Approach to the patient with diarrhea

dr Putra Hendra
UNIBA
 Diarrhea
Definition:
abnormal increase in stool liquidity, stool
frequency, and stool weight (more than 200
grams per day).

Diarrhea :
< 2 weeks: acute infection
> 2 weeks: chronic
Osmotic, secretory, exudative,
motility
The amount of fluid absorbed differs throughout the intestine

Duodenum / Ileum Colon Rectum

jejunum ~2L ~ 1.3 L
~5.5 L

Intake
2 liter
Stool
<200 ml
 Mechanism of Diarrhea

1. Osmotic diarrhea
2. Secretory diarrhea
3. Inflammatory diarrhea
4. Abnormal gastrointestinal motility
Raised CI Secretion
 Clinical approach to diarrhea

Diarrhea Pseudodiarrhea

Acute Chronic
 Acute Diarrhea

Infectious Non infectious

 Etiology of infectious diarrhea

Bacterial
Shigella Sp.
Aeromonas Shigelloides
Salmonella Sp.
Vibrio Sp.
Compylobactor Sp.
Clostridium difficile
E.coli (ETEC, EPEC, EIEC, EAEC and EHEC)
 Viral
Norwalk
Rotavirus
Enteric adenovirus
Cytomegalovirus
Herpes simple virus

Fungal
Candida Sp.
Histoplasma Sp.

Parasite
Entamoeba histolytica
Giardia lamblia
Strongyloides
Cryptosporidium
Cyclospora Cayetanensis
 Vibrio Cholera

Gram-negative
Curved rod
.5-.8 m width
1.4-2.6 m length
Facultative anaerobe
Single polar flagellum
Chemoorganotroph
Optimal growth 20-30
degrees
 Short incubation period (2 hours to 5
days)
75% of those infected do not develop
symptoms
100-1000 organisms may cause
disease, although a million are needed
to consistently infect
 Transmission
Direct fecal-oral contamination or
ingestion of contaminated water and food
Linked to inadequate environmental
management (lack of safe water and
sufficient sanitation)
Human-Human contact does not spread
the bacterium
Underlying diseases
AIDS

Hyperthyroidism
 Clinical Setting
Food poisoning Water Diarrhea Dysentery
(entero/neuro (non-Invasive (Invasive organism)
toxin producing) Organism)
Fever Rare Non or Low Grade Common
Incubation < 6 hours 6 hours-3 days 1-3 days
Peroid
Mucous-bloody stool Non Non Common
Nausea vomiting ++ + +
Tenesmus - - +
Voluminous stool + ++ +

Etiology Staphylococcus EPEC, ETEC, EAEC Shigella

aureus, C.perfringens Aeromonas, P.shigelloides
B, ceceus Vibrio Cholerae EIEC EHEC
Salmonella Giardia, Salmonella
Cryptospodium Campylobactor
Salmonella C.difficile, virus E.Histolytica
V.Parahemolyticus
 Treatment

1. Supportive

2. Symptomatic

3. Specific
 Drug of choice Alternative
Shigella sp. Norfloxacin , ofloxacin Ciprofloxacin, ceftriaxone
Areomonas sp. Amlnoglycoside TMP/SMX, loramphenical
Ceftriaxone
Campylobacter Erythromycin Ciprofloxacin
Norfloxacin
Clostridium difficile Metronidazole Bacitacin
Vancomycin
Vibrio cholerae Tetracycline Doxycycline , TMP/SMX
E. histolytica Metronidazole Emitine
Giardia lamblia Metronidazole Quinacrine hydrochloride
Strongyloides Thiabendazole Albendazole
 Chronic Diarrhea

Functional Organic

HIV Non-HIV
 Chronic organic diarrhea (Non HIV)

Inflammatory Secretory

Malabsorption
Chronic Inflammatory Diarrhea

Infection
Inflammatory bowel
Radiation
Ischemic
Malabsorption syndrome

Diarrhea
Malnutrition
Malabsorption syndrome

Strongyloidiasis
Giardiasis
Capillariasis
Lymphoma
 PEMERIKSAAN PENUNJANG
Pemeriksaan tinja
Makroskopis dan mikroskopis
Ph dan kadar gula dalam tinja
Kultur dan uji resistensi
Pemeriksaan keseimbangan asam
basa AGD
Urinalisis : Bj, endapan
Pemeriksaan kadar ureum
kreatinin faal ginjal
Pemeriksaan keseimbangan cairan &
elektrolit Hb-Ht, Na, K, Ca dan F
Pemeriksaan intubasi duodenum
EKG menilai deplesi elektrolit
(biasanya kalium)
 KOMPLIKASI
Kehilangan air dan elektrolit Dehidrasi, Hipokalemia, Asidosis metabolik,
Kejang, Alkalosis metabolik
Gangguan sirkulasi darah Syok hipovolemik
Gangguan gizi Hipoglikemia, Malnutrisi energi protein, Intolerasi laktosa
sekunder

PENENTUAN DERAJAT DEHIDRASI

Berdasarkan BB
Ringan pe BB < 5 %
Sedang pe BB 5 10 %
Berat pe BB > 10 %
Menurut Haroen Noerasid (modifikasi)
Ringan Rasa haus & Oliguria ringan
Sedang Tanda diatas + turgor kulit,
ubun2 & mata cekung
Berat Tanda diatas + somnolen,
sopor, koma, syok, nafas kussmaul
 score

Muntah
1
Voxs cholerica 2
Kesadaran apatis
1
Kesadaran somnolen, soporous s/d coma
2
Sis tolik </ sama dengan 90 mmhg
2
Nadi > / sama dengan 120/m 1

Napas Kussmaul (>30/m)

1
Turgor kulit kurang 1
Facies cholerica
2
Extremitas dingin
1
Washer hand 1
Sianosis
2
 Degree of Dehydration

Mild dehydration (3-5%)

Moderate dehydration (7-10%)

Sever dehydration (10-15%)

 Degree of Dehydration

Severe dehydration (10-15%)

-Rapid weak pulse.
-Low BP, sunken eyes and fontanel
-No tears or urine & v. dry mucous
membrane
-Clear skin tenting. Cool mottled skin with
delayed capillary refill.
 Pilihan Cairan
Beri Rl (utama) atau NaCl
Jika pasiennya tidak dapat makan diberi
Dekstros dan RL
Jika muntah2 maka berikan Dekstros dan
NaCl, tetapi jika pasien muntah + diare
utamakan RL
Oralit
Cara Pemberian
IV Untuk dehidrasi berat
Enteral Untuk dehidrasi ringan, sedang
tetapi anak tidak mau/ tidak dapat minum
atau jika kesadaran menurun
Oral Bila kesadaran anak baik, anak mau
minum, biasanya diberikan untuk dehidrasi
ringan dan sedang
Observasi kondisi fisik klien terutama status
hidrasi
 Signs of Hypervolemia:
Hypertension
Polyuria
Peripheral edema
Wet lung Especially when
hypo-
albuminemia
Jugular vein engorgement
 Management of
Hypervolemia:
Prevention is the best way
Guide fluid therapy with CVP level or

pulmonary wedge pressure

Diuretics
Increase oncotic pressure: FFP or

albumin infusion (may followed by

diuretics)
Dialysis
 Parenteral Vaccine
2 doses administered 2 weeks apart
Efficacy of approximately 50%
Protection hardly exceeds 6 months
Does not prevent transmission of
infectious agent
Not recommended for general public
health use