DIARE KRONIK

Dr dr Juwita Sembiring SpPD KGEH

GASTROENTEROLOGY-HEPATOLOGY
DIVISION
INTERNAL MEDICINE DEPARTEMENT
FK-USU/ADAM MALIK HOSPITAL
DEFENISI
DIARE, BAB (DEFEKASI) YANG TDK NORMAL,PERUBAHAN
FREKWENSI,KONSISTENSI,URGENSI DAN CONTINENCE
DGN TINJA BENTUK CAIR ATAU SETENGAH PADAT,
KANDUNGAN AIR TINJA > DARI BIASA > DARI 200 GRAM
ATAU 200 ML/24 JAM.
DEFENISI LAIN,BAB ENCER FREWENSI>DARI 3 KALI PER
HARI,DAPAT/TANPA DISERTAI LENDIR DAN DARAH.

DIARE (AKUT,KRONIK)
DIARE AKUT,<2MINGGU,DPT SELF LIMITED
DIARE KRONIK,PERSISTEN,DIHUB.SIMPTOM SISTEMIK
ATAU ABDOMINAL PAIN,AKTIVITAS
TERBATAS,KUALITAS HIDUP.

DIARE KRONIK ADALAH DIARE YANG BERLANGSUNG

LEBIH DARI 2 MINGGU.
PATOFISIOLOGI
1. RETENSI CAIRAN OSMOTIK DLM LUMEN
USUS
2. SEKRESI AKTIF ELEKTOLIT
3. PERUBAHAN STRUKTUR DINDING USUS
4. PENINGKATAN FILTRASI
5. PERUBAHAN MOTILITAS
ETIOLOGI
BERAGAM, DAPAT DITEMUKAN 1 ATAU LEBIH.
DIARE KRONIK BERDASARKAN
KARAKTERISTIK TINJA,
DIARE DGN TINJA BERLEMAK
DIARE DGN TINJA BERDARAH
DIARE DENGAN TINJA CAIR/ENCER (TANPA
LEMAK,DARAH)
ETIOLOGI DIARE KRONIK
BERDASARKAN KRAKTERISTIK TINJA
A. TINJA BERLEMAK/STEATOREA
- Penyakit Pankreas:Pankreatitis Kronik, Karsinoma
Pancreas, Insufisiensi Pankreas (Defenisi Lipase).
- Penyakit Mukosa Usus Halus : Spru Tropik, Penyakit Crohn,
Enteritis Radiasi, Penyakit Seliak, Limfoma Usus,
Limfangiektasia
- Defesiensi Garam Empedu Kualitatif Atau Kuantitatif
A. Penyakit Hati Kolestatik : Sirosis Bilier Primer,
Kolangitis - Sklerosing, Hepatitis Neonatal
B. Pertumbuhan Bakteri Berlebihan (Bacterial-
Overgrowth) D Usus Halus
- Sindroma Pasca Gastrektomi
- Infeksi : Tbc Usus, Pertumbuhan Bakteri Anaerob-
Berlebihan (Bacterial Overgrowth)
B. TINJA BERDARAH
- PENYAKIT USUS INFLAMATORIK (KOLITIS ULSERATIF,
KOLITIS CROHN)
- KANKER KOLON & POLIP KOLON
- LESI ANAL DLL
- INFEKSI :
* BAKTERI : SHIGELLA,SALMONELLA,
CAMPYLOBACTER,
TUBERKULOSIS KOLON, YERSINIA.
* PARASIT : - PROTOZOA:AMUBA (E.HISTOLYTICA),
GIARDIA LAMBLIA
- INFESTASI CACING : TRICHIURA,
SCHISTOSOMIAMIS
- KOLITIS/PROKTITIS RADIASI
- KOLITIS ISKEMIK KRONIK
- EFEK SAMPING OBAT ANTI BIOTIK : KOLITIS
PSEUDOMEMBRAN
C. TINJA TDK BERDARAH,TDK BERLEMAK /
STEATOREA

1.TINJA CAIR ATAU SEPERTI AIR (WATERY STOOL)

- Kolitis Mikroskopik (Limfositik) & Kolagen
- Intoleransi Laktosa
- Diare Karena Obat : Antibiotika (Mis : Neomisin,
Ampisilin, Klindamisin, Sitostatik)
- Diare Pasca Reseksi Usus Halus : Karena Jamur (Candida),
Bakteri (Pertumbuhan Bakteri Berlebihan, Salmonella Dll),
Parasit (Giardia Lamblia,Cacing Askaris,Cacing Tambang)
- Alergi Makanan
- DEFEK IMUN PRIMER (IMUNODEFESIENSI Siga)
- Penyakit Hirscprung, Volvulus, Malrotasi, Poliposis Dll
- Diare Kolera Pankreatik (Vipoma). Villous Adenoma,
Carcinoma Medulla Tiroid, Ganglioneuroma,
Pheochromocytoma, Tumor Karsinoid.
2. TINJA ENCER/LEMBEK (SEMISOLID)
- Obat Eksogen Seperti Penggunaan Laksans Berlebihan Dan
Makanan/Obat Tertentu (Misal : Prostigmin, Antasida
Mengandung Magnesium Dll)
- Infeksi Usus: Parasit (Misal : Giardiasis, Cacing Tambang Dll)
Bakteri (Salmonella, Campylabacter Jejuni, Yersinia,
Pertumbuhan Bakteri Berlebihan, Tbc Usus) Jamur(candida)
- Infeksi Hiv Dengan Superimposisi Patogen Usus Seperti
Cryptosporidium Dan Isospora Belli
- Gangguan Motilitas :
A. Neuropati Otonom Diabetik
B. Tiroktosikosis Atau Hipertiroid
C. Penyakit Divertikular
D. Skeleroderma
E. Amyloidosis
F. Pasca Reseksi Gaster Atau Vagotomi
- Intoleransi Makanan
- Sindrom Usus Iritatif (Ibs/Psikogen)
- Sindrom Karsinoid
- Malabsorbsi Karbohidrat, Defesiensi Disakaridase
(Laktose, Sukrose), Bahan Makanan Yang Tidak
Diabsorbsi (Wheat Starch, Fiber, Laktulose, Sorbitol,
Fruktose),
- Obat-obat & Pencampur Makanan : Antibiotika, Obat
Antihipertensi, Obat Antiaritmia, Antineoplastik
Antasida (Mengandung Magnesium)
- Pemanis (Sorbitol, Fruktose), Etanol, Kafein
- Insufisiensi Adrenal
- Inkontinensia Fekal
- Alergi Makanan
 DIAGNOSIS
PENDEKATAN DIAGNOSIS E/ DIARE KRONIK
PENDERITA DIARE KRONIK

ANAMNESIS : POLA DIARE, TIPE TINJA, MAKAN OBAT/LAKSAN,

DEMAM/TIDAK, NYERI PERUT/TIDAK, FAKTOR KELUARGA DLL

PEMERIKSAAN FISIK : MALNUTRISI, PUCAT, ANEMIA, MASA TUMOR ABDOMEN,

TANDA SIROSIS HATI, GEJALA EXTRA-INTESTINAL PENYAKIT USUS INFLAMATORIK DLL

PEMERIKSAAN PENUNJANG RUTIN/ SKRINING :

DARAH : HB, HT, LEUKOSIT, TROMBOSIT, HITUNG JENIS LEUKOSIT, GULA DARAH, EUREUM-KREATININ, SGOT-SGPT.
URINE : REDUKSI -PEMERIKSAAN TINJA 3 KALI ; SEL TELUR & PARASIT, DARAH SAMAR,
PHENOLPHTHALEIN (PEMLAKSATIF), KUANTITIF-KUALITATIF LEMAK TINJA

BNO 7&/ PROKTOSIGMODOSCOPY DENGAN BIOPSI

EVALUASI EKSTENSIF TERMASUK PENGUMPULAN TINJA 72 JAM & PUASA (RAWAT),

TERMASUKANALISIS BERAT TINJA, STOOL OSMOLALITY, STOOL’ ELECTROLYTE
CONCENTRATION, STOOL’S OSMOTIC GAP, FLUID BALANCE DLL.

PEMERIKSAAN OMD FOLLOW THROUGH/ENTEROCLYSIS

TOTAL KOLONOSKOPI & ILEOSKOPI + BIOPSI
ENDOSKOPI SCBA TERMASUK USUS HALUS(DUODENO-JEJUNOSKOPI)
+BIOPSI
PEMERIKSAAN FUNGSI USUS DAN PANKREAS, CEA, THIN LAYER
CHROMATOGRAPHY DLL
D-XYLOSE TEST, SCHILLING TEST
H2 BREATH TEST
PABA, STOOL ELASTASE TEST
ERCP, ABDOMINAL CT-SCAN
 DIAGNOSIS

INFEKTIF CAMPURAN NON INFEKTIF

INFLAMASI (IBD), OSMOTIK, SEKRETORIK

PARASIT, BAKTERI, MALABSORPSI ASAM EMPEDU,
JAMUR, VIRUS GANGGUAN MOTILITAS, KOLITIS ISKEMIK,
KOLITIS RADIASI, KEGANASAN DLL.

PEMERIKSAAN TINJA

DIARE BERDARAH
DIARE STEATOREA DIARE TIDAK BERDARAH DAN
TIDAK STEATOREA

PENY. USUS INFLAMATORIK

PENY.PANKREAS,PENY. (IBD), KANKER KOLO-REKTAL EKSOGEN,GIARDIASIS,INFEKSI HIV+
MUKOSA USUS, DEFISIENSI AMEBIASIS USUS, TBC PATOGEN, GANGGUAN MOTILITAS,
GARAM EMPEDU, SINDROM USUS, PARASITE, ENTERO SINDROM USUS IRITABEL (IBS)
PASCA GASTREKTOMI KOLITIS RADIASI/ISKEMIK
PENGOBATAN
1. PENGOBATAN SUPORTIF
- ORAL/ENTERAL
- PARENTERAL
2. PENGOBATAN FARMAKOLOGIK
A.PENGOBATAN SIMTOMATIK
a. REHIDRASI
b. ANTISPASMODIK
c. DEMAM,PARASETAMOL ATAU ANTALGIN
d. OBAT ANTI DIARE :
1. DIPHENOXYLATE,LOPERAMID(R/IMODIUM),
CODEIN HCl/PHOSPHATE
2. OCTREOTIDE9R/SANDOSTATIN)
3. OBAT ANTI DIARE YANG MENGERASKAN
TINJA & ABSORBSI ZAT TOKSIK
d. Obat Anti Diare :
1. DIPHENOXYLATE,LOPERAMID(R/IMODIUM),
CODEIN Hcl/PHOSPHATE
2. Octreotide9r/Sandostatin)
3. Obat Anti Diare Yg Mengeraskan Tinja & Absorbsi Zat
Toksik
E. Anti Emetik
F. Vitamin,mineral
G. Obat Extract Enzim Pankreas
H. Aluminium Hydroxide
I. Phenotiazines Dan Asam Nikotinat
J. Obat Tradisional
B- PENGOBATAN KAUSAL
1. INFEKSI
A. Bakteri
B. Jamur
C. Protozoa
D. Cacing
2. NON-INFEKSI
A. Penyakit Usus Inflamatorik
B. Kolitis Radiasi
C. Kolitis Iskemik
D. Sindrom Usus Iritatif
E. Tumor
F. Hipertiroidi
G. Insufisiensi Pankreas Atau Pankreatitis
Kronik Atau Karsinoma Pankreas Atau
Malabsorbsi Makanan
H. Diare Pada Dm
I. Diare Pada Sirosis Hati
J. Diare Pada Malabsorbsi lemak dan garam empedu
K. Diare Karena OAINS
L. Alergi Makanan
 DIARE
INTRODUCTION

ACUTE DIARRHEA CHRONIC DIARRHEA

Chronik Diarrhea Chronic Diarrhea
continous Remisi , relaps
SELF LIMITING
Common infection
+/- Blood

INFECTION
MALABSORPSI

ISCHEMIC

RADIATION

CANCER
IBS
(Irritable bowel sindrome)

IBD
(Inflammatory Bowel Disease)
IBD : NONSPESIFIC DIFFUSE CHRONIC
INFLAMATION AT INTESTINE WITH
UNDETERMINED ETIOLOGY AND
REMISION OR EXACERBATION
EPISODE

IBD : COLITIS ULCERATIVE

CROHN DISEASE
INDETERMINATE COLITIS (8 – 15)%
 EPIDEMIOLOGY
USA / EUROPE 
USA / INCIDENS : 5 – 15 /100.000 POPULATION
CAUCASIAN > AFRICAN > ASIAN, HISPANIC
JEWS > NON JEWS
JAPANESSE, KOREAN , INDONESIAN DATA (-)

HAM HOSPITAL

YEAR 2005 2006 2007

COLONOSCOPY/ YEAR 280 210 238
IBD (4.63 %) (4,28 %) (4,20 %)
COLITIS ULCERATIVE (4.28 %) (3,33 %) (3,78 %)
CROHN DISEASE (0.35 %) (0,95 %) (0,42 %)
 ETIOLOGY
UNKNOWN

MULTI FACTORIAL :
* GENETIC
* INFECTION
* EMOTION/ PSYCHOLOGICAL
* ENVIRONMENT
* SMOKING
* IMMUNOLOGY
PATOGENESE
 SIGN AND SYMPTOMS
IBD : CHRONIC, RECURRENT, PROGESSIVE DISEASE ( PHASE
REMISSION AND ACUTE ATTACKS )

GENERAL MANIFESTATION, CHRONIC DIARE WITH / WITHOUT

BLOOD, ABDOMINAL PAIN.
NAUSEA LOSS OF APPETITE
GENERAL UNWEIL OPHTHALMO PATHIES
WEIGHT LOSS VOMITING
ARTHRALGIA ABSCESS
FEVER FISTULA
SKIN CHANGES LYMPH NODE SWELLING

COLITIS ULSERATIVE/ ANEMIA, DIARRHEA

CROHN DISEASE/ ABDOMINAL PAIN, WEIGHT LOSS
 IBD LOCALIZATION

CROHNS DS COLITIS ULCERATIVE

LEFT SIDED ( 30 - 40% )
EGD (3-5%) PROCTITIS ( 30 - 40% )
PANCOLITIS ( 10 - 20% )
SMALL INTEST. (25 - 30%)
LARGE INTEST. (30 %)
COLON TRANS
ANORECTAL DS /
Fistula,Fissure,Abcess (30-40%)

SIGMOID

RECTUM
DIAGNOSTIC
 DIAGNOSTIC
GOLD STANDARD :
ANAMNESIS
Diarrhea
Blood ABDOMINAL PAIN, WEIGHT
Abdominal pain
LOSS, ANEMIA, DIARRHEA,
FEVER,LED 
acut-remisi-kronik-eksaserbasi
IMAGING ( SMALL BOWEL X
RAY, CT SCAN ABDOMEN,
CLINIS
Intensif GASTROSCOPY,
Ekstra intestinal COLONOSCOPY WITH
ILEOSCOPY )
LABORATORIES
Eksklusi
Gambaran keadaan umum

ENDOSCOPI

PATOLOGI
Yang sesuai

RADIOLOGI
Yang menyokong

PERJALANAN KLINIK
THE SEVERITY OF IBD
COLITIS ULCERATIVE : TRUELOVE CLASIFICATION

MILD MODERATE SEVERE

STOOL FREQUENCY <4X >6X > 10X

BLEEDING SLIGHT PROFUSE CONTINUOUS

FEVER (-) > 37,5 > 38,8

HEMOGLOBLIN > 10G/DL < 10 G/DL < 8 G/DL

BSR < 30 MM > 30 MM > 50 MM

ALBUMIN NORMAL 3 – 4 G/DL < 3 GR/DL

 CALCULATION OF THE CROHN’S DISEASE ACTIVITY INDEX (CDAI)

VARIABLE RANGE OF WEIGHT

VALUES
1 Liquid or soft stools summed 0-70 2
over 7 days
2 Daily abdominal pain ratings 0-21 6
summed over 7 days
3 General well-being ratings 0-28 6
summed over 7 days
4 Number of extraintestinal 0-3 30
manifestations
5 Use of opiates for diarrhea 0-1 4

6 Abdominal mass 0-5 10

7 47-Hematocrit (males) -- 6
42-Hematocrit (famales)
8 Percent of body weight -- 1
below standard

CDAI = THE SUM OF EACH VARIABLE MULTIPLIED BY ITS WEIGHT

DIFFERENTIAL DIAGNOSTIC

INFECTION NON INFECTION

-BACTERIAL INFECTION : - PSEUDOMEMBRANOUS

CAMPYLOBACTER, YERSINIA COLITIS
ENTEROCOLITIS, - ISCHEMIC COLITIS
SALMONELLA, SHIGELLA, - RADIATION – INDUCED
TUBERCULOSIS COLITIA
- DIVERTICULITIS
-VIRAL DYSENTERY - BECHECT’S DISEASE
- EOSINOPHILIC
-PARASITIC INFECTION : GASTROENTERITIS
AMEBA, SCHISTOSOMA - SCLERODERMIA
- DRUG-INDUCED COLITIS
 MANAGEMENT
MULTIDIMENTION CARE
NUTRITION
PSYCHOSOSIAL
CONTROL OF BOWEL DISORDERS (INTRALUMEN) AND
(EXTRALUMEN)

MEDICAMENTOSA
AMINOSALICYLATE : Sulfasalazine, 5-ASA (Mesalamine)
ANTIBIOTIC : Metronidazole,Cyprofloksasin
IMMUNOSUPPRESSAN : Azathiopirine,MTX
PROBIOTIC
ANTI TNF-, INFLIXIMAB

SURGICAL TREATMENT
 MEDICAMENTOSA

DRUG NAME POSOLOGI DAILY INDICATION

DOSE
5-ASA Supositoria 3x500 mg DISTAL CU/PROCTITIS

5-ASA Supositoria 3x250 mg MAINTAINANCE DISTAL CU

5-ASA Enema 1-4 g LEFT SIDE CU TH

5-ASA Tablet 2-4 g PANCOLITIS CU TH

5-ASA Tablet 1-1,5 g MAINTAINANCE DOSE CU

Sulfasalazin Tablet 3g PANCOLITIS CU TH

Sulfasalazin Tablet 1-2 g MAINTAINANCE DOSE CU

 DRUG NAME POSOLOGI DAILY DOSE INDICATION

Budesonid Enema/Oral 2 mg DISTAL CU/PROCTITIS TH

Hidrokortison Foam 100-200 mg DISTAL CU/PROCTITIS TH
Glukortikoid Oral 40-100 mg Pan Colitis CU and PC
(equivalen (MILD-MODERATE) TH
prednisolon)
Glucokortikoid IV 1 mg/kg CU AND SEVERE PC
(equivalen
prednisolon)
Cyklosporin IV 1 mg/kg CU AND SEVERE PC
Cyklosporin IV 2,5-4 mg/kg REFRACTER CU AND PC
Azathioprin IV 2,5-4 mg/kg REFRACTER CU AND PC
6Mercaptopurin IV 1-2 mg/kg REFRACTER CU AND PC

Metotraksat Im 25 mg/mgg PC
 PRINCIPLE THERAPHY FOR IBD
COLITIS ULCERATIVE CROHN DS

MILD AND MODERATE MILD AND MODERATE

5-ASA/SASP Oral Steroid/Topical±5-ASA
Oral or rectal DUE TO BOWEL
INVOLVEMENT

SEVERE SEVERE
Steroid IV continue with Steroid Steroid IV tappering dose to oral ± 5-
Oral/Local+5-ASA ASA

FAILED FAILED
Second line drug or surgical Second line drug or surgical

National Consensus Management of IBD

 COMPLICATION

CROHN DISEASE ULCERATIVE COLITIS

FISTULA TOXIC MEGACOLON

ABCESS BLEEDING
TUMOR PERFORATION
STRICTURE CARCINOMA
CARCINOMA
 POSSIBLE COURSES OF IBD

PRIMARY ATTACK

WRONG REMISSION CHRONIC CARCINOMA

DIAGNOSIS ACTIVITY
(“SELF-LIMITING”)

RELAPSE
 PROGNOSTIC
DEPEND ON:

 FIRST ATTACK
BABY AGED, > 60 YEARS PROGNOSA  MALAM
 WIDE OF LESION,
MINIMAL ,LOCALIZED  BONAM
DIFFUSE, OVERALL  MALAM
 COMPLICATION +/-
 RESPONS FOR THE TREATMENT
CONCLUSION :

 The prevalence IBD in Asia is lower than

European Countries / US.
 IBD are diseases with unknown aetiology
 IBD are precipitated by interaction of
genetic, enviroment &immunoregulatory
factor
 The diagnosis based on clinical evaluation,
imaging, endoscopic and histological
 5 ASA the first line therapy for IBD.
THANK
YOU