Septy Aulia Rahmy

0810710103

ACUTE DIARRHEA IN PEDIATRIC PATIENTS

1. Define diarrhea!
Diarrhoea is the passage of unusually loose or watery stools, usually at least three times in a 24 hour
period. It is the consistency of the stools rather than the number that is most important.
Frequent passing of formed stools is not diarrhoea. Babies fed only breastmilk often pass loose,
"pasty" stools; this also is not diarrhoea. (WHO)

2. Describe the epidemiology of acute diarrhea in pediatric! When the most prevalence episode of
diarrhea occurred in children? And why?
Kebanyakan episode diare terjadi pada 2 tahun pertama kehidupan.
Insiden paling tinggi pada golongan umur 6-11bln (masa diberikannya makanan pendamping).
Pola ini bisa disebabkan faktor dari penurunan kadar antibodi ibu, kurangnya kekebalan aktif pada
bayi, pengenalan makanan yang kemungkinan terpapar bakteri tinja dan kontak langsung dengan
tinja manusia dan binatang saat bayi mulai merangkak.

3. Explain the etiology acute diarrhea in pediatric!

Important etiologic agents of acute diarrhea in developing countries:

o Rotavirus (15 25%)
o Escherichia coli enterotoksigenic (10- 20%)
o Shigella (5 15%)
o Camphylobacter jejuni (10 15%)
o Cryptosporidium (5 15%)

4. Classify diarrhea in pediatric!

Jenis-jenis diare:
o Diare osmotik: diare yang diakibatkan oleh adanya zat yang tidak terserap aktif secara osmotik dan
mereda dengan puasa.
o Diare sekretory: diare cair yang banyak akibat peningkatan rangsangan ion dan sekresi air,
penghambatan absorpsi ion dan air, atau keduanya dan tidak mereda dengan puasa. Sekresi air ke
intestnal lumen yang melebihi absorpsinya.
 o Diare karena gangguan motilitas: gangguan dalam motilitas yang mempercepat waktu transit
(transit time) yang menyebabkan penurunan absorpsi sehingga terjadi diare.
o Diare inflamasi: gangguan pada epitelium intestine dikarenakan patogen mikroba atau virus,
absorpsi air menjadi tidak efisien.
o Klasifikasi yang secara umum digunakan adalah diare osmotik dan diare sekretory

Pembagian lain
o Diare Cair akut
- Sifatnya akut (<14 hari, kebanyakan <7hari)
- Pengeluaran tinja lunak atau cair dan tanpa darah
- Kadang disertai muntah dan panas
- Dapat menyebabkan dehidrasi; bila asupan makanan berkurang menyebabkan malnutrisi
- Penyebab terpentinng: Rotavirus, Essericia coli enterotoxigenik, shigella, campylobacter jejuni,
Criptosporodium
o Disentri
- Tinja disertai darah
- Dapat menyebabkan anorexia, penurunan BB cepat, kerusakan ukosa usus karena bakteri invasi
-
Penyebab utama : shigella
o Diare persistent
- Mula- mula bersifat akut, tapi >14hari
- Dimulai dari diare cair dan disentri
- BB turun secara nyata
- Volume tinja sangat banyak sehingga dehidrasi
- Disebabkan bukan karena mikroba tunggal, contoh: E.coli enteroagregatif, shigella,
criptosporidium.
- Jangan dikacaukan dgn diare kronik. Diare kronik bersifat intermitten atau berlangsung lama
dengan penyebab non infeksi, seperti penyakit yang sensitif terhadap glutten atau gangguan
metabolisme menahun

5. Explain pathogenesis of acute diarrhea that caused by

a. viral infection
Beberapa jenis virus seperti Rotavirus, berkembang biak dalam epitel villi usus halus merusak
sel epitel Villi memendek Hilangnya sel-sel villi usus mensekresi air dan elektrolit.
Kerusakan villi dapat juga dihubungkan dg hilangnya enzim disakaridase absorbsi disakarida
terutama laktosa berkurang. Penyembuhan terjadi bila villi mengalami regenerasi dan epitel villinya
menjadi matang.

b. lactose intolerance
Enzim laktase yang berfungsi memecah gula susu (laktosa) terdapatdi mukosa (brush border) usus
halus.
Enzim tersebut bekerja memecah laktosa menjadi monosakarida yang siap untuk diserap oleh
tubuh yaitu glukosa dan galaktosa.
Apabila ketersediaan laktase tidak mencukupi, laktosa yang terkandung dalam susu tidak akan
mengalami proses pencernaan dan akan dipecah (difermentasi) oleh bakteri di dalam usus besar.
Proses fermentasi yang terjadi dapat menimbulkan gas yang menyebabkan kembung dan rasa sakit
di perut.
 Sedangkan sebagian laktosa yang tidak dicerna akan tetap berada dalam saluran cerna dan tidak
terjadi penyerapan air dari faeses sehingga penderita akan mengalami diare.

c. enterotoxin (E.coli, V.cholera)

d. shigella and emtamoeba

6. Explain the clinical presentation of acute diarrhea in pediatric (the sign and/or symptomp of some
dehydration and severe dehydration)
o At first, the child becomes irritable, restless, and the temperature increases and then the diarrhea
starts.
o Watery diarrhea , probably accompanied with blood or mucous
o Change of stool colour become greenish because the stool mixed with bile acid
o Erosion of anus and perianal area because of frequent defecating and acid stool
o Vomiting may occur before or after diarrhea due to inflammation of the stomach or due to acid base
and electrolyte imbalance
o Dehydration appears when the patient has lost significant amount of fluids and electrolytes.
o Based on the amount of fluid loss, dehydration can be classified into: mild dehydration (4 5%),
moderate dehydration (6 9%) and severe dehydration ( 10%)
o Based on plasma tonicity can be classified into hypotonic dehydration (Na plasma < 130 mEq/L),
isotonic (Na plasma 130 - 150 mEq/L) and hypertonic dehydration (Na plasma >150 mEq/L)
o In the early stages of dehydration, there are no signs or symptoms. As dehydration increases, signs
and symptoms develop. Initially these include: thirst, restless or irritable behaviour, decreased skin
turgor, sunken eyes, and sunken fontanelle (in infants).
o In severe dehydration, these effects become more pronounced and the patient may develop
evidence of hypovolaemic shock, including: diminished consciousness, lack of urine output, cool
 moist extremities, a rapid and feeble pulse (the radial pulse may be undetectable), low or
undetectable blood pressure, and peripheral cyanosis. Death follows soon if rehydration is not
started quickly

7. Explain the five principles of therapy of acute diarrhea in pediatric!

The essential therapy of diarrhea includes :
1. Fluid administration
2. Continued breastfeeding and feeding
3. Antibiotics, only if indicated
4. Do not routinely give antidiarrheal agents
5. Treat accompanying disease, if present

8. Explain what is oral rehydration solution ?

ORT is based on the principle that the absorption of sodium in the intestine (along with other
electrolytes and water) is conducted through active absorption of certain food molecules, such as
glucose (from the breakdown of sucrose and starch) or L amino acid (from the breakdown of protein
and peptides)
If an isotonic solution with balanced glucose and electrolytes levels is given to a diarrheal patient,
the glucose-sodium bond will be well absorbed followed by absorption of water and other
electrolytes.
This process will correct the water and electrolytes loss in diarrheal patients without concerning the
etiology or the patients age
Because deficit of potassium and base also occur in patients with acute diarrhea, potassium and
citric or bicarbonate is added to the ORS
The mixture of glucose and salts is called oral rehydration salt (ORS) or in Indonesia it is known as
Oralit.
Guideline from WHO/UNICEF fo the composition of ORS are as follows :
ORS osmolality should be less than or same as plasma osmolality, that is around 300 m.mol/litre
Sodium concentration should be enough to replace sodium loss efficiently
Ratio of glucose : sodium (in m.mol/L) at least 1:1 to reach the maximal absorption of sodium
Base concentration should be 10 m.mol/litre for citrate or 30 m.mol/litre for bicarbonate, for proper
correction of metabolic acidosis due to diarrhea.
Potassium concentration should be 20 m.mol/litre (for adequate replacement of potassium loss.)