Sri Winarsih - FMUB

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 Diare
merupakan masalah utama pada anak2
karena faktor perilaku dan lingkungan

Dinegara sedang berkembang, diare:

penyebab utama dari kesakitan dan
kematian pada anak
- biaya kesehatan meningkat

Diareinfeksi seringkali akut dan merupakan

efek langsung pada usus

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 Diare :
- peningkatan kadar air pada tinja, baik karena
gangguan penyerapan air dan / atau sekresi
air aktif oleh usus
- penurunan konsistensi dan peningkatan
frekuensi berdasarkan data dasar individu
Sebagian besar penderita diare akut
menunjukkan 3 - 7x defekasi per hari dengan
volume tinja total < 1 liter per hari.
Padadiare infeksi yang berat, jumlah defekasi
dapat mencapai > 20 per hari hipovolemik
dan hipokalemia
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 Durasidiare:
- Diare akut : < 14 hari
- Diare persisten: > 14 hari
- Diare kronis : > 30 hari

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 Penyebab: bakteri, virus, protozoa.
Infeksi virus adalah penyebab utama diare di
dunia (rotavirus).

Penggantian cairan dan elektrolit adalah dasar

terapi (glukosa, natrium, potassium, klorida,
dan air). Terapi rehidrasi oral lebih disukai
pada diare ringan dan sedang.

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 Penyakit diare bisa dicegah dengan kebersihan
diri dan persiapan makanan yang aman

Strategi edukasi penting

Secara umum, profilaksis dengan antibiotik tidak

direkomendasikan
Terapi antimikroba sering tidak diindikasikan
karena kebanyakan kasus adalah ringan dan
bersifat self limited (viral).

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 Biasanya
episode diare dimulai dengan tiba-tiba
dan mereda dalam 1 atau 2 hari tanpa
pengobatan

Bayi, anak-anak, orang tua, dan orang yang

lemah berisiko menjadi diare berkepanjangan
atau berat.
berakibat kekurangan air, elektrolit, dan
gangguan asam basa, kolaps kardiovaskular
dan kematian

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 Manajemen diare ditujukan pada
1. mencegah kehilangan air dan elektrolit
2. manajemen diet,
3. menghilangkan gejala,
4. mengobati penyebab
5. mengobati gangguan sekunder

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 Themost common pathogens for travellers
diarrhea include:
Enterotoxigenic E.coli (ETEC), Shigella,
Campylobacter, Salmonella, and viruses.

Common pathogens responsible for food

poisoning include:
Staphylococcus, Salmonella, Shigella, and
Clostridium

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 Salmonella
Escherichia coli
Clostridium perfringens
Usus halus Staphylococcus aureus
Aeromonas hydrophila
Bacillus cereus
Vibrio cholera

Campylobacter
Shigella
Usus besar

Clostridium difficile
Yersinia
(kolon) Vibrio parahaemolyticus
Enteroinvasive E. coli (EIEC)
Plesiomonas
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Usus halus Usus besar
Rotavirus Cytomegalovirus
Norovirus Adenovirus
Herpes simplex
virus

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 Cryptosporidium
Microsporidium
Usus halus Isospora
Cyclospora
Giardia lamblia

Usus besar Entamoeba histolytica

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V. cholerae Cholerae toxin (5 subunit B + 1 subunit A)

Subunit A

Adenyl cyclase
ATP Cyclic AMP
Na
diarrhea
H2O

epithelial cell of small intestine

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 Watery diarrhea
Large volume
Abdominal cramping
Bloating, gas
Weight loss
Fever is rarely a significant symptom
Stool does not contain blood or inflammatory
cells

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 Frequent
Regular
Small volume
Often painful bowel movements
Fever
Bloody or mucoid stools are common
Red blood cells and inflammatory cells may
be seen routinely on the stool smear

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 Diare
Mual, muntah, sakit perut, sakit kepala,
demam, menggigil, dan malaise.
Nyeri abdomen dengan kram
Tenesmus (tegang, tidak efektif, dan
nyeri defekasi)

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 Pemeriksaan fisik
Khas menunjukkan hiperperistaltik dan nyeri tekan

Tes laboratorium
Analisis tinja meliputi : mikroorganisme, darah, mukus,
(juga volume tinja total setiap hari )
Endoskopi dan biopsi kolon untuk mengevaluasi adanya
colitis atau kanker
Radiografi untuk membantu dalam hal kondisi neoplastik
atau inflamasi

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 Diare cair dengan tanda-tanda hipovolemia
(penurunan turgor kulit, hipotensi ortostatik)
Tinja mengandung darah dan lendir (diare
berdarah) infeksi patogen invasif
Demam (suhu tubuh 38,5o C)
Adanya 6x defekasi dg tinja yang tidak
berbentuk per 24 jam / durasi penyakit > 48 jam
Nyeri perut yang parah
Penggunaan antibiotik sebelumnya
Pasien umur tua (70 tahun) atau yang
immunocompromised
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 Riwayat yang cermat dapat diprediksi untuk
agen etiologi.
Diare berdarah EHEC, Shigellosis, PMC
Fecal leukocyte perlu tes utk Clostridium
difficile
Wabah harus mempertimbangkan infeksi:
Staphylococcus aureus, Bacillus cereus, Clostridium
perfringens, Vibrio, Salmonella, Campylobacter,
Shigella, or E. coli
Makan sea food yang tidak dimasak dengan
baik kemungkinan infeksi Vibrio or
noroviruses
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 Penggunaan antibiotik menjadi predisposisi
untuk infeksi:
- cytotoxigenic Clostridium difficile

Perjalanan ke daerah tropis meningkatkan

kemungkinan infeksi oleh :
- ETEC, viral (Norovirus atau Rotavirus)
- infeksi parasit (Giardia, Entamoeba,
Strongyloides, and Cryptosporidium)

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 Fecal testing is recommended in patients:
- recent use of antibiotics,
- daycare center attendance,
- hospitalization,
- illness accompanied by fever,
- bloody stools,
- systemic illness

For community-acquired or travelers diarrhea:

- stool samples should be sent for culture of
Salmonella, Shigella, Campylobacter, and
E. coli O157:H7.

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 Symptoms that begin within 6 hours suggest
ingestion of a preformed toxin of Staphylococcus
aureus or Bacillus cereus

Symptoms that begin at 8 to 16 hours suggest

infection with Clostridium perfringens

Symptoms that begin at more than 16 hours can

result from viral or bacterial infection
(e.g., contamination of food with ETEC or EHEC)

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 Laxatives
Antacids containing magnesium
Antineoplastics: Auranofin (gold salt)
Antibiotics: Clindamycin,
Tetracyclines,
Sulfonamides,
any broad-spectrum antibiotic
Antihypertensives: Reserpine, Guanethidine,
Methyldopa, Guana-benz/drel
Angiotensin-converting enzyme inhibitors

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 Cholinergics: Bethanechol, Neostigmine
Cardiac agents: Quinidine, Digitalis, Digoxin
Nonsteroidal antiinflammatory drugs
Misoprostol
Colchicine
Proton pump inhibitors
H2-receptor blockers

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 As person-to-person contact is the mechanism
by which viral disease spreads isolation
techniques must be initiated
For bacterial, parasite, and protozoal infections,
strict food handling, sanitation, water, and other
environmental hygiene practices can prevent
transmission.
Antibiotics and bismuth subsalicylate are
advocated to prevent travelers diarrhea, in
conjunction with treatment of drinking water and
caution with consumption of fresh vegetables.

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 Penyebaran human to human adalah penyebaran
penyakit virus perlu teknik isolasi

Untuk infeksi bakteri, parasit, dan protozoa

penanganan makanan yang ketat, sanitasi, air, dan
praktik kebersihan lingkungan lainnya dapat
mencegah penularan (peranan public health)

Antibiotik dan bismut subsalicylate dianjurkan

untuk mencegah travellers diarrhae (berhubungan
dengan kualitas air minum dan konsumsi sayuran
segar)
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 Dokter harus memahami dengan jelas
bahwa diare, seperti batuk, mungkin
merupakan mekanisme pertahanan tubuh
untuk membersihkan diri dari zat berbahaya
atau patogen respons terapeutik yang
benar tidak harus menghentikan diare

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 Rehydration
Oral glucose or starch-containing electrolyte
solution in the vast majority of cases
WHO recommended electrolyte concentrations
e.g. Ceralyte, Pedialyte, or generic solutions

Drugs are grouped into several categories:

- antimotility, adsorbents, antisecretory compounds,
ANTIBIOTICS, enzymes, intestinal microflora
mostly these drugs are not curative but palliative

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 R/ 3.5 g of NaCl,
2.5 g of NaHCO3 (or 2.9 g of Na citrate),
1.5 g of KCl, and
20 g of glucose or glucose polymer
(e.g., 40 g of sucrose or 4 tablespoons of sugar
or 5060 g of cooked cereal flour such as rice,
maize, sorghum, millet, wheat, or potato) per
liter of clean water
This makes a solution of approximately Na 90 mM, K
20 mM, Cl 80 mM, HCO3 30 mM, glucose 111 mM

Vitamin A and zinc repletion should be considered for

patients with likely or documented deficiency.
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 Antimotility

Opiates and opioid derivatives

- delay the transit of intraluminal contents
- increase gut capacity, prolonging contact and
absorption.

Limitations to the use of opiates include an

addiction potential (a real concern with long-term
use) and worsening of diarrhea in selected
infectious diarrhea

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 Diphenoxylateis available as a 2.5-mg tablet and
as a 2.5 mg/5mL solution.
Diphenoxylate is rarely toxic.

Atropine In adults, when taken as 2.5 to 5 mg 3-4

dd, not to exceed a 20-mg total daily dose.
Some patients may complain of atropinism (blurred
vision, dry mouth, and urinary hesitancy).
It should not be used in patients who are at risk of
bacterial enteritis with E. coli, Shigella, or Salmonella.

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 Antimotility
agents are contraindicated in most
toxin-mediated diarrheal illnesses (EHEC,
PMC, shigellosis)

should be avoided in patients with high fever

and bloody diarrhea
(slowing of fecal transit time is thought to result
in extended toxin-associated damage)

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 Adsorbents

- Adsorbents are used for symptomatic relief.

- Many not requiring a prescription, are, nontoxic
- Nonspecific action they adsorb nutrients, toxins,
drugs, and digestive juices.
- Polycarbophil absorbs 60 times its weight in water
and can be used to treat both diarrhea and
constipation.
this hydrophilic nonabsorbable product is safe
and may be taken 4dd 500mg, up to 6 g/day in
adults.
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 Antisecretory Agents

- Bismuth subsalicylate appears to have

antisecretory, antiinflammatory, antibacterial

Bismuth subsalicylate is marketed for

indigestion, relieving abdominal cramps, and
controlling diarrhea, including travellers
diarrhea, but may cause interactions with
several components if given excessively

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 The indiscriminate use of antimicrobial therapy
in GI infections produces increases in
- antimicrobial resistance, side effects of
antimicrobial agents
- superinfections due to eradication of normal
flora
Antibioticsare not essential in the treatment for
most mild diarrheas, and empirical therapy for
acute GI infections

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 Appropriate antibiotic therapy
1. Shortens the duration of illness and reduces
morbidity (cholera, ETEC, shigellosis,
campylobacteriosis, yersiniosis)
2. Can be lifesaving in invasive infections
(C. difficile, salmonellosis).
3. Reduces shedding of organisms (Shigella sp.
, Campylobacter sp.)

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 Lactobacillus preparations
- are considered probiotics agents
- contain bacteria or yeast, such as lactic acid bacteria
are dietary supplements that have been used for
many years in hopes of replacing colonic microflora.
- restores normal intestinal function and
- suppresses the growth of pathogenic microorganisms
- lactobacillus preparations should be administered
with milk, juice, water, or cereal.
A dairy product diet containing 200 to 400 g of lactose
or dextrin is equally effective in producing
recolonization of normal flora.
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Masuk akal untuk melanjutkan terapi simtomatik untuk bbrp
hari sebelum mempertimbangkan evaluasi lebih lanjut
pada pasien yang tidak memiliki penyakit parah, terutama
terutama jika pada tinja tidak ada darah dan leukosit .
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