B. Subagyo
ACUTE DIAORHHEA
Diarrhea, its come from Greek= to flow
through,penyakit gangguan transport air dan
elektrolit intestinal
Defekasi normal :
*Bayi minum ASI, 2-3-4 wks:4-12 x/hari-lebih
berat badan meningkat/ tidak menurun
*Infant: formula feeding, defekasi 1-3 X/hari
* normal 4 tahun atau lebih: < 3 x / hari
*Normal infant, daef: 5-10 g/kg bb weight/day.
*Adult: 100-200 gr/day
(J.M.Rhoads & D.W.Powel,
1991)
DEFINISI DIARE AKUT:
1. Peningkatan Frekuensi buang air
besar
2.Perubahan konsistensi & frekuensi
3.Neonatus: BAB > 4 kali/hari (ASI: > 4
kali,normal bisa > 12 x) BAB > 10
gr/kg bb/hari. Anak > 3 th; bab >
200 gr/hari
4.Bersifat mendadak
5.Berlangsung < 1 minggu
(S/D < 14 HARI) Pada anak yang
sebelumnya sehat (J.M.Rhoads & D.W.Powel,
1991)
DEFINISI DIARE AKUT
DIARE BERLANGSUNG < 14 HARI
Umumnya kurang dari 7 HARI)
BAB lunak-cair, darah +/-, lendir +/-
Muntah +/-, panas +/-
ASI +/-
PASI +/-
DIARE PERSISTEN
DIARE BERLANGSUNG LEBIH DARI 14 HARI
DIARE KRONIK,
DIARE YG BERLANGSUNG LEBIH DARI 14
HARI BERLANGSUNG INTERMITEN (HILANG
TIMBUL (PMPD. 1999)
ETIOLOGI:
*INFEKSI; Amoeba , Cholera, E. coli
*NONINFEKSI MISALNYA
ALERGI SUSU SAPI (CMA) s/d 1-2-3 th
*AIDS
*dari infeksi akut sembuh lamamalnutrisi
*Malabsorpsi : KH, Lemak, Pretein
EPIDEMIOLOGI
Prevalensi diare tinggi :
*Usia 6 bulan - 2 tahun: +PASI
*masa/fase oral,
*sistim imun mukosa usus belum sempurna,
*antibodi (SIgA) terhadap virus minimalVirus Rota,
*mulai PASI
*CMA
*Hygiene dan sanitasi buruk
*Terjadi pd bulan-bulan tertentu
*Kadang terjadi KLB
*Di Indonesia terdapat 60 juta / tahun, dimana 1 – 5
% menjadi diare kronik
CARA PENULARAN ANTIGEN:
FEKAL-ORAL:
*air minum-makanan yg tercemar
*bakteri-virus: PER-FEKAL-ORAL
dapat melalui-vektor: spt lalat-atau
serangga lainnya
*atau langsung seperti
-mandi (di sungai), tangan kotor,
cuci pakaian kotor, membersihkan
tinja, cuci sayuran dengan air kotor.
CARA PENULARAN
4 F: FINGERS
FESES-FLUID ORAL
FOODS
FLIES
FINGERS
FEKAL
KUMAN / VIRUS
AIR/ MAKANAN/VEKTOR
DIARE
ROTAVIRUS
LAKTASE DEFF
LAKTOSE INTRA.LUMINAL
OSMOL
menyerap “air” jar usus
DIARE
CMA/FOOD ALLERGY
efektor; m.g.i
DIARE
SIKAP PERILAKU & WAHAM
PENYEBAB MEMBURUKNYA
DIARE
Waham: anak njalaki-anak, mau tambah pintar
Anak diare cair,ibu melarang banyak minum
Masa “oral” 6 bulan-12 bulan (24 bulan)
Perilaku tidak higienis:
Makanan-minuman kotor/dihinggapi lalat
Makanan-air minum tidak dimasak
Alergi, sistim kekebalan minimal
Penggunakan PASI yg tidak benar(susu formula: takaran,
kebersihan, termasuk kebersihan alat2 minum)
Gencarnya Promosi promosi PASI~pendidikan &
sosioekonomi masyarakat. (susu formula)
PEMBAGIAN DIARE
Berdasarkan
Etiologi :
rus : Bakteri :
Parasit :
otavirus -E. coli ALERGI
-Entamoeb
erbanyak)-Salmonella
a malabsorpsi
nterovirus -Shigella
-Cryptospor
c -Staphyllococus,etc idium
-etc
ETIOLOGI DIARE
Causative agent of gastroenteritis VIRUS
BACTERIA Astrovirus
Calciviruses
Aeromonas Norovirus **
Bacillus cereus Enteric Adenovirus
Campylobacter jejuni Rotavirus
Clostridium perfringens Cytomegalovirus *
Herpes Simplex Virus *
Clostridium difficile PARASITER
Escheria coli Balantidium Coli
Pleisomonas Shigellosis Blastocystis hominis
Salmonella Cryptosporodium Parvum
Cyclospora Cayetanensis
Shigella
Encephalitozoon Intestinalis *
Staphylococcus aureus Entamoboeba histolytica
Vibriocholerae 01 and 0139 Enterocutazoon biemeasi
Vibrio parahaemolyticus Giardia Lamblia
Yersinia enterocolitica Isospora belli
* Generally Associated with disease, only among Strongiloides Stercoralis
Trichuris Trichuria
immunocompromised person
** Norvalk like viruses
Other Causes of Diarrhea
FEEDING DIFFICULTY FOOD POISONING
ANATOMIC DEFECT Heavy Metal
Malrotation Scombroid
Intestinal duplication Ciguatera
Hirschprung Disease Mudhrooms
Fecal Impaction NEOPLASMA
Short Bowel Syndrome Neuroblastoma
Microvillus Atrophy Ganglioneuroma
Strictures Phaechromocytomas
MALABSORPTION Carcinoid
Disacharidase Deficiencies Zolinger-Ellison Syndrome
Glucose-Galactose Malabsorption Vasoactive Intestinal Peptide Syndrome
Pancreatic Insufficiency
MISCELLANEUS
- Cystic Fibrosis
Nongastrointestinal Infection
- Schwachmann Syndrome
Milk Allergy
Reduced Intraluminal bile Salts
Crohn Disease ( Regional enteritis)
- Cholestasis
Familial dysautonomia
Hartnup Disease
Abetalipoproteinemia
Protein-losing enteropathy
Celiac Disease Ulcerative Colitis
ENDOCRINOPATHIES Acrodermatitis enteropathy
Thyrotoxicosis Laxative abuse
Addison disease Motility disorders
Adrenogenital Syndrome Pellagra
Differential Diagnosis of Osmotic
versus secretory Diarrhea
Osmotic Diarr Secretoric Diarr
Vol of Stool < 200 ml/24 hrs > 200 ml/24 hrs
Response to fasting
diarrhea stop diarrhea continue
Stool Na+ < 70 mEq/L >70mEq/L
Reducing substances
positif negative
Stool pH <5 >6
Calcium – Dependent
Bacterial toxins : Clostridium difficile enterotoxin
Neurotransmitters : Acethylcholine, Serotonin
Paracrine Agent : Bradykinin
Causes of Osmotic Diarrhea
Malabsorption of Water-Soluble Nutrients
Glucose-Galactose Malabsorption
- Congenital
- Acquired
Disaccharidase Deficiencies ( Lactase & Sucrase Isomaltase)
- Congenital
- Acquired
Excessive intake of Carbonates fluids
Excessive intake of nonabsorbable soluts
- Sorbitol
- Lactulose
- Magnesium hydroxide
F.K Ghisham 2004
BACTERIAL ENTEROTOXINS THAT AFFECT
INTESTINAL ELECTROLYTE TRANSPORT
TROUGH STIMULATION OF ADENYLATE OR
GUANYLATE CYCLASE
Drugs
*Chemotheurapeutic agent (e,g..cytosine
arabinose, methotrexate)
*Ipecac
*Neomycin
*Para-amino salicylic acid
Crohn’s Disease
Cause of Small Bowel Villous Damage &
Crypt Hyperplasia
Irradiation
Autoimmune Enteropathy
Small Bowel Ischemia
Eosinophilic Gastroenteropathy
H2O
Na+,Cl-,K+,HCO3- 311 oam/l
A.A-AL-MS 245 osm/l
285-295 osm/l
KUMAN-VIRUS MASUK
KERUSAKN VILI KEDALAM MULUT:
MANDI,MINUM, MAKAN
DIARE
Susu sapi Susu formula
Susu sapi Susu formula
Bayi Minum
ASI
CRO
SIKLUS DIARE AKUT-DIARE
KRONIK-MALNUTRISI-INFEKSI
GNG
DIARE
AKUT ABSORPSI
INFEKSI
DIARE KRONIK
MALNUTRISI
PEAK STOOL VOL ELEKTROLIT OSMOTIC GAP
ml/kg/day mMol/L
mOsm/L
290-2[(Na)
+(K)]
Na+ K+ Cl- HCO3-
Cholera 180 80 30 86 32 7
Enterotoxigenic
Escherichia coli
160 53 37 24 18 110
Rotavirus 130-160 37 38 22 6 140
Normal stool 5-10 22 54 21 ND 140
(askanatt)
APATIS, SOMNOLEN,KOMA, ASIDOSIS,NADI, AKRAL
DINGIN, TENSI TURUN, TURGOR JELEK
.B. Berdasarkan Skor Maurice King
Bagian tubuh Nilai 1 Nilai 2 Nilai 3
yg diperiksa
DEHIDRASI RINGAN/TANPA
DEHIDRASI:CAIRAN PER-ORAL (HF)
DEFISIT: 30-50 ML/KG BB/CRT/ORS/3-4jam
RUMATAN: 100 ML/KG BB
TETESAN CAIRAN INFUS
1 ML=15 TETES,
Kalau 1 TETES PERMENIT, maka dalam
1 JAM= 4 MLL, dalam
24 JAM= 96 ML
1 ML=20 TETES,
Kalau 1 TETES PERMENIT, maka dalam
1 JAM= 3 MLL , dalam
24 JAM= 72 ML
1 ML=60 TETES,
1 TETES PERMENIT, maka dalam
1 JAM= 1 MLL , dalam
APAKAH ANAK DIARE(MTBS)
JIKA YA, TANYAKAN:
SUDAH BERAPA LAMA?
APAKAH BERAKNYA BERDARAH (APAKAH ADA DARAH DALAM
TINJA?)
LIHAT & RABA:
LIHAT KEADAAN UMUM ANAK:
APAKAH ANAK: LETARGIS ATAU SADAR?
GELISAH & REWEL/MUDAH MARAH?
LIHAT APAKAH MATANYA CEKUNG?
BERI ANAK MINUM, APAKAH ANAK:
TIDAK BISA MINUM ATAU MALAS MINUM.
HAUS, MINUM DENGAN LAHAP?
CUBIT KULIT PERUT UNTUK MENGETAHUI TURGOR.
APAKAH KEMBALINYA: SANGAT LAMBAT(LEBIH DARI 2
DETIK)? LAMBAT
KLASIFIKASI DIARE
Tidak cukup tanda2 untuk diklasifikasikan
sebagai dehidrasi berat atau ringan/sedang
*TANPA DEHIDRASI
Beri cairan & makanan sesuai Rencana Terapi
A.
Nasehati ibu tentang kapan harus kembali
segera*kunjungan ulang setelah 5 hari bila
tidak ada perbaikan
Terdapat dua atau lebih dari tanda2 berikut:
Gelisah, rewel/mudah marah
Mata cekung
Haus, minum dengan lahap
Cubitan kulit perut kembalinya lambat
DEHIDRASI RINGAN/SEDANG
Beri cairan & makanan sesuai Rencana Terapi B.
Jika anak juga mempunyai klasifikasi berat lainnya:
Rujuk segera ke RS & selama dalam perjalanan
mintalah agar ibu memberikan larutan oralit sedikit
demi sedikit
Nasehati ibu kapan harus kembali
Kunjungan ulang setelah 5 hari bila tidak ada
perbaikan
Terdapat 2 atau lebih dari tanda2 berikut ini:
Letargis atau tidak sadar
Mata cekung
Tidak bisa minum atau malas minum
Cubitan kulit perut kembalinya lambat
DEHIDRASI BERAT:
Jika tidak ada klasifikasi berat lainnya:
Beri cairan untuk dehidrasi berat (Rencana Terapi C)
Jika anak juga mempunyai klasifikasi berat lainnya:
Rujuk segera & selama dalam perjalanan agar
mintalah ibu terus memberikan larutan oralit sedikit
demi sedikit
Anjuran agar ibu tetap memberikan ASI
Jika ada kolera didaerah tersebut, beri antibiotika
untuk kolera (MTBS, 1997)
C. Berdasarkan Gejala
Klinis
Gejala klinis Ringan Sedang Berat
i berat
sisa 100 ml-(20 ml) (40 ml) (60 ml) : 3 jam
Rumatan 100 ml dibagi sisa waktu(24 jam -3 jam
) Dehidras
i sedang 80 ml/kgBB/7 jam tetesan minimal
V (RL)
Oralit
Rumatan=100 ml/sisa waktu (CRT/ORS)
ORS
Dehidras Rumatan=100 ml dibagi sisa waktu
i ringan CRT
30-50 ml/kgBB/3-4 jam tetesan minimal
20 ml/kg(10’)-atau 30 ml/kg dalam 30’-60’
BAIK JELEK
BAIK JELEK
4 fold
Management of Dehydration
(WHO)
SIGNS No signs of Some (mod.) Severe
dehydration dehydration dehydration
G General
condition
well,
alert
restless,
irritable
lethargic,
unconscious
E Eyes normal sunken sunken
M Mouth &
Drinking
normal thirsty, drink
eagerly
poor or una-ble
to drink
S Skin pinch returns rapidly returns slowly very slowly
DEHIDRASI RINGAN
Diberikan CRT; 30-50 ml/kg BB/ atau
tetesan minimal
KOMPOSISI CAIRAN TUBUH
C.Intraselule
r 40%
Cairan
tubuh C.Intersti
60% sial 15 %
C.Ekstraselule
r 20 %
Plasma
Lemak,
darah
protein,
5%
mineral
40 %
KOMPOSISI CAIRAN
Cairan Na Cl K Ca Asetat laktat Dekst Kal Osm
ASAH-ASIH-ASUH:
NUTRISI:pendidikan OTU PENYAKIT:
PJB,DARAH,GINJAL
PARU,HATI, SAL.CERNA
SAL.URINE, SSM TLG,OTAK
MATA,HIDUNG,TELINGA DLL
HORMONAL (hipotiroid,pubertas
precock),sakit jiwa
TUMBUH KEMBANG
Shigella
(Thomas G.Cleary. T.B in Nelson;Textbook of Pediatrics, 2004)
Shigella species:
S.dysentriae (serogroup A); 13 serotype
S.flexneri (serogroup B); 15 serotype
S.boydii (serogroup C); 18 sertype
S.Sonnei (serogroup D); 1 serotype
Invasif
Shiga toxin=s.dysentriae serotype 1 & Shet-1
Transmisi
Contaminated food & water
Person to person transmission is the probably
the major mechanism of infection in the most
areas of the world.
Spread in the families, custodial instutions
& child care centers demonstrated the ability
of low numbers of organisms to cause
disease on person-to-person basis.
Transmisi
Shigella require very low inocula to cause illnes.
Ingestion of as low as 10 S.dysentriae serotype
1 organism can cause dysentery in some
susceptible individuals.
This is the contrast to organisms such Vibrio
cholerae, which require ingestion of 10 8-1010
organisms to cause illnes
The inoculum effect explains the ease of person
to person transmission of shigella in contrast to
V.cholerae
Pathogenesis
The basic virulence trait shared by all shigellae
is the ability to invade intestine.
This characteristic is encoded on a large (120-
140 megadalton) plasmid that is responsible for
synthesis of group of polypeptide involved in
cell invasion & killing. Shigellae that lose the
virulence plasmid enteroinvasive. E.coli that
harbor this plasmid (enteroinvasive E coli) be
have) clinically like shigellae.
Pathogenesis
Shiga toxin
A potent protein synthesis-inhibiting exotoxin,
is produced in significant amounts by
S.dysentriae serotype 1, by certain E.coli,
which are known as Shiga toxin-producing
E.coli (STEC), and rarely by other organisms.
The watery diarrhea fase of shigellosis may
be caused by enterotoxins
Pathogenesis
The pathologic changes of shigella take place primarily
in the colon, the target organ of shigellae. The
changes are most intense in the distal colon, although
pancolitis may accur. Grossly, localized or difusse
mucosal edema, ulceration, friable mucosal,bleeding &
exudate may be seen. Microscopycally ulcerations,
pseudomembranes, epithelial cell death, infiltration
extending from mucosae by polymorphonuclear &
mononuclear cells, & submucosal edema occur
Immunity
SIgA & serum antibodies develop within days to
weeks after ingestion with shigella.
Both antipolysaccharide & antivirulence plasmid
polypeptide antibodies have been described:
protection is serotype specific.
Induction of multiple cytikines & brisk
inflammatory respones is followed by healing.
Interferron-y produced by NK cells is critically
important to resistence.
Clinical Manifestation of Shigella
Bacillary dysentery is clinically similar
regardless of whether the disease is
caused by any of the four species of
shigella or enteroinvasive E.coli;
however, tehre are some clinical
differences, particulary relating to the
greater severity & risk of
complications with S.dysenterae
serotype 1 infection
Clinical Manifestation of
Shigella
Incubation:12 hr’s-day’s
Severe abdominal pain ( tenesmus )
High fever
Emesis, anoreksia, generalized toxicity, painful
defecation
Shiga toxin ~ convultion
Frekuent
Abdominal distention, tenderness, hyperactive bowel
sounds, tender rectum on digital examination.
Berak diawali cair dalam jumlah besar, diikuti bab
sedikit2
Clinical Manifestation of
Shigella
The diarrhea may be watery & large volume initialy,
evolving into frequent small-volume, bloody mucoid
stools; however, some children never progress the stage
of bloody diarrhea, whereas in others the firt stools are
bloody. Significant dehydration related to the fluid &
electrolyte losses in both feces & emesis can occur.
Untreated diarrhea may last 1-2 wk; only about 10% of
patients have diarrhea persisting for more than 10 days.
Persistent diarrhea accurs in malnourihed infant, those
with AIDS, and occasionally previously normal children.
Even nondysenteryc disease can be complicated by
persistent illness.
Clinical Manifestation of
Shigella
Neurologic findings are among the most
common extraintestinal manifestations of
bacillary dysentery, occuring in as many as
40% of hospitalized infected children.
Enteroinvasive E coli can cause similar
neurologic toxicity. Convultions, headache,
lethargy, confusion, nuchal rigidity, or
hallucinations may be present before or after
the onset of diarrhea.
Clinical Manifestation of
Shigella
The cause of these neurologic findings is
not understood. In the past, these
symptoms were attributed to the
neurotoxicity of Shiga toxin, but it is now
clear that axplanation is wrong. Seizures
sometimes occur when little fever is
present, suggesting that simple febrile
convultion do not explain their
appearance.
Hypocalcemia or hyponatremia may be
associated with seuzures in small
number patients. Althoug symptoms
often suggest central nervous system
infection, and cerebrospinal fluid
pleocytosis with minimally elevated
protein levels can occur, meningitis due
to shigellae is rare.
The most common complication of
shigellosis is dehydration. Inappropriate
secretion of antidiuretic hormone
Cholera (Vibrio Cholerae)
Diare cair~cucian beras
Diare frequent-disertai tumpah2
Cepat mengalami dehidrasi berat
Tanpa panas
Endemis
T/cairan rehidrasi
Tetrasiklinin-klroramfenicol-kotrimoxasol
Amoeba
Anak >3 tahun (?)=pola makan
bermacam2kontaminasi kuman>>
Berak lembek, berdarah, berlendir,
frekuensi kadang >10 x/hari
Tenesmus
Tanpa panas
T/metronidazole-tetrasiklin