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Diarrhea is a major cause of childhood morbidity and mortality worldwide. Acute diarrhea is a major problem when it occurs with malnutrition or in the absence of basic medical care. Most acute diarrhea is viral and is selflimited, requiring no diagnostic testing or specific intervention. Chronic diarrhea lasts more than 2 weeks and has a wide range of possible causes, including more difficult to diagnose serious and benign conditions (Nelson:2007).
During fasting, the motility of the small intestine is characterized by a cyclical event called the migrating motor complex (MMC), which serves to clear nondigestible residue from the small intestine (the intestinal “housekeeper”). This organized, propagated series of contractions lasts on average 4 min, occurs every 60–90 min, and usually involves the entire small intestine. After food ingestion, the small intestine produces irregular, mixing contractions of relatively low amplitude, except in the distal ileum where more powerful contractions occur intermittently and empty the ileum by bolus transfers.
ILEOCOLONIC STORAGE AND SALVAGE
Primary function of the small intestine is the digestion and assimilation of nutrients from food, the small intestine and colon together perform important functions that regulate the secretion and absorption of water and electrolytes, the storage and subsequent transport of intraluminal contents aborally, and the salvage of some nutrients after bacterial metabolism of carbohydrate that are not absorbed in the small intestine. Alterations in fluid and electrolyte handling contribute significantly to diarrhea. Alterations in motor and sensory functions of the colon result in highly prevalent syndromes such as irritable bowel syndrome (IBS), chronic diarrhea, and chronic constipation.
The resident bacteria in the colon are necessary for the digestion of unabsorbed carbohydrates that reach the colon even in health, thereby providing a vital source of nutrients to the mucosa. Normal colonic flora also keeps pathogens at bay by a variety of mechanisms. In health, the ascending and transverse regions of colon function as reservoirs (average transit, 15 h), and the descending colon acts as a conduit (average transit, 3 h). The colon is efficient at conserving sodium and water, a function that is particularly important in sodium depleted patients in whom the small intestine alone is unable to maintain sodium balance. Diarrhea or constipation may result from alteration in the reservoir function of the proximal colon or the propulsive function of the left colon.
COLONIC MOTILITY AND TONE
The intrinsic innervation, also called the enteric nervous system, comprises myenteric, submucosal, and mucosal neuronal layers. The myenteric plexus regulates smoothmuscle function, and the submucosal plexus affects secretion, absorption, and mucosal blood flow. The extrinsic innervations of the small intestine and colon are part of the autonomic nervous system and also modulate motor and secretory functions. Parasympathetic fibers via the vagus nerve reach the small intestine and proximal colon along the branches of the superior mesenteric artery. The distal colon is supplied by sacral parasympathetic nerves (S2–4) via the pelvic plexus; these fibers course through the wall of the colon as ascending intracolonic fibers as far as, and in some instances including, the proximal colon. Sympathetic input to the gut is generally excitatory to sphincters and inhibitory to nonsphincteric muscle.
INTESTINAL FLUID ABSORPTION AND SECRETION
Short duration or phasic contractions mix colonic contents, and high-amplitude (>75 mmHg) propagated contractions (HAPCs) are sometimes associated with mass movements through the colon and normally occur approximately five times per day, usually on awakening in the morning and postprandially. Increased frequency of HAPCs may result in diarrhea or urgency. Colonic tone refers to the background contractility upon which phasic contractile activity (typically contractions lasting <15 s) is superimposed. It is an important cofactor in the colon’s capacitance (volume accommodation) and sensation.
COLONIC MOTILITY AFTER MEAL INGESTION
After meal ingestion, colonic phasic and tonic contractility increase for a period of ~2 h. The initial phase (~10 min) is mediated by the vagus nerve in response to mechanical distention of the stomach. The subsequent response of the colon requires caloric stimulation and is mediated at least in part by hormones, e.g., gastrin and serotonin. DIARRHEA Diarrhea is loosely defined as passage of abnormally liquid or unformed stools at an increased frequency. For adults
On an average day, 9 L of fluid enter the gastrointestinal (GI) tract; ~1 L of residual fluid reaches the colon; the stool excretion of fluid constitutes about 0.2 L/d.
and abdominal pain. and other conditions (Harrison. defined by frequent watery stools in the setting of normal growth and weight gain and is caused by excessive intake of fruit juices that contain non-digestible carbohydrates. Diarrhea may be classified by etiology or by physiologic mechanisms (secretory or osmotic). 2007). 2008). 2007). malabsorbed substances. or with malabsorption caused by intestinal injury. fever. leading to secretion into the small bowel lumen. such as vasoactive intestinal peptide secreted by a neuroendocrine tumor (neuroblastoma) (Nelson. Namunn. stool weight >200 g/d can generally be considered diarrheal. astrovirus) and bacterial Secretory diarrhea occurs when the intestinal mucosa directly secretes fluid and electrolytes into the stool. and inflammation (Nelson. The remaining 10% or so are caused by medications. lactose) often can occur in the colon. or a chemical stimulus. 2006). Chronic Common Postinfectious secondary lactase deficiency Irritable bowel syndrome . norovirus. ACUTE DIARRHEA BAB dengan frekuensi > 3 kali/hari dengan konsistensi tinja cair. such as that seen with pancreatic insufficiency. Diarrhea is excessive daily stool liquid volume (>10 mL stool/kg body weight/day) (Nelson. Secretion also is stimulated by mediators of inflammation and by various hormones. Most infectious diarrheas are acquired by fecal-oral transmission or. Diarrhea typically improves tremendously when the child's beverage intake is reduced or changed (Nelson. 2008). via ingestion of food or water contaminated with pathogens from human or animal feces. which pull water into the bowel lumen. cramps. and acidic stools. Cholera is a secretory diarrhea stimulated by the enterotoxin of Vibrio cholerae. digestive enzymes. Differential Diagnosis of Diarrhea Infant Acute Common Gastroenteritis* Systemic infection Antibiotic associated Overfeeding Rare Primary disaccharidase deficiency Hirschsprung toxic colitis Adrenogenital syndrome Postinfectious secondary lactase deficiency Child Gastroenteritis* Food poisoning Systemic infection Antibiotic associated Toxic ingestion Adolescent Gastroenteritis* Food poisoning Antibiotic associated Hyperthyroidism Cow's milk/soy protein intolerance Chronic nonspecific diarrhea of infancy (toddler's diarrhea) Celiac disease Cystic fibrosis AIDS enteropathy Irritable bowel syndrome Celiac disease Lactose intolerance Giardiasis Inflammatory bowel disease AIDS enteropathy Acquired immune defects Secretory tumor Pseudoobstruction Factitious Inflammatory bowel disease Lactose intolerance Giardiasis Laxative abuse (anorexia nervosa) AIDS enteropathy Secretory tumors Primary bowel tumor Rare Primary immune defects Familial villous atrophy Secretory tumors Congenital chloridorrhea Acrodermatitis enteropathica Lymphangiectasia Abetalipoproteinemia Eosinophilic gastroenteritis Short bowel syndrome Intractable diarrhea syndrome Autoimmune enteropathy Factitious *Gastroenteritis includes viral (rotavirus. bacteria or their toxins. 2007). ischemia. commonly known as toddler's diarrhea. toxic ingestions. mucus secretion. more commonly. 2008). Acute gastroenteritis is an acute infection mainly affecting the small intestine that causes diarrhoea with or without vomiting (ABC of pediatric: 2002). resulting in gas production. 2006). Etiologic agents include viruses. Infectious Agents. A classic example is lactose intolerance. 2007). Osmotic diarrhea occurs after malabsorption of ingested substances. persistent if 2–4 weeks. and suppressive resident flora) defenses. as in Crohn's disease or UC. More than 90% of cases of acute diarrhea are caused by infectious agents. Gastroenteritis secara teknis adalah peradangan baik lambung (muntah) maupun usus (diare). peristalsis. Diarrhea may be further defined as acute if <2 weeks. these cases are often accompanied by vomiting. This toxin causes increased levels of cAMP within enterocytes. secretion may be the result of inflammation. Acute infection or injury occurs when the ingested agent overwhelms the host’s mucosal immune and nonimmune (gastric acid. istilah ini secara tidak tepat sering digunakan untuk menunjukkan kondisi infeksi akut dan bersifat sementara yang menyebabkan muntah atau diare atau keduanya (manual kedokteran darurat. Fermentation of some of these malabsorbed substances (ex. chemicals. Most common cause of loose stools in early childhood is chronic nonspecific diarrhea. Osmotic diarrhea also can result from maldigestion. parasites. and chronic if >4 weeks in duration (Harrison. bersifat mendadak dan berlangsung dalam waktu kurang dari 2 minggu (14 hari) (Pediatricia. The pathophysiology underlying acute diarrhea by infectious agents produces specific clinical features that may also be helpful in diagnosis (Harrison.on a typical Western diet.
V. pada anak muntah-muntah). but the secretory component of the diarrhea would not stop completely until the inflammation receded. Shigella. Viral enteritis damages the intestinal lining. Neither of these methods for classifying diarrhea works perfectly because most diarrheal illnesses are a mixture of secretory and osmotic components. E. A child with cholera. can be performed. Another way to differentiate between osmotic and secretory diarrhea is to stop all feedings and observe. C. Factors that seem to worsen or improve the diarrhea should be determined. If the diarrhea stops completely while the patient is receiving nothing by mouth (NPO). If diarrhea occurs after a course of antibiotics. Campylobacter. Cholera Kerusakan sel dan radang atau atrofi sel epitel : Rotavirus. Norwalk Hiperosmolaritas (diare osmotik) Pemeriksaan fisik . a pure secretory diarrhea. Recent travel should be documented. with a focus on the abdominal examination. T/E kulit <<. kejang.(Salmonella. Patofisiologi: Produksi enterotolsin : ETEC. kesadran. fever. Tanda dehidrasi mata cowong. Is there abdominal distention or tenderness? Are bowel sounds hyperactive? Is there blood in the stool on rectal examination? Is the anal sphincter tone adequate? Laboratory testing should include stool culture and complete blood count if bacterial enteritis is suspected. other) agents. or a more specific test. bibir kering. Ion Na >>: hipernatremia (haus. such as blood in the stool. such as serum antibody tests for celiac disease or colonoscopy for suspected UC. air mata (-). iritabilitas >>. number and character of stools. Yersinia. A child with viral enteritis may have decreased stool volume while NPO. peristaltik<</kembung). The associated inflammation results in release of mediators that cause excessive secretion. (TIK >>). and presence of other symptoms. This observation must be done only in a hospitalized patient receiving IV fluids to prevent dehydration. hiperiritabilitas. (Nelson. additional stool testing is tailored to the patient's presentation. 2007) Akibat: Volume cairan : dehidrasi (>10%BBdehidrasi berat)Syok. Status gizi. 2007) The history should include the onset of diarrhea. a Clostridium difficile toxin assay should be ordered. Ion H >>: asidosis metabolik (napas kussmaul). and weight loss. Komplikasi. would continue to have massive stool output. rewel. Secretory diarrhea is characterized by an osmotic gap of less than 50 because most of the dissolved substances in the stool are electrolytes. A number significantly higher than 50 defines osmotic diarrhea and indicates that malabsorbed substances other than electrolytes account for fecal osmolarity. A trial of lactose restriction for several days is helpful to rule out lactose intolerance. UUB cekung. and a list of medications being used should be obtained. estimates of stool volume. Ion Ca<<: Chvostek sign (+). anak kehausan. Physical examination should be thorough. Ion K<< : hipokalemia (lemas otot. if stools are reported to be oily or fatty. causing malabsorption and osmotic diarrhea. (nelson. the patient has osmotic diarrhea. dietary factors should be investigated. such as lactose breath hydrogen analysis. fecal fat content should be checked. Suhu badan. Tests for specific diagnoses should be sent when appropriate. difficile. coli.
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