletion for a given amount of total body water loss.

Assessment of
Dehydration

Scoring System
Degree of dehydration
Score

General condition

Healthy

Skin elasticity
Eye
Fontanel
Mouth
Pulse

Normal
Normal
Normal
Normal
Normal

Amount of score:

1
Irritability,
sleepy,
apathy
Decreased
Sunken
Sunken
Dry
120-140

2
Delirium, coma
or shock
Very
decreased
Very sunken
Very sunken
Dry & cyanotic
> 140

0- 2 Mild dehydration
3- 6 Moderate dehydration
7-12 Severe dehydration
Maurice King, 1974

Treatment of
Dehydration

Complications

Kidney failure
Coma
Shock
Heat-related illnesses and associated
complications
Electrolyte abnormalities

11/26/15

Conclusion
Probably this patient got acute
secretoric diarrhea caused by fungal
infection.
Probably this patient got moderate
dehydration.

Prevention
Wash your hands frequently,
especially after using the toilet,
changing diapers.
Wash your hands before and after
preparing food.
Wash diarrhea-soiled clothing in
detergent and chlorine bleach.
Never drink unpasteurized milk or
untreated water.
Drink only bottled water.
Proper hygiene.
Give ORS for the dehydration.

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http://www.womenshealthapta.org
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