DIARRHEA

BY : HASRI SALWAN

Diarrhea
Definition
( WHO): loose of semisolid/ liquid stool, frequency
3x / day with / without blood or mucus
Mother: change of consistency and frequency
defecation

Konsistensi
konstipasi

Konsistensi
diare

Frekuensi BAB normal

Hal yang berkaitan dengan definisi

Perubahan konsistensi dan frekuensi BAB.
Pada bayi (terutama yang dapat ASI)
frekuensi BAB bisa sampai 8-12 x/hari.
Monitor: peningkatan BB

Epidemiology:
Diarrhoea:
One of causes morbidity & mortality child
Indonesia: morbidity rate: 200400 permil
70-80%: child < 5 year
die: 350.000-500.000 child / year

Penyebab Kematian Bayi 0-11 bulan

Tidak diketahui
penyebabnya, 3.7 %

Tetanus, 1.7
%

Meningtis,
4.5 %
Kelainan Kongenital,
5.7 %
Pneumonia,
12.7 %

Masalah
Neonatal
46,2 %

Diare,
15 %
Masalah neonatal :
-Asfiksia
-BBLR
Sumber : Riskesdas 2007

-Infeksi, dll

Kematian 1-11 bulan menurut Riskesdas 2007

Penyebab Kematian Balita 0-59 bulan

Tidak diketahui
penyebabnya, 5.5 %

Tetanus, 1.5
%

Meningtis,
5.1 %
Kelainan Kongenital,
4.9 %
Pneumonia,
13.2 %

Masalah
Neonatal
36 %

Masalah neonatal :
-Asfiksia
Diare, 17.2
%
Sumber : Riskesdas 2007

-BBLR
-Infeksi, dll

Penyebab kematian umur 1-4 tahun

ANGKA KESAKITAN

Aetiology (1):
1. Infection :
2.Diet
3.Drugs
4.Neurogenic/psychogenic

Etiology : infection (80%) :

1. Virus : Rotavirus, virus Norwalk, Norwalk
like virus, Astrovirus, Calcivirus,
Adenovirus.
2. Bacteria : Escherichia coli (EPEC, ETEC,
EHEC, EIEC), Salmonella, Shigella, Vibrio
cholera 01, Clostridium difficile,
Aeromonas hydrophilia, Plesiomonas
shigelloides, Yersinia enterocolitica,
Campylobacter jejuni, Staphylococcus
aureus, Clostridium botulinum

3. Parasite : Entamoeba histolytica, Dientamoeba

fragilis, Giardia lamblia, Cryptosporidium
parvum, Cyclospora sp, Isospora belli,
Blastocystis hominis, Enterobius vermicularis.
4. Worms : Strongiloides stercoralis, Capillaria
philippinensis, Trichinella spiralis.
5. Fungal: Candidiasis, Zygomycosis,
Coccidioidomycosis

Aetiology (2):
Diet : (10%)
Food poisoning
Food allergy
Food malabsorption
Drugs : (10%)
Laxatives, sorbitol, antacids,
lactulose, theophyllin, antibiotic
(AAD)

Classification of diarrhea :
Stool appearance:
Watery :
Cholera
Non cholera (Acute Infantile Diarrhea)
Bloody (dysentri)/mucosy
Duration :
Acute : 2 weeks
Prolonged (> 7days)
Chronic : > 2 weeks /3 episodes in a month
Persistent : cause by infectio secretion

Pathophyisiology:
Diarrhoea :
accumulation of water + electrolyte in lumen
3 mechanisms:
( 1) secretory diarrhoea
( 2) osmotic diarrhoea
( 3) cytotoxic / inflammatory diarrhoea
(4) Increased motility

Secretory Diarrhoea

Bacteria produces toxin

Effect of toxin: activating intracellular
protein stimulate electrolyte and water
secretion watery diarrhoea

(2) osmotic diarrhoea

Enzyme system insufficient or Short Bowel
syndrome food is digested partially
osmotic burden intraluminal bacterium
decompose the food
short chain fatty
acid and other material diarrhoea

(3) cytotoxic/inflammatory diarrhoea

Cytotoxic: Viral, inflammatory : allergy, IBD
Viral invasive and cytotoxic damage entrocytes
at villus villus atrophy (Absorption decrease)
crypt hyperplasia (secretion increase)
mixed diarrhoea
Inflammation (1) immune cells cytokines +
chemokines + prostaglandins induce secretion
and activate enteric nerves (2) metaloproteins
destroyed entrocytes at villus (Absorption
decrease) crypt hyperplasia (secretion
increase) mixed diarrhoea
Absorption decrease immature entrocyte with
insufficient disacharidase and peptide hydrolase.
Diarrhoea

Stool Form
secretory diarrhoea : watery, high level
electrolyte
osmotic diarrhoea : semisolid, low level
electrolyte
cytotoxic / inflammatory diarrhoea : mix

Pathophysiology
loss of water & electrolyte
Dehydration death
imbalance of electrolyte and acid-base
hypoglycemia,under/malnutrition,
shock, etc

Clinical manifestation of dehydraton

Alertness: irritable, weak / lethargy
Thirsty, nausea, vomiting,
Pulse: rapid, weak.
Respiratory rate: rapid, kussmaull
Fontanel : sunken
Eyes: sunken, no tear
Mouth: dry mucosa
Turgor: diminish (> 1 second)

Determining degree of dehydration

1. Laboratory : BW, hematocryte
2. Clinical feature: scoring system
1.
2.
3.

IMCI/MTBS, practical and easy to applied

P2 Diarrhoea = Programe National Diarrhoeal
Diseases Control Program (CDD)
Maurice King Score; others

General clinical manifestation

Degreesofdehydration
1.
2.
3.
4.

No dehydration
Mild dehydration : 1-4% of BW
Moderate deh. : 5-10% of BW
Severe deh : 10% of BW

= Previous Water Lost (PWL)

Giving solution
Loss of Body Weight
0%

5%

10%

15%

Ex : normal BW 10 kg, if diarrhea 9 kg :

loss of BW 10%
Dehydration
No,Mild, moderate, severe, shock,death
No,
Mild-moderate, severe, shock,death
Rehydration
Mild-moderate : (5%+10%):2 = 7,5% = 75 ml/kgBW
Severe : WHO 10% (100ml/kgBW), FK Unsri = 12%

Therapy
WHO:
(1) Fluid therapy: prevent & treat dehydration
(2) Dietetic : continue especially breast feeding
(3) Drug therapy: no AB,
except for cholera and bloody stool
WHO recommend : Zinc,
not yet: Probiotik And prebiotik
(4) Education

1. Fluid therapy
Consideration :
Route : oral or parenteral
Type of solution
Amount of solution
Time /rate of giving the fluid

Solidmass
40%
Diartr
hea

Intravasculler

5%

Intracelluler

albumin

Intertitiel

15%

40%

Diarrhea
Na 50-60
K 28
Alb (-)

Solidmass
40%
Intravasculer

5%

Intraceluller

Albumin, Na

Intertitiel

40%

Na

15%

dehidrasi

Diare

Solidmass
40%
Intraceluller
Intravasculer
albumin

Intertitie
l

rehydratio
n
IVFD

Solidmass
40%
Intraceluller
Intravasculer
albumin

Intertitie
l

Need
time

Route:
Per Oral
more beneficial compared to parenteral
(cheap, frequency and duration of diarrhoea:
decrease)
Given in : no and mild-moderate dehydration
In especially situation: can be given by NGT
( 20 ml/kgBW/hour)
Home based solution, ORS, renalyte,
pedialyte, etc

ORS Composition
Reduced
Grams/litre
Osmolarity ORS

Reduced
Mmol/L
Osmolarity ORS

SodiumChloride

2.6

SodiumChloride

75

Anhidrous
Glukose

13.5

Anhidrous
Glukose

75

Potassium
chloride

1.5

chloride

65

Potassium

20

citrate

10

TotalOsmolarity

245

Trisodiumcitrate, 2.9
dihydrate

Parenteral/Intravenously
Given in:
severe dehydration
Mild/moderate deh. : ORT failed

After rehydration is reached, as soon as

possible ( 4-6 hours) change to oral solution.
Kind of intravenous solution : kristaloid ( RL,
Nacl, Nacl+Dektrose)

Amount of fluid
Requiremet for 1 day :
1. Previous Water Lost (PWL)= degrees oh
dehydration :

mild-moderate: 75 ml/kgbw
severe 125 ml/kgbw

2. C(oncomitant)/On-going WL:

= stool out put (? )

25 ml/kgbw

= daily requirement ( 100 ml/kgbw

3. N(ormal)WL:

Parenteral/Intravenously
Severe dehydration:
WHO: RL
< 1 year: 30 ml / 1 hour 70 ml / 5 hours
1 year: 30 ml / 0,5 hour 70 ml / 2,5 hours
RSCM/ FKUI: KAEN 3B
< 1 year: 30 ml / 1 hour 70 ml / 5 hours
1 year: 30 ml / 0,5 hour 70 ml / 2,5 hours
RSMH/ FK UNSRI: RL
30 ml/hour 120 ml/4 hours

Parenteral/IV: rate of infusion

PWL must be restore quickly (Rehydration phase)
Severe dehydration: for PWL
WHO: RL
< 1 year: 30 ml / 1 hour 70 ml / 5 hours
1 year: 30 ml / 0,5 hour 70 ml / 2,5 hours
RSCM/ FKUI: KAEN 3B
< 1 year: 30 ml / 1 hour 70 ml / 5 hours
1 year: 30 ml / 0,5 hour 70 ml / 2,5 hours
RSMH/ FK UNSRI: RL
30 ml/hour 120 ml/4 hours
The important thing is MONITORING every hour

After Rehydration : Maintenance phase

CWL :
ORS
= Stool out put/25 ml kgbw/24 hr

NWL :
= daily requirement

2. Dietetic therapy
Breast feeding continued
continue to eat and drink as usual:
portion > usual
Do not consume the stimulating food
Consume food with potassium high
Baby consumes formula milk, change:
LLM/BL/LF if there is lactose
intolerance

3 . Drug therapy (medikamentosa)

Antimicrobial
Limited
WHO and National Health Department :
cholera and dysentery
Considerable to invasive diarrhoea
Other indication: suspect cholera, suspect
shigellosis, proven amoebiasis, proven
giardiasis, and bacterial overgrowth

Other indication of Antibiotic:

Invasive diarrhoea: leucocyte stool = 10 /
hpf ?, temperature > 38,5 oC
Meteorismus

With other disease (need for antibiotic)

Seng (Zinc)
Mikronutrien esensial
Berperan dlm :
proses pertumbuhan dan diferensiasi sel
menjaga stabilitas dinding sel
Ikut proses ekspresi gen dan pengaturan ion
intraseluler.
Meningkatkan sisstem imun spesifik/nonspesifik

Seng dalam pengobatan & pencegahan diare

Seng menurunkan insidens diare akut dan
persisten antara 14-65%
Seng menurunkan insiden diare 2-3 bln yad
Seng memperpendek durasi dan mengurangi
proporsi diare yg menjadi kronik
Seng mengembalikan nafsu makan anak
Sediaan: tablet atau sirup
Dosis: 2- 6 bl: 10 mg, > 6 bulan : 20 mg
Diberikan selama 10-14 hari

Otherdrugs
Antivomiting:
Mostvomitingstopafterrehydration
InterferewithORT
domperidon,metoclopramide

Stoolhardener
Notatherapy;notrecommended
kaolin

Antisecretory:racecadotril,chlorpromazine
Antiperistaltic:dangerous

Healtheducation
1. Howtotreatdiarrheaathome:
2. PlanA(bellow)
3. Whentoconsulthealthprovider
Signofseveredehydration
Bloodydiarrhea

4. Preventionofdiarrhea
Foodhandling,Fecalhandling,(fly control)
vaccination

MTBS = IMCI
ManajemenTerpaduBalitaSakit
IntegratedManagementofChildhood
Illness
ProgramWHO,diadaptasiDepkes

IMCI:Does the child have diarrhoea?

IF YES, ASK:
Forhowlong?
Istherebloodinthestool?
1. Howlong?<14days:acute,14days:persistent
2. Bloodystool?No:(dx:=1),yes:disentry
Classification:degreeofdehydrationgeneral
apprerance,sunkeneye,thristhy,turgor.Classification
dehydration(without,some=mildtomoderate,severe)