Approach to the patient with diarrhea

dr Putra Hendra
UNIBA
 Diarrhea
 Definition:
abnormal increase in stool liquidity, stool frequency,
and stool weight (more than 200 grams per day).

 Diarrhea :
< 2 weeks: acute –infection
> 2 weeks: chronic—
Osmotic, secretory, exudative, motility
The amount of fluid absorbed differs throughout the intestine

Duodenum / jejunum Ileum Colon – Rectum

~5.5 L ~2L ~ 1.3 L

Intake
2 liter
Stool
<200 ml
 Mechanism of Diarrhea

1. Osmotic diarrhea
2. Secretory diarrhea
3. Inflammatory diarrhea
4. Abnormal gastrointestinal motility
Raised CI Secretion
 Clinical approach to diarrhea

Diarrhea Pseudodiarrhea

Acute Chronic
 Acute Diarrhea

Infectious Non infectious

 Etiology of infectious diarrhea

• Bacterial
• Shigella Sp.
• Aeromonas Shigelloides
• Salmonella Sp.
• Vibrio Sp.
• Compylobactor Sp.
• Clostridium difficile
• E.coli (ETEC, EPEC, EIEC, EAEC and EHEC)
• Viral
• Norwalk
• Rotavirus
• Enteric adenovirus
• Cytomegalovirus
• Herpes simple virus

• Fungal
• Candida Sp.
• Histoplasma Sp.

• Parasite
• Entamoeba histolytica
• Giardia lamblia
• Strongyloides
• Cryptosporidium
• Cyclospora Cayetanensis
 Vibrio Cholera

• Gram-negative
• Curved rod
• .5-.8 μm width
• 1.4-2.6 μm length
• Facultative anaerobe
• Single polar flagellum
• Chemoorganotroph
• Optimal growth 20-30 degrees
 Short incubation period (2 hours to 5 days)
 75% of those infected do not develop
symptoms
 100-1000 organisms may cause disease,
although a million are needed to consistently
infect
 Transmission
 Direct fecal-oral contamination or ingestion of
contaminated water and food
 Linked to inadequate environmental
management (lack of safe water and sufficient
sanitation)
 Human-Human contact does not spread the
bacterium
Underlying diseases

 AIDS

 Hyperthyroidism
 Clinical Setting
Food poisoning Water Diarrhea Dysentery
(entero/neuro (non-Invasive (Invasive organism)
toxin producing) Organism)
Fever Rare Non or Low Grade Common
Incubation < 6 hours 6 hours-3 days 1-3 days
Peroid
Mucous-bloody stool Non Non Common
Nausea vomiting ++ + +
Tenesmus - - +
Voluminous stool + ++ +

Etiology Staphylococcus EPEC, ETEC, EAEC Shigella

aureus, C.perfringens Aeromonas, P.shigelloides
B, ceceus Vibrio Cholerae EIEC EHEC
Salmonella Giardia, Salmonella
Cryptospodium Campylobactor
Salmonella C.difficile,
virus E.Histolytica

V.Parahemolyticus
 Treatment

1. Supportive

2. Symptomatic

3. Specific
 Drug of choice Alternative
Shigella sp. Norfloxacin , ofloxacin Ciprofloxacin, ceftriaxone
Areomonas sp. Amlnoglycoside TMP/SMX, loramphenical
Ceftriaxone
Campylobacter Erythromycin Ciprofloxacin
Norfloxacin
Clostridium difficile Metronidazole Bacitacin
Vancomycin
Vibrio cholerae Tetracycline Doxycycline , TMP/SMX
E. histolytica Metronidazole Emitine
Giardia lamblia Metronidazole Quinacrine hydrochloride
Strongyloides Thiabendazole Albendazole
 Chronic Diarrhea

Functional Organic

HIV Non-HIV
 Chronic organic diarrhea (Non HIV)

Inflammatory Secretory

Malabsorption
Chronic Inflammatory Diarrhea

• Infection
• Inflammatory bowel
• Radiation
• Ischemic
Malabsorption syndrome

• Diarrhea
• Malnutrition
Malabsorption syndrome

• Strongyloidiasis
• Giardiasis
• Capillariasis
• Lymphoma
 PEMERIKSAAN PENUNJANG
Pemeriksaan tinja
Makroskopis dan mikroskopis
Ph dan kadar gula dalam tinja
Kultur dan uji resistensi
Pemeriksaan keseimbangan asam
basa  AGD
Urinalisis : Bj, endapan
Pemeriksaan kadar ureum
kreatinin faal ginjal
Pemeriksaan keseimbangan cairan &
elektrolit  Hb-Ht, Na, K, Ca dan F
Pemeriksaan intubasi duodenum
EKG  menilai deplesi elektrolit
(biasanya kalium)
 KOMPLIKASI
Kehilangan air dan elektrolit  Dehidrasi, Hipokalemia, Asidosis
metabolik, Kejang, Alkalosis metabolik
Gangguan sirkulasi darah  Syok hipovolemik
Gangguan gizi Hipoglikemia, Malnutrisi energi protein, Intolerasi
laktosa sekunder

PENENTUAN DERAJAT DEHIDRASI

Berdasarkan BB
Ringan pe↓ BB < 5 %
Sedang pe↓ BB 5 – 10 %
Berat pe↓ BB > 10 %
Menurut Haroen Noerasid (modifikasi)
Ringan Rasa haus & Oliguria ringan
Sedang Tanda diatas + turgor kulit↓,
ubun2 & mata cekung
Berat Tanda diatas + somnolen,
sopor, koma, syok, nafas kussmaul
Daldiyono score :

Gejala klinis

score

•Muntah 1
•Voxs cholerica 2
•Kesadaran apatis 1
•Kesadaran somnolen, soporous s/d coma 2
•Sis tolik </ sama dengan 90 mmhg 2
•Nadi > / sama dengan 120/m 1

•Napas Kussmaul (>30/m) 1

•Turgor kulit kurang 1
•Facies cholerica 2
•Extremitas dingin 1
•Washer hand 1
•Sianosis 2
•Umur>50 -1
•Umur>60 -2

Cairan yg diberikan dalam 2 jam :

Score/15 x 10%xBB kgX 1 liter
Cholera in Zimbabwe

Robin Cochran-Dirksen
 Degree of Dehydration

 Mild dehydration (3-5%)

 Moderate dehydration (7-10%)

 Sever dehydration (10-15%)

 Degree of Dehydration

Severe dehydration (10-15%)

-Rapid weak pulse.
-Low BP, sunken eyes and fontanel
-No tears or urine & v. dry mucous membrane
-Clear skin tenting. Cool mottled skin with
delayed capillary refill.
 Pilihan Cairan
Beri Rl (utama) atau NaCl
Jika pasiennya tidak dapat makan diberi Dekstros
dan RL
Jika muntah2 maka berikan Dekstros dan NaCl,
tetapi jika pasien muntah + diare utamakan RL
Oralit
Cara Pemberian
IV  Untuk dehidrasi berat
Enteral Untuk dehidrasi ringan, sedang tetapi
anak tidak mau/ tidak dapat minum atau jika
kesadaran menurun
Oral Bila kesadaran anak baik, anak mau
minum, biasanya diberikan untuk dehidrasi
ringan dan sedang
Observasi kondisi fisik klien terutama status hidrasi
 Signs of Hypervolemia:
 Hypertension
 Polyuria
 Peripheral edema
 Wet lung Especially when
hypo-
albuminemia
 Jugular vein engorgement
 Management of Hypervolemia:
 Prevention is the best way
 Guide fluid therapy with CVP level or
pulmonary wedge pressure
 Diuretics
 Increase oncotic pressure: FFP or
albumin infusion (may followed by diuretics)
 Dialysis
 Parenteral Vaccine
 2 doses administered 2 weeks apart
 Efficacy of approximately 50%
 Protection hardly exceeds 6 months
 Does not prevent transmission of infectious
agent
 Not recommended for general public health use