DIARRHEA

BY : HASRI SALWAN
Diarrhea
Definition
( WHO): loose of semisolid/ liquid stool, frequency
≥ 3x / day with / without blood or mucus

Mother: change of consistency and frequency

defecation
Konsistensi
konstipasi

Konsistensi
diare
Frekuensi BAB normal
Hal yang berkaitan dengan definisi
Perubahan konsistensi dan frekuensi BAB.
Pada bayi (terutama yang dapat ASI)
frekuensi BAB bisa sampai 8-12 x/hari.
Monitor: peningkatan BB
Epidemiology:
Diarrhoea:
One of causes morbidity & mortality child
Indonesia: morbidity rate: 200–400 permil
70-80%: child < 5 year 
die: 350.000-500.000 child / year
 Penyebab Kematian Bayi 0-11 bulan
Tidak diketahui penyebabnya, 3.7 % Tetanus, 1.7 %

Meningtis, 4.5 %

Kelainan Kongenital, 5.7 %

Pneumonia, 12.7 % Masalah Neonatal

46,2 %

Diare, 15 %

Masalah neonatal :
-Asfiksia
-BBLR
-Infeksi, dll
Sumber : Riskesdas 2007
Kematian 1-11 bulan menurut Riskesdas 2007
 Penyebab Kematian Balita 0-59 bulan

Tidak diketahui penyebabnya, 5.5 % Tetanus, 1.5 %

Meningtis, 5.1 %

Kelainan Kongenital, 4.9 %

Masalah Neonatal
36 %
Pneumonia, 13.2 %

Masalah neonatal :
-Asfiksia
Diare, 17.2 % -BBLR
-Infeksi, dll
Sumber : Riskesdas 2007
Penyebab kematian umur 1-4 tahun
ANGKA KESAKITAN
Aetiology (1):

1. Infection :
2. Diet
3. Drugs
4. Neurogenic/psychogenic
Etiology : infection (80%) :

1. Virus : Rotavirus, virus Norwalk, Norwalk

like virus, Astrovirus, Calcivirus,
Adenovirus.
2. Bacteria : Escherichia coli (EPEC, ETEC,
EHEC, EIEC), Salmonella, Shigella, Vibrio
cholera 01, Clostridium difficile,
Aeromonas hydrophilia, Plesiomonas
shigelloides, Yersinia enterocolitica,
Campylobacter jejuni, Staphylococcus
aureus, Clostridium botulinum
3. Parasite : Entamoeba histolytica,
Dientamoeba fragilis, Giardia lamblia,
Cryptosporidium parvum, Cyclospora sp,
Isospora belli, Blastocystis hominis,
Enterobius vermicularis.
4. Worms : Strongiloides stercoralis, Capillaria
philippinensis, Trichinella spiralis.
5. Fungal: Candidiasis, Zygomycosis,
Coccidioidomycosis
Aetiology (2):
Diet : (10%)
• Food poisoning
• Food allergy
• Food malabsorption
Drugs : (10%)
• Laxatives, sorbitol, antacids,
lactulose, theophyllin, antibiotic
(AAD)
Classification of diarrhea :

Stool appearance:
• Watery :
• Cholera
• Non –cholera (Acute Infantile Diarrhea)
• Bloody (dysentri)

Duration :
• Acute : 2 weeks
• Prolonged (> 7days)
• Chronic : > 2 weeks /3 episodes in a month
• Persistent : cause by infectio secretion
Pathophyisiology:
Diarrhoea :
accumulation of water + electrolyte in lumen
3 mechanisms:
( 1) secretory diarrhoea
( 2) osmotic diarrhoea
( 3) cytotoxic / inflammatory diarrhoea
(4) Increased motility
Secretory Diarrhoea

Bacteria produces toxin

Effect of toxin: activating intracellular
protein  stimulate electrolyte and water
secretion watery diarrhoea
Gambaran villi usus
 ABSORPTION

villus

cript

SECRETION
Patofisiologi rota virus

Virus
menyerang
entrosit di
leher villus
 ABSORPTION MECHANISME

Intra Lumen Glc Na

Microvilli H K
Co-transfor
Difussion
Solvent drag Na Cl Na Cl
Enterocite
Nucleus
Tight junction
Na pump

Na
Lamina propia
 Entero
toksin celah
protein
bagi
Transpor
Reseptor elektrolit

Protein perantara
(second mesenger)
NAME OF TOXIN
Cholera enterotoxin (ctx)
E. coli heat labile toxin
E. coli heat stable toxin
Shiga toxin
Perfringens enterotoxin
Botulinum toxin
Pseudomonas Exotoxin A
Staphylococcus enterotoxins* Staphylococcus aureus
Toxic shock syndrome toxin
(TSST-1)*
Exfoliatin toxin*
Erythrogenic toxin (streptococcal
pyrogenic exotoxin SPE)*
BACTERIA INVOLVED ACTIVITY
ADP ribosylation of G proteins stimulates adenlyate
Vibrio cholerae cyclase and increases cAMP in cells of the GI tract,
causing secretion of water and electrolytes
Escherichia coli Similar to cholera toxin
Stimulates guanylate cyclase and promotes secretion
Escherichia coli
of water and electrolytes from intestinal epithelium
Enzymatically cleaves rRNA resulting in inhibition of
Shigella dysenteriae
protein synthesis in susceptible cells
Stimulates adenylate cyclase leading to increased
Clostridium perfringens
cAMP in epithelial cells
++
Zn dependent protease that inhibits neurotransmission at
Clostridium botulinum
neuromuscular synapses resulting in flaccid paralysis
Pseudomonas aeruginosa Inhibits protein synthesis; similar to diphtheria toxin
Massive activation of the immune system, including
lymphocytes and macrophages, leads to emesis
Acts on the vascular system causing inflammation,
Staphylococcus aureus
fever and shock
Cleavage within epidermal cells (intraepidermal
Staphylococcus aureus
separation)
Same as TSST - inflammation, fever and shock; can
Streptococcus pyogenes
cause localized erythematous reactions
(2) osmotic diarrhoea

Enzyme system insufficient or Short Bowel

syndrome  food is digested partially 
osmotic burden intraluminal  bacterium
decompose the food short chain fatty
acid and other material  diarrhoea
Proses defisiensi
laktase
Gambaran klinik intolerasi laktosa :
• Fese berbau asam dan berbuih
• Meteorismus ringan
• Flatulens/sering flatus/ keluas gas
• Eritema natum/Diaper rash.
• Abdominal pain,cramp,disekitar area
periumbilikal, atau kuadrant bawah.
(3) cytotoxic/inflammatory diarrhoea
Cytotoxic: Viral, inflammatory : allergy, IBD
Viral  invasive and cytotoxic  damage entrocytes
at villus  villus atrophy (Absorption decrease)
 crypt hyperplasia (secretion increase) 
mixed diarrhoea
Inflammation  (1) immune cells  cytokines +
chemokines + prostaglandins  induce secretion
and activate enteric nerves (2) metaloproteins
destroyed entrocytes at villus  (Absorption
decrease)  crypt hyperplasia (secretion
increase)  mixed diarrhoea
Absorption decrease  immature entrocyte with
insufficient disacharidase and peptide hydrolase.
Diarrhoea
Stool Form
• secretory diarrhoea : watery, high level
electrolyte
• osmotic diarrhoea : semisolid, low level
electrolyte
• cytotoxic / inflammatory diarrhoea : mix
Pathophysiology
loss of water & electrolyte 
v Dehydration  death
v imbalance of electrolyte and acid-base
v hypoglycemia, under/malnutrition,
v shock, etc
Clinical manifestation of dehydraton
Alertness: irritable, weak / lethargy
Thirsty, nausea, vomiting,
Pulse: rapid, weak.
Respiratory rate: rapid, kussmaull
Fontanel : sunken
Eyes: sunken, no tear
Mouth: dry mucosa
Turgor: diminish (> 1 second)
Determining degree of dehydration

1. Laboratory : BW, hematocryte

2. Clinical feature: scoring system

1. IMCI/MTBS, practical and easy to applied

2. P2 Diarrhoea = Programe National Diarrhoeal
Diseases Control Program (CDD)
3. Maurice King Score; others
General clinical manifestation
 Degrees of dehydration
1. No dehydration
2. Mild dehydration : 1-4% of BW
3. Moderate deh. : 5-10% of BW
4. Severe deh : 10% of BW

= Previous Water Lost (PWL)

Giving solution
Loss of Body Weight

0% 5% 10% 15%
Ex : normal BW 10 kg, if diarrhea 9 kg :
loss of BW 10%
Dehydration
No,Mild, moderate, severe, shock,death
No, Mild-moderate, severe, shock,death
Rehydration
Mild-moderate : (5%+10%):2 = 7,5% = 75 ml/kgBW
Severe : WHO 10% (100ml/kgBW), FK Unsri = 12%
Therapy
WHO:
(1) Fluid therapy: prevent & treat dehydration
(2) Dietetic : continue especially breast feeding
(3) Drug therapy: no AB,
except for cholera and bloody stool
WHO recommend : Zinc,
not yet: Probiotik And prebiotik
(4) education
1. Fluid therapy

Consideration :
• Route : oral or parenteral
• Type of solution
• Amount of solution
• Time /rate of giving the fluid
 Solid mass
40%
Intravasculler
Intracelluler
Diartr 5%
hea albumin
Intertitiel 40%

15%
 Solid mass
Diarrhea 40%
Na 50-60 Intravasculer
Intraceluller
K 28 5%
Alb (-) Albumin, Na
Intertitiel 40%
Na
15% K
 dehidrasi Solid mass
40%
Intraceluller
Diare Intravasculer
albumin
Intertitie
l
rehydratio Solid mass
n 40%
Intraceluller
IVFD Intravasculer
albumin
Intertitie
l

Need
time
Route:

Per Oral
• more beneficial compared to parenteral
(cheap, frequency and duration of diarrhoea:
decrease)
• Given in : no and mild-moderate dehydration
• In especially situation: can be given by NGT
(≤ 20 ml/kgBW/hour)
• Home based solution, ORS, renalyte,
pedialyte, etc
ORS Composition

Reduced Grams/litre Reduced Mmol/L

Osmolarity ORS Osmolarity ORS

Sodium Chloride 2.6 Sodium Chloride 75

Anhidrous 13.5 Anhidrous 75
Glukose Glukose
Potassium 1.5 chloride 65
chloride
Trisodium citrate, 2.9 Potassium 20
dihydrate
citrate 10
Total Osmolarity 245
Parenteral/Intravenously

• Given in:
– severe dehydration
– Mild/moderate deh. : ORT failed
• After rehydration is reached, as soon as
possible ( 4-6 hours) change to oral solution.
• Kind of intravenous solution : kristaloid ( RL,
Nacl, Nacl+Dektrose)
 KATION ORGAN ANION Osm
+ + + -
Na K Ca Dex Glc Cl Lact Aset bnat
Gastric juice pH low 10-30 5 - 40 80-150 0
Gastric juice pH high 70-140 5 - 40 55 – 95 5 - 20
Bile salt 131-164 2,6-12 89-117 40
Diare cholera / noncholera 101/56 27/25 92/55 32/14
D5% 10:4 51,3 10,7 50 62 402
Renalyte / Pedialyte 75/45 20/20 -/25 20/- 65/35 Citrat 10/30
Oralit lama/baru(kf) 90/75 20/20 20/13,5 80/65 30/- - / Citrat 10 311/245
Darrow 122 35 104 53 314
DG aa 61 17,5 25 52 26 320
D10% 10:4:7 65,3 10,7 100 62 14 706,5
D5% 10:4:7 ≈ KAEN 3A 65,3 10,7 50 62 14 428,5
RL otsuka 130 4 3 109 28 273
RD 5% 147 4 4,4 50 156 586
Ringer Otsuka 147 4 4,5 156 310
KAEN 3A 60 10 27 50 20 290
KAEN 3B 50 20 27 50 20 290
KAEN MG3 50 20 100 50 20 695
3A 106 16,7 51 55 305
2A=AA / D5% 1:1 77 25/50 77 293/432
D5% 4:1 ≈ KAEN 4A 30,7 50 30,7 339
D5% 3:1 ≈ KAEN 1B 38,5 50 38,5 355
D5% 2:1 51,3 50 51,3 380
Amount of fluid
Requiremet for 1 day :
1. Previous Water Lost (PWL)= degrees of
dehydration :
– mild-moderate: 75 ml
– severe 125 ml
2. C(oncomitant)/On-going WL:
– = stool out put (? )
– ± 25 ml
3. N(ormal)WL:
– = daily requirement (± 10
Parenteral/Intravenously

Severe dehydration:
WHO: RL
< 1 year: 30 ml / 1 hour  70 ml / 5 hours
≥ 1 year: 30 ml / 0,5 hour  70 ml / 2,5 hours
RSCM/ FKUI: KAEN 3B
< 1 year: 30 ml / 1 hour  70 ml / 5 hours
≥ 1 year: 30 ml / 0,5 hour  70 ml / 2,5 hours
RSMH/ FK UNSRI: RL
30 ml/hour  120 ml/4 hours
Parenteral/IV: rate of infusion
PWL must be restore “quickly” (Rehydration phase)
Severe dehydration: for PWL
WHO: RL
< 1 year: 30 ml / 1 hour  70 ml / 5 hours
≥ 1 year: 30 ml / 0,5 hour  70 ml / 2,5 hours
RSCM/ FKUI: KAEN 3B
< 1 year: 30 ml / 1 hour  70 ml / 5 hours
≥ 1 year: 30 ml / 0,5 hour  70 ml / 2,5 hours
RSMH/ FK UNSRI: RL
30 ml/hour  120 ml/4 hours
The important thing is MONITORING each hour
After Rehydration : Maintenance phase

• CWL :
– ORS
– = Stool out put/25 ml kgbw/24 hr
• NWL :
– = daily requirement
2. Dietetic therapy

• Breast feeding continued

• continue to eat and drink as usual:
portion > usual
• Do not consume the stimulating food
• Consume food with potassium high
• Baby consumes formula milk, change:
LLM/BL/LF if there is lactose
intolerance
3 . Drug therapy (medikamentosa)
Antimicrobial
• Limited
• WHO and National Health Department :
cholera and dysentery
• Considerable to invasive diarrhoea
• Other indicated: suspect cholera, suspect
shigelosis, proven amubiasis, proven
giardiasis, and bacterial overgrowth
Other indication of Antibiotic:
• Invasive diarrhoea: leucocyte stool = 10 /
hpf ?, temperature > 38,5 oC
• Meteorismus
• With other disease (need for antibiotic)
 Seng (Zinc)
Mikronutrien esensial
Berperan dlm :
• proses pertumbuhan dan diferensiasi sel
• menjaga stabilitas dinding sel
• Ikut proses ekspresi gen dan pengaturan ion
intraseluler.
• Meningkatkan sisstem imun spesifik/nonspesifik
Seng dalam pengobatan & pencegahan diare
• Seng menurunkan insidens diare akut dan
persisten antara 14-65%
• Seng menurunkan insiden diare 2-3 bln yad
• Seng memperpendek durasi dan mengurangi
proporsi diare yg menjadi kronik
• Seng mengembalikan nafsu makan anak
Sediaan: tablet atau sirup
Dosis: 2- 6 bl: 10 mg, > 6 bulan : 20 mg
Diberikan selama 10-14 hari
Other drugs
• Anti vomiting:
– Most vomiting stop after rehydration
– Interfere with ORT : domperidon
• Stool hardener
– Not a therapy; not recommended
– ka0lin
• Anti secretory: racecadotril, chlorpromazine
• Anti peristaltic: dangerous
 Health education
1. How to treat diarrhea at home :
2. Plan A (bellow)
3. When to consult health provider
– Sign of severe dehydration
– Bloody diarrhea
4. Prevention of diarrhea
– Food handling, Fecal handling, (fly control)
– vaccination
 MTBS = IMCI
• Manajemen Terpadu Balita Sakit
• Integrated Management of Childhood
Illness

• Program WHO , diadaptasi Depkes

IMCI: Does the child have diarrhoea?

IF YES, ASK:
• For how long?
• Is there blood in the stool?
1. How long ? < 14 days: acute, ≥ 14 days:
persistent
2. Bloody stool? No: (dx: = 1), yes: disentry
Classification: degree of dehydration  general
apprerance, sunken eye, thristhy, turgor.
Classification dehydration (without, some =
mild to moderate, severe)