Diarrhea

Updated: Jan 31, 2020 

 Author: Stefano Guandalini, MD; Chief Editor: Carmen Cuffari,
MD  more...
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Practice Essentials
 Diare adalah pembalikan status penyerapan air bersih dan absorpsi
elektrolit menjadi sekresi. Kadar air yang diperbesar dalam tinja (di
atas nilai normal sekitar 10 mL / kg / d pada bayi dan anak kecil, atau
200 g / d pada remaja dan dewasa) disebabkan oleh
ketidakseimbangan dalam fisiologi anak kecil dan anak. proses usus
besar yang terlibat dalam penyerapan ion, substrat organik, dan air.
Tanda dan gejala
 Diare akut didefinisikan sebagai timbulnya tiba-tiba 3 atau lebih tinja
per hari dan berlangsung tidak lebih dari 14 hari; diare kronis atau
persisten didefinisikan sebagai episode yang berlangsung lebih dari
14 hari. Perbedaan ini memiliki implikasi tidak hanya untuk klasifikasi
dan studi epidemiologi tetapi juga dari sudut pandang praktis, karena
diare yang berlarut sering memiliki etiologi yang berbeda,
menimbulkan masalah manajemen yang berbeda, dan memiliki
prognosis yang berbeda.
 Presentasi klinis dan perjalanan diare tergantung pada penyebabnya
dan pada host. Pertimbangkan hal-hal berikut untuk menentukan
sumber / penyebab diare pasien:

Stool characteristics (eg, consistency, color, volume, frequency)

• Adanya gejala enterik terkait (misalnya, mual / muntah,

demam, sakit perut)
• Penggunaan penitipan anak (patogen umum: rotavirus,
astrovirus, calicivirus; Campylobacter, Shigella, Giardia, dan
spesies Cryptosporidium [spp])
• Riwayat konsumsi makanan (misalnya, makanan mentah /
terkontaminasi, keracunan makanan)
• Paparan air (misalnya, kolam renang, lingkungan laut)
 • Riwayat berkemah (kemungkinan paparan sumber air yang
terkontaminasi)
• Riwayat perjalanan (patogen umum memengaruhi wilayah
tertentu; juga pertimbangkan rotavirus dan Shigella,
Salmonella, dan Campylobacter spp terlepas dari riwayat
perjalanan tertentu, karena organisme ini lazim di seluruh
dunia)
• Pajanan binatang (mis. Anjing / kucing muda: Campylobacter
spp; kura-kura: Salmonella spp)
• Kondisi predisposisi (misalnya, rawat inap, penggunaan
antibiotik, keadaan immunocompromised)

Tanda dan gejala diare mungkin termasuk yang berikut:

• Dehidrasi: Kelesuan, kesadaran tertekan, fontanel anterior
cekung, selaput lendir kering, mata cekung, kurang air mata,
turgor kulit buruk, keterlambatan pengisian kapiler
• Gagal tumbuh dan kekurangan gizi: Mengurangi massa otot /
lemak atau edema perifer
• Nyeri perut / kram
• Borborygmi
• Eritema perianal

See Clinical Presentation for more detail.

Diagnosis

 Studi laboratorium tinja meliputi:
 • Pemeriksaan untuk sel telur dan parasit
 • Jumlah leukosit
 • Tingkat pH: Tingkat pH 5,5 atau kurang atau adanya zat pereduksi
menunjukkan intoleransi karbohidrat, yang biasanya sekunder akibat
penyakit virus.
 • Pemeriksaan eksudat untuk ada / tidaknya leukosit
 • Kultur: Selalu kultur untuk Salmonella, Shigella, dan Campylobacter
spp dan Y enterocolitica di hadapan tanda-tanda klinis kolitis atau
jika ada leukosit tinja; mencari Clostridium difficile pada mereka yang
diare ditandai dengan kolitis dan / atau tinja berdarah; nilai untuk
Escherichia coli, khususnya O157: H7, dengan diare berdarah dan
riwayat makan daging sapi; layar untuk Vibrio dan Plesiomonas spp
dengan sejarah makan makanan laut mentah atau perjalanan asing
 • Enzim immunoassay untuk antigen rotavirus atau adenovirus
 • Uji aglutinasi lateks untuk rotavirus
Studi laboratorium lain mungkin termasuk yang berikut:
• Kadar albumin serum: Enteropati kehilangan protein yang rendah akibat
infeksi usus enteroinvasive (mis. Salmonella spp, enteroinvasive E coli)
• Kadar alfa-antitripsin tinja: Infeksi usus enteroinvasive tinggi
• Kesenjangan anion untuk menentukan sifat diare (yaitu, osmolar vs
sekretori)
• Biopsi usus: Dapat diindikasikan dengan adanya diare kronis atau
berlarut-larut, serta dalam kasus-kasus di mana pencarian penyebab
diyakini wajib (misalnya, pada pasien dengan sindrom imunodefisiensi
yang didapat [AIDS] atau pasien yang sebaliknya sangat
immunocompromised)

See Workup for more detail.

Management
Diare akut yang timbul biasanya sembuh sendiri; namun, infeksi akut dapat
berlangsung lama. Manajemen umumnya mendukung: Dalam kebanyakan
kasus, pilihan terbaik untuk pengobatan diare akut adalah penggunaan
awal terapi rehidrasi oral (ORT). [1]
Farmakoterapi
Vaksin (misalnya, rotavirus) dapat membantu meningkatkan resistensi
terhadap infeksi. Agen antimikroba dan antiparasit dapat digunakan untuk
mengobati diare yang disebabkan oleh organisme tertentu dan / atau
keadaan klinis. Obat-obatan tersebut meliputi:
• Sefiksim
• Ceftriaxone
• Sefotaksim
• Eritromisin
• Furazolidone
• Iodoquinol
• Metronidazol
• Paromomisin
• Quinacrine
• Sulfametoksazol dan trimetoprim
• Vankomisin
• Tetrasiklin
• Nitazoxanide
• Rifaximin
Lihat Perawatan dan Pengobatan untuk lebih detail.
Latar Belakang
Diare akut didefinisikan sebagai timbulnya tiba-tiba 3 atau lebih tinja yang
longgar per hari. Kadar air yang diperbesar dalam tinja (di atas nilai normal
sekitar 10 mL / kg / d pada bayi dan anak kecil, atau 200 g / d pada remaja
dan dewasa) disebabkan oleh ketidakseimbangan dalam fisiologi anak
kecil dan anak. proses usus besar yang terlibat dalam penyerapan ion,
substrat organik, dan air. Gangguan umum dalam bentuk akutnya, diare
memiliki banyak penyebab dan mungkin ringan hingga berat.
Diare akut pada masa kanak-kanak biasanya disebabkan oleh infeksi usus
kecil dan / atau besar; Namun, banyak kelainan dapat menyebabkan diare,
termasuk sindrom malabsorpsi dan berbagai enteropati. Diare akut yang
timbul biasanya sembuh sendiri; namun, infeksi akut dapat berlangsung
lama. Sejauh ini, komplikasi diare akut yang paling umum adalah dehidrasi.

Meskipun istilah "gastroenteritis akut" umumnya digunakan secara sinonim

dengan "diare akut," istilah yang pertama adalah istilah yang keliru. Istilah
gastroenteritis menyiratkan peradangan pada lambung dan usus kecil,
sedangkan, pada kenyataannya, keterlibatan lambung jarang jika pernah
terlihat pada diare akut (termasuk diare dengan asal infeksi); selain itu,
enteritis juga tidak ada secara konsisten. Contoh sindrom diare akut
menular yang tidak menyebabkan enteritis termasuk diare yang
disebabkan oleh Vibrio cholera dan diare yang diinduksi Shigella. Jadi,
istilah diare akut lebih disukai daripada gastroenteritis akut.
Episode diare secara klasik dibedakan menjadi akut dan kronis (atau
persisten) berdasarkan durasinya. Diare akut dengan demikian
didefinisikan sebagai episode yang memiliki onset akut dan berlangsung
tidak lebih dari 14 hari; diare kronis atau persisten didefinisikan sebagai
episode yang berlangsung lebih dari 14 hari. Perbedaan ini, didukung oleh
Organisasi Kesehatan Dunia (WHO), memiliki implikasi tidak hanya untuk
klasifikasi dan studi epidemiologi tetapi juga dari sudut pandang praktis
karena diare yang berkepanjangan sering memiliki serangkaian penyebab
yang berbeda, menimbulkan masalah manajemen yang berbeda, dan
memiliki prognosis yang berbeda. .
Pathophysiology
Diare adalah pembalikan status penyerapan air bersih dan absorpsi
elektrolit menjadi sekresi. Gangguan seperti itu bisa merupakan hasil dari
gaya osmotik yang bekerja di lumen untuk mengarahkan air ke usus atau
hasil dari keadaan sekretori aktif yang diinduksi dalam enterosit. Dalam
kasus sebelumnya, diare bersifat osmolar, seperti yang diamati setelah
konsumsi gula yang tidak dapat diserap seperti laktulosa atau laktosa
dalam malabsorber laktosa. Sebaliknya, dalam keadaan sekretori aktif
yang khas, sekresi anion yang ditingkatkan (kebanyakan oleh
kompartemen sel crypt) paling baik dicontohkan dengan diare yang
diinduksi enterotoksin.
Pada diare osmotik, keluaran tinja sebanding dengan asupan substrat yang
tidak terserap dan biasanya tidak masif; tinja diare segera menurun dengan
penghentian nutrisi yang menyinggung, dan celah ion tinja tinggi, melebihi
100 mOsm / kg. Faktanya, osmolalitas tinja dalam keadaan ini dicatat tidak
hanya oleh elektrolit tetapi juga oleh nutrisi yang tidak diserap dan produk-
produk degradasinya. Celah ion diperoleh dengan mengurangkan
konsentrasi elektrolit dari total osmolalitas (diasumsikan 290 mOsm / kg),
sesuai dengan rumus: ion gap = 290 - [(Na + K) × 2].
Pada diare sekretori, proses transpor ion sel epitel berubah menjadi
sekresi aktif. Penyebab paling umum dari diare sekretorik onset akut
adalah infeksi bakteri pada usus. Beberapa mekanisme mungkin sedang
bekerja. Setelah kolonisasi, patogen enterik dapat melekat atau menyerang
epitel; mereka dapat menghasilkan enterotoksin (eksotoksin yang
memperoleh sekresi dengan meningkatkan messenger kedua intraseluler)
atau sitotoksin. Mereka juga dapat memicu pelepasan sitokin yang menarik
sel-sel inflamasi, yang, pada gilirannya, berkontribusi pada sekresi
teraktifasi dengan menginduksi pelepasan agen seperti prostaglandin atau
faktor pengaktif trombosit. Ciri-ciri diare sekretori meliputi tingkat
pembersihan yang tinggi, kurangnya respons terhadap puasa, dan celah
ion tinja yang normal (yaitu, 100 mOsm / kg atau kurang), yang
menunjukkan bahwa penyerapan nutrisi masih utuh.
Frequency
United States
Di Amerika Serikat, satu perkiraan sebelum pengenalan imunisasi
antirotavirus spesifik pada tahun 2006 mengasumsikan kejadian kumulatif
1 rawat inap untuk diare per 23-27 anak pada usia 5 tahun, dengan lebih
dari 50.000 rawat inap. Dengan perkiraan ini, rotavirus dikaitkan dengan 4-
5% dari semua rawat inap masa kanak-kanak dan biaya hampir $ 1 miliar.
[2] Lebih lanjut, diare akut bertanggung jawab atas 20% rujukan dokter
pada anak di bawah 2 tahun dan 10% pada anak di bawah 3 tahun.
Dampak vaksinasi terhadap morbiditas rotavirus sangat luar biasa, dengan
pengurangan yang signifikan dari rawat inap terkait diare dan kunjungan ke
unit gawat darurat pada anak-anak pada tahun 2007-2008 dibandingkan
dengan periode sebelum penggunaan. [3]
Sebuah studi oleh Olortegui et al yang mencakup 2.082 anak-anak
melaporkan bahwa 35% anak-anak mengalami infeksi astrovirus dan
prevalensi astrovirus dalam tinja diare adalah 5,6%, dan tingkat
keparahannya melebihi semua enteropatogen kecuali rotavirus. [36]
International
Di negara-negara berkembang, rata-rata 3 episode per anak per tahun
pada anak di bawah 5 tahun dilaporkan; namun, beberapa area
melaporkan 6-8 episode per tahun per anak. Dalam keadaan ini, malnutrisi
merupakan faktor risiko tambahan yang penting untuk diare, dan episode
diare berulang menyebabkan pertumbuhan yang goyah dan secara
substansial meningkatkan mortalitas. [4] Kematian anak-anak akibat diare
terus-menerus menurun secara perlahan selama 2 dekade terakhir,
sebagian besar karena meluasnya penggunaan solusi rehidrasi oral;
Namun, tampaknya telah meningkat selama beberapa tahun terakhir.
Karena satu-satunya penyebab paling umum diare menular di seluruh
dunia adalah rotavirus, dan karena vaksin telah digunakan selama lebih
dari 3 tahun sekarang, pengurangan frekuensi keseluruhan episode diare
diharapkan dalam waktu dekat.
Sebuah studi oleh Lübbert et al menemukan kejadian infeksi Clostridium
difficile di Jerman pada tahun 2012 menjadi 83 kasus per 100.000
populasi. Kemungkinan kekambuhan meningkat dengan masing-masing
kambuh; rekurensi awal infeksi ditemukan pada 18,2% pasien dengan
kejadian indeks, dengan 28,4% pasien mengalami rekurensi kedua dan
30,2% pasien rekurensi kedua mengalami rekurensi ketiga. [5]
Mortality/Morbidity
Kematian akibat diare akut secara keseluruhan menurun tetapi tetap tinggi.
Sebagian besar perkiraan memiliki diare sebagai penyebab kedua
kematian anak, dengan 18% dari 10,6 juta kematian tahunan pada anak-
anak yang lebih muda dari usia 5 tahun.
Meskipun ada penurunan yang progresif dalam angka kematian penyakit
diare global selama 2 dekade terakhir, morbiditas diare dalam laporan yang
diterbitkan dari tahun 1990-2000 sedikit meningkat di seluruh dunia
dibandingkan dengan laporan sebelumnya. Di Amerika Serikat, rata-rata
369 kematian / tahun terkait diare terjadi di antara anak-anak berusia 1-59
bulan selama 1992-1998 dan 2005-2006. [6] Sebagian besar kematian bayi
terkait diare dilaporkan pada 2005-2007, dengan 86% kematian terjadi di
antara bayi berat lahir rendah (<2500 g). [7]
Selain itu, di negara-negara di mana jumlah korban diare paling tinggi,
kemiskinan juga menambah beban tambahan yang sangat besar, dan
konsekuensi jangka panjang dari lingkaran setan infeksi enterik, diare, dan
kekurangan gizi sangat menghancurkan. [4]
Sex
Sebagian besar kasus diare menular tidak spesifik jenis kelamin. Wanita
memiliki insiden infeksi spesies Campylobacter yang lebih tinggi dan
sindrom uremik hemolitik (HUS).
Age
Diare virus paling umum terjadi pada anak kecil. Rotavirus dan adenovirus
sangat lazim pada anak di bawah 2 tahun. Astrovirus dan norovirus
biasanya menginfeksi anak di bawah 5 tahun. Enterocolitis Yersinia
biasanya menginfeksi anak-anak di bawah 1 tahun, dan organisme
Aeromonas merupakan penyebab diare yang signifikan pada anak-anak.
 Anak-anak yang sangat muda sangat rentan terhadap dehidrasi sekunder
dan malabsorpsi nutrisi sekunder. Usia dan status gizi tampaknya menjadi
faktor utama dalam menentukan tingkat keparahan dan durasi diare.
Faktanya, semakin muda anak, semakin tinggi risiko untuk dehidrasi parah,
yang mengancam jiwa sebagai akibat dari pergantian air tubuh yang tinggi
dan kapasitas kompensasi ginjal terbatas pada anak-anak yang sangat
muda. Apakah usia yang lebih muda juga berarti risiko menjalankan kursus
yang berkepanjangan adalah masalah yang tidak pasti. Di negara-negara
berkembang, diare postenteritis terus-menerus memiliki korelasi terbalik
yang kuat dengan usia.

Diarrhea Clinical Presentation
Updated: Jan 31, 2020 
 Author: Stefano Guandalini, MD; Chief Editor: Carmen Cuffari,
MD  more...
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History
Acute diarrhea in developed countries is almost invariably a benign, self-
limited condition, subsiding within a few days. The clinical presentation and
course of illness depend on the etiology of the diarrhea and on the host.
For example, rotavirus is more commonly associated with vomiting,
dehydration, and a greater number of work days lost than nonrotavirus
gastroenteritis.
 A prospective study conducted in the United States in 604 children
aged 3-36 months in community settings before the introduction of
rotavirus vaccine found that the highest incidence of acute diarrhea
was in January and August, with an overall incidence of 2.21 episodes
per person-year. [8] Close to 90% of episodes were acute (ie, lasting <
14 d, with a median duration of 2 d and a median of 6 stools per day).
 Diarrhea implies an increase in stool volume and diminished stool
consistency.
o In children younger than 2 years, diarrhea is defined as daily
stools with a volume greater than 10 mL/kg.
 o In children older than 2 years, diarrhea is defined as daily
stools with a weight greater than 200 g. In practice, this typically
means loose-to-watery stools passed 3 or more times per day.
o Individual stool patterns widely vary; for example, breastfed
children may normally have 5-6 stools per day.
 Flatulence associated with foul-smelling stools that float suggests fat
malabsorption, which can be observed with infection with Giardia
lamblia.
 Knowledge of the characteristics of consistency, color, volume, and
frequency can be helpful in determining whether the source is from the
small or large bowel. Table 1 outlines these characteristics and
demonstrates that an index of suspicion can be easily generated for a
specific set of organisms.
Table 1. Stool Characteristics and Determining Their Source (Open Table
in a new window)
Stool
Characteristic Small Bowel Large Bowel
s

Appearance Watery Mucoid and/or bloody

Volume Large Small

Frequency Increased Highly increased

Possibly positive but

Blood Commonly grossly bloody
never gross blood

pH Possibly < 5.5 >5.5

Reducing
Possibly positive Negative
substances

Commonly >10/high
WBCs < 5/high power field
power field

Possible leukocytosis,
Serum WBCs Normal
bandemia

Organisms Viral Invasive bacteria

  Escherichia
Coli (enteroinvasive,
enterohemorrhagic)
 Rotavirus  Shigella species
 Adenovirus  Salmonella species
 Calicivirus  Campylobacter spe
 Astrovirus cies
 Norovirus  Yersinia species
 Aeromonas species
 Plesiomonas specie
s

Enterotoxigenic bacteria
 E coli
 Klebsiella
Toxic bacteria
 Clostridium
 Clostridium difficile
perfringens
 Cholera species
 Vibrio species

Parasites
Parasites
 Giardia species
 Entamoeba
 Cryptosporidium spe
organisms
cies

See the list below:

 Associated systemic symptoms include the following:
o Some enteric infections commonly have systemic symptoms,
whereas others less commonly are associated with systemic
features.
o Table 2 outlines the frequency of some of these symptoms with
particular organisms. It also outlines incubation periods and usual
duration of symptoms of common organisms. Certain organisms
(eg, C difficile, Giardia, Entamoeba species) may be associated
with a protracted course.
Table 2. Organisms and Frequency of Symptoms (Open Table in a new
window)
Incubati Durati Vomiti Fev Abdomi
Organism
on on ng er nal Pain

Rotavirus 1-7 d 4-8 d Yes Low No

 Delaye
Adenovirus 8-10 d 5-12 d Low No
d

Norovirus 1-2 d 2d Yes No No

Astrovirus 1-2 d 4-8 d +/- +/- No

Calicivirus 1-4 d 4-8 d Yes +/- No

Aeromonas
None 0-2 wk +/- +/- No
species

Campylobacter
2-4 d 5-7 d No Yes Yes
species

Variab
C difficile Variable No Few Few
le

C perfringens Minimal 1d Mild No Yes

Enterohemorrh
1-8 d 3-6 d No +/- Yes
agic E coli

Enterotoxigenic
1-3 d 3-5 d Yes Low Yes
E coli

Plesiomonas
None 0-2 wk +/- +/- +/-
species

Salmonella
0-3 d 2-7 d Yes Yes Yes
species

Shigella
0-2 d 2-5 d No High Yes
species

Vibrio species 0-1 d 5-7 d Yes No Yes

Y enterocolitica None 1-46 d Yes Yes Yes

Giardia species 2 wk 1+ wk No No Yes

Cryptosporidiu Month
5-21 d No Low Yes
m species s

Entamoeba 1-2+
5-7 d No Yes No
species wk

See the list below:

 Daycare considerations are as follows:
o Certain organisms are spread quickly in daycare. These
organisms include rotavirus; astrovirus; calicivirus;
and Campylobacter, Shigella,
Giardia, and Cryptosporidium species.
o Increase in daycare usage has raised the incidence of rotavirus
and Cryptosporidium species.
 Food history can be helpful.
o Ingestion of raw or contaminated food is a common cause of
infectious diarrhea.
o Organisms that cause food poisoning include the following:
 Dairy food -Campylobacter and Salmonella species
 Eggs -Salmonella species
 Meats -C perfringens and Aeromonas, Campylobacter,
and Salmonella species
 Ground beef - Enterohemorrhagic E coli
 Poultry -Campylobacter species
 Pork -C perfringens, Y enterocolitica
 Seafood - Astrovirus and Aeromonas,
Plesiomonas, and Vibrio species
 Oysters - Calicivirus and Plesiomonas and Vibrio species
 Vegetables -Aeromonas species and C perfringens
o Guidelines on fruit juice intake for children by the American
Academy of Pediatrics recommend that in the evaluation of
children with chronic diarrhea, excessive flatulence, abdominal
pain, and bloating, the pediatrician should determine the amount
of juice being consumed. [9]
 Water exposure can contribute to diarrhea.
o Water is a major reservoir for many organisms that cause
diarrhea.
o Swimming pools have been associated with outbreaks of
infection with Shigella species; Aeromonas organisms are
associated with exposure to the marine environment.
 o Giardia, Cryptosporidium, and Entamoeba organisms are
resistant to water chlorination; therefore, exposure to
contaminated water should raise index of suspicion for these
parasites.
 A history of camping suggests exposure to water sources
contaminated with Giardia organisms.
 Travel history may indicate a cause for diarrhea.
o Enterotoxigenic E coli is the leading cause of traveler's
diarrhea.
o Rotavirus and Shigella,
Salmonella, and Campylobacter organisms are prevalent
worldwide and need to be considered regardless of specific travel
history.
o Risk of contracting diarrhea while traveling is, by far, highest for
persons traveling to Africa.
o Travel to Central and South America and Eastern European
countries is also associated with a relatively high risk of
contracting diarrhea.
o Other organisms that are prevalent in particular parts of the
world include the following:
 Nonspecific foreign travel history - Enterotoxigenic E
coli and Aeromonas, Giardia, Plesiomonas,
Salmonella, and Shigella species
 Underdeveloped tropical visit -C perfringens
 Travel to Africa -Entamoeba species, Vibrio cholerae
 Travel to South America and Central America
-Entamoeba species, V cholerae, enterotoxigenic E coli
 Travel to Asia -V cholerae
 Travel to Australia -Yersinia species
 Travel to Canada -Yersinia species
 Travel to Europe -Yersinia species
 Travel to India -Entamoeba species, V cholerae
 Travel to Japan -Vibrio parahaemolyticus
 Travel to Mexico -Aeromonas, Entamoeba,
Plesiomonas, and Yersinia species
 New Guinea -Clostridium species
 Animal exposure can contribute to diarrhea.
o Exposure to young dogs or cats is associated
with Campylobacter organisms.
o Exposure to turtles is associated with Salmonella organisms.
 Certain medical conditions predispose patients to infection, including
the following:
o C difficile - Hospitalization, antibiotic administration
 o Plesiomonas species - Liver diseases or malignancy
o Salmonella species - Intestinal dysmotility, malnutrition,
achlorhydria, hemolytic anemia (especially sickle cell disease),
immunosuppression, malaria
o Rotavirus - Hospitalization
o Giardia species -Agammaglobulinemia, chronic pancreatitis,
achlorhydria, cystic fibrosis
o Cryptosporidia species - Immunocompromised or
immunosuppressed state
Physical
The following may be observed:
 Dehydration
o Dehydration is the principal cause of morbidity and mortality.
o Assess every patient with diarrhea for signs, symptoms, and
severity.
o Lethargy, depressed consciousness, sunken anterior fontanel,
dry mucous membranes, sunken eyes, lack of tears, poor skin
turgor, and delayed capillary refill are obvious and important signs
of dehydration. Table 3 below details dehydration severity and
symptoms.
Table 3. Dehydration Severity, Signs, and Symptoms (Open Table in a new
window)
5-10%
Hydratio 0-5% Dehydration 10% or More
Dehydration
n (Mild) (Severe)
(Moderate)

General Well Restless Lethargic

Eyes Normal Sunken Very sunken

Tears Present Absent Absent

Mouth Moist Dry Very dry

Thirst Drinks normally Thirsty Drinks poorly

Pinch retracts Pinch retracts Pinch stays

Skin
immediately slowly folded

 
See the list below:
  Failure to thrive and malnutrition
o Reduced muscle and fat mass or peripheral edema may be
clues to the presence of carbohydrate, fat, and/or protein
malabsorption.
o Giardia organisms can cause intermittent diarrhea and fat
malabsorption.
 Abdominal pain
o Nonspecific nonfocal abdominal pain and cramping are
common with some organisms.
o Pain usually does not increase with palpation.
o With focal abdominal pain worsened by palpation, rebound
tenderness, or guarding, be alert for possible complications or for
another noninfectious diagnosis.
 Borborygmi: Significant increases in peristaltic activity can cause an
audible and/or palpable increase in bowel activity.
 Perianal erythema
o Frequent stools can cause perianal skin breakdown,
particularly in young children.
o Secondary carbohydrate malabsorption often results in acidic
stools.
o Secondary bile acid malabsorption can result in a severe
diaper dermatitis that is often characterized as a "burn."
Causes
Although infectious agents are by far the most common cause for sporadic
or endemic episodes of acute diarrhea, one should not dismiss other
causes that can lead to the same presentation.
 Causes of diarrhea with acute onset include the following:
o Infections
 Enteric infections (including food poisoning
 Extraintestinal infections
o Drug-induced
 Antibiotic-associated
 Laxatives
 Antacids that contain magnesium
 Opiate withdrawal
 Other drugs
o Food allergies or intolerances
 Cow's milk protein allergy
 Soy protein allergy
 Multiple food allergies
 Olestra
 Methylxanthines (caffeine, theobromine, theophylline)
o Disorders of digestive/absorptive processes
  Glucose-galactose malabsorption
 Sucrase-isomaltase deficiency
 Late-onset (adult-type) hypolactasia, resulting in lactose
intolerance
o Chemotherapy or radiation-induced enteritis
o Surgical conditions
 Acute appendicitis
 Intussusception
o Vitamin deficiencies
 Niacin deficiency
 Folate deficiency
o Vitamin toxicity
 Vitamin C
 Niacin, vitamin B3
o Ingestion of heavy metals or toxins (eg, copper, tin, zinc)
o Ingestion of plants (eg, hyacinths, daffodils, azalea,
mistletoe, Amanita species mushrooms
 Infectious causes of acute diarrhea in developed countries
o Viruses
 Rotavirus - 25-40% of cases
 Norovirus - 10-20% of cases
 Calicivirus - 1-20% of cases
 Astrovirus - 4-9% of cases
 Enteric-type adenovirus - 2-4% of cases
o Bacteria
 Campylobacter jejuni - 6-8% of cases
 Salmonella - 3-7% of cases
 E Coli - 3-5% of cases
 Shigella - 0-3% of cases
 Y enterocolitica - 1-2% of cases
 C difficile - 0-2% of cases
 Vibrio parahaemolyticus - 0-1% of cases
 V cholerae - Unknown
 Aeromonas hydrophila - 0-2% of cases
o Parasites
 Cryptosporidium - 1-3% of cases
 G lamblia - 1-3% of cases
A study by Yi et al of 207 stool samples from hospitalized children in
metropolitan Atlanta, Ga, with health-care–associated vomiting and/or
diarrhea found that 20 children (10%) were positive for rotavirus and 7
children (3%) were positive for norovirus. The results indicated that these
pathogens have an important role in pediatric nosocomial illness. [10]
Diarrhea Treatment & Management
 Updated: Jan 31, 2020 
 Author: Stefano Guandalini, MD; Chief Editor: Carmen Cuffari,
MD  more...
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Medical Care
In 2003 the Center for Disease Control (CDC) put forth recommendations
for the management of acute pediatric diarrhea in both the outpatient and
inpatient settings including indication for referral. [1]
Indications for medical evaluation of children with acute diarrhea include
the following:
 Younger than 3 months
 Weight of less than 8 kg
 History of premature birth, chronic medical conditions, or concurrent
illness
 Fever of 38ºC or higher in infants younger than 3 months or 39ºC or
higher in children aged 3-36 months
 Visible blood in the stool
 High-output diarrhea
 Persistent emesis
 Signs of dehydration as reported by caregiver, including sunken
eyes, decreased tears, dry mucous membranes, and decreased urine
output
 Mental status changes
 Inadequate responses to oral rehydration therapy (ORT) or caregiver
unable to administer ORT
The report also includes information on assessment of dehydration and
what steps should be taken to adequately treat acute diarrhea.
Treatment of dehydration due to diarrhea includes the following:
 Minimal or no dehydration
o Rehydration therapy - Not applicable
o Replacement of losses
 Less than 10 kg body weight - 60-120 mL oral
rehydration solution for each diarrhea stool or vomiting
episode
  More than 10 kg body weight - 120-140 mL oral
rehydration solution for each diarrhea stool or vomiting
episode
 Mild-to-moderate dehydration
o Rehydration therapy - Oral rehydration solution (50-100 mL/kg
over 3-4 h)
o Replacement of losses
 Less than 10 kg body weight - 60-120 mL oral
rehydration solution for each diarrhea stool or vomiting
episode
 More than 10 kg body weight - 120-140 mL oral
rehydration solution for each diarrhea stool or vomiting
episode
 Severe dehydration
o Rehydration therapy - Intravenous lactated Ringer solution or
normal saline (20 mL/kg until perfusion and mental status
improve), followed by 100 mL/kg oral rehydration solution over 4
hours or 5% dextrose (half normal saline) intravenously at twice
maintenance fluid rates
o Replacement of losses
 Less than 10 kg body weight - 60-120 mL oral
rehydration solution for each diarrhea stool or vomiting
episode
 More than 10 kg body weight - 120-140 mL oral
rehydration solution for each diarrhea stool or vomiting
episode
 If unable to drink, administer through nasogastric tube or
intravenously administer 5% dextrose (one fourth normal
saline) with 20 mEq/L potassium chloride
ORT is the cornerstone of treatment, especially for small-bowel infections
that produce a large volume of watery stool output. ORT with a glucose-
based oral rehydration syndrome must be viewed as by far the safest, most
physiologic, and most effective way to provide rehydration and maintain
hydration in children with acute diarrhea worldwide, as recommended by
the WHO; by the ad hoc committee of European Society for Pediatric
Gastroenterology, Hepatology and Nutrition (ESPGHAN); and by the
American Academy of Pediatrics. [11] However, the global use of ORT is still
insufficient. Developed countries, in particular the United States, seem to
be lagging behind despite studies that demonstrate beyond doubt the
efficacy of ORT in emergency care settings, in which intravenous
rehydration unduly continues to be widely privileged.
Not all commercial ORT formulas promote optimal absorption of
electrolytes, water, and nutrients. The ideal solution has a low osmolarity
(210-250) and a sodium content of 50-60 mmol/L. Administer maintenance
fluids plus replacement of losses. Educate caregivers in methods
necessary to replace this amount of fluid. Administer small amounts of fluid
at frequent intervals to minimize discomfort and vomiting. A 5-mL or 10-mL
syringe without a needle is a very useful tool. The syringe can be quickly
used to place small amounts of fluid in the mouth of a child who is
uncooperative. Once the child becomes better hydrated, cooperation
improves enough to take small sips from a cup. This method is time
intensive and requires a dedicated caregiver. Encouragement from the
physician is necessary to promote compliance. Oral rehydration is now
universally recommended to be completed within 4 hours.
The addition of zinc to oral rehydration solution has been proven effective
in children with acute diarrhea in developing countries and is recommended
by the WHO. [12] However, no evidence suggests efficacy in children living in
developed countries, in which the prevalence of zinc deficiency is assumed
to be extremely low.
The composition of almost all other beverages (carbonated or not) that are
commercially available and frequently used in children with diarrhea is
completely inadequate for rehydration or for maintaining hydration,
considering the sodium content, which is invariably extremely low, and
osmolarity that is often dangerously elevated. For instance, Coca-Cola,
Pepsi-Cola, and apple juice have an osmolarity of 493, 576, and 694-773,
respectively.
However, research conducted in a community clinic in Nicaragua indicated
that green tea and pomegranate extract combined with a standard oral
rehydration solution help children with diarrhea improve faster. [13] Results
showed the average time to achieve a Bristol Stool Scale (BSS) score of 4
or less was significantly shorter in the extract group than in the control
group (3.1 vs 9.2 hours, respectively). In addition, a BSS score of 4 or less
in the first bowel movement after treatment was achieved by more patients
in the extract group than the control group (60% vs 29%, respectively).
BSS scores in the extract group were maintained on day 2. [13]
At completion of hydration, resumption of feeding is strongly
recommended. In fact, many studies convincingly demonstrate that early
refeeding hastens recovery. Also, robust evidence suggests that, in the
vast majority of episodes of acute diarrhea, refeeding can be accomplished
without the use of any special (eg, lactose-free or soy-based) formulas.
Antimotility agents are not indicated for infectious diarrhea, except for
refractory cases of Cryptosporidium infection. Antimicrobial therapy is
indicated for some nonviral diarrhea because most is self-limiting and does
not require therapy.
Therapies recommended for some nonviral diarrheas include the following:
 Aeromonas species: Use cefixime and most third-generation and
fourth-generation cephalosporins.
  Campylobacter species: Erythromycin shortens illness duration and
shedding.
 C difficile: Discontinue potential causative antibiotics. If antibiotics
cannot be stopped or this does not result in resolution, use oral
metronidazole or vancomycin. Vancomycin is reserved for the child
who is seriously ill.
 C perfringens: Do not treat with antibiotics.
 Cryptosporidium parvum: Administer paromomycin; however,
effectiveness is not proven. Nitazoxanide, a newer anthelmintic, is
effective against C parvum.
 Entamoeba histolytica: Metronidazole followed by iodoquinol or
paromomycin is administered in symptomatic patients. Asymptomatic
carriers in nonendemic areas should receive iodoquinol or
paromomycin.
 E coli: Trimethoprim-sulfamethoxazole (TMP-SMX) should be
administered if moderate or severe diarrhea is noted; antibiotic
treatment may increase likelihood of hemolytic-uremic syndrome
(HUS). Parenteral second-generation or third-generation
cephalosporin is indicated for systemic complications.
 G lamblia: Metronidazole or nitazoxanide can be used.
 Plesiomonas species: Use TMP-SMX or any cephalosporin.
 Salmonella species: Treatment prolongs carrier state, is associated
with relapse, and is not indicated for nontyphoid-uncomplicated
diarrhea. Treat infants younger than 3 months and high-risk patients
(eg, immunocompromised, sickle cell disease). TMP-SMX is first-line
medication; however, resistance occurs. Use ceftriaxone and
cefotaxime for invasive disease.
 Shigella species: Treatment shortens illness duration and shedding
but does not prevent complications. TMP-SMX is first-line medication;
however, resistance occurs. Cefixime, ceftriaxone, and cefotaxime are
recommended for invasive disease.
 V cholerae: Treat infected individuals and contacts. Doxycycline is
the first-line antibiotic, and erythromycin is second-line antibiotic.
 Yersinia species: TMP-SMX, cefixime, ceftriaxone, and cefotaxime
are used. Treatment does not shorten disease duration; reserve for
complicated cases.
Consultations
See the list below:
 Surgeon
o Certain organisms cause abdominal pain and bloody stools.
o Symptoms resembling appendicitis, hemorrhagic colitis,
intussusception, or toxic megacolon may be appreciated.
 o If the infectious etiology in individuals with such symptoms is
not certain, seek consultation with a surgeon.
 Infectious-disease specialist: Consider consultation with an
infectious-disease specialist for any patient who is
immunocompromised because of HIV infection, chemotherapy, or
immunosuppressive drugs because atypical organisms are more likely,
and complications can be more serious and fulminate.
Diet
Breastfed infants with acute diarrhea should be continued on breast milk
without any need for interruption. In fact, breastfeeding not only has a well-
known protective effect against the development of enteritis, it also
promotes faster recovery and provides improved nutrition. This is even
more important in developing countries, where withdrawal of breastfeeding
during diarrhea has been shown to have a deleterious effect on the
development of dehydration in infants with acute watery diarrhea.
 Bananas, rice, applesauce, and toast diet
o A banana, rice, applesauce, and toast (BRAT) diet was
introduced in the United States in 1926 and has enjoyed vast
popularity. However, no evidence shows that this diet is useful,
and its poor protein content may be a contraindication; therefore, it
is not recommended.
o A strong body of evidence now suggests that resuming the
prediarrhea diet is perfectly safe and must be encouraged,
obviously respecting any (usually temporary) lack of appetite.
 Lactose ingestion
o Although rotavirus can cause secondary transient lactose
intolerance, this finding is believed to be generally not clinically
relevant; use lactose-containing formulas in all individuals with
diarrhea.
o In an incident of worsening of diarrhea proven to be secondary
to a clinically important lactose malabsorption in infants positive
for rotavirus, a very transient use of lactose-free formulas (5-6 d)
can be considered.
Diarrhea Guidelines
Updated: Jan 31, 2020 
 Author: Stefano Guandalini, MD; Chief Editor: Carmen Cuffari,
MD  more...
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Guidelines Summary
British Society of Gastroenterology guidelines for the investigation of
chronic diarrhoea in adults  [35]
Clinical assessment
 Recommend a careful detailed history to plan investigations.
 Recommend screening blood tests for the exclusion of anemia, celiac
disease, etc, as well as stool tests for inflammation.
 Recommend making a positive diagnosis of irritable bowel syndrome
(IBS) following basic blood and stool screening tests.
Cancer or inflammation
 Recommend excluding colorectal cancer in those with altered bowel
habit ± rectal bleeding by colonoscopy.
 Suggest use of testing for fecal blood loss by fecal immunochemical
testing in primary or secondary care, either as an exclusion test or to
guide priority of investigations in those with lower gastrointestinal
symptoms (chronic diarrhea) but without rectal bleeding.
 Fecal calprotectin is recommended to exclude colonic inflammation in
those suspected with IBS and under the age of 40.
Secondary clinical assessment
 If symptoms persist despite normal first-line investigations and
treatment, then referral for further investigations is recommended.
 We recommend blood and stool tests to exclude malabsorption and
common infections (especially in the immunocompromised or elderly).
Common disorders
 In those with functional bowel or IBS-diarrhea, a positive diagnosis of
bile acid diarrhea should be made either by selenium-75-homocholic
acid taurine ( 75SeHCAT) testing or serum bile acid precursor 7α-
hydroxy-4-cholesten-3-one (7αHCO, or 7αC4) (depending on local
availability).
 Recommend colonoscopy with biopsies of the right and left colon (not
rectal) to exclude microscopic colitis.
Malabsorption
 If lactose maldigestion is suspected, suggest hydrogen breath testing
(if available) or withdrawal of dietary lactose/carbohydrates from the
diet.
 Magnetic resonance (MR) enterography (MRE) is recommended for
evaluation of small bowel abnormalities depending on availability.
 Video capsule endoscopy (VCE) is recommended for assessing
small bowel abnormalities depending on local availability.
  We do not recommend small bowel barium follow through or barium
enteroclysis for the evaluation of small bowel abnormalities because of
its poor sensitivity and specificity.
 Recommend enteroscopy only for targeted lesions identified by MRE
or VCE and not for diagnosis of chronic diarrhea.
 Recommend fecal elastase testing when fat malabsorption is
suspected. We do not recommend para-aminobenzoic acid (PABA)
testing.
 MR imaging (MRI) (rather than computed tomography (CT)) is
recommended for assessing structural anomalies of the pancreas in
suspected chronic pancreatitis.
 If small bowel bacterial overgrowth is suspected, we recommend an
empirical trial of antibiotics, as there is insufficient evidence to
recommend routine hydrogen or methane breath testing.
Surgical and structural disorders
 We recommend use of anorectal manometry and endoanal
ultrasound only when other local pathology has been excluded and
conservative measures exhausted.
 Recommend radiologic modalities for the investigation of fistulae—
MRI or CT with contrast follow through.
Rare causes
 Diarrhea due to hormone secreting tumors is rare; hence, we
recommend testing only when other causes of diarrhea have been
excluded.
Canadian Association of Gastroenterology (CAG) diagnostic and treatment
guidelines for bile acid diarrhea (BAD)
The Canadian Association of Gastroenterology (CAG) has issued
guidelines on the diagnosis and treatment of bile acid diarrhea (BAD). [37]
Diagnosis of bile acid diarrhea
In patients with chronic nonbloody diarrhea, the initial assessment for
suspected bile acid diarrhea (BAD) should be based on risk factors (history
of cholecystectomy, terminal ileal resection, radiotherapy) rather than
symptoms.
In patients with chronic diarrhea, including diarrhea-predominant irritable
bowel syndrome (IBS-D) and functional diarrhea, 75selenium homocholic
acid taurine (SeHCAT) testing or 7α-hydroxy-4-cholesten-3-one (C4) assay
is recommended to evaluate for BAD. SeHCAT testing is also
recommended in patients with persistent diarrhea who have Crohn disease
of the small intestine without objective evidence of inflammation. The
guidelines do not take a position for or against the use of fibroblast growth
factor 19 (FGF19) assay for BAD diagnosis.
In patients with suspected BAD, SeHCAT testing is preferred over initiation
of empiric bile acid sequestrant therapy (BAST) to establish diagnosis.
Induction therapy for bile acid diarrhea
In patients with type 1 or type 3 BAD, any remediable causes (eg, Crohn
disease, microscopic colitis, small intestinal bacterial overgrowth [SIBO])
should be treated along with BAD to induce a clinical response.
In patients with BAD, cholestyramine treatment is preferred over no
treatment to induce a clinical response. Cholestyramine is preferred over
other BASTs as initial therapy except in patients who cannot tolerate
cholestyramine.
In patients who are receiving empiric BAST, the daily dose should be
gradually titrated to minimize adverse effects.
BAST is discouraged in patients with Crohn disease with extensive ileal
involvement or resection.
Patients with BAD who have recurrent or worsening symptoms despite
stable BAST therapy should be re-evaluated diagnostically.
Concurrent medications should be reviewed in patients being considered
for BAST therapy to minimize the possibility of drug interactions.
Maintenance treatment for bile acid diarrhea
In patients with BAD in whom BAST elicits a response, a trial of intermittent
on-demand dosing is recommended.
Patients who are unable to tolerate BAST should receive alternative
antidiarrheal agents instead of no treatment to alleviate long-term
symptoms.
Empiric BAST being given as maintenance therapy should be administered
at the lowest dose necessary to minimize symptoms. The guidelines do not
take a position on whether to recommend for or against measuring fat-
soluble vitamin levels at baseline and annually thereafter.
Diarrhea
Approved by the Cancer.Net Editorial Board, 03/2019

Diare melibatkan buang air besar yang sering, longgar, atau berair. Pergerakan usus juga
disebut feses.

Dengan diare, Anda memiliki buang air besar lebih sering daripada biasanya. "Garis dasar"
Anda adalah jumlah buang air besar yang biasa Anda miliki dalam sehari.

Jika Anda mengalami diare selama perawatan kanker, tanyakan kepada tim perawatan
kesehatan Anda tentang cara mengelolanya. Menghilangkan efek samping adalah bagian
penting dari perawatan dan perawatan kanker. Ini disebut perawatan paliatif atau perawatan
suportif.

Causes of diarrhea
Causes of diarrhea related to cancer and its treatment include:

• Kemoterapi

• Imunoterapi

• Kanker yang mempengaruhi pankreas

• Terapi radiasi ke panggul

• Pengangkatan sebagian usus

• Penyakit graft-versus-host, efek samping dari transplantasi sumsum tulang

Kondisi yang tidak terkait dengan kanker yang dapat menyebabkan diare meliputi:

• Penyakit usus radang dan iritasi

• Infeksi virus

• Ketidakmampuan untuk mencerna makanan tertentu

• Infeksi Clostridium difficile, bakteri penyebab diare

• Antibiotik
Your health care team may do medical tests to find out what is causing diarrhea.
Grades of diarrhea
Dokter menggunakan nilai yang ditetapkan oleh National Cancer Institute untuk
menggambarkan tingkat keparahan diare:
Grade 1. Melewati hingga 4 lebih banyak feses sehari daripada baseline seseorang.

Grade 2. Melewati 4 hingga 6 lebih banyak feses sehari daripada baseline seseorang.

Kelas 3. Ini mungkin memerlukan perawatan di rumah sakit atau klinik. Ini ditandai oleh
beberapa faktor:

• Melewati 7 atau lebih feses sehari

• Ketidakmampuan untuk mengontrol pergerakan usus, yang dikenal sebagai inkontinensia

• Kesulitan memenuhi kebutuhan sehari-hari tanpa bantuan

Kelas 4. Ini adalah kondisi yang mengancam jiwa yang membutuhkan perawatan intensif
segera.

Risiko diare

Meski tidak nyaman, diare ringan biasanya tidak menimbulkan masalah serius.

Tetapi diare parah dapat menyebabkan dehidrasi dan ketidakseimbangan elektrolit. Ini terjadi
ketika tubuh kehilangan banyak air. Ini juga dapat menyebabkan masalah kesehatan lainnya.
Untuk menghindari masalah seperti itu, ambil langkah-langkah untuk mencegah diare atau
mengobatinya sejak dini.

Prevention and treatment of diarrhea

Pilihan pencegahan dan perawatan tergantung pada gejala dan penyebab diare Anda.

Tanyakan kepada tim perawatan kesehatan Anda tentang obat-obatan untuk mencegah diare.
Ini termasuk loperamide (Imodium) serta kombinasi dari difenoksilat dan atropin (Lomotil).
Anda mungkin menerima ini untuk diare yang disebabkan oleh kemoterapi.

Para peneliti sedang mempelajari obat untuk diare yang disebabkan oleh terapi radiasi ke
daerah panggul. Tetapi ini belum disetujui oleh Administrasi Makanan dan Obat-obatan A.S.

Pertimbangkan opsi-opsi ini untuk membantu Anda mengelola diare ringan:

• Hindari kafein, alkohol, susu, lemak, serat, jus jeruk, jus prune, dan makanan
pedas.

• Hindari obat-obatan seperti obat pencahar, pelunak tinja, dan metoclopramide

(Reglan). Kadang-kadang, dokter meresepkan metoclopramide untuk
mencegah mual dan muntah dari kemoterapi.

• Makan kecil, sering makan. Dan pilih makanan yang mudah dicerna. Ini
termasuk pisang, nasi, saus apel, dan roti panggang. Jika kemoterapi
menyebabkan diare, dokter Anda dapat merekomendasikan diet rendah residu.
Ini termasuk makanan rendah serat.
 • Minumlah air dan cairan bening lainnya untuk mencegah dehidrasi. Orang
dengan dehidrasi berat mungkin perlu menerima cairan melalui jalur intravena
(IV).

Jika diare Anda lebih parah atau tidak membaik setelah mencoba opsi di atas, hubungi tim
perawatan kesehatan Anda. Tergantung pada gejala Anda, dokter Anda dapat:

• Buat perubahan pada obat diare Anda

• Periksa level elektrolit Anda dan / atau berikan cairan IV

• Periksa adanya infeksi sebagai penyebab diare

• Ubah jadwal atau dosis kemoterapi

Terkadang, diare disebabkan oleh pankreas yang tidak bekerja dengan baik. Ini terjadi pada
beberapa orang dengan kanker pankreas. Dalam kasus seperti itu, mengganti enzim pankreas
dapat membantu.