When Warteg Gives Him

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Pemicu 2
 Skenario
Mr. Surip, a 26-year-old previously healthy male, has
been in Jakarta for about 2 weeks since he came
home from his study in the States. Ever since, he
has eaten any kinds of Indonesian food, and
Warteg is always his favorite, especially the one
across his old school.
Today, Mr. Surip present to your clinic reporting a 2-
day history of watery diarrhea and he has noticed
that theres blood in his stool. He has up to 8 bowel
movement per day. He has had intermittent
abdominal cramps as well. For the past 2 days, he
also feels nauseated, but no vomiting. His vital signs
are normal, his bowel sounds are hyperactive and
the remainder of the physical exam is remarkable
only for mild, diffuse abdominal tenderness.
 DEFINITION diarrhea
Defecation with fecal liquid / semi
liquid stools contain more water than
is usually more than 200 grams or
200 ml / 24 hours.
CHAPTER dilute more than 3x / day
may be accompanied by mucus /
blood
 Classification Diarrhea
A. Based on the time of diarrhea
1) Accute diarrhea
Diarrhea that lasts less than 15 days
2) Chronic diarrhea
Diarrhea lasting more than 15 days

B. Based on the severity of diarrhea

1) Small Diarrhea
2) Of diarrhea
 Classification Diarrhea
C. Based on the mechanism patofisiologik
1) osmotic diarrhea (abated during fasting)
=> excessive osmotic force generated by the
solute in the lumen -> liquid suspended in the
lumen -> feces diluted
2) secretory diarrhea (settled during the fast)
=> Net intestinal fluid secretion is increased ->
feces diluted
D. Based on the causes
1) infective diarrhea
2) non-infective diarrhea
- Diarrhea organic: if found cause anatomik,
hormonal or toksikologik
- Functional diarrhea
Organis Periode Muntah Diare Demam Makanan yg Diagno Clinical
me inkubasi berkaitan sis fatures
dan
Pengobata
n

Staphyloc 1-8 jam +++ +/- +/- Staphylococcus Makanan Bisa terjadi
occus berkembang dan tinja mual dan
(megeluar didaging, produk bisa muntah
kan racun) roti, dan ditest u/ dalm 24
memproduksi toksin jam.
enterotoksin Supportive
care
Bacillus 1-8 jam +++ +/- - Nasi goreng yang Makanan Menyebabk
cereus(me dipanaskan dan tinja an mual dan
ngeluarka muntah dan diare bisa muntah
n racun) ditest u/ berat.
toksin supportive
care
B cereus 10-16 jam +/- +++ - Racun di Makanan Nyeri
(diarrheal daging,rebusan, dan tinja abdomen,
toxin) kuah daging bisa water
ditest u/ diarrhea,mu
toksin al dlm 24-
48 jam.
Antibiotik-
Clostridiu 8-16 jam +/- +++ - Tumbuh di makanan Makanan Diare,nyeri
m yg dihangatkan, dan tinja abdominal,
perfingens unggas, bisa mual,kadan
memproduksi ditest u/ g muntah
enterotoksin toksin Sembuh
Organism Period Muntah Diare Dema Makanan yg Diagno Clinical
e e m berkaitan sis fatures
inkuba dan
si Pengobat
an

Clostridiu 12-72 +/- - - Tumbuh di Makana Diplopia,

m jam lingkungan kedap n dan disfagia,
botulinum udara(ikan yg tinja dishponia,
difermentasikan) bisa gangguan
ditest u/ pernapasa
toksin, n
bisa
dibiakk
an
Clostridiu Muncul - +++ ++ Berhubungan tinja Demam,
m difficile 7-12 dngn obat bisa tinja
hari antimikroba ditest u/ berdarah.
setelah (cindamicin toksin Pengobata
minum &cephalosporin n:metroni
antibioti plng sering) dazole
k
Enterohem 1-8 hari + +++ - Daging sapiyg tinja Nyeri
oraggic tdk bisa abdomen,
E.coli dimasak(hamburg ditest u/ tinja
er), susu yg tdk toksin berdarah.
dipasteurisasi Pd
dewasas
mbuh dlm
Organism Period Muntah Diare Dema Makanan yg Diagno Clinical
e e m berkaitan sis fatures
inkuba dan
si Pengobat
an

Enterotoxi 1-3 hari +/- +++ +/- Air dan makanan tinja Water
genic yg terkontaminasi bisa diarrhea,n
E.Coli feses ditest u/ yeri
toksin, abdomen
bisa selama 3-
dibiakk 7 hari
an Floroquino
lonpeng
obatan
pertama
Vibrio 2-48 + + +/- Makanan yg tdk tinja Water
parahaem jam dmasak , seafood bisa diarrhea,n
olitik mentah ditest di yeri
medium abdomen,
spesial mual dan
muntah
Sembuh
dlm 2-5
hari
Vibrio 24-72 + +++ - Air yg tinja Tetrasiklin
cholerae jam terkontaminasi,ik bisa memperd
an, kerang, ditest ek sekresi
makanan kaki 5 dimediu dr vibrio
 Etiologi Diare
Osmotic diarrhea Eksudatif disease
Drugs / chemicals Bacterial infection =>
hiperosmotik Epithelial damage
Ulcerative colitis
General Malabsorbsi Crohn's disease
Intestinal mucosa
absorption defect
Motility disorders
Reduction of intestinal
Secretory diarrhea length
Bacterial enterotoxin Neurological dysfunction
Viral infection Hyperthyroidism
Ileal resection Growth of intestinal
Laxative drug effects bacteria
DM
 Simtom, gejala klinik dan sifat
Simtom dan tinja ETEC
Rotavirus EIEC
gejala
Mual dan Dari ---- ----
muntah permulaan ---- +
Panas + Kadang- Tenesmus,
Sakit Tenesmus kadang kolik
Gejala lain Sering hipotensi
Sifat tinja: Sedang distensi Sedikit
Volume Sampai abdomen Sering
Frekuensi 10x/lebih Banyak Kental
Konsistensi Berair Sering +
Mukus Jarang Berair +
Darah ---- + Tidak spesifik
Bau ---- ---- Hijau
Warna Hijau, kuning Bau tinja *
Leukosit ---- Tidak
Sifat lain berwarna
----
Simtom dan Salmonella Shigella V cholerae
gejala
Mual dan + Jarang Jarang
muntah + + ---
Panas Tenesnus, kolik Tenesmus,kolik Kolik
Sakit Pusing Pusing

Gejala lain Bakteremia/tok Dapat kejang

semia sistemik
Sifat tinja:
Volume Sedikit Sedikit Sangat banyak
Frekuensi Sering Sering sekali Hampir terus
menerus
Konsistensi Berlendir Kental Flacks
Mukus + Sering
Darah Kadang- Sering Anyir
Bau kadang Tak berbau
Warna Bau telur Hijau
Leukosit busuk +
Sifat lain Hijau Tinja seperti
+ air cucian nasi
PATHOFISIOLOGY DIARRHE
1. Osmolarity raised intraluminal osmotic
diarrhea
2. Secretion of fluid and electrolyte
secretory diarrhea
3. Malabsorbsi bile acids, fatty malabsorbsi
4. Defect anion exchange system / active
electrolyte transport in enterosit
5. Motility and abnormal intestinal transit time
6. Intestinal permeability disorders
7. Inflammatory bowel wall diarrhea
inflamatorik
8. Infection of the intestinal wall infectious
diarrhea
 Diarrhea Treatment
Rehydration
No dehydration: soft drinks, fruit juice, soup
Dehydration: IV fluids or oral rehydration isotonic
Type of liquid
The amount of fluid
The entrance or how fluid
Schedule fluid

Diet
Consumption of foods that are easily digestible and
avoid caffeinated drinks, alcohol and soft drinks as they
may intestinal motility and secretion
Anti-diarrhea medication
a. derivatives opioid drugs: loperamide, difenoksilat,
tinktur opium, bismuth subsalisilat
b. drugs that hardened feces: atapulgite 4x2tab/hari
smectite 3x1sachet/BAB
c. Drugs antisecretorik: hidrase 3x1tab/hari
Antimicrobial drugs
 DETERMINATION DEGREES
Dehydration
Based BB
light of BB <5%
was a BB 5 - 10%
weight of BB> 10%
According Haroen Noerasid (modification)
Light & Thirst light Oliguria , sign was
above + skin turgor, sunken eyes ubun2
& Weight
Sign above + somnolen, sopor, coma,
shock, breathing kussmaul
 Based on fluid ketonusan
Isotonic dehydration
Loss of water and Na in the same proportion
Is dehydration due to diarrhea
mark very quickly, thirsty and sweaty cold
extremities, decreased consciousness and
hypovolaemic shock symptoms
Dehydration Hipertonis
There is a shortage of liquid water and Na, but the
proportion lost more water (Na> 150 mmol / L)
signs were very thirsty, iritabel
Dehydration Hipotonis
There is a shortage of liquid water and Na, but the
proportion lost more Na (Na> 130 mmol / L) child
sign lethargy, seizures
 Complication
Loss of water and electrolytes
Dehydration, Hypokalaemia, metabolic
acidosis, seizures, metabolic Alkalosis
Blood circulation disorders hypovolaemic
shock
Hypoglycemia
Disturbance nutrition, protein energy
Malnutrition
Rectal irritation may occur due to liquid
feces contain substances that can irritate.
 Dehydration
Dehydration is a lack of total body fluid, a loss of
more water than sodium (hypertonic dehydration),
or loss of water and sodium in the same amount
(dehidrasiisotonik), or the loss of more sodium than
water (dehydration hipetonik).
Hypertonic dehydration characterized by high levels
of serum sodium (more than 145 mmol / Liter) and
effective serum osmolality increased (more than 285
mOsmol / Liter)
Isotonic dehydration of the mark with a normal
serum sodium levels (135-14) mmol / Liter) and
effective serum osmolality (270-285 mOsmol / Liter).
Hypotonic dehydration characterized by low serum
sodium levels (less than 135 mmol / liter) and
effective serum osmolality (less dari270 mOsmol /
Liter).
 Patofisiologi
1. Intraluminal osmotic pressure => suspended in the fluid lumen =>
watery feces
2. Water and electrolyte secretion in intestinal ,
3. absorption => stool volume>> and watery feces
4. Resistance mechanisms of active transport of Na + K + ATPases =>
absorption of water and Na abnormal
5. Hipermotilitas and intestinal absorption ireguralitas
6. Abnormal intestinal permeability krn morphological abnormalities in the
intestinal epithelial membrane
7. Damage to the gut mucosal inflammation krn => excessive mucus
production, eksudasi water and electrolytes into the lumen => noise
absorption
8. Bacterial infection divided by 2:
non-invasive => enterotoxin
Invasive => damage to the mucosa, diarrhea can be mixed with mucus
and blood
 Conclusion
Likely affected Mr.Surip traveler's E.
Coli
 Advice
Eat with good sanitation
Drink plenty of water
If it has not healed to a doctor refers
 refferences
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Thomson learning, 2007.
Le Tao, Lam wilbur, dkk. First Aid For The Pedriatic
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Behrman Richard.E, Vaughan Victor.C.Nelson Ilmu
Kesehatan Anak. Edisi 12.Jakarta : EGC, 1992.
http://www.emedicine.com
http://www.rch.org.au/clinicalguide.com
http://www.rchhandbook.org
Rudolph AM, Hoffman JIE, rudolph CD. Buku Ajar
Pediatri Rudolph 20th ed. Jakarta: Penerbit Buku
Kedokteran EGC, 2007.