Case report : Gastroenteritis

PRESENTED BY ADE IRMA 070100054 SRI WAHYUNI 070100076

SUPERVISOR : Prof. dr. Atan Baas Sinuhaji, Sp.A(K)

PEDIATRIC DEPARTEMENT HAJI ADAM MALIK GENERAL HOSPITAL 2011

Definition Gastroenteritis
Diarrhoea is the passage of unusually loose or

watery stools, usually at least three times in a 24 hour period. However, it is the consistency of the stools rather than the number that is most important. Frequent passing of formed stools is not diarrhoea (WHO, 2005).

WHO. The Treatment of Diarrhoea: a Manual for Physicians and Other Senior Health Workers 2005. 2

Epidemiology

Farthing et al. Acute Diarrhea. World Gastroenterology Organisation, 2008;

Inverse association between coverage rates of oral rehydration solution (ORS) use and rates of mortality from diarrhoea in various countries.

Farthing et al. Acute Diarrhea. World Gastroenterology Organisation, 2008;

Etiology
Causes of diarrhoea with acute onset include

the following: Infections Drug-induced Food allergies or intolerances Disorders of digestive/absorptive processes Chemotherapy or radiation-induced enteritis Vitamin deficiencies
Guandalini S. Diarrhea. Available from: http://emedicine.medscape.com/article/928598-followup [Accesed 23 February 2011]. 5

Infectious causes of acute diarrhoea in developed countries

Viruses Bacteria Parasites Cryptosporidium - 13% of cases G lamblia - 1-3% of cases

Rotavirus - 25-40% of cases Norovirus - 10-20% of cases Calicivirus - 1-20% of cases Astrovirus - 4-9% of cases Enteric-type adenovirus 2-4% of cases

Campylobacter jejuni - 68% of cases Salmonella - 3-7% of cases E Coli - 3-5% of cases Shigella - 0-3% of cases Y enterocolitica - 1-2% of cases C difficile - 0-2% of cases Vibrio parahaemolyticus 0-1% of cases V cholerae - Unknown Aeromonas hydrophila 0-2% of cases

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Guandalini S. Diarrhea. Available from: http://emedicine.medscape.com/article/928598-followup [Accesed 23 February 2011].

Classification
Acute watery diarrhoea (including cholera) which lasts several hours or days: the main danger is dehydration; weight loss also occurs if feeding is not continued; Acute bloody diarrhoea (Dysentry ) Bloody and mucous present. The main dangers are damage of the intestinal mucosa, sepsis and malnutrition Persistent Diarrhoea which lasts 14 days or longer Diarrhoea with severe malnutrition (marasmus or kwashiorkor):

Main dangers are severe systemic infection, dehydration, heart failure and vitamin and mineral deficiency
WHO. The Treatment of Diarrhoea: a Manual for Physicians and Other Senior Health Workers.2005.

Feces from humans or animals containing pathogenic microbes or their toxins

food

fluids

fingers

Ingestion of organism and/ or toxin

Organisms multiply and toxin produced but infection remain in GI tract DIARE

Organism invade or toxins absorbed

dissemination Symptoms of systemic infection ex. Fever etc.

Pathogenesis of diarrhoea

Pathophysiology

Silbernagl S and Lang F. Color Atlas of Pathophysiology. New York: Thieme, 2009;

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http://www.wrongdiagnosis.com/bookimages/16/5413.1.png

Diagnosis
History : ask presence of blood in the

stool; duration of diarrhea; number of watery stools per day; number of episodes of vomiting etc. Physical examination: look and feel Take temperature
WHO. The Treatment of Diarrhoea: a Manual for Physicians and Other Senior Health Workers 11 2005.

Look and Feel

WHO. The Treatment of Diarrhoea: a Manual for Physicians and Other Senior Health Workers 2005.

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Laboratory

Complete blood count

Electrolyte

Anal swab

Culture stool

Immuno assay

Guandalini S. Diarrhea. Available from: http://emedicine.medscape.com/article/928598-followup [Accesed 23 February 2011].

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Differential Diagnose
Appendicitis

Intussuception
Crohn disease

Irritable bowel syndrome

Guandalini S. Diarrhea. Available from: http://emedicine.medscape.com/article/928598-followup [Accesed 23 February 2011].

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Treatment
ORS, iv infusion Zn Nutrition Vitamin A Antibiotic Probiotic

WHO. The Treatment of Diarrhoea: a Manual for Physicians and Other Senior Health Workers.2005.

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Ionic composition of intravenous infusion solutions

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Prevention
Water, sanitation, and hygiene: Safe food: Cooking eliminates most pathogens from foods Exclusive breastfeeding for infants Weaning foods are vehicles of enteric infection. Micronutrient supplementation: the effectiveness of this depends on the childs overall immunologic and nutritional state; further research is needed.

vaccines
Farthing et al. Acute Diarrhea. World Gastroenterology Organisation, 2008;
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CASE REPORT
February 13th 2011

Worms infection Weight loss (+)

7-months-old girl (BW: 7kg & BH: 70cm)

Vomitiing

diarrhea

Fever
Since since one week ago high temperature

The frequency is 3 times in a day

Since 3 days ago The frequency is 10 times in a day

The volume 20 cc for each time vomiting

the contents of vomite is that what she ate and drank

The volume glass every time diarrhea

In feces the water is more than the dregs Mucus (+)

Fever lowered with antipyretic

Seizure (-) shiver (-) recurrent fever (+) since birth
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Blood (+)

History of birth

Patient was born spontaneously aided by a midwife cried immediately at birth Cyanosis (-)

History of maternal conditions

fever (-), hypertension (-), diabetes mellitus(-), drugs(-) used the herbal medicine while two months pregnancy (used for abortion) Patient is the fifth child mother age is 32 years old 0-2 months : Breast feed and cow milk 2 months now : breast feed, cow milk and porridge BCG (+), Polio (three times), Hepatitis B (two times), DPT (two times).

Ate history History of immunization

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PHYSICAL EXAMINATION
Generalized Status:
Body weight : 7 kg Body height : 70 cm BW/ BH : 82,3% (mild malnutrition) Sensorium : Compos Mentis Body Temperature: 38,2 oC Anemic (-) Icteric (-) Cyanotic (-) Oedem (-) Dyspnoe (-)
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Head Neck Chest Abdominal Extremities Urogenital

Light reflexes (+/+) Isochoric pupiloric, pale on inferior palpebrals conjunctival (-/-) sunken eyes (+) Examination of the ear, mouth and nose cannot be found any abnormalities.

Lymph node enlargement (-) symmetrical fusiform. Heart rate was 132 bpm, regular, murmur (-) Respiratory rate 40 tpm regular, ronchi (-) Soft and tenderness, peristaltic was increased the liver and spleen was unpalpable, turgor slow to return.

Pulse was 132 bpm, regular, pressure and volume were normal acral was warm. Blood pressure was 90/60 mmHg Female. No abnormalities
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Working Diangnosis Gastroenteritis with mild-moderate dehydration.

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Management
IVFD RL 75cc/kgBB/4hours 130 cc 130

gtt/i micro Paracetamol 3 x 100 mg (pulv) Breast feed + porridge diet of 700 ccal with 96 gram of protein

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Investigation Plan
Complete Blood Count

Electrolit
Ad random glucose

Renal function test

Liver function test

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Laboratorium Findings (December 13th 2010) from Patology Clinic Adam Malik General Hospital
Result Test Complete Blood Count Hemoglobin (Hb) Erytrocyes (RBC) Leucocytes (WBC) 10.50 g% 4.82 x 106/mm3 11.00 x 103/ mm3 11.1-14.4 3.71-4.25 6.0-17.5 Normal Value

Hematocrit
Thrombocyte (PLT) MCV MCH MCHC RDW

33.20 %
456 x 103/ mm3 68.80 fL 21.80 pg 31.70 g% 15.70 % Cell Count

35-41
217-497 82-100 24-30 28-32 14.9-18.7

Neutrophil Lymphocyte Monocyte Eosinophil Basophil

37.80 % 47.10 % 12.90 % 0.12 % 2.040 % Electrolit

37-80 20-40 2-8 1-6 0-1

Sodium Potassium Chloride

133 3,4 90 Carbohydrate metabolism

135-155 3.6-5.5 96-106

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< 200

Ad random glucose

104.00 mg\dl

Follow Up Date 14/2/2011

S : Diarrhea (+), the frequency is 7 times in a day, in feces the water is more than the dregs O: Consciousness: Compos Mentis T: 37.7oC, BW: 7kg, BH: 70cm, BW/ BH: 82,3% Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior palpebrals conjunctiva (-/-), Ears and Nose: no, Mouth: dry mouth (+) Neck : Lymph node enlargement (-) Chest : Symmetrical fusiformic, retraction (-), HR: 126 bpm, regular, murmur (-) RR: 38 tpm, regular, ronchi(-). Abdomen : Soft and terderness, normal peristaltic. No liver and spleen enlargement. Extremities : Pulse 126 bpm, regular, Pressure/Volume: adequate, warm acral BP: 90/60 mmHg Urogenital : Female, no abnormalitites A: Gastroenteritis without dehydration. P : IVFD D5% NaCl 0.225%: 30 gtt/i micro Paracetamol 3 x100 mg (pulv) porridge 700 ccal with 14 gram of protein

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Follow Up Date 15/2/2011

S : Diarrhea (+), the frequency is 3 times in a day, the volume 20 cc everytime diarrhea , in feces the water is more than the dregs O: Consciousness: Compos Mentis T: 36.8oC, BW: 8kg, BH: 70cm, BW/ BH: 94.12% Head : Eyes: Light reflexes(+/+), isochoric pupil, pale inferior palpebrals conjunctiva (-/-), Ears, Nose, Mouth: no abnormalities Neck : Lymph node enlargement (-) Chest : Symmetrical fusiformic, retraction (-), HR: 140 bpm, regular, murmur (-) RR: 4 tpm, regular, ronchi(-). Abdomen : Soft and terderness, normal peristaltic. No liver and spleen enlargement. Extremities : Pulse 140 bpm, regular, Pressure/Volume: adequate, warm acral, BP: 90/60 mmHg Urogenital : Female, no abnormalitites A: Gastroenteritis without dehydration. P : IVFD D5% NaCl 0.225%: 30 gtt/i micro Paracetamol 3 x100 mg (pulv) Zink 1x20 mg porridge 700 ccal with 14 gram of protein
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Follow Up Date 16/2/2011

S : Diarrhea (+), the frequency is 4 times in a day, the volume 20 cc everytime diarrhea , in feces the water is more than the dregs O: Consciousness: Compos Mentis T: 37.4oC, BW: 8kg, BH: 70cm, BW/ BH: 94.12% Head : Eyes: Light reflexes(+/+), isochoric pupil, pale inferior palpebrals conjunctiva (-/-), sunken eyes (-), Ears and Nose: no abnormalities, Mouth: dry mouth (+) Neck : Lymph node enlargement (-) Chest : Symmetrical fusiformic, retraction (-), HR: 132 bpm, regular, murmur (-) RR: 52 tpm, regular, ronchi(-). Abdomen : Soft and terderness, normal peristaltic. No liver and spleen enlargement. Turgor fast return (+) Extremities : Pulse 132 bpm, regular, Pressure/Volume: adequate, warm acral, BP: 100/60 mmHg Urogenital : Female, no abnormalitites A: Gastroenteritis without dehydration. P : IVFD D5% NaCl 0.225%: 30 gtt/i micro Paracetamol 3 x100 mg (pulv) Zink 1x20 mg porridge 700 ccal with 14 gram of protein 29 Oralit 50-100 cc/each time diarrhea

Follow Up Date 17/2/2011

S : Diarrhea (+), the frequency is 4 times in a day, in feces the water and dregs were the same, mucus (+), blood (-). O: Consciousness: Compos Mentis T: 38oC, BW: 8kg, BH: 70cm, BW/ BH: 94.12% Head : Eyes: Light reflexes(+/+), isochoric pupil, pale inferior palpebrals conjunctiva (-/-), sunken eyes (-), tears (+). Ears, Nose, and Mouth: no abnormalities Neck : Lymph node enlargement (-) Chest : Symmetrical fusiformic, retraction (-), HR: 152 bpm, regular, murmur (-) RR: 40 tpm, regular, ronchi (-). Abdomen : Soft and terderness, normal peristaltic. No liver and spleen enlargement. Turgor fast return (+) Extremities : Pulse 152 bpm, regular, Pressure/Volume: adequate, warm acral, BP: 100/60 mmHg Urogenital : Female, no abnormalitites A: Gastroenteritis without dehydration. P : IVFD D5% NaCl 0.225%: 30 gtt/i micro Paracetamol 3 x100 mg (pulv) Zink 1x20 mg porridge 700 ccal with 14 gram of protein 30 Oralit 50-100 cc/each time diarrhea

Laboratorium Findings (December 17th 2010) from Patology Clinic Adam Malik General Hospital
Result Test Complete Blood Count Hemoglobin (Hb) Erytrocyes (RBC) Leucocytes (WBC) Hematocrit Thrombocyte (PLT) MCV MCH MCHC RDW 8.80 g% 3.97 x 106/mm3 9.21 x 103/ mm3 26.30 % 404 x 103/ mm3 56.20 fL 22.20 pg 33.50 g% 17.40 % Cell Count Neutrophil Lymphocyte Monocyte 23.80 % 53.50 % 20.20 % 37-80 20-40 2-8 11.1-14.4 3.71-4.25 6.0-17.5 35-41 217-497 82-100 24-30 28-32 14.9-18.7 Normal Value

Eosinophil
Basophil

1.80 %
0.700 %

1-6
0-1 31

Electrolit Sodium Potassium Chloride 137 2.0 108 Carbohydrate metabolism Ad random glucose 86.80 mg\dl Liver function test Total bilirubin Direct bilirubin ALP SGOT SGPT 0.23 mg/dl 0.09 mg/dl 83 U/L 24 U/L 10 U/L Renal function test <1 0-0.2 < 462 < 32 < 31 < 200 135-155 3.6-5.5 96-106

Ureum
Creatinine Uric acid

8.00 mg/dl
0.23 mg/dl 1.7 mg/dl Anal swab

< 50
0.17-0.42 < 5.7

Color Consistency Blood Mucus Worm egg Amoeba Red blood cells White blood cells

Yellow Watery Negative Negative Negative Negative 0-1 0-1 Negative Negative Negative Negative

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Discussion
Theory
Diarrhea is the passage of unusually loose or watery stools, usually at least three times in a 24 hour period. However, it is the consistency of the stools rather than the number that is most important

Case
the patient was admitted with chief complain diarrhea and the frequency is 10 times in a day with the water is more than the dregs.

Acute diarrhea is thus defined as an the patient has acute diarrhea because episode that has an acute onset and lasts he has diarrhea for 7 days no longer than 14 days A child with diarrhea should be assessed the patient was restless, has sunken for dehydration. In some dehydration, eyes, thirsty and eagerly to drink. we must look at the condition (restless, irritable), sunken eyes, thirsty and eagerly to drink, and feel the skin pinch that goes back slowly

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Theory

Case

Replacement of fluid and electrolytes This patient, general supportive care is the most important to treat diarrhea. should include IVFD RL 75cc/kgBB/4hours The children usual diet should be continued during diarrhea and increased afterwards. Food should never be withheld and the child's usual foods should not be diluted. Breastfeeding should always be continued. By giving zinc as soon as diarrhea starts, the duration and severity of the episode as well as the risk of dehydration will be reduced The patient continued to has breastfeeding addition with porridge diet of 700 ccal with 96 gram of protein

On February 15th 2011, the patient got zinc for the first time.

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Summary
It has been reported that a case of a 7-months-old girl diagnosed as gastroenteritis with mildmoderate dehydration. The diagnosis was established based on history taking, clinical manifestation, and laboratory finding. The treatment of this patient are IVFD D5% NaCl 0.225%, Paracetamol, Zink, Oralit, and diet (porridge) 700 ccal with 14 gram of protein. The patient has been recovered after get medication for 4 days in Adam Malik General Hospital and was controlled at Adam Malik General Hospital gastroentererology polyclinic. 35

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