DIARRHOEA
( 1 )( 1 )
DIARRHOEA
VOLUME OF WATER IN
THE STOOLS ↑↑
LOOSE WATERY
WATER
HYPERSECRETION
PERISTALSIS
AREA FOR
ABSORPTION
MALABSORPTION
ABSORPTION
MALDIGESTION
HYPEROSMOLAR
DIARRHOEA
- FREQ. ≥ 3 X /DAY
- CHANGING OF CONSISTENCY
- WITH/ WITHOUT VOMITING
- WITH/WITHOUT BLOODY STOOL
DYSENTERY SEVEREACUTE WATERY
DIARRHOEA
DYSENTERY
FORMPERSISTENT
SEVERE
MALNUTRITION
< 14 DAYSBLOODY
DIARRHOEA> 14 DAYS
BABIES FED ONLY BREAST MILK OFTEN BABIES FED ONLY BREAST MILK OFTEN
FREQUENT PASSING OF FORMED STOOLS FREQUENT PASSING OF FORMED STOOLS
( 5( 5--6 x / DAY ) 6 x / DAY ) ( 5( 5--6 x / DAY ) 6 x / DAY )
THIS ALSO NOT DIARRHOEATHIS ALSO NOT DIARRHOEA
INFLAMMATION
INFECTION - VIRAL
- FUNGAL
- BAKTERIA
- PARASITE
- ALLERGYDIARRHOEA
NONINFLAMMATION
NON INFECTION - ALLERGY
- etc
- HORMONAL
- ANATOMICAL
- etc
VIRAL DIARRHOEA
1. ROTAVIRUS ==> 6 MONTHS to 2.5 YEARS
2. NORWALK VIRUS
3. ENTERIC ADENOVIRUS
4. ASTROVIRUS
5. CALICI VIRUS5. CALICI VIRUS
6. CORONA VIRUS
7. SMALL ROUND VIRUS
- PARVOVIRUS LIKE AGENT
- MINI ROTAVIRUS
- MINI REOVIRUS
PRACTICALITY
• LIQUID STOOLS ≥ 3x/DAY,
• WITH/WITHOUT VOMITING,
• WITH/WITHOUT
MUCOUS/BLOOD
CLASSIFICATION
1. AGE
2. ONSET
3. ETIOLOGY
4. SEVERITY
5. PATHOGENESIS5. PATHOGENESIS
6. HOST DEFENSE
7. SOURCE OF INFECTION
8. EPIDEMIOLOGY
9. SITE OF PATHOLOGY
10.WHO (2005)
1.AGE
-NEONATAL DIARRHOEA : DIARRHOEA IN
NEONATES
-INFANTILE DIARRHOEA : DIARRHOEA IN
INFANTS
-CHILDHOOD DIARRHOEA : DIARRHOEA IN
CHILDREN2. ONSET
-ACUTE DIARRHOEA : < 7 DAYS (90-95%)
- PROLONGED DIARRHOEA : 7-14 DAYS
- CHRONIC DIARRHOEA : > 14 DAYS
-RADANG : INFEKSI / NON INFEKSI
-NON RADANG
3. ETIOLOGY
-INFLAMMATION : INFECTION /
NON INFECTION
-NONINFLAMMATION
4. SEVERITY ( WHO, 1984)
-MILD DIARRHOEA : ≤ 1x / 2 hours or ≤ 5 mL / KgBW / hour
-SEVERE DIARRHOEA : > 1x / 2 hours or > 5mL/KgBW/hour
5.HOST DEFENSE
-IMMUNOCOMPETENT
-IMMUNOCOMPROMISED :AIDS, LEUKEMIA, etc.-IMMUNOCOMPROMISED :AIDS, LEUKEMIA, etc.
6. SOURCE OF INFECTION
-NOSOCOMIAL : INFECTION IN HOSPITAL
-COMMUNITY
7. PATHOGENESIS
ABSORPTIVE/OSMOTIC SECRETORY
1. FASTING STOPS CONTINUES
2. STOOLS OSM. 400 280
3. Na + 30 1003. Na 30 100
4. K+ 30 40
5. (Na+K)x 2 120 280
6. SOLUTE GAP 280 0
8. EPIDEMIOLOGY
-ENDEMIC : PRESENT AT ALL TIMES
-EPIDEMIC : OUTBREAK
-MIXED
9. SITE OF PATHOLOGY
-SMALL INTESTINAL: CHOLERA, ETEC,
ROTAVIRUS & G. LAMBLIA
DIARRHOEA
-LARGE INTESTINAL: SHIGELLOSIS, AMOEBIASIS
-BOTH : CAMPYLOBACTERIOSIS,
SALMONELLOSIS
10. WHO (2005)
-ACUTE DIARRHOEA
-PERSISTENT DIARRHOEA
-DYSENTERY FORM
-DIARRHOEA WITH SEVERE
MALNUTRITION
MICROORGANISMS
GASTRIC ACID
MULTIPLICATION
COLONIZATION
ADHERENT
- INVASION
- DAMAGE
ENTEROTOXIN
MALABSORPTIONHYPERSECRETION
HYPERPERISTALSIS
DIARRHOEA
PATHOGENESIS OF ACUTE INFECTIOUS DIARRHOEA
COLONIC SALVAGE
DIARRHOEA
Cleansing Effect• Pathogens
Defense
Loss Of• Water & Electrolytes• Nutrients
Defense
Self LimitedSelf Limited
•••• Water & Electrolytes
•••• Diets
•••• Water & Electrolytes
•••• Diets
• Dehydration
• Hypoglycemia
Starvation
Malnutrition
D
I
A
R
R
WATER DEHYDRATION
BASE ASIDOSIS METABOLIC
ELEKTROLIT Na+ ==> � atau �
K+ ==> �
Ca2+ ==> �
Mg2+ ==> �
Zn ==> ACRODERMATITIS ENTEROPATHICA
ELEKTROLYTES Na+ � or �
K+ �
Ca2+ � ==> TETANY
Mg2+ � ==> TETANY
Zn � ==>ACRODERMATITIS ENTEROPATHICA
R
H
O
E
A
NUTRIENTS - HYPOGLYCEMIA
- STARVATION
- PCM
MUCOSAL
INJURY
- MALABSORPTION
- PROTEIN LOSING ENTEROPATHY
- SENSITIZATION
- NECROTIZING ENTEROCOLITIS
TETANY
HYPOCALCEMIC
HYPOMAGNESEMICTETANY HYPOMAGNESEMIC
ALKALOTIC
LOSS OF WATER VIA STOOLS
DEHYDRATION
PLASMA WATER
FEVER HEMOCONCENTRATION HYPOVOLEMIAFEVER HEMOCONCENTRATION HYPOVOLEMIA
SHOCK RBF* SYMPATH. DISCHARGE
- HEART RATE
- VASOCONSTRICTIONCOMA ARF**
* Renal Blood Flow** Acute Renal Failure
SIGNS OF DEHYDRATION
1.1. LETHARGIC TO LETHARGIC TO COMATOSECOMATOSE
2.2. SUNKEN SUNKEN ANTERIOR ANTERIOR FONTANELLAFONTANELLA
7.7. WEAKNESS OF WEAKNESS OF RADIAL PULSERADIAL PULSE
8.8. HYPOTENSIONHYPOTENSION
9.9. THIRSTYTHIRSTY
↓↓↓↓↓↓↓↓↓↓↓↓↓↓↓↓FONTANELLAFONTANELLA3.3. SUNKEN EYESSUNKEN EYES4.4. ABSENT OF ABSENT OF
TEARSTEARS5.5. DRY OF MOUTH & DRY OF MOUTH &
TONGUETONGUE
6.6. HR HR ↑↑↑↑↑↑↑↑
10.10. TURGORTURGOR↓↓↓↓↓↓↓↓↓↓↓↓↓↓↓↓11.11. OLIGURIA/ANURIAOLIGURIA/ANURIA
12.12. BW BW ↓↓↓↓↓↓↓↓↓↓↓↓↓↓↓↓
DEHYDRATION
VOLUME PLASMA SODIUM
• SOME DEHYDRATION
= 5 - 10 % BB
• SEVERE DEHYDRATION
= > 10% BB
• ISONATREMIA
= 135 - 150 mEq/L
• HYPO/HYPER
NATREMIA
THE OBJECTIVES OF TREATMENT ACUTE DIARRHOEA
DEHYDRATION PROTEIN CALORY MALNUTRITION
PREVENTION TREAT
DURATION, SEVERITY,
EPISODES
WATER & ELECTROLYTES FEEDING ZINC
MANAGEMENT
ASSESSMENT TREATMENT
1. Degree of 1. Water & electrolytes1. Degree of
Dehydration
2. Associated :
• Malnutrition
• Pneumonia
• etc
1. Water & electrolytes
2. Diets
3. Drugs
- Zinc
- antimicrobial
- Symptomatic
- antidiarrhoeal
NO SIGN OF NO SIGN OF
DEHYDRATIONDEHYDRATION
SOME SOME
DEHYDRATIONDEHYDRATION
SEVERE SEVERE
DEHYDRATIONDEHYDRATION
CONDITION CONDITION WELL, ALERTWELL, ALERT RESTLESS / RESTLESS /
IRRITABLEIRRITABLE
LETHARGIC, LETHARGIC,
FLOPPY, COMAFLOPPY, COMA
EYESEYES NORMALNORMAL SUNKENSUNKEN SUNKEN SUNKEN
DEGREE OF DEHYDRATION (WHO,2005)
THIRSTTHIRST NORMALLY, NOT NORMALLY, NOT
THIRSTYTHIRSTY
THIRSTY, DRINK THIRSTY, DRINK
EAGERLYEAGERLY
DRINKS POORLYDRINKS POORLY
SKIN TURGOR SKIN TURGOR QUICKLYQUICKLY SLOWLYSLOWLY VERY SLOWLYVERY SLOWLY
NB : 1. READING FROM RIGHT TO LEFT
2. CONSIDERED SEVERE OR SOME DEHYDRATION IF TWO OR
MORE OF THE SIGN ARE PRESENT
FLUIDS TREATMENT
REHYDRATION MAINTENANCE
INITIAL REPLETION NORMAL + ABNORMALINITIAL REPLETION NORMAL + ABNORMAL
HOLLIDAY –
SEGAR
CHOLERA
COT
HOLLIDAY - SEGAR≤ 10 kg 100 mL / kg
10 - 20 kg 1000 mL + 50 mL/ kg
for each > 10 kg
> 20 kg 1500 mL + 20 mL/ kg> 20 kg 1500 mL + 20 mL/ kg
for each > 20 kg
NB : 100 mL ≡ 2,5 mEq Na+
≡ 2 mEq K+
≡ 100 calori
REHYDRATION
ORAL I.V.
• RINGER’S LACTATE
ORS*
• RINGER’S LACTATE
• RINGER’S ACETATE(ORALIT@)
* Oral Rehydration Salts
PREVIOUS STANDARD WHO
ORAL REHYDRATION SALTS
(ORS)
1. ISOTONIC
2. Na+ equivalent with plasma (90 mEq/l)
3. GLUCOSE = 2 - 3%
4. K+ (higher than plasma →→→→ 20 mEq/l)
5. BASE = 30 - 48 mEq/L
Na+
2K+ENTEROCYTES
LUMEN• CHO
• Peptide
• Amino Acid
Na+
water
LAMINA
PROPRIA
BASEMENT
MEMBRANE
3Na+
BLOOD VESSELS
ORAL REHYDRATION SALTS
(WHO)
PREVIOUS
(mmol/L)
NEW
(mmol/L)
Na 90 75
K 20 20
Cl 80 65
Citrat 10 10
Glucose 111 75
311 245
NEW (LOW OSMOLARITY) WHO
ORAL REHYDRATION SALTS
�� STOOL OUTPUT STOOL OUTPUT ↓↓↓↓↓↓↓↓↓↓↓↓↓↓↓↓ = 20%= 20%
�� VOMITING VOMITING ↓↓↓↓↓↓↓↓↓↓↓↓↓↓↓↓ = 30%= 30%�� VOMITING VOMITING ↓↓↓↓↓↓↓↓↓↓↓↓↓↓↓↓ = 30%= 30%
�� THE NEED FOR SUPPLEMENTAL I.V THE NEED FOR SUPPLEMENTAL I.V
FLUID FLUID ↓↓↓↓↓↓↓↓↓↓↓↓↓↓↓↓ = 33%= 33%
BOWEL LUMEN BLOOD VESSELS
SUGAR SOLUTION
SALT SOLUTION
ORS SOLUTION
DIARRHOEA
INDICATION OF I.V FLUIDS
1. SEVERE DEHYDRATION
WITH/WITHOUT SHOCK
2. SEVERE DIARRHOEA
3. INTAKE BY MOUTH ↓↓↓↓↓↓↓↓
4. GLUCOSE MALABSORPTION4. GLUCOSE MALABSORPTION
5. ABDOMINAL DISTENSION /
PARALYTIC OBSTR.
6. OLIGURIA / ANURIA FOR
SEVERAL HOURS
DEHYDRATION
NO SIGN OF SOME SEVERE
> 10%< 5% 5 - 10% > 10%
A B C
A. NO SIGN OF DEHYDRATION
1. ORALIT
• < 2 years = 50 - 100 mL / X loose stool
• ≥ 2 years = 100 - 200 mL / X loose stool
2. GIVE THE CHILD MORE FLUIDS & 2. GIVE THE CHILD MORE FLUIDS &
FOODS THAN USUAL
↓↓↓↓
PREVENTION OF DEHYDRATION
3. GIVE SUPPLEMENTAL ZINC (10-20mg/day)
FOR 10 – 14 DAYS
B. SOME DEHYDRATION
ORALIT →→→→ 75 mL/kg BW /3 or 4
hours
INDICATIONINDICATION
• Ringer’s Lactate
• Ringer’s Acetate
C. SEVERE DEHYDRATION
100 mL/ kgBW/3-6 hours
• < 1 year →→→→ * initial = 30 mL/kgBW/ 1
hour
* repletion= 70 mL/kgBW/5* repletion= 70 mL/kgBW/5
hours
• > 1 years→→→→* initial = 30 mL/kgBW/ ½
hours
* repletion = 70 mL/kgBW/2½
hours
ORALIT
• PREVENTION
• TREATMENT• TREATMENT
• MAINTENANCE
DEHYDRATION DIARRHOEA
DIARRHOEA
REHYDRATION
ANURIA/OLIGURIA ADEQUATE
URINE *
RENAL
FAILURE
PHYSIOLOGIC
OLIGURIA
NO
PROBLEM
FLUIDS ↓↓↓↓ FLUIDS ↑↑↑↑↑↑↑↑
NB : 1. * 1 mL / kg BW / hour
2. Oliguria : < 400 mL / m2 / day
Renal Renal
FailureFailure
Physiologic Physiologic
OliguriaOliguria
LasixLasix@@ diuresis (diuresis (--)) diuresis (+)diuresis (+)
LaboratoryLaboratory
�� Urine osmolality Urine osmolality
(mOsm/kgH(mOsm/kgH O)O)
<350<350 >500>500
(mOsm/kgH(mOsm/kgH22O)O)
�� NaNa++ urine (mEq/l)urine (mEq/l) > 40> 40 <20<20
�� Fr. excr of NaFr. excr of Na+ + >1%>1% <1%<1%
100%plasma .urine/Cr .Cr
plasmaurine/Na Na×=
++Fractional Excretion of
Na+
FEEDING
1. AFTER REHYDRATION
2. < 4 MONTHS
- BREASTMILK (+)
- BREASTMILK (-) ==> ????
3. > 4 MONTHS3. > 4 MONTHS
- BREASTMILK
- RICE PORRIDGE
- BANANAS
- FISHES
- “TAHU, TEMPE”
- FORMULA MILK � STOP
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