ACUTE DIARRHEA + MILD TO

MODERATE DEHYDRATION
PRESENTED BY:
MUHAMMAD FAWWAZI MULTAZAM, S.KED
 OUTLINE
introduction

Case Presentation

Literature Review

Discussion
INTRODUCTION
 INTRODUCTION

Diarrhea is a public health problem in developing

countries like Indonesia

Most of the acute diarrhea caused by infection.

Transmission of diarrhea : 4F= field, flies, fingers, fluid

CASE PRESENTATION
 IDENTIFICATION

• NAME : BY. AAK

• AGE/DATE OF BIRTH : 3 MONTHS/ NOVEMBER 3RD, 2019
• GENDER : MALE
• RELIGION : MOSLEM
• FATHER NAME : TN. S
• MOTHER NAME : NY. D
• ADDRESS : PALEMBANG
• RACE : MELAYU
• HOSPITALIZATION DATEX : 05 FEBRUARY 2020, PUKUL 20.00 WIB
 ANAMNESIS

• CHIEF COMPLAINT
WATERY DIARRHEA
• ADDITIONAL COMPLAINT
VOMITING AND FEVER
 CLINICAL HISTORY

• SINCE ± 2 BEFORE ADMISSION, PATIENT HAD WATERY DIARRHEA WITH A FREQUENCY OF

ABOUT 10 TIMES PER DAY, THE AMOUNT OF ABOUT 1/2 GLASS EACH DEFECATE, MORE WATER
CONSISTENCY THAN PULP, NO MUCUS, NO BLOOD. VOMITING TWICE A DAY, VOMITING DID
NOT SPRAY, THE CONTENT WHAT WAS DRUNK, THE AMOUNT OF VOMITING ± ¼ STARFRUIT
GLASS, FEVER WAS PRESENT BUT NOT TOO HIGH, URINATING WAS NORMAL, THE PATIENT
HAD DIFFICULTY DRINKING AND LOOKED WEAK. THE PATIENT THEN WENT TO THE HEALTH
CENTER AND WAS GIVEN PARACETAMOL AND ORS.
 CLINICAL HISTORY

• ± 1 DAY BEFORE ADMISSION THE MOTHER OF THE PATIENT ADMITTED HER SON HAD NO
IMPROVEMENT WITH A FREQUENCY OF DIARRHEA ABOUT 10 TIMES PER DAY, THE AMOUNT OF
ABOUT 1/2 GLASS EACH DEFECATE, MORE WATER CONSISTENCY THAN PULP, NO MUCUS, NO
BLOOD. THERE IS VOMITING ONCE, VOMITING DOES NOT SPRAY, THE CONTENT WHAT IS
DRUNK, THE AMOUNT OF VOMITING ± 1/4 GLASSFRUIT STARFRUIT, FEVER IS PRESENT BUT
NOT TOO HIGH, URINATING IS NORMAL, THE PATIENT THEN GOES TO THE EMERGENCY ROOM
RSMH FOR FURTHER MANAGEMENT.
 MEDICAL HISTORY

Past Illness Family’s Feeding

History Illness History History
• No history • No history • 0-now :
of the of similar breast milk
similar diseases in • 1 week-
diseases the family now:
formula milk
 PREGNANCY AND BIRTH HISTORY

PREGNANCY
Antenatal care : 3 visits
Pregnancy disease : none Conclusion
Pregnancy and birth history was good

Birth (G1P0A0)

Newborn status:
Birth place : clinic Birth weight : 2500 gr
Childbirth helper : midwife Birth length : 47 cm
Mode of delivery : spontaneous Head circumference : no information
Gestational age : aterm Spontaneous cry : yes
APGAR score : no information
Congenital disease : none
Early breastfeeding initiation : yes
 GROWTH AND DEVELOPMENT HISTORY
GROWTH
Birth weight 2500 gr, birth length 47 cm
Today’s weight 3000 gr, today’s height 49 cm

Development

Psychomotor:
Lie down and turn around by himself : 3 month
Sit down :-
 IMMUNIZATION HISTORY
BASIC IMMUNIZATION BOOSTER
HB0 V
BCG V
DPT 1 V DPT 2 DPT 3 -
HEPATITIS B 1 V HEPATITIS B 2 V HEPATITIS B 3 -
Hib 1 - Hib 2 Hib 3 -
POLIO 1 V POLIO 2 POLIO 3 -
CAMPAK POLIO 4 -
Conclusion
Basic immunization is not complete yet
Good nutrition with short stature
Good nutrition with short stature
Good nutrition with short stature

PHYSICAL EXAMINATION
Good nutrition with short stature
Good nutrition with short stature

GENERAL STATUS
General state : moderate pain
Awareness : compos mentis
Pulse rate : 124 bpm, regular, good filling and pressure
Respiratory rate : 32x per minute
Temperature : 37.8 ºC
SpO2 : 99%

Anthropometric Data
Weight : 3 kg Height for age : -2 SD < Z < -3 SD  Stunted
Height : 49 cm -1 SD < Z < -2 SD  Good nutrition
Weight for age : -2 SD < Z < -3 SD  Underweight)
Conclusion of nutritional status

Conclusion of nutritional status

Good nutrition with short stature
 PHYSICAL EXAMINATION
SPECIFIC STATUS
Head
Shape : normocephalic, symmetric, concave fontanela
Hair : dark, not easily revoked
Eye : conjungtiva anemic (-), sclera icteric (-), sunken eyes(+)
Nose : secret (-), nasal flare (-)
Ear : secret (-)
Mouth : cyanosis (-), dry (+), chelitis (-)
Throat : pharynx hyperemic (-), T1-T1

Neck
Lymph nodes enlargement (-)
 PHYSICAL EXAMINATION
SPECIFIC STATUS
Thorax/Lung
Inspection : symmetric statically & dynamically, retraction (-/-)
Palpation : stem fremitus right = left
Percussion : sonor in both lungs
Auscultation : vesicular (+) normal, ronchi (-), wheezing (-)

Thorax/Cor

Inspection : ictus cordis aren’t seen

Palpation : ictus cordis aren’t palpated in left midclavicle line ICS IV
Percussion : normal
Auscultation: HR 124 bpm, reguler, normal heart sound I and II, murmur (-), gallop (-)
 PHYSICAL EXAMINATION
SPECIFIC STATUS
Abdomen
Inspection : flat
Auscultation : bowel sound (+) increased
Palpation : liver and spleen weren’t palpated, skin pinch (turgor) goes back slowly (more
than 3s), epigastric pain (+)
Percussion : tympani, shifting dullness (-)

Extremity, inguinal, and Genitalia

Extremity : extremity palpable cold, pale (-), cyanosis (-), oedema (-), CRT < 2”
Inguinal : lymph nodes enlargement (-)
Genitalia : normal
 PHYSICAL EXAMINATION
NEUROLOGIC
Leg Arm
Examination
Right Left Right Left
Movement Good Good Good Good
Strength +5 +5 +5 +5
Tone Eutony Eutony Eutony Eutony
Clonus - -
Physiological reflex +N +N +N +N
Pathologycal reflex

Sensoric function : Normal

N. Cranial function : Normal
Meningeal sign : (-)
 PROBLEM LIST
• Watery Diarrhea
• Vomiting
• Fever

DIFFERENTIAL DIAGNOSIS
• Acute Diarrhea + Mild To Moderate Dehydration Ec
Rotavirus
• Acute Diarrhea + Mild To Moderate Dehydration Ec
Bacterial
 WORKING DIAGNOSIS

• ACUTE DIARRHEA + MILD TO MODERATE

DEHYDRATION EC ROTAVIRUS
 TREATMENT
• IVFD NaCl 0.9% 1800 cc in 4 hours 
velocity 450 cc/hour, started at 18.00
Rehydration
• Maintenance: KAEN. 3A 65 cc/hour
gtt 16 dpm (macro)
• Antaside syrup 3 x 5 ml (oral)
Medication • Omeprazole 1 x 25 mg (iv) if pain
persists
• Lactulose syrup 3 x 5 ml (oral)
 PROGNOSIS
• QUO AD VITAM : BONAM
• QUO AD FUNCTIONAM : BONAM
• QUO AD SANATIONAM : BONAM
 FOLLOW UP
February, S : Diarrhea 5x A:
6th, 2020 Acute diarrhea + mild to moderate
08.30 PM O : Sens: CM, BP: 80/60, HR: 110x/m, RR: 32x/m, dehydration
T: 37,3 oC
Head : sunken eye (-), conjungtiva anemic (-), sclera P :
icteric (-), nasal flare (-) ORS 15-30 cc/diarrhea peroral
Zinc Syr 1x10 mg peroral
Thorax : simetric, retraction (-)
Paracetamol 10-15cc/BW if T > 38,5o C
Cor : BJ I dan II N, murmur (-), gallop (-)
Pulmo : Vesicular (+) normal, ronchi (-/-), wheezing (-
/-)
Abdomen : flat, bowel sound (+) increase, turgor
<2”
Ekstremities : warm, cyanosis (-)
 FOLLOW UP
January, S : defecation 1x, a little, post dysimpaction A:
6th, 2020 O : Sens: CM, BP: 100/70, HR: 112x/m, RR: 22x/m, Profuse vomiting caused by acute gastritis
T: 36.8 oC mild to moderate dehydration
Head : sunken eye (-), conjungtiva anemic (-), sclera Constipation
icteric (-), nasal flare (-)
Thorax : simetric, retraction (-) P:
Cor : BJ I dan II N, murmur (-), gallop (-) IVFD KAEN 3A 16 dpm  D5 ½ NS 16
Pulmo : Vesicular (+) normal, ronchi (-/-), wheezing (- dpm (micro)
Maintenance: KAEN. 3A 65 cc/hour gtt 16
/-)
dpm (macro)
Abdomen : flat, bowel sound (+) increase, turgor
Antaside syrup 3 x 5 ml (oral)
<3”
Omeprazole 1 x 25 mg (iv) Lactulose syrup
Ekstremities : warm, cyanosis (-) 3 x 5 ml (oral)
Glycerol 100% 12 ml + NaCl 0.9% 15 cc
every 12 hours
 LAB. EXAMINATION
HEMATOLOGI (05-01-2020)
• HB : 10,8 G/DL (11,1-14,4 G/DL )

• HT : 32 VOL% (35-41 VOL%)

• ERITROSIT : 4,25 X 10 MM3/JAM (3,71-4,25 X10 MM3/JAM)

• LEUKOSIT : 19.000 /MM3 (6.000-17.500 /MM3)

• TROMBOSIT : 273.000 /MM3 (217.000-497.000 /MM3)

• MCV : 74,2 FL (93-115)

• MCH : 25 (29-35)

• MCHC : 34 (28-34)

• HITUNG JENIS : 0/1/47/40/12 (0-1/1-6/50-70/20-40/2-8 MM3)

• KALSIUM : 9,0 MG/DL (8,4-10,8)

• NATRIUM : 134 MEQ/L (135-155)

• KALIUM : 4,2 MEQ/L (3,5-6)

• KLORIDA : 91 (96-106)

• CRP KUANTITATIF : POSITIF 20 MG/L (< 5 MG/L)

• KESAN: PENINGKATAN CRP DAN LEUKOSIT.

LITERATURE REVIEW
 Epidemiology

-H.PYLORI TRANSMISSION IS STILL UNCLEAR. CLOSE CONTACT

WITH H. PYLORI-INFECTED INDIVIDUALS WHETHER ORALLY,
ORAL, GASTRO-ORAL, OR STOOL-ORAL IS CONSIDERED A FORM OF
H. PYLORI TRANSMISSION
-INFECTED PARENTS, ESPECIALLY MOTHERS, MAY PLAY A ROLE IN
THE TRANSMISSION OF H. PYLORI IN THE FAMILY
-IN DEVELOPING COUNTRIES, THE PREVALENCE OF H. PYLORI IN
CHILDREN RANGING FROM 30-80%
-H. PYLORI PREVALENCE IN CHILDREN IN DEVELOPED
COUNTRIES IS ESTIMATED AT 10%
 Diagnostic examination

-The Various Methods, both invasive and non-invasive,

can be used to diagnose H infection. pylori.
-Invasive methods include endoscopy and biopsy
followed by histological examination, culture, urease
test, and PCR, while non-invasive methods include
serology and C-urea breath test

In children with clinical symptoms of dyspepsia, it

is recommended to use a screening test that is
non-invasive
 ENDOSCOPY
Endoscopic examination is recommended to be done in cases
with gastrointestinal symptoms suspected of an organic
abnormality and if H. pylori is found on endoscopic examination,
the patient should immediately receive therapy.

Endoscopy is an important procedure for obtaining tissue for

histological examination, culture, or urease testing. This action is
rarely used for epidemiological studies of H. pylori infection and
evaluation of eradication results and is not used for screening
children who show no symptoms.
 THE UREASE TEST FOR BIOPSY
TISSUES

• The urease test can detect H. pylori infection

quickly. The urease test performed on gastric
biopsy tissue will show changes in the color of the
media used due to an increase in pH due to urea
digestion by urease
 HISTOLOGY

Helicobacter pylori was first seen by Robin Warren using

hematosiline & eosin (HE) staining. The use of Giemsa or
Whartin-Starry staining techniques has made it easier for
anatomic pathologists to diagnose H. pylori infection. In cases of
chronic active gastritis, H. pylori can sometimes not be detected
with routine microscopy, but can be detected by Giemsa or
Whartin-Starry staining.
 The Organic breeding is the best way to make a diagnosis of
any bacterial infection including H. pylori. H. pylori can be
breed from gastric and duodenal biopsy tissue However,
breeding is still considered an impractical type of examination

The Serological test

The sensitivity and specificity value of serological tests should be

as low as 90%.
Besides being used as a screening test, it is often used as a
support for clinical and epidemiological research
 UJI C-13 BAND C-14 UREA BREATH
The C-urea breath test is one of the success steps in the diagnosis and
management of H. pylori infection. This method is the most accurate and
simple non-invasive diagnostic method

The C-urea breath test only detects infections that are happening, so it is
recommended that, besides being a filter for H. pylori infection, as well as
evaluating eradication therapy
C-14 urea breath is the first C-urea breath test developed. In this
examination, the patient is asked to drink a certain amount of
radioactivity-labeled urea

C-13 which is a non-radioactive isotope is starting to be widely used in

children. High sensitivity and specificity values ​in children have been
reported by several researchers
 POLYMERASE CHAIN REACTION
(PCR)

Polymerase chain reaction is a laboratory technique that in vitro can

produce large quantities of specific DNA chains. This check can detect
fingerprinting of H molecules. Pylori and count the number of bacteria in
the biopsy network. The sensitivity and specificity of this examination
are high
 Treatment
-By this far, No agreement has been reached by gastroenterologists
regarding the treatment of H. pylori infection in children.

-Various types of drugs that have been used are bismuth, ranitidine
bismu tsitrat, H2 antagonist, PPI, and some antibiotics

-Eradication rate was reported that was achieved by using a

combination of 3 types of drugs (PPI, clarithromycin and
amoxicillin) of 87- 92%, whereas if only using 2 drug types (PPI and
moxicillin) of 70%. The combination of amoxicillin, bismuth, and
metronidazole also gives a high eradication rate, which is 96%.
- The consensus of gastroenterologists in the United States and
Europe is that they use 3 types of drugs consisting of PPIs, and
a combination of 2 antibiotics for 7 days
- Recommended drug combinations are (1) PPI, metronidazole,
and clarithromycin, or (2) PPI, amoxicillin (if there is an
alleged resistance to metronidazole), or (3) PPI, amoxicillin
and metronidazole (if there is resistance to clarithromycin)
- In the Netherlands and Belgium, a combination of 0.6 mg / kg
omeprazole twice daily, amoxicillin 30 mg / kg twice daily, and
clarithromycin 15 mg / kg twice daily, for 7 days.
 Reinfection

- Reinfection of H pylori may have been found, and if found

more is a recurrence of a failed treatment.
- The incidence of reinfection does not show the differences
between the developing countries (20%) and developed
countries (13%).
 Constipation

CONSTIPATION IS A CONDITION THAT IS OFTEN FOUND IN CHILDREN AND

CAN CAUSE SOCIAL AND PSYCHOLOGICAL PROBLEMS. CONSTIPATION IS
MORE A CLINICAL SYMPTOM THAN AS A SEPARATE DISEASE.

ONE OBSTACLE IN STUDYING CONSTIPATION IS THE DIFFICULTY OF

DETERMINING THE DEFINITION OF THIS DISORDER. THERE ARE THREE
IMPORTANT ASPECTS TO DETERMINE THE PRESENCE OF CONSTIPATION,
NAMELY STOOL CONSISTENCY, FREQUENCY OF DEFECATION AND
PHYSICAL FINDINGS
 Classification of Constipation

Based on pathophysiology, constipation can be classified into

constipation due to structural abnormalities and functional
constipation. Constipation due to structural abnormalities
occurs through the process of stool flow obstruction, while
functional constipation is associated with impaired colonic or
anorectal motility
 Management/Treatment for Constipation
- In starting the treatment of constipation, it is necessary to underline the
importance of an explanation to parents and patients about the
physiological basis of constipation and soiling
- The toilet training is often recommended as a constipation therapy in
children
- Fibrous food is highly recommended in children who suffer from
constipation
- Biofeedback training has been reported as one of the best practices of
constipation in children. The child is trained to increase rectal sensation,
strengthen and control the anal sphincter, and improve coordination of
muscle contractions and relaxation correctly
Basically, constipation therapy in children is divided into two
phases, namely (1) excretion and (2) maintenance therapy. The
feces consistency can be reduced by administering mineral oil or
osmotic laxatives to facilitate excretion

Oral laxatives can be divided into several groups, namely lactative

fibers (psyllium, methycellulose, polycarbophil), osmotic
laxatives (mono and disaccharides, for example sorbitol,
lactulose), laxative oxidants (magnesium sulfate, sodium
phosphate, polycilblicol), stromylilycol stool softeners, laxative
emollients (ducosate, mineral oil), laxative stimulants (bisacodyl,
phenolphthalein), prokinetics and others
 CASE ANALYSIS

THE PATIENT IS GIVEN OF REHYDRATION OF IVFD NACL 0.9% 1800

CC IN 4 HOURS AT A SPEED OF 450 CC / HOUR. AFTER THE
DEHYDRATION HAS RESOLVED, CONTINUE MAINTENANCE FLUID
KAEN 3A AT A SPEED OF 65 CC / HRTT 16X / M (MACRO).

IN ADDITION, TO TREAT GASTRITIS, PATIENTS ARE GIVEN ANTACIDS

OF 3 X 5 ML SYRUP ORALLY, IF STILL IN PAIN CAN BE GIVEN AN
INJECTION OF OMEPRAZOLE 1 X 25 MG (IV). TO OVERCOME
CONSTIPATION, PATIENTS ARE GIVEN LACTULOSE SYRUP 3 X 5 ML
(ORALLY) AND ARE DEPOSITED WITH GLYCEROL 100% 12 ML + 0.9%
• THENUTRITIONAL STATUS OF THIS PATIENT SHOWS A GOOD
NUTRITIONAL STATE THAT IS BASED ON THE WHO BB / PB CURVE
BETWEEN (0 SD) - (-2 SD).
• THE RESULTS OF THE LABORATORY EXAMINATION SHOWED NO
INCREASEMENT IN LEUKOCYTE LEVELS WHICH MIGHT INDICATE THE
CAUSE WAS NOT CAUSED BY A BACTERIAL INFECTION.

• IN GENERAL, THE PATIENT'S RESPONSE TO THE THERAPY GIVEN IS GOOD

SO THAT THE PROGNOSIS FOR THIS PATIENT IS BONAM
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