diarrhea is loosely defined as passage of abnormally liquid or unformed stools at an increased...

8/9/2019 Diarrhea is Loosely Defined as Passage of Abnormally Liquid or Unformed Stools at an Increased Frequency

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Diarrhea is loosely defined as passage of abnormally liquid or unformed stools at an

increased frequency. For adults on a typical Western diet, stool weight >200 g/d can

generally be considered diarrheal.Diarrhea may be further defined as acute if 2

wee!s, persistent if 2"# wee!s, and chronic if ># wee!s in duration.$wo common

conditions, usually associated with the passage of stool totaling 200 g/d, must bedistinguished from diarrhea, as diagnostic and therapeutic algorithms differ.

Diare longgar didefinisi!an sebagai bagian dari abnormal cairan atau berbentu!

bang!u di pening!atan fre!uensi. %ntu! orang dewasa pada !has &arat diet, berat

feses> 200 g / d secara umum dapat dianggap diare.Diare dapat lebih didefinisi!an

sebagai a!ut 'i!a 2 minggu, terus(menerus 'i!a 2(# minggu, dan !ronis 'i!a> #

minggu dalam durasi.Dua !ondisi umum, biasanya berhubungan dengan berlalunya

tin'a total 200 g / d, harus dibeda!an dari diare, diagnostic dan algoritma terapi

berbeda

)*%$+ D)--+)

ore than 01 of cases of acute diarrhea are caused by infectious agents these

cases are often accompanied by 3omiting, fe3er, and abdominal pain. $he

remaining 401 or so are caused by medications,to5ic ingestions, ischemia, and

other conditions.nfectious )gents ost infectious diarrheas are acquired by fecal(

oral transmission or, more commonly, 3ia ingestion of food or water contaminated

with pathogens from human or animal feces. n the immunocompetent person, theresident fecal microflora, containing >600 ta5onomically distinct species, are rarely

the source of diarrhea and may actually play a role in suppressing the growth of

ingested pathogens.Disturbances of flora by antibiotics can lead to diarrhea by

reducing the digesti3e function or by allowing the o3ergrowth of pathogens, such as

*lostridium difficile 7*hap. 4289. )cute infection or in'ury occurs when the ingested

agent o3erwhelms the host:s mucosal immune and nonimmune 7gastric acid,

digesti3e en;ymes, mucus secretion, peristalsis, and suppressi3e resident flora9

defenses. +stablished clinical associations.with specific enteropathogens may offer

diagnostic clues.n the %nited


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lebih disebab!an oleh obat(obatan, ingestions beracun, is!emia, dan !ondisi

lainnya. )gen infe!si diare ebanya!an infe!si diperoleh oleh fecal(oral transmisi

atau, lebih umum, melalui !onsumsi ma!anan atau air yang ter!ontaminasi dengan

patogen dari !otoran manusia atau hewan. Dalam imuno!ompeten yang orang,

mi!roflora tin'a pendudu!, mengandung> 600 ta!sonomi spesies yang berbeda, 'arang sumber diare dan mung!in sebenarnya berperan dalam mene!an

pertumbuhan patogen ditelan. @angguan flora dengan antibioti! dapat

menyebab!an diare dengan mengurangi fungsi pencernaan atau dengan

memung!in!an pertumbuhan berlebih dari patogen, seperti *lostridium difficile

7&ab. 4289. nfe!si a!ut atau cedera ter'adi !eti!a agen tertelan menguasai mu!osa

host !e!ebalan tubuh dan nonimmune 7asam lambung, en;im pencernaan, se!resi

lendir, peristalti!, dan Flora pendudu! pene!an9 pertahanan. )sosiasi !linis

Didiri!an dengan enteropatogen tertentu mung!in menawar!an petun'u! diagnosti!.

Di )meri!a #E h without

impro3ement, recent antibiotic use, new community outbrea!s, associated se3ere

abdominal pain in patients >60 years, and elderly 7G0 years9 or

immunocompromised patients. n some cases of moderately se3ere febrile diarrhea

associated with fecal leu!ocytes 7or increased fecal le3els of the leu!ocyte proteins9

or with gross blood, a diagnostic e3aluation might be a3oided in fa3or of anempirical antibiotic trial 7see below9. $he cornerstone of diagnosis in those

suspected of se3ere acute infectious diarrhea is microbiologic analysis of the stool.

Wor!up includes cultures for bacterial and 3iral pathogens, direct inspection for o3a

and parasites, and immunoassays for certain bacterial to5ins 7*. difficile9, 3iral

antigens 7rota3irus9, and proto;oal antigens 7@iardia, +. histolytica9. olecular

diagnosis of pathogens in stool can be made by identification of unique DC)

sequences and e3ol3ing microarray technologies could lead to a more rapid,

sensiti3e, specific, and cost(effecti3e diagnostic approach in the future. Aersistent

diarrhea is commonly due to @iardia 7*hap. 2029, but additional causati3e

organisms that should be considered include *. difficile 7especially if antibiotics had


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been administered9, +. histolytica, *ryptosporidium, *ampylobacter, and others. f

stool studies are unre3ealing, then fle5ible sigmoidoscopy with biopsies and upper

endoscopy with duodenal aspirates and biopsies may be indicated. &rainerd

diarrhea is an increasingly recogni;ed entity characteri;ed by an abrupt(onset

diarrhea that persists for at least # wee!s, but may last 4"8 years, and is thought tobe of infectious origin. t may be associated with subtle inflammation of the distal

small intestine or pro5imal colon. 60 tahun, dan

lansia 7G0 tahun9 atau immunocompromised pasien. Dalam beberapa !asus diare

demam dari cu!up parah ter!ait dengan leu!osit fecal 7atau pening!atan !adar

!otoran dari protein leu!osit9 atau dengan darah !otor, e3aluasi diagnosti! mung!in

dihindari mendu!ung percobaan antibioti! empiris 7lihat di bawah9. ?andasandiagnosis mere!a yang dicurigai a!ut diare menular adalah analisis mi!robiologis

dari tin'a. &e!er'a termasu! budaya untu! patogen ba!teri dan 3irus, inspe!si

langsung untu! telur dan parasit, dan immunoassay untu! ba!teri tertentu racun 7*.

difficile9, antigen 3irus 7rota3irus9, dan antigen proto;oa 7@iardia, +. histolytica9.

Diagnosis mole!uler patogen dalam tin'a dapat dila!u!an dengan identifi!asi urutan

DC) yang uni! dan ber!embang microarray te!nologi dapat menyebab!an lebih

cepat, sensitif, spesifi!, dan Aende!atan diagnosti! hemat biaya di masa depan.

Diare persisten umumnya disebab!an @iardia 7&ab. 2029, tetapi organisme

penyebab tambahan yang harus dipertimbang!an termasu! *. difficile 7terutama

'i!a antibioti! telah diberi!an9, +. histolytica, *ryptosporidium, *ampylobacter, danlain(lain. Hi!a penelitian tin'a yang unre3ealing, sigmoidos!opi !emudian fle!sibel

dengan biopsi dan endos!opi atas dengan aspirasi duodenum dan biopsi dapat

diindi!asi!an. &rainerd diare adalah entitas sema!in dia!ui ditandai dengan diare

mendada!(onset yang berlangsung selama setida!nya # minggu, namun dapat

berlangsung 4(8 tahun, dan dianggap berasal dari infe!si. ni mung!in ter!ait

dengan peradangan halus distal usus !ecil atau usus pro!simal. Aemeri!saan

stru!tural dengan sigmoidos!opi, !olonos!opi, atau perut *$ scan 7atau

pende!atan pencitraan lainnya9 mung!in tepat pada pasien dengan diare persisten

uncharacteri;ed untu! mengecuali!an &D, atau sebagai pende!atan awal pada


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pasien yang dicurigai diare a!ut menular seperti mung!in disebab!an oleh is!emi!

!olitis, di3erticulitis, atau obstru!si parsial usus.

)cute diarrhea is defined as the abrupt onset of 8 or more loose stools per day. $he

augmented water content in the stools 7abo3e the normal 3alue of appro5imately 40

m?/!g/d in the infant and young child, or 200 g/d in the teenager and adult9 is due to

an imbalance in the physiology of the small and large intestinal processes in3ol3ed

in the absorption of ions, organic substrates, and thus water. ) common disorder in

its acute form, diarrhea has many causes and may be mild to se3ere.

*hildhood acute diarrhea is usually caused by infection of the small and/or large

intestine howe3er, numerous disorders may result in diarrhea, including a

malabsorption syndrome and 3arious enteropathies. )cute(onset diarrhea is usually

self(limited howe3er, an acute infection can ha3e a protracted course. &y far, themost common complication of acute diarrhea is dehydration.

)lthough the term Iacute gastroenteritisI is commonly used synonymously with

Iacute diarrhea,I the former term is a misnomer. $he term gastroenteritis implies

inflammation of both the stomach and the small intestine, whereas, in reality, gastric

in3ol3ement is rarely if e3er seen in acute diarrhea 7including diarrhea with an

infectious origin9 in addition, enteritis is also not consistently present. +5amples of

infectious acute diarrhea syndromes that do not cause enteritis include Jibrio

cholerae" induced diarrhea and


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state of acti3e secretion. $he most common cause of acute(onset secretory

diarrhea is a bacterial infection of the gut.


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watery diarrhea secondary to small bowel hypersecretion occurs with ingestion of

preformed bacterial to5ins, enteroto5in(producing bacteria,and enteroadherent

pathogens. Diarrhea associated with mar!ed 3omiting and minimal or no fe3er may

occur abruptly within a few hours after ingestion of the former two types 3omiting is

usually less, and abdominal cramping or bloating is greater fe3er is higher with thelatter. *ytoto5in( producing and in3asi3e microorganisms all cause high fe3er and

abdominal pain. n3asi3e bacteria and +ntamoeba histolytica often cause bloody

diarrhea 7referred to as dysentery9. Qersinia in3ades the terminal ileal and pro5imal

colon mucosa and may cause especially se3ere abdominal pain with tenderness

mimic!ing acute appendicitis. Finally, infectious diarrhea may be associated with

systemic manifestations. -eiter:s syndrome 7arthritis, urethritis, and con'uncti3itis9

may accompany or follow infections by


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demam dapat ter'adi tiba(tiba dalam beberapa 'am setelah !onsumsi dari mantan

dua 'enis muntah biasanya !urang, dan !ram perut atau !embung adalah lebih

besar demam lebih tinggi dengan yang !edua. *ytoto5in( memprodu!si dan

mi!roorganisme in3asi3e semua menyebab!an demam tinggi dan perut rasa sa!it.

&a!teri in3asif dan +ntamoeba histolytica sering menyebab!an diare berdarah7disebut sebagai disentri9. Qersinia menyerang terminal ileum dan !olon pro!simal

mu!osa dan mung!in menyebab!an sa!it perut sangat parah dengan !elembutan

meniru apendisitis a!ut. )!hirnya, diare infe!si mung!in ter!ait dengan manifestasi

sistemi!. -eiter


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agents such as loperamide can be useful ad'uncts to control symptoms. # wee!s warrants e3aluation to e5clude serious underlying

pathology. n contrast to acute diarrhea, most of the causes of chronic diarrhea are

noninfectious. $he classification of chronic diarrhea by pathophysiologic mechanism

facilitates a rational approach to management, though many diseases cause

diarrhea by more than one mechanism 7$able #0(89.


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penyebab utama !ematian. Aasien mendalam dehidrasi, terutama bayi dan orang

tua, membutuh!an J rehidrasi. Dalam nonfebrile cu!up parah dan diare tida!

berdarah, )ntimotility dan agen antise!resi seperti loperamide dapat tambahan

yang berguna untu! mengendali!an ge'ala. )gen tersebut harus dihindari dengan

disentri demam, yang dapat diperburu! atau ber!epan'angan oleh mere!a. bismuthsubsalicylate dapat mengurangi ge'ala muntah dan diare, tetapi tida! boleh

diguna!an untu! mengobati pasien immunocompromised atau mere!a dengan

gangguan gin'al !arena dari risi!o bismuth ensefalopati. &i'a!sana penggunaan

antibioti! yang tepat dalam !asus yang dipilih a!ut diare dan dapat mengurangi

!eparahan dan durasi 7@br. #0(29. banya! do!ter mengobati pasien sedang sampai

berat dengan demam disentri empiris tanpa e3aluasi diagnosti! mengguna!an

!uinolon, misalnya ciproflo5acin 7600 mg bid selama 8(6 d9. Aengobatan empiris

'uga dapat dianggap !arena dicurigai giardiasis dengan metronida;ole 7260 mg qid

selama G d9. sele!si antibioti! dan re'imen dosis sebali!nya ditentu!an oleh spesifi!

patogen, pola geografis perlawanan, dan !ondisi yang ditemu!an 7&ab. 422, 4#8,

dan 4#R(4629. *a!upan antibioti! diindi!asi!an apa!ah atau tida! organisme

penyebab ditemu!an pada pasien yang immunocompromised, memili!i !atup

'antung me!anis atau cang!o! 3as!ular baru(baru ini, atau sudah berusia lan'ut.

)ntibioti! profila!sis diindi!asi!an untu! pasien tertentu bepergian !e negara(

negara berisi!o tinggi di antaranya !emung!inan atau !eseriusan diare diperoleh

a!an sangat tinggi, termasu! mere!a yang immunocompromise, &D,

hemochromatosis, atau achlorhydria lambung. Aenggunaan trimetoprim /

sulfametho5a;ole, ciproflo5acin, atau rifa5imin dapat mengurangi diare ba!teri

dalam wisatawan tersebut dengan 01, mes!ipun rifa5imin mung!in tida! coco!untu! in3asi3e penya!it. )!hirnya, do!ter harus waspada untu! mengidentifi!asi

apa!ah wabah diare Aenya!it ini ter'adi dan mengingat!an otoritas !esehatan

masyara!at segera. al ini dapat mengurangi u!uran utama dari pendudu! yang

ter!ena bencana.

D)-+ -BC<

Diare berlangsung> # minggu waran e3aluasi untu! mengecuali!an serius yang

mendasari patologi. &erbeda dengan diare a!ut, sebagian besar penyebab diare

!ronis yang tida! menular. lasifi!asi diare !ronis dengan me!anisme patofisiologis

memfasilitasi pende!atan rasional untu! mana'emen, mes!ipun banya! penya!it

menyebab!an diare lebih dari satu e!anisme 7$abel #0(89. Aenyebab diare

se!retori se!retori! disebab!an oleh ter'adinya penurunan cairan dan transportasi

ele!trolit di mu!osa enterocolonic. mere!a adalah ditandai secara !linis oleh berair,

ber3olume besar output fecal yang biasanya tanpa rasa sa!it dan bertahan dengan

puasa. arena tida! ada malab(diserap ;at terlarut, tin'a osmolalitas dicatat oleh

endogen yang normal ele!trolit tanpa !esen'angan osmoti! tin'a.


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Diarrhea

Diarrhea results from rapid mo3ement of fecal matter through the large intestine.


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refle5 passing from the rectum to the conus medullaris of the spinal cord and then

bac! to the descending colon, sigmoid, rectum, and anus. When the spinal cord is

in'ured somewhere between the conus medullaris and the brain, the 3oluntary

portion of the defecation act is bloc!ed while the basic cord refle5 for defecation is

still intact. Ce3ertheless, loss of the 3oluntary aid to defecationTthat is, loss of theincreased abdominal pressure and rela5ation of the 3oluntary anal sphincterToften

ma!es defecation a difficult process in the person with this type of upper cord in'ury.

&ut, because the cord defecation refle5 can still occur, a small enema to e5cite

action of this cord refle5, usually gi3en in the morning shortly after a meal, can often

cause adequate defecation. n this way, people with spinal cord in'uries that do not

destroy the conus medullaris of the spinal cord can usually control their bowel

mo3ements each day.

diare

asil diare dari gera!an cepat tin'a melalui usus besar. &eberapa penyebab diare

dengan ge'ala sisa fisiologis penting adalah sebagai beri!ut.

Enteritis. +nteritis berarti peradangan biasanya disebab!an bai! oleh 3irus atau

ba!teri dalam saluran usus. Di diare infe!si biasa, infe!si yang paling luas dalam

usus besar dan u'ung distal ileum. Di mana(mana infe!si hadir, mu!osa men'adi

luas 'eng!el, dan la'u se!resi men'adi sangat diting!at!an.


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yang sangat menggairah!an !edua 749 motilitas dan 729 !elebihan se!resi lendir di

distal colon.$hese dua efe! ditambah!an bersama(sama dapat menyebab!an diare

ditandai.

Ulcerative colitis. olitis ulserati3a adalah penya!it di mana daerah luas dindingusus besar men'adi meradang dan ulserasi. otilitas usus ulserasi sering begitu

besar sehingga gera!an massa ter'adi hampir sepan'ang hari bu!an untu! biasa 40

sampai 80 menit. Huga, se!resi usus besar adalah sangat enhanced.)s )!ibatnya,

diare pasien telah diulang buang air besar. Aenyebab !olitis ulserati3a tida!

di!etahui. beberapa do!ter percaya bahwa itu hasil dari alergi atau !e!ebalan efe!

merusa!, tetapi 'uga bisa ter'adi a!ibat !ronis infe!si ba!teri belum dipahami.

)papun sebab, ada !ecenderungan turun(temurun yang !uat untu! !erentanan

untu! !olitis ulserati3a.


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duodenum pro3ides an especially strong stimulus for 3omiting. $he sensory signals

that initiate 3omiting originate mainly from the pharyn5, esophagus, stomach, and

upper portions of the small intestines. )nd the ner3e impulses are transmitted, as

shown in Figure RR"2, 7Ceutral connections of the U3omiting center.V $his so(called

3omiting center includes multiple sensory, motor, and control nuclei mainly in themedullary and pontile reticular formation but also e5tending into the spinal cord.9

tiple distributed nuclei in the brain stem that all together are called the U3omiting

center.V From here, motor impulses that cause the actual 3omiting are transmitted

from the 3omiting center by way of the 6th, Gth, th, 40th, and 42th cranial ner3es to

the upper gastrointestinal tract, through 3agal and sympathetic ner3es to the lower

tract, and through spinal ner3es to the diaphragm and abdominal muscles.

Antiperistalsis, the Prelude to Vomiting. n the early stages of e5cessi3egastrointestinal irritation or o3erdistention, antiperistalsis begins to occur often many

minutes before 3omiting appears. )ntiperistalsis means peristalsis up the digesti3e

tract rather than downward. $his may begin as far down in the intestinal tract as the

ileum, and the antiperistaltic wa3e tra3els bac!ward up the intestine at a rate of 2 to

8 cm/sec this process can actually push a large share of the lower small intestine

contents all the way bac! to the duodenum and stomach within 8 to 6 minutes.$hen,

as these upper portions of the gastrointestinal tract, especially the duodenum,

become o3erly distended, this distention becomes the e5citing factor that initiates

the actual 3omiting act. )t the onset of 3omiting, strong intrinsic contractions occur

in both the duodenum and the stomach, along with partial rela5ation of theesophageal(stomach sphincter, thus allowing 3omitus to begin mo3ing from the

stomach into the esophagus. From here, a specific 3omiting act in3ol3ing the

abdominal muscles ta!es o3er and e5pels the 3omitus to the e5terior, as e5plained

in the ne5t paragraph.

Vomiting Act. Bnce the 3omiting center has been sufficiently stimulated and the

3omiting act instituted, the first effects are 749 a deep breath, 729 raising of the hyoid

bone and laryn5 to pull the upper esophageal sphincter open, 789 closing of the

glottis to pre3ent 3omitus flow into the lungs, and 7#9 lifting of the soft palate to close

the posterior nares. Ce5t comes a strong downward contraction of the diaphragmalong with simultaneous contraction of all the abdominal wall muscles.$his

squee;es the stomach between the diaphragm and the abdominal muscles, building

the intragastric pressure to a high le3el. Finally, the lower esophageal sphincter

rela5es completely, allowing e5pulsion of the gastric contents upward through the

esophagus. $hus, the 3omiting act results from a squee;ing action of the muscles of

the abdomen associated with simultaneous contraction of the stomach wall and

opening of the esophageal sphincters so that the gastric contents can be e5pelled.


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UChemoreceptor Trigger one! in the "rain #edulla for $nitiation

of Vomiting %y Drugs or %y #otion &ickness. )side from the 3omiting initiated by

irritati3e stimuli in the gastrointestinal tract itself, 3omiting can also be caused by

ner3ous signals arising in areas of the brain.$his is particularly true for a small arealocated bilaterally on the floor of the fourth 3entricle called the chemoreceptor

trigger ;one for 3omiting. +lectrical stimulation of this area can initiate 3omiting but,

more important, administration of certain drugs, including apomorphine, morphine,

and some digitalis deri3ati3es, can directly stimulate this chemoreceptor trigger

;one and initiate 3omiting. Destruction of this area bloc!s this type of 3omiting but

does not bloc! 3omiting resulting from irritati3e stimuli in the gastrointestinal tract

itself. )lso, it is well !nown that rapidly changing direction or rhythm of motion of the

body can cause certain people to 3omit. $he mechanism for this is the following=

$he motion stimulates receptors in the 3estibular labyrinth of the inner ear, and from

here impulses are transmitted mainly by way of the brain stem 3estibular nuclei intothe cerebellum, then to the chemoreceptor trigger ;one, and finally to the 3omiting

center to cause 3omiting.

'ausea

+3eryone has e5perienced the sensation of nausea and !nows that it is often a

prodrome of 3omiting. Causea is the conscious recognition of subconscious

e5citation in an area of the medulla closely associated with or part of the 3omiting

center, and it can be caused by 749 irritati3e impulses coming from the

gastrointestinal tract, 729 impulses that originate in the lower brain associated withmotion sic!ness, or 789 impulses from the cerebral corte5 to initiate

3omiting.Jomiting occasionally occurs without the prodromal sensation of nausea,

indicating that only certain portions of the 3omiting center are associated with the

sensation of nausea.

@angguan %mum


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tetapi 'uga memperluas !e sumsum tulang bela!ang.9 tiple inti didistribusi!an di

batang ota! bahwa semua bersama(sama disebut Imuntah pusat.I Dari sini, impuls

motor yang menyebab!an muntah sebenarnya ditransmisi!an dari pusat muntah

dengan cara(6, !e(G, , 40, dan 42 saraf !ranial !e saluran cerna bagian atas

saluran, melalui saraf 3agal dan simpati! untu! saluran yang lebih rendah, danmelalui saraf tulang bela!ang !e diafragma dan otot perut.

Antiperistalsis, Prelude to #untah. Aada tahap awal iritasi gastrointestinal yang

berlebihan atau o3erdistensi, antiperistalsis mulai sering ter'adi banya! menit

sebelum muntah muncul. )ntiperistalsis berarti peristaltic up saluran pencernaan

daripada !e bawah. ni mung!in mulai se'auh turun di saluran usus sebagai ileum,

dan gelombang antiperistaltic per'alanan mundur up usus pada ting!at 2 sampai 8

cm / deti! proses ini benar(benar dapat mendorong bagian besar dari usus !ecil

yang lebih rendah si semua per'alanan !embali !e duodenum dan perut dalam

wa!tu 8 sampai 6 minutes.$hen, !arena ini atas bagian dari saluran pencernaan,terutama duodenum, men'adi terlalu buncit, distensi ini men'adi fa!tor menari! yang

memulai actual muntah tinda!an. Aada awal muntah, !ontra!si intrinsi! yang !uat

ter'adi bai! di duodenum dan lambung, bersama dengan rela!sasi sebagian dari

esofagus(lambung sfingter, sehingga memung!in!an muntahan untu! mulai

bergera! dari perut !e !erong!ongan. Dari sini, tertentu muntah tinda!an yang

melibat!an otot(otot perut membutuh!an atas dan mengusir para muntahan !e luar,

seperti yang di'elas!an dalam paragraf beri!utnya.

#untah Undang(Undang.


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langsung merangsang !emoreseptor ini memicu ;ona dan memulai muntah.

Aenghancuran ini blo! daerah 'enis ini muntah tetapi tida! memblo!ir muntah a!ibat

rangsangan iritasi pada saluran pencernaan itu sendiri.


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diarrhea is loosely defined as passage of abnormally liquid or unformed stools at an increased...

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