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 1
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; 3

 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; 4

 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

Rotavirus - 25-40% of Campylobacter jejuni - 6-

cases 8% of cases Cryptosporidium - 1-
Norovirus - 10-20% of Salmonella - 3-7% of 3% of cases
cases cases G lamblia - 1-3% of
Calicivirus - 1-20% of E Coli - 3-5% of cases cases
cases Shigella - 0-3% of cases
Astrovirus - 4-9% of Y enterocolitica - 1-2% of
cases cases
Enteric-type adenovirus - C difficile - 0-2% of cases
2-4% of cases Vibrio parahaemolyticus -
0-1% of cases
V cholerae - Unknown
Aeromonas hydrophila -
0-2% of cases

6
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
7
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 Organism invade or toxins absorbed

produced but infection remain in GI
tract
dissemination
DIARE
Symptoms of
systemic
infection ex.
Fever etc.

Pathogenesis of diarrhoea 8
 Pathophysiology

Silbernagl S and Lang F. Color Atlas of Pathophysiology. New York: Thieme, 2009;
 10
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
2005. 11
 Look and Feel

WHO. The Treatment of Diarrhoea: a Manual for Physicians and Other 12

Senior Health Workers 2005.
 Laboratory

Complete Culture Immuno

Electrolyte Anal swab
blood count stool assay

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

February 2011].

13
 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].

14
 Treatment
ORS, iv infusion
Zn
Nutrition
Vitamin A
Antibiotic
Probiotic

WHO. The Treatment of Diarrhoea: a Manual for Physicians and Other Senior Health 15
Workers.2005.
16
Ionic composition of intravenous infusion solutions

17
 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; 18

 CASE REPORT Worms
infection
February 13th 2011 7-months-old girl
(BW: 7kg & BH: 70cm) Weight loss (+)

Vomitiing diarrhea Fever

Since since one

Since 3 days ago
The frequency is 3 week ago
times in a day The frequency is 10
high temperature
times in a day
The volume glass Fever lowered with
The volume 20 cc every time diarrhea antipyretic
for each time
vomiting In feces the water is
Seizure (-)
more than the dregs

the contents of Mucus (+) shiver (-)

vomite is that what
recurrent fever (+) 19
she ate and drank Blood (+)
since birth
 Patient was born spontaneously
aided by a midwife
History of birth cried immediately at birth
Cyanosis (-)

fever (-), hypertension (-), diabetes mellitus(-),

History of drugs(-)
used the herbal medicine while two months
maternal pregnancy (used for abortion)
conditions Patient is the fifth child
mother age is 32 years old

0-2 months : Breast feed and cow milk

Ate history 2 months now : breast feed, cow milk and
porridge

History of BCG (+), Polio (three times), Hepatitis B (two

20
immunization times), DPT (two times).
 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 (-)
21
 Light reflexes (+/+)
Isochoric pupiloric,
pale on inferior palpebrals conjunctival (-/-)
Head sunken eyes (+)
Examination of the ear, mouth and nose cannot
be found any abnormalities.

Neck Lymph node enlargement (-)

symmetrical fusiform.
Chest

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

Pulse was 132 bpm, regular, pressure and

volume were normal
Extremities acral was warm.
Blood pressure was 90/60 mmHg

Urogenital Female. No abnormalities 22

 Working Diangnosis

Gastroenteritis with mild-moderate

dehydration.

23
 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

24
 Investigation Plan
Complete Blood Count
Electrolit
Ad random glucose
Renal function test
Liver function test

25
 Laboratorium Findings (December 13th 2010) from Patology Clinic
Adam Malik General Hospital
Result Normal Value
Test
Complete Blood Count
Hemoglobin (Hb) 10.50 g% 11.1-14.4
Erytrocyes (RBC) 4.82 x 106/mm3 3.71-4.25
Leucocytes (WBC) 11.00 x 103/ mm3 6.0-17.5
Hematocrit 33.20 % 35-41
Thrombocyte (PLT) 456 x 103/ mm3 217-497
MCV 68.80 fL 82-100
MCH 21.80 pg 24-30
MCHC 31.70 g% 28-32
RDW 15.70 % 14.9-18.7
Cell Count
Neutrophil 37.80 % 37-80
Lymphocyte 47.10 % 20-40
Monocyte 12.90 % 2-8
Eosinophil 0.12 % 1-6
Basophil 2.040 % 0-1
Electrolit
Sodium 133 135-155
Potassium 3,4 3.6-5.5
Chloride 90 96-106
Carbohydrate metabolism 26
Ad random glucose 104.00 mg\dl < 200
 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

27
 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

28
 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 Normal Value
Test
Complete Blood Count
Hemoglobin (Hb) 8.80 g% 11.1-14.4
Erytrocyes (RBC) 3.97 x 106/mm3 3.71-4.25
Leucocytes (WBC) 9.21 x 103/ mm3 6.0-17.5
Hematocrit 26.30 % 35-41
Thrombocyte (PLT) 404 x 103/ mm3 217-497
MCV 56.20 fL 82-100
MCH 22.20 pg 24-30
MCHC 33.50 g% 28-32
RDW 17.40 % 14.9-18.7
Cell Count
Neutrophil 23.80 % 37-80
Lymphocyte 53.50 % 20-40
Monocyte 20.20 % 2-8
Eosinophil 1.80 % 1-6
Basophil 0.700 % 0-1 31
 Electrolit
Sodium 137 135-155
Potassium 2.0 3.6-5.5
Chloride 108 96-106
Carbohydrate metabolism
Ad random glucose 86.80 mg\dl < 200
Liver function test
Total bilirubin 0.23 mg/dl <1
Direct bilirubin 0.09 mg/dl 0-0.2
ALP 83 U/L < 462
SGOT 24 U/L < 32
SGPT 10 U/L < 31
Renal function test
Ureum 8.00 mg/dl < 50
Creatinine 0.23 mg/dl 0.17-0.42
Uric acid 1.7 mg/dl < 5.7
Anal swab
Color Yellow
Consistency Watery
Blood Negative Negative
Mucus Negative Negative
Worm egg Negative Negative
Amoeba Negative Negative
Red blood cells 0-1 32
White blood cells 0-1
 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 33
 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 The patient continued to has
continued during diarrhea and breastfeeding addition with porridge
increased afterwards. Food should diet of 700 ccal with 96 gram of
never be withheld and the child's protein
usual foods should not be diluted.
Breastfeeding should always be
continued.
By giving zinc as soon as diarrhea On February 15th 2011, the patient got
starts, the duration and severity of the zinc for the first time.
episode as well as the risk of
dehydration will be reduced

34
 Summary
It has been reported that a case of a 7-months-old
girl diagnosed as gastroenteritis with mild-
moderate 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
36