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