Problem 2b

adhelina

LO 1 DIARRHEA

Definition
Diarrhea is the passage of 3 or more loose or
liquid stools per day, or more frequently than is
normal for the individual.
It is usually a symptom of gastrointestinal
infection, which can be caused by a variety of
bacterial, viral and parasitic organisms.
Infection is spread through contaminated food or
drinking-water, or from person to person as a
result of poor hygiene.

epidemiol
ogi

KLASIFIKASI

Acute, persistent, &

chronic diarrhea
Acute diarrhea is defined as a
greater number of stools of
decreased form from the normal
lasting for less than 14 days.
If the illness persists for more than
14 days, it is called persistent.
If the duration of symptoms is longer
than 1 month, it is considered
chronic diarrhea.

Primary
mechanis
m

Defect

Stool
examinatio
n

examples

comment

secretory Decreased
absorption,incr
eased
secretion,electr
olyte transport

Watery,nor
mal
osmolality,
osmoles =
2x (Na+
K)

Cholera,toxi
genic,E.coli,
carcinoid,
VIP,neurobla
stoma,cong
enital
chloride,cry
ptosporidias
is

Persist
during
fasting,bile
salt
malabsorpti
on may also
increase
intestinal
water
sceretion,no
stool
leukocytes

osmotic

Watery,acid
ic,and
reducing
substance,i
ncreased
osmolality,o
smoles>2
x(Na+ K)

Lactase
deficiency,gl
ucosegalactose,m
alabsorbtion
,lactulose,la
xative abuse

Stops with
fasting,incre
ased breath
hydrogen
with
carbohydrat
e
malabsorpti
on,no stool

Maldigestion,tr
ansport defect
ingestion of
unabsorbable

Ethiology (noninfection)

Bacterial
Organism
Escherichia coli
Enterotoxigenic strains
Shiga toxin-producing
strain
Enteropathogenic strains
Enteroinvasive strains

Pathogenic
Mechanism
Cholera like toxin, no
invasion
Shiga toxin, no invasion
Attachment, enterocyte
effacement, no invasion
Invasion, local spread

Clinical Features

Travelers diarrhea,
including watery diarrhea
Hemorrhagic colitis,
hemolyticuremic syndrome
Watery diarrhea, infants,
and toddlers
Fever, pain, diarrhea,
dysentery

Salmonella spp

Invasion, translocation,
lymphoid inflammation,
dissemination

Fever, pain, diarrhea or

dysentery, bacteremia,
extra-intestinal infection,
common source of
outbreaks

Shigella spp

Invasion, local spread

Fever, pain, diarrhea,

dysentery, epidemic spread

Yersinia enterocolitica

Invasion, translocation,
lymphoid inflammation,
dissemination

Fever, pain, diarrhea,

mesenteric lymphadenitis,
extra-intestinal infection,
food sources

Vibrio cholerae, other

Vibrio spp

Enterotoxin, no invasion

Watery diarrhea, cholera,

pandemic spread

Clostridium difficile

Cytotoxin, local invasion

Fever, pain, bloody

diarrhea, after antibiotic
use, nosocomial acquistion

Clostridium perfringens

Enterotoxin, no invasion

Watery diarrhea, food

sources, pigbel

Mycobacterium
tuberculosis

Invasion, mural
inflammatory foci with
necrosis and scarring

Chronic abdominal pain,

complications of
malabsorption, stricture,
perforation, fistulas,
hemorrhage

Organism

Symptoms and signs

Salmonella

Nausea, vomiting, headache, meningismus, fever,

diarrhea, abdominal pain, watery stool (may contain mucus
or blood)

Shigella

Cramps, bloody diarrhea, high fever, malaise, convulsions,

pus and blood in diarrheal stools

Campylobacter

Fever, vomiting, abdominal pain, diarrhea, high fever,

malaise, headache, cramps, nausea

Signs and Symptoms of Parasitic

Infection
Sign and symptom Agent
Dysentry
Balantidium coli
Abdominal pain

Diarrhea

Anisakis
Ascaris
Clonorchis
Entamoeba histolytica
Fasciola hepatica
Hookworm
Stongyloides
Trichinella
Trichuris
Blastocystis
Cyrptosporidium
Dientamoeba fragilis
Entamoeba histolytica
Giardia
Schistosoma
Strongyloides
Trichinella
Trichuris

Entamoeba histolytica
Schistosoma
Trichuris
Fever

Entamoeba histolytica
Leishmania donovani
Plasmodium
Toxocara
Toxoplasma
Trichinella
Trypanosoma

Incub
ation

Duratio
n

Vomiting

Fever

Abdomina
l Pain

1-7 d

4-8 d

Yes

Low

No

8-10 d

5-12 d

Delayed

Low

No

Norovirus

1-2 d

2d

Yes

No

No

Astrovirus

1-2 d

4-8 d

+/-

+/-

No

Calicivirus

1-4 d

4-8 d

Yes

+/-

No

Aeromonas
species

None

0-2 wk

+/-

+/-

No

Campylobact
er species

2-4 d

5-7 d

No

Yes

Yes

Variabl
e

Variable

No

Few

Few

1d

Mild

No

Yes

Organism
Rotavirus
Adenovirus

C difficile

Minima
C perfringens
l

Incubati
on

Duratio
n

Vomitin
g

Fever

Abdomina
l Pain

Enterohemor
rhagic E coli

1-8 d

3-6 d

No

+/-

Yes

Enterotoxige
nic E coli

1-3 d

3-5 d

Yes

Low

Yes

Plesiomonas
species

None

0-2 wk

+/-

+/-

+/-

Salmonella
species

0-3 d

2-7 d

Yes

Yes

Yes

Shigella
species

0-2 d

2-5 d

No

High

Yes

Vibrio
species

0-1 d

5-7 d

Yes

No

Yes

Yenterocoliti
ca

None

1-46 d

Yes

Yes

Yes

Giardia
species

2 wk

1+ wk

No

No

Yes

5-21 d

Months

No

Low

Yes

5-7 d

1-2+ wk

No

Yes

No

Organism

Cryptosporid
ium species
Entamoeba

ETIOLOGY

Viruses : Enterovirus, adenovirus, rotaviru

Enteral Infection

Infection

Bacteria : Vibrio, E. coli, Shigella,

Salmonella, Campylobactr,
Yersinia, Aeromonas
Protozoa : G. Lamblia, E.
Histolitica, Isospora belli
Parasites

Caused
of diare

Helmin : Ascaris,
Trichuris, Oxyyuris,
Strongyloides
Fungal : Candida albicans

Parenteral Infections : OMA, Tonsilofaringitis,

Bronkopneumonia, Morbilli
Malabsorption : Carbohydrate, Lipid, Protein
Food : out-of-date, poisonous
Allergic
Immunodeficiency
Phsycology : afraid,

Symptoms

Weepy
Anxious
Decreased appetite & weight
Frequent, loose, watery
stools
Abdominal cramps
Abdominal pain
Fever
Blood in the stool
Bloating
Dehydration signs (if lost
much fluid)
Nausea and vomiting

RISK FACTOR
Nutrition

Hygiene
Sanitation

Social
Culture
Patient

Germ
caused
diarrhea

COMMUNITY

Human that
carier the
germ
Health
people

Compact
inhabitant

Social
Economi

Other
factor

Laboratory test

Stool examination
Blood gas analyze
Ureum and creatinin examination
Electrolic serum examination
Glucose percentage test.

19

Diarrhea treatment for

children
A. Rehydration
Colum
nA

Column B

Column C

Column D

4-10x/days
Sometimes
Thirsty

>10x / days
Often
Very thirsty/
cant drink
- during 6 hours

>3 weeks

Urine

<4x /
days
-/ few
Normal

2 . Inspection
General
Tears
Eyes
Mouth &tongue
Breath

Good
+
Normal
Wet
Normal

Sleepy/
anxiety
sunken
Dry
Faster

1.Anamnesis
Frequent
Vomiting
Thirsty

Few,
concentrated

unconscious/anxi
ety
sunken & dry
Very dry
more faster &
deep

3. Skin
Palpation
Turgor

column A

Column B

Column C

Back to
normal fast
Normal

Back to normal
slower
Normal/fast

Very slow

Normal

Concave

Very concave

Column D

Very slow, weak

Pulse
Fontanel
4.
Temperature

Very high,
>38oC

5. Weight

Loss <2,5 %

Loss 2,5 10 %

Loss > 10%

6. Conclusion

Dehydration
(-)

2 sign mild/
moderate
dehydration
Plan B

2 sign or more
severe dehydration

Plan A

Plan C

Stools :
blood/slime +
fever
Antibiotics

Plan A
(to prevent dehydration)

1. Give patients more liquid than usual, such as:

. Oralite,dll
Keep breastfeeding and give formula milk
2. Continue give meals
Porridge with meats or fish.
Bananas/ juices to additional Kalium.
Give foods every 3-4 hours (6x a day).

Plan A
(to prevent dehydration)

3. Bring patient to medical centre if:

Often defecation
Very thristy
Sunken eyes
Fever
Anorexia
Bloody stools
4. Give oralite
<2 years : 50-100 ml (1/4 -1/2 cup)
2-5 years : 100-200 ml (1/2-1 cup)

Plan B
(for mild/ moderate dehydration)
1. Use this table for plots:

Add age of patient if weight not known

Give oralite in of

Plan C
(for severe dehydration)
Are you give intravena to
patient?

Yes

no
Patient can drink?

Yes

no
Are you have a skill to
installed a tools?
no
Suggested to give liquid
intravena
IV Dose for patient :
First 1 hour: 30 ml/kg
2 hour : 40 ml/kg

1. Give liquid intravena

2. After 1-3 hour recheck
again and choice suitable
about treatment
1. Begin to give oralitr

20-25% liquid must given

in one hour
Yes

1. Begin rehydration with

NGT
2. If IV threatment
available, suggest to the
nearest medical centre.
Dose of liquid/ NGT:
20 ml/kg/Hour

ANTIMICROBIAL

Clinic diagnose

First Drugs choice

Other drugs

Cholera

Tetrasiklin

Furazolidone
Trimethoprin (TMP)
sulafamethoxazole
(SMX)

Dysentry shigella

Trimethoprin (TMP) Nalidixic Acid

sulafamethoxazole
(SMX)
Ampisilin

Acute bowel
Amubiasis

Metronidazole

Dehidrometine

Acute Giardiasis

Metronidazole

Quinacrine

Complication
Dehydration
Acid base disorders (metabolic
acidosis) Kussmaul respiratory,
hypoglycemia, nutritional disorders,
circulation disorders

LO 2 DEHYDRATION

Dehydration
Too much water lost, not enough
water taken in, or most often a
combination of the two.

Causes

Diarrhea: Diarrhea is the most common

reason a person loses excess water. A
significant amount of water can be lost
with each bowel movement. Worldwide,
more than four million children die each
year because of dehydration from diarrhea.
Vomiting: Vomiting can also be a cause of
fluid loss; as well, it makes it difficult to
replace water by drinking it.
Sweat: The body can lose significant
amounts of water when it tries to cool itself
by sweating. Whether the body is hot
because of the environment (for example,
working in a warm environment), intense
exercising in a hot environment, or
because a fever is present due to an
infection, the body uses a significant
amount of water in the form of sweat to
cool itself. Depending upon weather
conditions, a brisk walk will generate up to
16 ounces of sweat (a pound of water).

Diabetes: In people with diabetes,

elevated blood sugar levels cause sugar
to spill into the urine and water then
follows. Significant dehydration can
occur. For this reason, frequent
urination and excessive thirst are
among the symptoms of diabetes.
Burns: Burn victims become
dehydrated because water seeps into
the damaged skin. Other inflammatory
diseases of the skin are also associated
with fluid loss.
Inability to drink fluids: The inability
to drink adequately is the other
potential cause of dehydration. Whether
it is the lack of availability of water or
the lack of strength to drink adequate
amounts, this, coupled with routine or
extraordinary water losses, can
compound the degree of dehydration

Signs & Symptoms

Thirst
Less frequent
urination
Dry skin
Fatigue
Light-headedness
Dark-colored urine

Signs of dehydration in
children include:
Dry mouth and tongue
No tears when crying
No wet diapers for 3 hours
or more
Sunken abdomen, eyes, or
cheeks
High fever
Listlessness or irritability
Skin that does not flatten
when pinched and
released
Grayish skin

PHYSICAL EXAM findings are related to the degree

of dehydration, moderate, mild, or severe
Finding

Mild

Moderate

Severe

Decrease body
weight

3-5%

6-10%

11-15%

BP

Normal

Normal

NormalReduced

Tears

Decreased

Decreased

Absent

HR

Normal

Increased

Tachycardia

Skin turgor

Normal

Decreased

Decreased

Fontanelle

Normal

Sunken

Sunken

Mucous
membrane

Slightly dry

Dry

Mottled or gray

Eyes

Normal

Sunken orbits

Deeply sunken
orbits

Cap refill

2-3 sec

3-4 sec

>4 sec

Mental status

Normal

Normal to
listless

Normal to
lethargic or

Scoring System
Degree of dehydration
Score

General condition

Healthy

Skin elasticity
Eye
Fontanel
Mouth
Pulse

Normal
Normal
Normal
Normal
Normal

1
Irritability,
sleepy,
apathy
Decreased
Sunken
Sunken
Dry
120-140

2
Delirium, coma
or shock
Very
decreased
Very sunken
Very sunken
Dry & cyanotic
> 140

Amount of score: 0- 2 Mild dehydration

3- 6 Moderate dehydration
7-12 Severe dehydration
Maurice King, 1974