DIARRHOEA

Atan Baas Sinuhaji

Department of ChildHealth
School of Medicine,University Of Sumatera Utara
Medan
 DIARRHOEA

VOLUME OF WATER IN
THE STOOLS

LOOSE WATERY
 HYPERSECRETION

PERISTALSIS

WATER AREA FOR

ABSORPTION

MALABSORPTION
HYPEROSMOLAR

MALDIGESTION
 DIARRHOEA

- FREQ. 3 X /DAY
- CHANGING OF CONSISTENCY
- WITH/ WITHOUT VOMITING
- WITH/WITHOUT BLOODY STOOL

ACUTE WATERY DYSENTERY SEVERE

PERSISTENT
DIARRHOEA FORM MALNUTRITION

BLOODY
< 14 DAYS > 14 DAYS
DIARRHOEA
BABIES FED ONLY BREAST MILK OFTEN
FREQUENT PASSING OF FORMED STOOLS
( 5-6 x / DAY )

THIS ALSO NOT DIARRHOEA

 INFECTION - VIRAL
- FUNGAL
- BACTERIA
- PARASITES

INFLAMMATION

DIARRHOEA NON INFECTION - ALLERGY

- etc

NONINFLAMMATION - HORMONAL
- ANATOMICAL
- etc
 VIRAL DIARRHOEA

1. ROTAVIRUS ==> 6 MONTHS to 2.5 YEARS

2. NORWALK VIRUS
3. ENTERIC ADENOVIRUS
4. ASTROVIRUS
5. CALICI VIRUS
6. CORONA VIRUS
7. SMALL ROUND VIRUS
- PARVOVIRUS LIKE AGENT
- MINI ROTAVIRUS
- MINI REOVIRUS
 PRACTICALITY

LIQUID STOOLS 3x/DAY,

WITH/WITHOUT VOMITING,
WITH/WITHOUTMUCOUS/BLOOD
 CLASSIFICATION
1. AGE
2. ONSET
3. ETIOLOGY
4. SEVERITY
5. PATHOGENESIS
6. HOST DEFENSE
7. SOURCE OF INFECTION
8. EPIDEMIOLOGY
9. SITE OF PATHOLOGY
10.WHO (2005)
1.AGE
-NEONATAL DIARRHOEA : DIARRHOEA IN
NEONATES
-INFANTILE DIARRHOEA : DIARRHOEA IN
INFANTS
-CHILDHOOD DIARRHOEA : DIARRHOEA IN
CHILDREN
2. ONSET
-ACUTE DIARRHOEA : < 7 DAYS (90-95%)
- PROLONGED DIARRHOEA : 7-14 DAYS
- CHRONIC DIARRHOEA : > 14 DAYS
3. ETIOLOGY
-INFLAMMATION : INFECTION /
-RADANG : INFEKSI
NON INFECTION
/ NON INFEKSI
-NON RADANG
-NONINFLAMMATION
4. SEVERITY ( WHO, 1984)
-MILD DIARRHOEA : 1x / 2 hours or 5 mL / KgBW / hour
-SEVERE DIARRHOEA : > 1x / 2 hours or > 5mL/KgBW/hour

5.HOST DEFENSE
-IMMUNOCOMPETENT
-IMMUNOCOMPROMISED :AIDS, LEUKEMIA, etc.

6. SOURCE OF INFECTION
-NOSOCOMIAL : INFECTION IN HOSPITAL
-COMMUNITY
7. PATHOGENESIS

ABSORPTIVE/OSMOTIC SECRETORY
1. FASTING STOPS CONTINUES
2. STOOLS OSM. 400 280
3. Na + 30 100
4. K+ 30 40
5. (Na+K)x 2 120 280
6. SOLUTE GAP 280 0
8. EPIDEMIOLOGY
-ENDEMIC : PRESENT AT ALL TIMES
-EPIDEMIC : OUTBREAK
-MIXED

9. SITE OF PATHOLOGY

-SMALL INTESTINAL: CHOLERA, ETEC,

ROTAVIRUS & G. LAMBLIA
DIARRHOEA
-LARGE INTESTINAL: SHIGELLOSIS, AMOEBIASIS
-BOTH : CAMPYLOBACTERIOSIS,
SALMONELLOSIS
10. WHO (2005)

-ACUTE DIARRHOEA
-PERSISTENT DIARRHOEA
-DYSENTERY FORM
-DIARRHOEA WITH SEVERE
MALNUTRITION
 MICROORGANISMS

GASTRIC ACID

MULTIPLICATION

COLONIZATION
ADHERENT

ENTEROTOXIN - INVASION
- DAMAGE

HYPERSECRETION MALABSORPTION
HYPERPERISTALSIS

COLONIC SALVAGE DIARRHOEA

PATHOGENESIS OF ACUTE INFECTIOUS DIARRHOEA

 DIARRHOEA

Cleansing Loss Of
Effect Water & Electrolytes
Pathogens Nutrients

Defense Dehydration
Hypoglycemia
Starvation
Malnutrition
Self
Self Limited
Limited
Water
Water && Electrolytes
Electrolytes
Diets
Diets
 WATER DEHYDRATION

ELEKTROLIT
ELEKTROLYTES Na+ ==> atau
Na+ or
K+ ==>
K+ ==>
Ca2+
D Ca2+ ==> TETANY
Mg2+ ==>
I Mg2+
Zn ==> ==> TETANY
ACRODERMATITIS ENTEROPATHICA
A Zn ==>ACRODERMATITIS ENTEROPATHICA
R BASE ASIDOSIS METABOLIC
R
H NUTRIENTS - HYPOGLYCEMIA
O - STARVATION
E - PCM
A
MUCOSAL - MALABSORPTION
INJURY - PROTEIN LOSING ENTEROPATHY
- SENSITIZATION
- NECROTIZING ENTEROCOLITIS
 HYPOCALCEMIC

TETANY HYPOMAGNESEMIC

ALKALOTIC
 LOSS OF WATER VIA STOOLS

DEHYDRATION

PLASMA WATER

FEVER HEMOCONCENTRATION HYPOVOLEMIA

SHOCK RBF* SYMPATH. DISCHARGE

COMA ARF** - HEART RATE

- VASOCONSTRICTION
* Renal Blood Flow
** Acute Renal Failure
 SIGNS OF DEHYDRATION
1. LETHARGIC TO 7. WEAKNESS OF
COMATOSE RADIAL PULSE
2. SUNKEN 8. HYPOTENSION
ANTERIOR 9. THIRSTY
FONTANELLA 10. TURGOR
3. SUNKEN EYES 11. COOL MOIST
4. ABSENT OF EXTREMITIES
TEARS 12. OLIGURIA/ANURIA
5. DRY OF MOUTH & 13. BW
TONGUE
6. HR
 DEHYDRATION

VOLUME PLASMA SODIUM

SOME DEHYDRATION ISONATREMIA

= 5 - 10 % BB = 135 - 150 mEq/L
SEVERE DEHYDRATION
= > 10% BB HYPO/HYPER
NATREMIA
 THE
THE OBJECTIVES
OBJECTIVES OF
OF TREATMENT
TREATMENT ACUTE
ACUTE DIARRHOEA
DIARRHOEA

DEHYDRATIONPROTEIN CALORY DURATION, SEVERITY

MALNUTRITION EPISODES
PREVENTION TREAT

WATER & ELECTROLYTES FEEDING ZINC

 MANAGEMENT

ASSESSMENT TREATMENT

1. Degree of 1. Water &

Dehydration electrolytes
2. Associated : 2. Diets
Malnutrition 3. Drugs
Pneumonia - Zinc
etc - antimicrobial
 DEGREE OF DEHYDRATION (WHO,2005)
NO SIGN OF SOME SEVERE
DEHYDRATION DEHYDRATION DEHYDRATION

CONDITION WELL, ALERT RESTLESS / LETHARGIC,

IRRITABLE FLOPPY, COMA

EYES NORMAL SUNKEN SUNKEN

THIRST NORMALLY, NOT THIRSTY, DRINK DRINKS POORLY

THIRSTY EAGERLY

SKIN TURGOR QUICKLY SLOWLY VERY SLOWLY

NB : 1. READING FROM RIGHT TO LEFT

2. CONSIDERED SEVERE OR SOME DEHYDRATION IF TWO OR
MORE OF THE SIGN ARE PRESENT
 FLUIDS TREATMENT

REHYDRATION MAINTENANCE

INITIAL REPLETION NORMAL + ABNORMAL

HOLLIDAY CHOLERA
SEGAR COT
 HOLLIDAY - SEGAR
10 kg 100 cal / kg
10 - 20 kg 1000 cal + 50 cal/ kg
for each > 10 kg
> 20 kg 1500 cal + 20 cal/ kg
for each > 20 kg
NB : 100 cal 100 ml water
2,5 mEq Na+
2 mEq K+
 REHYDRATION

ORAL I.V.

RINGERS LACTATE
ORS*
(ORALIT@) RINGERS ACETATE

* Oral Rehydration Salts

 PREVIOUS STANDARD WHO
ORAL REHYDRATION SALTS
(ORS)

1. ISOTONIC
2. Na+ equivalent with plasma (90 mEq/l)
3. GLUCOSE = 2 - 3%
4. K+ (higher than plasma 20 mEq/l)
5. BASE = 30 - 48 mEq/L
 CHO
Peptide
Na+ LUMEN

Amino Acid water

Na+
2K+ ENTEROCYTES

3Na+ BASEMENT
MEMBRANE

BLOOD VESSELS
LAMINA
PROPRIA
 ORAL REHYDRATION SALTS
(WHO)

PREVIOUS NEW
(mmol/L) (mmol/L)

Na 90 75
K 20 20
Cl 80 65
Citrat 10 10
Glucose 111 75
311 245
NEW (LOW OSMOLARITY) WHO
ORAL REHYDRATION SALTS

STOOL OUTPUT = 20%

VOMITING = 30%
THE NEED FOR SUPPLEMENTAL I.V
FLUID = 33%
 LUMEN USUS P.DARAH INTERSTISIAL
ORALIT
LARUTAN GULA
@
LGG LARUTAN GARAM

DHF

DIARE @
Larutan Garam Gula
 INDICATION OF I.V FLUIDS
1. SEVERE DEHYDRATION
WITH/WITHOUT SHOCK
2. SEVERE DIARRHOEA
3. INTAKE BY MOUTH
4. GLUCOSE MALABSORPTION
5. ABDOMINAL DISTENSION /
PARALYTIC OBSTR.
6. OLIGURIA / ANURIA FOR
SEVERAL HOURS
 DEHYDRATION

NO SIGN OF SOME SEVERE

< 5% 5 - 10% > 10%

A B C
 A. NO SIGN OF DEHYDRATION
1. ORALIT
< 2 years = 50 - 100 mL / X loose stool
2 years = 100 - 200 mL / X loose stool
2. GIVE THE CHILD MORE FLUIDS &
FOODS THAN USUAL

PREVENTION OF DEHYDRATION
3. GIVE SUPPLEMENTAL ZINC (<6 months=10
mg/day;> 6 months =20mg/day) for 10-14 days
 B. SOME DEHYDRATION

ORALIT 75 mL/kg BW /3 or 4
hours
INDICATION

Ringers Lactate
Ringers Acetate
 C. SEVERE DEHYDRATION
100 mL/ kgBW/3-6 hours
< 1 year * initial = 30 mL/kgBW/ 1
hour
* repletion= 70 mL/kgBW/5
hours
> 1 years* initial = 30 mL/kgBW/
hours
* repletion = 70 mL/kgBW/2
hours
 ORALIT

PREVENTION
TREATMENT
MAINTENANCE

DEHYDRATION DIARRHOEA
 DIARRHOEA

REHYDRATION

ANURIA/OLIGURIA ADEQUATE
URINE *

RENAL PHYSIOLOGIC NO
FAILURE OLIGURIA PROBLEM

FLUIDS FLUIDS
NB : 1. * 1 mL / kg BW / hour
2. Oliguria : < 400 mL / m2 / day
 Renal Physiologic
Failure Oliguria
Lasix@ diuresis (-) diuresis (+)

Laboratory
Urine osmolality <350 >500
(mOsm/kgH2O)
Na+ urine (mEq/l) > 40 <20
Fr. excr of Na+ >1% <1%

Fractional Na urine/Na plasma
Excretion of 100%
Na+ Cr . urine/Cr . plasma
 FEEDING

1. AFTER REHYDRATION
2. < 4 MONTHS
- BREASTMILK (+)
- BREASTMILK (-) ==> ????
3. > 4 MONTHS
- BREASTMILK
- RICE PORRIDGE
- BANANAS
- FISHES
- TAHU, TEMPE
- FORMULA MILK STOP