PHARMACOTHERAPY

DIARRHEA
 Definisi DIARE
• Diare:
buang air besar(defekasi)berbentuk cair
atau setengah cair(setengah padat),
kandungan air tinja lebih dari 200 gram
atau 200 ml/24 jam
• Diare:
BAB cair atau lembek dengan frekuensi
lebih dari 2-3x sehari atau didapatkan
penurunan konsistensi dan
peningkatan frekuensi BAB
dibandingkan yang biasanya (Wanke et al., 2008a;
Ahlquist & Camilleri, 2001)
DEFINITION&
EPIDEMIOLOGY
• Definition
– Increase in frequency
– Decrease in consictency
• Epidemiology
– Too many
(unmeasurable)
– 1.3 billion/year in world
– 4 million mortality
 ETIOLOGY
PRIMER (body defense mechanism)
• Food
• Infections
• Malabsorption
• Medications
• Stress
SECUNDER (the other disease)
• Inflammatory Bowel Disease
• Cancer
• Etc.
 Klasifikasi berdasar penyebab

• Diare spesifik:tanda yang muncul spesifik,

adanya lendir dan darah di feses, demam
Penyebab: bakteri, parasit, amuba
• Diare non spesifik:feses cair, lembek,
tidak ada darah, tidak ada ledir dan
demam
Penyebab: makanan, malabsorbsi, stress
 DIARE SPESIFIK
FESES
• Bau langu = infeksi virus
• Bau busuk, ada lendir, darah = agen
enteroinvasif
(Shigela, Salmonela, Campylobakter)
• Bau asam = gangguan osmolaritas
Klasifikasi diare durasi kejadian
• Akut:
berlangsung ≤3 hari (72 jam)self limiting
disease
• Kronik:
Berlangsung ≥ 14 hari cari tahu
penyebabpilih obat yang sesuai
• Persisten:
berlangsung lebih dari 30 hari
 PATOFISIOLOGI
• GANGGUAN ABSORBSI

INFEKSI/MALNUTRISISEL EPITEL
RUSAKMALABSORBSIDIARE
• GANGGUAN SEKRETORIK

GABUNGAN GANGGUAN
ABSORBSI DAN SEKRESI
 GANGGUAN SEKRESI
• Kuman/toksinsel  memacu siklik
AMP(CAMP) di sel epitel ususCAMP↑
memacu pengeluaran ion Cl yg
berlebihintrasel lebih positiv 
homeostasis ion Na di eksresikan  Na
keluar H2O keluar  feses encer

• Contoh : makanan
Cyclic AMP-CAMP
GANGGUAN MOTILITAS
• Pacuan neural&hormonal (Ach) Motilitas
meningkatAbsorbsi terganggu masa feses yg
belum saatnya dikeluarkan dipaksa keluar 
frekuensi ↑ (tidak encer, hanya lembek)

• Contoh: stress. obat

• GANGGUAN OSMOLARITAS

Berkurangnya enzim  Kh. tidak terdigesti /

gagal terabsorbsi  diubah mjd asam laktat
 osmolaritas naik  usus menarik cairan 
hipotonis Diare banyak dan cair

Contoh: obat
 Keseimbangan
Cairan dan Elektrolit
• 9 L/hari cairan masuk
• Jejenum
• Air, Na, Cl, K diserap
• HCO3 diekskresikan
• ileum
• 1-1,5L/hari cairan
masuk kolon
• colon. • Na dan Cl diabsorbsi
• K dan HCO3 diekskresi
 DESIRED OUTCOMES &
STRATEGY
Goal therapy: Strategi:
• Prevent • Diet Management
dehydration and • Rehydration
malnutrition • Antidiarrhe
• Stop diarhe • Therapy causative
(Establish normal
bowel pattern) • Symptomatic
treatment
• Relieve symtom
Rekomendasi Terapi
lanjutan
 REHIDRASI
• Tanpa dehidrasi : dgn Cairan Rumah tangga (1gelas
air+2 sdm gula+1 sdt garam)
• Untuk dehidrasi ringan oralit, peroral ,75cc/kgBB,
<300mOsm
• Untuk dehidrasi berat
Ringer Laktat iv (29g
glukosa:3,5gNaCl:2,5gBicNat:1,5g KCL) / L
30cc/kgBB, 70cc/kgBB
bisa diganti NaCl isotonis + Bicnat 7,5% 50 ml/L
 ORALIT/PHAROLIT
• Dosis: sesuai keadaan
• >1 th : 2jam pertama 2 gelas
larutan:selanjutnya ½ gelas tiap buang air
besar
• 1-5 th: 2jam pertama 4 gelas larutan,
selanjutnya 1 gelas tiap buang air besar
• >5th &dewasa: 2jam pertama 6 gelas,
selanjutnya 2 gelas tiap buang air besar
SIGN OF DEHYDRATION
• Vomiting, kesadaran apatis, tensi
sistolik<90, nadi > 120/menit, nafas >
30/menit, turgor kulit menurun, jari
tangan keriput, ektremitas dingin  score
1
• Serak, koma, sianosis, tensi diastolik<60
 score 2
Volume cairan yg ditambahkan dalam 2 jam
Score/15X10%XBB(kg)X1 Liter
Pediatric Diare
 DIARRHEA
INFECTIOUS
Common Foodborne Pathogens
• − Bacterial
• − Parasitic
• − Viral
Traveler’s Diarrhea
 CAMPYLOBACTER
• Second most commonly reported cause of diarrhea in
US
− 1-6 million cases per year
• Sources: raw poultry, meat, unpasteurized milk
• Incubation period: 2-5 days
• Symptoms: diarrhea, abdominal cramps, fever, bloody
• stools, vomiting (C. jejuni, C. coli), bacteremia (C.
fetus)
• Duration: 2-10 days
• Treatment: macrolides (DOC-C. jejuni), quinolones,
carbapenem (DOC-C. fetus)
 SALMONELOSIS
• Recently replaced Campylobacter as most commonly
reported cause of diarrhea in U.S.
• Sources: Poultry (microwaveable stuffed chicken
• products), reptiles (pet turtles), livestock, pets
(nontyphi);
• humans (typhi), raw eggs (CSC “cake batter” ice
• cream)
• Incubation period: 1-3 days
• 40,000 (non-typhi) and 350 (typhi) cases reported in the
• Duration: 4-7 days
• Treatment: antibiotics not routinely needed; may prolong
transmission period and cause relapse
 SHIGELA
• Sources: milk, dairy products, potato salad
(food/water
contaminated with fecal matter)
• Incubation period: 24-48 hours (highly contagious)
• Serogroups: dysenteriae, flexneri, boydii, sonnei*
• Symptoms: abdominal cramps, diarrhea, fever,
bloody/mucus stool
• Duration: 4-7 days
• Treatment: DOC-FQ (cipro OK in kids),
ceftriaxone/cefixime (efficacy varies), azithromycin,
− Shorten duration, reduces transmission
 DIARE TRAVELLERS
• Rapid, dramatic change in GI flora
• Include potential pathogens:
• Bacterial (60%)
− Campylobacter (0-30%)
− Salmonella (0-15%)
− Shigella (0-15%)
• Viral (10%)
− Rotavirus (0-20%)
• Parasitic (3%)
• Unknown (20-30%)
 TREATMENT OF
INFECTIOUS DIARRHEA
BAC FQ DOXI MKRL CEFTR KOTR

Camp √ √ √
E Coli √ √ √
Salm √ √ √ √
Shige √ √ √ √
Vibrio √ √
Yersini √ √ √
 TERAPI ANTIBIOTIK
 PENYEBAB  KEBERHASILAN
- Rotavirus © tidak efektif
- Enterotoksin © tidak efektif
- Shigella © efektif
- Campylobacter © efektif, bila cepat
diberikan
- Vibrio Colera © efektif
- Salmonela © tidak efektif,
nontify kec.komplikasi
- E. Histolitica © efektif
 PILIHAN ANTIBIOTIK
 Shigella : Kotrimoksazol (4X500/5 hari),
Asam nalidisat dan Ampisilin (dibeberapa
daerah) 4X250/10 hari
 Campylobacter : Eritromisin (3X500/7 hari)

 Vibrio Colera : Kotrimoksazol (2X3,2X2, dlm

6 hari), Kloramfenikol (4X500/7hari) dan
Eritromisin
 E. Histolitika atau amuba lain : Metronidazol
(4X500/3 hari)
 ANTI DIARE
– ADSORBEN mengabsorbsi ion disekitar
lumen usus (attapulgit*newdiatap,enterostop)
– DEMULCEN (kaolin-pectin)
– ASTRINGENT (diapet)
– ANTIMOTILITY (OPIAT) (loperamid)
– ANTISECRETORI (bismut subsalisilat)
– PROBIOTIK (lactobacilus *lacto-B)
 OPIOID
• Agonist at opioid receptors of GI muscle
• Reduce muscle movement, but increase tone of
contraction of rectal sphincter
• Reduce fluid & electrolyte secretion in GI
• Fast action
• Cause addiction (long term usage)
• Caution to use in children
• Loperamide (ImodiumR), diphenoxylate (LomotilR) :
potency > opium tincture
 THE OTHERS
• Adsorbent - charcoal, kaolin, chalk: trap
toxin, substance into their suface
• Astringent - tea leaves: precipitate
surface protein -> reduce diarrhea
• Bismuth subsalicylate: inhibit PG secre tion
-> inhibit diarrhea
• Octreotide: somatostatin receptor binding
-> inhibit GI fluid secretion
• Probiotic : recolonisasi (lactobacillus)
 TERAPI DIARE
TRAVELLERS
• Oral fluids: in most cases, all that is needed
− Decreased frequency of stools 16-18%
− Shortened duration of illness
• Antimotility agents:
− Decrease stool frequency by 50%; reduce duration to
hours
− Avoid in patients with blood in stool or high fever
Antibiotics:
− Illness can be shortened to 1-1.5 days
− Three days of treatment recommended, but single
dose therapy is an option
TERAPI MALABSORBSI

LEMAK ~ Giardia : antiparasit

Tidak adanya enzim : desensitisasi
terapi enzim
KARBOHIDRAT ~ terapi enzim
 TERAPI
SIMPTOMATIK
• TIDAK DIANJURKAN ! HARUS
HATI-HATI, dengan
PERTIMBANGAN YANG BAIK

• Jika amat sakit ~ loperamid

dalam jangka pendek (3-4
tablet) selama 1-2 hari

• tidak diperkenankan utk anak”

• Antiemetik~waspada
efek kejang pada anak

Carboadsorben~tidak
dianjurkan untuk diare
akut
TERAPI HERBAL
• SAMBILOTO
(Andrographidis herba)

• ~efektif menghambat
enterotoksin dari E. Coli

• (tidak diperkenankan
untuk masa kehamilan-
abortifum)
 Enteral Nutrition (EN): Management of Diarrhea Guideline
www.criticalcarenutrition.com

START

Stool output>3-5 No
liquid BM or >750 mL No Intervention.
over 24 hr?

Yes

No No No No
Distended, tympanic, Medical/surgical hx Receiving cathartic
Risk of stool impaction?
or painful abdomen? consistent with diarrhea? agents? (see orange
(see blue box)
(see purple box) box)

Yes Yes Yes Yes

Discontinue EN. Change all oral liquid medications to

Medical intervention Rectal check; manual
MD to review pt. tablet or parenteral alternative;
as indicated. disimpaction if positive.
change oral electrolyte solutions to
Obtain abdominal x-ray
parenteral route; discontinue all
to rule out more proximal
known cathartics (see orange box)
impaction as indicated.
IBD, terminal ileal resection, chemotherapy, if possible.
short bowel, chronic pancreatitis, new ileostomy.

Chronic constipation, absent BM x 5 day,

elderly, regular narcotic use, limited fluid intake.

Citromag®, docusate, Milk of Magnesia® Rule out C. difficile infection,

No
cascara, enema, hypertonic or sorbtol- Initiate antidiarrheal agent. bowel obstruction, bowel ischemia,
Diarrhea resolved?
containg liquid medications, oral electrolyte Reassess need/dose q 24 hr. etc. If investigations negative,
solutions, lactulose, Kayexalate®, prokinetic consider a fiber- containing
agents, etc. enteral formulae.

Developed by: J. Greenwood, RD (Vancouver General Hospital) in collaboration with the CCCCPGC (23/6/03)
 PENCEGAHAN
DIARE
• 1. HIGYENE YANG BAIK

• 2. SANITASI, sumber air

• 3. DAYA TAHAN, gizi,

imunisasi, vit.A
 TUGAS
• Buat resume obat antidiare yg beredar di
Indonesia, Mekanisme obat, dosis
a. demulcen, adsorben
b. Astringent
c. Antimotilitas (opioid)
d. Probiotik
e. Antisekretori