SKENARIO 2 BLOK

GASTROINTESTIAL,
HEPATOLOGI, DAN PANKREAS
 KELOMPOK SGD 6
Ketua : Daffa Jihan Azmi Rambe 173307010027
Sekretaris : Tamimi Badzlina Nasution 173307010073
Anggota : Dea Christa 173307010006
Novita Dwi F 173307010020
Nindi Dwi Anggita 173307010023
Andre Jean Hananya 173307010026
Bunga Tiara Dita 173307010029
Pratama Zendrato 173307010045
Ably Dharmiati 173307010060
M. Insan Andika 173307010072
Ayu Hasanah Panjaitan. 173307010075
Sania Angelisa 173307010088
Rifki Meilando 173307010106
Skenario
Seorang bayi laki-laki, umur 5 bulan, dibawa ibunya ke puskesmas rawat
inap dengan keluhan mencret selama 3 hari, tidak ada lendir dan darah.
Frekuensi BAB 6-8 kali/hari, dengan volume kira kira setengah gelas
aqua/kali, komposisi : air lebih banyak dari ampas. Bayi mendapat ASI
dan sekali-kali mendapat susu formula ketika ibunya bekerja. Riwayat
demam (+) tidak begitu tinggi selama 2 hari, disertai muntah-muntah 3-4
kali/hari.
More Info 1
Pada pemeriksaan fisik dijumpai BB kg, bayi gelisah, mata sangat
cekung, sewaktu diberi minum oralit bayi muntah, turgor kembali dalam 4
detik. Pernafasan cepat (48 kali/menit), disertai takikardi (126 kali/menit),
dengan temperature 38,5 C. Pemeriksaan fisik jantung dan paru: Dalam
batas normal. Pemeriksaan fisik abdomen: Soepel, peristaltic meningkat.
More Info 2
Pada pemeriksaan laboratorium: dalam batas normal. Pada pemeriksaan
feses rutin: tidak ada kelainan. Dokter memberikan penatalaksanaan awal
pada pasien ini.
Lo. 1 Definition, Epidemiology, Etiology,
Pathogenesis of Diarrhea
Definition
Diarrhea is a bowel movement (defecation) with stools in the form of
liquid or half liquid (half solid), more fecal water content than usually
more than 200 grams or 200 ml/24 hours.

Acute diarrhea is defined as stools that are liquid or soft with more than
normal amounts, lasting less than 14 days.

Chronic diarrhea is diarrhea that lasts for 15 days.

Epidemiology
In Indonesia, every year there are around 100 million episodes of diarrhea in
adults per year. From the integrated surveillance report in 1989 the number of
diarrhea cases was obtained 13.3% in the Puskesmas, in the hospital obtained
0.45% in patients with hospitalization and 0.05% of outpatients. The main causes
of dysentery in Indonesia are Shigella, Salmonella, Campylobacter jejuni,
Escherichia coli, and Entamoeba histolytica. Severe dysentery due to Shigella
dysentery can sometimes also be caused by Shigella flexneri, Salmonella and
Enteroinvasive E. coli (EIEC).
Etiology
Acute diarrhea due to infection caused by the entry of microorganisms or toxins by
mouth. These germs can be through water, food or drinks contaminated with human or
animal feces, the contamination can be through the fingers / hands of patients who
have been contaminated (Suzanna, 1993). Microorganisms that cause acute diarrhea
due to infections as below:

VIRUS BACTERIA PROTOZOA

Rotavirus Shigella Giardia Lamblia
Norwalk virus Salmonella Entamoeba
Enteric adenovirus Campylobacter Histolytica
Calicivirus Eschersia Cryptosporidium
Astrovirus Yersinina
Small round viruses Clostridium difficile
Coronavirus Staphylococcus aurens
cytomegalovirus Bacillus cereus
Vibrio cholerae
Pathogenesis of Diarrhea
The pathogenesis of diarrhea is generally divided into several
categories:
◦ osmotic diarrhea
Caused by the intralumen osmolarity of the intestine is higher than
the osmolarity of the serum so that the fluid in the intestinal lumen
increases.
◦ Secretory Diarrhea
Caused by an increase in intestinal fluid secretion and reduced
absorption rate.
◦ Diarrhea due to motility disorders
This is caused by a rapid transit period so that the time of absorption
of water by the intestine is short to make the stool solid.
◦ Inflammatory / exudative diarrhea
Caused by the chronic inflammatory process of the intestinal wall in
the form of mucous, blood and protein exudation.
Reference : Buku Ajar ilmu penyakit dalam jilid 2 edisi VI BAB 23.
Gastroenterology diare Dharmika Djojoningrat. Hal 1735.
Lo. 2 Classification of Diarrhea and Risk
Factors
1. Diarrhea based on time
1. Acute diarrhea: diarrhea that occurs suddenly in infants and children who are
previously healthy.
2. Chronic diarrhea: diarrhea that continues for 2 weeks or more by losing
weight or losing weight (failure to thrive) during the diarrhea period. Chronic
diarrhea consists of:
a. Persistent diarrhea: diarrhea caused by infection.
b. Protacted diarrhea: diarrhea lasting more than 2 weeks with liquid stools
and a frequency of 4x or more per day.
c. Prolonged diarrhea: diarrhea that lasts more than 7 days Intractable.
d. Diarrhea: diarrhea that occurs repeatedly in a short time (eg 1-3 months)
e. Chronic non specific diarrhea: diarrhea lasting more than 3 weeks but not
accompanied by growth disorders and no signs of infection or
malabsorption.
2. Diarrhea based on causes
The cause of diarrhea can be divided into 2 parts, namely direct causes and indirect
causes or factors that can facilitate or accelerate the occurrence of diarrhea.

nutritional Sanitation Socio- Diarrhea

condition Hygiene cultural sufferers

Germs / causes of COMMUNITY Career

diarrheal diseases died

Population Social Other

density economy
factors
3. Diarrhea based on pathophysiology
1. Diarrhea secretion (secretory diarrhea) is caused by:
◦ Viral infections, pathogenic and apatogenic germs Small intestine
◦ Hiperperistaltic which can be caused by chemicals, food (eg food poisoning, spicy
food, already stale, etc.), nervous disorders, cold air, allergies, etc. Immune
◦ Deficiencies, especially SIgA (secretory Immunoglobulin A) which results in
overgrowth of bacteria / fungi.

2. Osmotic diarrhea (osmotic diarrhea)

◦ Food malabsorption
◦ KKP (Protein Calorie Deficiency)
◦ LBW (Infants Low Birth Weight) and newborns
Risk factor
1. The host 3.Environment
a) Age a) Environment sanitation
b) Gender b) Personal hygiene
c) Immunization Status c) Clean water supply
d) Exclusive breastfeeding
e) Nutritional status

2. Agent
a) Diarrhea because of a virus
b) Diarrhea due to bacteria
c) Diarrhea due to parasite
Reference : Suraatmaja, Sudaryat. 2005. Kapita Selekta
GASTROENTEROLOGI ANAK. Jakarta: CV. Sagung Seto
Lo. 3 Clinical Symptoms, Diagnosis of
Diarrhea, and Investigation
Clinical symptoms of diarrhea
Initially babies and children who experience diarrhea initially become whiny,
restless, body temperature usually increases, appetite decreases or does not
exist, then diarrhea develops. The stool is liquid and may be accompanied by
mucus and or blood. The stool's color is increasingly greenish because it is
mixed with bile. Anus and the surrounding area are blister due to frequent
defecation and stools becoming more acidic as a result of the increasing
number of lactic acid, which comes from lactose which cannot be absorbed by
the intestine during diarrhea. Symptoms of vomiting can occur before or after
diarrhea and can be caused by the stomach which is also inflamed or due to a
disturbance of acid base and electrolyte balance. If the patient has lost a lot of
fluids and electrolytes, then the symptoms of dehydration begin to appear.
Dehydration is a symptom that immediately occurs due to repetitive discharge
of feces.
Diagnosis
History of Diarrhea
• The frequency of bowel movements?
6-8 times per day, with a volume of 1/2 aqua glass per time
• The duration of diarrhea occurs (how many days?)
3 days
• Is there blood in the feces?
nothing
• Is there vomiting?
There is 3-4 times / day
• Local report on cholera outbreaks?
nothing
• Treatment of antibiotics recently taken by the child or other treatments?
nothing
• Symptoms of invagination (loud crying and pallor in the baby).
nothing
Physical examination Search:
Signs of mild dehydration or severe dehydration:
◦ fussy or nervous
◦ letargis / consciousness diminishes
◦ sunken eyes
◦ pinch the back of the stomach skin
◦ slowly or very slowly thirsty / drunk, or lazy to drink or unable to drink.
Vital signs:
◦ Fever
◦ Tachycard
◦ Takipnoe
◦ TD: -
Degree of Dehydration
Additional Checks
1. Stool: microscopic (is there mucus, blood, and WBC) and serology of rotavirus
2. CBC 3
3. Electrolytes
4. BUN and creatinine
Lo. 4 Differential Diagnosis
 Acute Diarrhea
Types / Frequency Baby Children Teenager
Oten Gastroenteritis Gastroenteritis Gastroenteritis
Sistemic infection Food poisoning Food poisoning
Related to antibiotic Sistemic infection R. of antibiotic
Overveeding Related of
(eating / excessive antibiotics
drinking)

Seldom Deficiency primer Ingested toxic Hyperthyroid-

disaccharidase material ism
Hirschsprung toxic
colitis
Adrenogenital
syndrome
 Chronic Diarrhea
Types / Frequency Baby Children Teenager
◦ Often Secondary lactase Secondary lactase Irritable Bowel
deficiency deficiency Syndrome
Cow / soy milk Post-infection Irritable Bowel
intolerance Disease
Nonspecific chronic Irritable Bowel Lactose
diarrhea Syndrome Intolerance

◦ Seldom Primary immune Enteropaty AIDS Enteropaty

system defects AIDS
Familial villous Immune System Secretory
atrophy defect tumor
Secretory Tumors Secretory Tumors Primary
intestinal
tumor
Referance
Nelson Ilmu Kesehatan Anak Esensial Edisi Keenam. Karen J. Marcdante, Robert M. Kleigman, Hal B. Jenson,
Richard E. Behrman. Hal 460
Lo. 5 MANAGEMENT OF
DIARRHEA
Management
1. Anti – Motility
◦ Loperamide
2. Adsorbents
◦ Attapulgite
◦ Kaolin
3. Other Treatment
◦ Oralit
◦ Probiotic
◦ Zinc
5 PILLARS OF DIARRHEA
1. Oralit
2. Zinc
3. Antibiotic
4. Breast Milk
5. Education
Reference :
- Basic Pharmacology & Drug notes, Edisi 2017, Hal 43-46.
- Buku Saku Lintas Diare, Departemen Kesehatan RI, edisi 2011.
- Situasi Diare di Indonesia, Departemen Kesehatan RI, edisi 2011.
Lo. 6 Complications, Prevention, and
Prognosis
Complication
1. Hypernatremia 9. Lactose intolerance
2. Hyponatremia 10.Glucose malabsorption
3. Fever 11.Gag
4. Edema /overhydration 12.Kidney failure
5. Acidosis
6. Hypokalemia
7. Paralytic Ileus
8. Seizures
Prognosis
Many patients experience diarrhea with an onset that quickly suffers
from a disease that is not too severe and can heal itself without the need for
treatment or evaluation. In severe cases, the greatest risk is dehydration
and electrolyte imbalance, especially in patients with infants, children and
the elderly who are weak.
In acute diarrhea, a good history and clinical examination must be done
to determine the diagnosis and good clinical examination to determine the
diagnosis of the cause of acute diarrhea and the presence / absence of
dehydration. Management of acute diarrhea consists of rehydration, diet,
anti-diarrhea drugs and anti-microbial drugs if the cause is infection.
Prevention
1. Exclusive breastfeeding
2. 2. Use of pacifiers and sterile milk bottles
3. Provision of correct weaning food (complementary food)
4. Maintain personal hygiene by washing hands before giving food
5. Maintain environmental cleanliness
6. CHAPTER in the toilet
7. Measles immunization
8. Rotavirus immunization
9. Vitamin A supplementation
10.Provision of clean drinking water, and food is always cooked thoroughly.
11.Avoid giving antibiotics and antidiarrhea that is not in accordance with the doctor's
recommendations.
Referensi :
- Goodman & Gilman. 2016. Manual Farmakologi dan Terapi. Jakarta: EGC. Hal:605
- Setiati S, Alwi I, dkk. 2014. Buku Ajar Ilmu Penyakit Dalam Jilid II. VI. Jakarta:InternaPublishing. Hal:1908
- Pelayanan kesehatan anak di rumah sakit. Jakarta: World health organization (WHO) Indonesia; 2009. P. 133-
134, 138-145.