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DIARRHEA
Diarrhea is a common symptom that can range
in severity from an acute, self-limited
annoyance to a severe, life-threatening illness.
Patients may use the term "diarrhea" to refer
to increased frequency of bowel movements,
increased stool liquidity, a sense of fecal
urgency, or fecal incontinence
 Definitions
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 Increase in daily stool weight above 200gm

 Increase in frequency, fluidity or amount
 Differentiate from incontinence/tk dpt mnhan and
IBS
 Acute lasts less than 7 - 14 days
 Chronic lasts more than 2 - 3 weeks
 Approaches to the classification of
diarrhoea
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 Mechanistic
Osmotic - eg carbohydrate/ fat malabsorption
Secretory- mucosal disease, defects of ion
absorption, stimulant laxatives
Gut hormone
Deranged /kacau motility- post vagtomy, IBS
carcinoid
Causes of diarrhoea
Colonic
Colonic neoplasia Endocrine
Ulcerative and Crohn's colitis Hyperthyroidism
Microscopic colitis Diabetes
Small bowel Hypoparathyroidism
Coeliac disease Addison's disease
Crohn's disease Hormone secreting tumours (VIPoma,
Other small bowel enteropathies, gastrinoma, carcinoid)
(e.g. Whipples disease, tropical sprue, amyloid,
intestinal lymphangiectasia )
Bile Acid malabsorption
Disaccharidase deficiency
Small bowel bacterial overgrowth
Mesenteric ischaemia
Radiation enteritis Other
Lymphoma Factitious diarrhoea
Giardiasis Surgical' causes (e.g. small bowel
Pancreatic resections)
Chronic pancreatitis Autonomic neuropathy
Pancreatic carcinoma Drugs
Cystic fibrosis Alcohol
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 Chronic diarrhoea

Colonic Small bowel Pancreatic

Frequency
Age
Malignancy

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Diarrhea

 Increase in frequency, size or loosening of

bowel movements.
 Differentiate from fecal incontinence or
functional bowel disease- normal stool
weight
 With western diet- less than 200g/day

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Pathophysiology

 Increased active anion secretion

 Decreased absorption of water and
electrolytes

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Types

 Transmissible agents
 Noninfectious - abnormal mucosa
 Inflammatory Bowel disease
 Celiac disease, microscopic colitis, eosinophilic and
allergic gastroenteritis, radiation enteritis
 Noninfectious - normal mucosa
 Osmotic diarrhea
 Mal-absorption
 Rapid intestinal transit- IBS

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Causes of acute
infectious diarrhea
Inflammatory Diarrhea

 Viral – Cytomegalovirus
 Protozoal - Entamoeba histolytica
 Bacterial - Cytotoxin productio;
Enterohemorrhagic E coli, Vibrio
parahaemolyticus, Clostridium difficile.
Mucosal invasion; Shigella, Campylobacter jejuni
Salmonella, Enteroinvasive E coli ,Aeromonas
Plesiomonas,Yersinia enterocolitica,Chlamydia
Neisseria gonorrhoeae, Listeria monocytogenes
 Causes of chronic diarrhea

 Osmotic diarrhea
CLUES: Stool volume decreases with fasting;
1. Medications: antacids, lactulose, sorbitol
2. Disaccharidase deficiency: lactose
intolerance
3. Factitious/yg dibuat diarrhea: magnesium
(antacids, laxatives)
Secretory diarrhea

 Large volume ( >1 L/d); little change with fasting;

1. Hormonally mediated: carcinoid, medullary
carcinoma of thyroid (calcitonin), Zollinger-
Ellison syndrome (gastrin)
2. Factitious diarrhea (laxative abuse):
phenolphthalein, cascara, senna
3. Villous adenoma
4. Bile salt malabsorption (ileal resection; Crohn's
ileitis; postcholecystectomy)
5. Medications
Inflammatory conditions

 Fever, hematochezia, abdominal pain

1. Ulcerative colitis
2. Crohn's disease
3. Microscopic colitis
4. Malignancy: lymphoma, adenocarcinoma
(with obstruction and pseudodiarrhea)
5. Radiation enteritis
Malabsorption syndromes

1 Weight loss, abnormal laboratory values; fecal fat

> 7-10 g/24 h, tropical sprue, Whipple's disease,
eosinophilic gastroenteritis, Crohn's disease,
small bowel resection (short bowel syndrome)
2. Lymphatic obstruction: lymphoma, carcinoid,
infectious (TB,), Kaposi's sarcoma, sarcoidosis,
retroperitoneal fibrosis
3. Pancreatic disease: chronic pancreatitis,
pancreatic carcinoma
4. Bacterial overgrowth: motility disorders
(diabetes, vagotomy, scleroderma), fistulas,
small intestinal diverticula
Motility disorders

 Systemic disease or prior abdominal surgery

1. Postsurgical: vagotomy, partial gastrectomy,
blind loop with bacterial overgrowth
2. Systemic disorders: scleroderma, diabetes
mellitus, hyperthyroidism
3. Irritable bowel syndrome
Chronic infections

 Parasites: Giardia lamblia, Entamoeba

histolytica, Cyclospora
 AIDS-related:
 Viral: Cytomegalovirus, HIV infection (?)
 Bacterial: Clostridium difficile,
Mycobacterium avium complex
 Protozoal: Microsporida (Enterocytozoon
bieneusi ), Cryptosporidium, Isospora belli
ACUTE DIARRHEA

 Diarrhea that is acute in onset and

persists for less than 3 weeks is most
commonly caused by infectious
agents, bacterial toxins (either
ingested preformed in food or
produced in the gut), or drugs
Infectious diarrhea

 Mostly feco-oral route

 Bacterial
 Viral
 Parasitic

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Bacterial

 Watery
 Enterotoxigenic-
 Vibrio cholera
 Enterotoxigenic E.coli
 Food borne toxins-
 Bacillus cereus
 Clostridium perfringens
 Mycobacterium avium-intracellular complex

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 Bacterial
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 Bloody
 Invasive
 Campylobacter jejuni
 Destructive
 Shigella
 Enteropathogenic E.coli
 Clostridium difficile
 Viral
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 Rotavirus
 Children less than 2 years
 Most common cause of diarrhea in children all over the
world
 Norwalk
 Older children and adults

 These viruses injure the small intestinal mucosa

 Watery diarrhea
 CMV
 Immunocompromised
 Parasitic
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 Protozoa
 Giardia lamblia
 Entamoeba histolytica
 Cryptosporidium

 Helminths
 Ascaris lumbricoides
 Ancylostoma
 Strongyloides stercoralis
 Trichinella spiralis
 Capillaria philippensis
 Opportunistic pathogens
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 Clostridium difficile
 Nosocomial pathogens in healthcare and long term
care facility
 Poor handwashing

 Clindamycin, cephalosporins, ampicillin

 Exotoxin mediated
 In immunocomromised Hosts
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 Besides the common pathogens,

 Giardia

 Legionella

 Candida albicans
 Cryptosporidium species

 Mycobacterium avium-intralcellulare

 CMV
 Others
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 Tropical sprue
 Inthose who live or travel to the tropics
 Overgrowth of predominantly coliform bacteria in the
small intestine
 Whipple’s Disease
 Infection by Tropheryma whippelii
 HLA B27
 History
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 Is it truly diarrhea?
 Duration-
 acute <3 weeks
 Chronic >4 weeks

 Texture/susunan
 Frequency
 Blood?
 History
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 Fever
 Vomiting
 Abdominal pain
 Fainting or dizzyness
 Travel
 Drug use
 Diet
 Weight loss
 History
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 Alcohol
 Abdominal operations
 Chemotherapy
 Radiation
 Immune status
 Comorbidities
 Physical
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 Vital signs
 Orthostatic signs
 Hyperventilation- acidosis

 Volume status
 Skin tenting
 Dry mucous membranes
 Resting tachycardia
 Hypotension
 Sunken eyeballs/cekung
 Scaphoid abdomen/mencembung
 Physical
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 Abdominal and rectal exam.

 Distension

 Bowel sounds
 Tenderness

 Masses

 Stool swab- culture

 Physical
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 Chronic diarrhea
 Malnutrition
 Weight loss
 Muscle wasting
 Tetany
 Oral and skin lesions
 Peripheral neuropathy
 Ataxia
 Edema
 Discriminant factors
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 <45  >45
 Female sex  Family history
 Other ‘functional’ Sx

Irritable bowel Colonic pathology

 Chronic diarrhoea in patients <45yrs
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 Flexible sigmoidoscopy
Fine et al 2000
800 patients studied
Microscopic colitis 10% >Crohn’s >UC
99.7% of pathology accessible/ssuai with FS
CHRONIC DIARRHEA

 Etiology
The causes of chronic diarrhea may be
grouped into six major
pathophysiologic categories
Osmotic Diarrheas
 As stool leaves the colon, fecal osmolality is equal
to the serum osmolality, ie, approximately 290
mosm/kg. Under normal circumstances, the major
osmoles are Na+, K+, Cl–, and HCO3–. The stool
osmolality may be estimated by multiplying the
stool (Na+ + K+) × 2 (multiplied by 2 to account
for the anions)
 The osmotic gap is the difference between the
measured osmolality of the stool (or serum) and the
estimated stool osmolality and is normally less than
50 mosm/kg
 An increased osmotic gap implies that the diarrhea
is caused by ingestion or malabsorption of an
osmotically active substance
 The most common causes of osmotic diarrhea are
disaccharidase deficiency (lactase deficiency),
laxative abuse, and malabsorption syndromes (see
below). Osmotic diarrheas resolve during fasting.
Osmotic diarrheas caused by malabsorbed
carbohydrates are characterized by abdominal
distention, bloating, and flatulence due to increased
colonic gas production.
Malabsorptive Conditions
 The major causes of malabsorption are small
mucosal intestinal diseases, intestinal resections,
lymphatic obstruction, small intestinal bacterial
overgrowth, and pancreatic insufficiency
 In patients with suspected malabsorption,
quantification of fecal fat should be performed
 Chronic diarrhoea in patients >45yrs
40 Rationale for total colonic examination

 Neoplasia
37% asymptomatic
individuals have adenomas8%
adenomas>1cm
(Lieberman 2000)
Prevalence in symptomatic?

 Higher prevalence of proximal

non-neoplastic pathology
e.g microscopic colitis, IBD 7-31%

 Colonoscopy or barium enema

and flexi sigmoidoscopy
41 Small bowel imaging (3)
 Capsule endoscopy?
Established role in the investigation of
iron deficiency anaemia
? Suspected small bowel malabsorption
or diarrhoea of unknown cause

 Superior to small bowel barium XR

70% vs 40% diagnostic yield
 Capsule Endoscopy:
Detection of inflammatory lesions
42 in the small intestine

Villous erosion Thickened infiltrated folds (Jejunum)

Apthous ulcerations (ileum) Linear ulcerations

 Capsule endoscopic diagnosis of
Crohn’s Disease
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Jejunal Crohn's Disease

 Labs
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 Stool tests for inflammation

 Pus cells- specific but low sensitivity( about 50%)
 Lactoferrin
 Released from leucocytes during an inflammatory reaction
 Sensitivity is 90% but less specific
 Labs
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 Stool culture
 Positive in only 40 to 60%
 Stool for ova and parasites
 Stool for Clostridium difficile toxin
 Stool Sudan test for fat
 Stool Electrolytes-differentiates secretory diarrhea
from osmotic diarrhea
 Stool pH-<7 indicates carbohydrate malabsorption
 Other investigations
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 Flexible sigmoidoscopy
 Pseudomembranes
 Inflammation

 Melanosis coli

 Blood Hormone levels

 Serum gastrin, VIP, somatostatin, cortisol, neurokinins,
calcitonin
 Carcinoid- serotonin, urine 5-hydroxyindoleacetic acid
 Management
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 Fluid therapy
 Personswith moderate to severe diarrhea lose large
amounts of Na, CL, K, HCO3 & H20
 Pre renal azotemia, hypokalemia, metabolic acidosis

 ORS/Oral Resust Solution

 IV Fluids
Jenis Patogen Pilihan pertama Alternatif
Enterotoxigenik (cholera like) diarrhea

Vibrio cholerae Doksisiklin, tetraciklin, kotrimoksazol, norfloksasin, siprofloksasin kloramfenikol, eritromisin,

E coli norfloksasin, siprofloksasin kotrimoksazol

C.difficile metronidazol vancomisin, bacitracin

Invasive (Dysentery Like ) diarrhea

ofloksasin, norfloksasin, si
shigella kotrimoksazol asam nalidiksat, azitro

Campylobacter erytromisin, azitromisin, klaritomisin siprofloksasin, norfloksasin

kotrimoksazol, ofloksasin, norfloksasin, siprofloksasin,

Salmonella seftriakson, sefotaksim azitromisin

Travvelers diarrhea

Profilaksis norfloksasin, siprofloksasin, kotrimoksazol

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Terapi norfloksasin, siprofloksasin, kotrimoksazol, azitromisin
Obat Manfaat Resiko

Difenoksilat Diare akut, kronis ESO: mata kabur,

mulut kering

Loperamid Diare akut, kronis ESO : badan tdk

enak, konstipasi,
ileus paralitikus,
depresi SSP
Paregorat Diare akut, kronis Potensi
penyalahgunaan
besar
Difenoksin Diare akut, kronis ESO : =
Difenoksilat
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 ORS(Oral Resust Solution) -principle
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 Saline solution (water plus Na+) by mouth - no

beneficial effect
 Na+ absorption is impaired in the diarrhoeal state
 if the Na+ is not absorbed water cannot be absorbed.

 Excess Na+ in the lumen of the intestine causes increased

secretion of water and the diarrhoea worsens.
 ORS
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 Glucose - absorbed through the intestinal wall -

unaffected by the diarrhoeal disease state - sodium is
carried in conjunction through by a co-transport
coupling mechanism. This occurs in a 1:1 ratio, one
molecule of glucose co-transporting one sodium ion
(Na+).
 ORS-History
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 First developed in the early 1950’s and was

formulated to mirror ions lost in stool.
 In the early 1960’s the mechanism by which ORT
works, the coupled transport of sodium and glucose,
was discovered.6
 In 1971, the efficacy of ORT demonstrated during an
epidemic of cholera in a refugee camp in
Bangladesh.
 ORT reduced the death rate from more than 50% to only
5%.7 By the early 1970’s a consensus was reached about
the effectiveness of ORT.
 ORS
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 Lancet- "potentially the most important medical

advance this century"
 World Health Organization estimates that 90% of
diarrheal deaths worldwide could be prevented
with appropriate treatment with ORS
 ORS
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 Sodium Chloride 3.5 grams

 Sodium Bicarbonate 2.5 grams
 Potassium Chloride 1.5 grams
 Glucose 20 grams
 ORS
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Solution Na K Cl Carb. Osmolality

Mmols
/L
WHO 90 20 80 111 310

Rice 90 20 60 111 260

Based
 ORS- caution
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 A number of studies have addressed the concern

that ORT can lead to hypernatremia in neonates
and infants.
 These studies show that administration of breast milk
or plain water after rehydration prevents this
problem.1
 IV Fluids
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 Must contain Potassium and a base

 Ringer’s lactate
 Chronic Diarrheas
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 Zn and Magnesium replacement

 Antibiotics
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 Invasive bacterial Enteritis- esp.Shigellae

 Quinilone orally twice daily for 3 days
 Cholera
 Traveler's diarrhea
 Prophylactic- not recommended
 A single dose of oral Quinilone at onset

 Clostridium difficile
 Metronidazole
 Oral Vancomycin
 Antimotility agents
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 Should be avoided
 Concern for promoting bacterial invasion or
prolonging the infection
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 Informasi pada pasien
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 Informasikan tanda dehidrasi

 Diet :

ASI pada bayi

Sari buah segar dan pisang
Hindari makanan berserat
Hindari minuman bergula
 Kontinuitas terapi

 Penggunaan obat, Efek samping dan penanganan

 Terapi suportif
 Conclusions
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 Baseline investigations (primary care)

 lower GI endoscopy with biopsy
 Consider factitious diarrhoea
 Small bowel malabsorption -
Distal duodenal biopsies -
small bowel imaging
 Pancreatic insufficiency
- faecal elastase, Pancreolauryl test, pancreatic imaging
 Other – SB bacterial overgrowth, BAM etc

In 1/3 patients no diagnosis made:

‘chronic idiopathic diarrhoea’
THE END
Good nutrition and hygiene can
prevent most diarrhea.

Thank You!

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