TUTORIAL REPORT BLOCK Xlll SCENARIO A : BUDIS CASE

Created by : GROUP l

FACULTy OF MEDICINE SRIWIJAyA UNIVERSITy 2008

BLOCK XIII PROBLEM BASED LEARNING SCENARIO A Created by : Group I 1.Ahmad Angga Lutfi 2.Aulia Annisa Rizki 3.Bedry Qintha 4.Cahyani Indah 5.Defayudina Dafilianty R 6.Halbana Al Maududy 7.M Azril Rizal Bin Ghozali 8.Naveen Kumar 9.Prihatina Anjela 10. Resi Anita

The Outlines
The Outlines

Chapter I

: Introduction

1. Scenario : Scenario A Budis case 2. Terms Clarification 3. Problems Identification 4. Problems Analysis 5. Hypothesis

Chapter II

: Content

Chapter III

: Conclusion

1. Conclusion

CHAPTER I INTRODUCTION 1.SCENARIO

Budi, a boy, 12 years old, was hospitalized due to diarrhea. Four days before admission, the patient had non projectile vomiting 6 times a day. He vomited what he ate. Three days before admission the patient got diarrhea 10 times a day around half glass in every defecation. There was no blood and mucous. Along those 4 days, he only drank plain water. Yesterday, he looked worsening, still diarrhea but no vomiting. Urination in 8 hours was less than usual. Budis family is in slum area. He also got fever. Physical examination: Look severe ill, compos mentis, BP 70/50 mmhg, RR 28x/minute, HR 144x/minute regular but weak, body temperature 38,70C, body weight 8,8 kgs, body height 75 cm. Hollow eye, no teras drop, and dry mouth. Thoraks : Simetris, retraction (- /-), vesicular breath sound, normal heart sound. Abdomen : Flat, shuffle, bowel sound was increase. Liver was palpable 1 cm below arcus costae and xiphoid processus, spleen unpalbable. Positive turgor. Redness skin surrounding anal orifice. Additional information: Laboratory examination : Hb : 12,8 g/dl; WBC : 9000/mm3 ; defferential count : 0/1/16/48/35/0 Urine : Makroscopic : yellowish colour Microscopic : WBC (-), RBC (-), protein (-) Faeces rutin : Macroscopic : watery more than waste material, blood (-), pus (-) WBC : 2 - 4/WF, RBC (-)

2.TERMS CLARIFICATION
Diarrhea Loose, watery, and frequent stool Non projectile vomiting Vomiting without force Defecation The act or process by which organisms eliminate solid, semisolid or liquid waste material (feces) from the digestive tract via the anus Plain water Common water that consumed by people Slum area A city district inhabited by people living in huts and shanties

Fever Increase of body temperature Urination Process of disposing urine from the urinary bladder through the urethra to the outside of the body

3.PROBLEM INDENTIFICATION
-

Budi, 12 months a boy, was hospitalized due to diarrhea. Four days before admission, he had non projectile vomiting 6 times per day He vomited what he ate. Three days before admission the patient got diarrhea 10 times a day around half glass in every defecation. Along those 4 days, he only drank plain water. He looked worsening, still diarrhea but no vomiting. Urination in 8 hours was less than usual. He lives in slum area He got fever

4.PROBLEM ANALYSIS
1. What is the anatomy and physiology of GI tract in infant 2. Chief complaint : Diarrhea - What is the definition? - What is the etiology? - Hows the pathophysiology ? - What is the indication of being hospitalized ? 3. Additional complaint : 1. Vomiting - What is the definition? - What is the etiology? - Hows the pathophysiology ? 2. Fever - What is the definition? - What is the etiology? - Hows the pathophysiology ? 2. What is the pathogenesis of the disease ? 3. What is the relationship between slum area and the disease ? 4. How is the relations between only drink plain water with the disease ?

5. How to diagnose ? - Anamnesis - Physical examination - Laboratorium examination - Supporting exam 6. What is the working diagnose of the disease ? - What is the definition ? - What is the etiology ? - What is the risk factor ?

- What is the pathophysiology ? - What are the signs and symptoms ? 7. Management 8. Prevention 9. Complication 10. Prognosis

5.HYPOTHESIS
Budi, a 12 months boy, suffered from acute diarrhea and severe dehydration caused by suspect rotavirus.

CHAPTER II CONTENT
1. Anatomy and physiology of GI tract

The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral cavity, where food enters the mouth, continuing through the pharynx, oesophagus, stomach and intestines to the rectum and anus, where food is expelled. The primary purpose of the gastrointestinal tract is to break down food into nutrients, which can be absorbed into the body to provide energy. First food must be ingested into the mouth to be mechanically processed and moistened. Secondly, digestion occurs mainly in the stomach and small intestine where proteins, fats and carbohydrates are chemically broken down into their basic building blocks. Smaller molecules are then absorbed across the epithelium of the small intestine and subsequently enter the circulation. The large intestine plays a key role in reabsorbing excess water. Finally, undigested material and secreted waste products are excreted from the body via defecation (passing of faeces). In the case of gastrointestinal disease or disorders, these functions of the gastrointestinal tract are not achieved successfully. Patients may develop symptoms of nausea, vomiting, diarrhoea, malabsorption, constipation or obstruction. Gastrointestinal problems are very common and most people will have experienced some of the above symptoms several times throughout their lives.

Basic structure: The gastrointestinal tract is a muscular tube lined by a special layer of cells, called epithelium. The wall is divided into four layers as follows: Mucosa: The innermost layer of the digestive tract has specialised epithelial cells supported by an underlying connective tissue layer called the lamina propria. The lamina propria contains blood vessels, nerves, lymphoid tissue and glands that support the mucosa. Depending on its function, the epithelium may be simple (a single layer) or stratified (multiple layers). Areas such as the mouth and oesophagus are covered by a stratified squamous (flat) epithelium so they can survive the wear and tear of passing food. Simple columnar (tall) or glandular epithelium lines the stomach and intestines to aid secretion and absorption. The inner lining is constantly shed and replaced, making it one of the most rapidly dividing areas of the body. Submucosa: The submucosa surrounds the muscularis mucosa and consists of fat, fibrous connective tissue and larger vessels and nerves. At its outer margin there is a specialized nerve plexus called the submucosal plexus or Meissner plexus. This supplies the mucosa and submucosa. Muscularis externa: This smooth muscle layer has inner circular and outer longitudinal layers of muscle fibres separated by the myenteric plexus or Auerbach plexus. Neural innervations control the contraction of these muscles and hence the mechanical breakdown and peristalsis of the food within the lumen. Serosa/ Mesentery: The outer layer of the GIT is formed by fat and another layer of epithelial cells called mesothelium. The Individual Components of the Gastrointestinal System Oral cavity The oral cavity or mouth is responsible for the intake of food. It is lined by a stratified squamous oral mucosa with keratin covering those areas subject to significant abrasion, such as the tongue, hard palate and roof of the mouth. Mastication refers to the mechanical breakdown of food by chewing and chopping actions of the teeth. The tongue, a strong muscular organ, manipulates the food bolus to come in contact with the teeth. It is also the sensing organ of the mouth for touch, temperature and taste using its specialised sensors known as papillae. Insalivation refers to the mixing of the oral cavity contents with salivary gland secretions. The mucin (a glycoprotein) in saliva acts as a lubricant. The oral cavity also plays a limited role in the digestion of carbohydrates. The enzyme serum amylase, a component of saliva, starts the process of digestion of complex carbohydrates. The final function of the oral cavity is absorption of small molecules such as glucose and water, across the mucosa. From the mouth, food passes through the pharynx and oesophagus via the action of swallowing. Salivary Glands Three pairs of salivary glands communicate with the oral cavity: - Parotid - Submandibular - Sublingual Oesophagus The oesophagus is a muscular tube of approximately 25cm in length and 2cm in diameter. It extends from the pharynx to the stomach after passing through an opening in the diaphragm. The wall of the oesophagus is made up of inner circular and outer longitudinal layers of muscle that are supplied by the oesophageal nerve plexus. This nerve plexus surrounds the lower portion of the oesophagus. The oesophagus functions primarily as a transport medium between compartments.

Stomach The stomach is a J shaped expanded bag, located just left of the midline between the oesophagus and small intestine. It is divided into four main regions and has two borders called the greater and lesser curvatures. The first section is the cardia which surrounds the cardial orifice where the oesophagus enters the stomach. The fundus is the superior, dilated portion of the stomach that has contact with the left dome of the diaphragm. The body is the largest section between the fundus and the curved portion of the J. This is where most gastric glands are located and where most mixing of the food occurs. Finally the pylorus is the curved base of the stomach. Gastric contents are expelled into the proximal duodenum via the pyloric sphincter. The inner surface of the stomach is contracted into numerous longitudinal folds called rugae. These allow the stomach to stretch and expand when food enters. The stomach can hold up to 1.5 litres of material. The functions of the stomach include: The short-term storage of ingested food. Mechanical breakdown of food by churning and mixing motions. Chemical digestion of proteins by acids and enzymes. Stomach acid kills bugs and germs. Some absorption of substances such as alcohol. Most of these functions are achieved by the secretion of stomach juices by gastric glands in the body and fundus. Some cells are responsible for secreting acid and others secrete enzymes to break down proteins. Small Intestine The small intestine is composed of the duodenum, jejunum, and ileum. It averages approximately 6m in length, extending from the pyloric sphincter of the stomach to the ileo-caecal valve separating the ileum from the caecum. The small intestine is compressed into numerous folds and occupies a large proportion of the abdominal cavity. The duodenum is the proximal C-shaped section that curves around the head of the pancreas. The duodenum serves a mixing function as it combines digestive secretions from the pancreas and liver with the contents expelled from the stomach. The start of the jejunum is marked by a sharp bend, the duodenojejunal flexure. It is in the jejunum where the majority of digestion and absorption occurs. The final portion, the ileum, is the longest segment and empties into the caecum at the ileocaecal junction. The small intestine performs the majority of digestion and absorption of nutrients. Partly digested food from the stomach is further broken down by enzymes from the pancreas and bile salts from the liver and gallbladder. These secretions enter the duodenum at the Ampulla of Vater. After further digestion, food constituents such as proteins, fats, and carbohydrates are broken down to small building blocks and absorbed into the body's blood stream. The lining of the small intestine is made up of numerous permanent folds called plicae circulares. Each plica has numerous villi (folds of mucosa) and each villus is covered by epithelium with projecting microvilli (brush border). This increases the surface area for absorption by a factor of several hundred. The mucosa of the small intestine contains several specialised cells. Some are responsible for absorption, whilst others secrete digestive enzymes and mucous to protect the intestinal lining from digestive actions. Large Intestine The large intestine is horse-shoe shaped and extends around the small intestine like a frame. It consists of the appendix, caecum, ascending, transverse, descending and sigmoid colon, and the rectum. It has a length of approximately 1.5m and a width of 7.5cm. The caecum is the expanded pouch that receives material from the ileum and starts to compress food products into faecal material. Food then travels along the colon. The wall of the colon is made up of several pouches (haustra) that are held under tension by three thick bands of muscle (taenia coli).

Rectum RECTUM is where stool is stored before excreted. The opening through which stool leaves your body is called the ANUS (double-pointed arrow). The rectum is the final 15cm of the large intestine. It expands to hold faecal matter before it passes through the anorectal canal to the anus. Thick bands of muscle, known as sphincters, control the passage of faeces. The mucosa of the large intestine lacks villi seen in the small intestine. The mucosal surface is flat with several deep intestinal glands. Numerous goblet cells line the glands that secrete mucous to lubricate faecal matter as it solidifies. The functions of the large intestine can be summarised as: - The accumulation of unabsorbed material to form faeces. - Some digestion by bacteria. The bacteria are responsible for the formation of intestinal gas. - Reabsorption of water, salts, sugar and vitamins. Anus ANUS has two muscular sphincters, the Internal, and the External sphincters. These strong muscles are crucial in keeping the stool in your RECTUM until you can find a nice toilet. You can consciously control the external sphincter, but not the internal one. The Levator Ani is part of the pelvic floor muscles that also help keep you from moving your bowels before you find a toilet. 2. Diagnostic Approach a. Anamnesis 1. Identity : 2. Chief complaint : 3. Additional complaint : : : 4. Previous history : 5. Family history : b. Differential Diagnosis Clinical form Classification : Clinical : acute diarrhoea, cholera, dysentery Severity of dehydration : without dehydration mild-moderate dehydration severe dehydration Type of dehydration : isotonic, hypotonic, hypertonic Clinical complicated : complicated, uncomplicated Clinical Form: antimicrobial usage, differed to : Acute diarrhoea Cholera Dysentery Cholera : clinical manifestation typically, child > 3 year ( especially > 5 year), outbreaks accident Dysentery : Diarrhoea with blood and or pus bloody stool Acute diarrhoea: non cholera and non dysentery. Diarrhea Dehydration Vomiting Nausea Fever Dysentery + + + +/Cholera + + + + Acute Diarrhea + + + + + Budi, a boy, 12 months old, live in the slum area Diarrhea Non projectile vomiting Decrease of urination Fever not mentioned not mentioned

Consciousness Heart Rate Respiration rate Faeces

Apatis - Coma Tachycardia Tachypnea Consist of blood + pus

Apatis - Coma Tachycardia Tachypnea Smells like baycline

Compos mentis Tachycardia Tachypnea Watery more than the material

c. Physical Examination General appearance Consciousness Blood pressure Respiration rate Temperature Body weight Body height Eyes Mouth Thoraks Budi Severe ill Compos mentis 70/50mmHg 38x/minute 38,70C 8,8 kg 75 cm Hollow eyes No tears drop Dry mouth Simetris Retraction ( - / - ) Vesicular breath sound Flat, shuffle Bowel sound increased Palpable 1 cm below arcus costae and xiphoid processus Unpalpable Positive Reddish skin Normal Health Compos Mentis 90/60mmHg 25-40x/minute 360C 10 kg ( 8 + 2N; age in year ) 71 78 cm No hollow eyes Tears drop Not dry Simetris No retraction ( - / -) Normal Flat, shuffle Not increase Not palbable Unpalpable Negative Not reddish Interpretation Abnormal Normal Tachycardia Normal Fever Under nutrition Normal Dehydration Dehydration Dehydration Normal Normal Normal Normal Increase peristaltis Undernutrition Normal Dehydration Irritation

Abdomen Liver Spleen Turgor Anal orifice

d. Laboratorium Examination Blood Hb WBC Differential count Macroscopic Microscopic Macroscopic 12,8 g/dl 9.000/mm3 0/1/16/48/35/0 Yellowish WBC (-) RBC (-) Protein (-) Watery more than waste material Blood (-) Pus (-) WBC : 2-4/WF RBC (-) 10-14 g/dl 5.000 10.000/mm3 0-1/1-3/2-6/20-60/2042/3-9 Yellowish WBC (-) RBC (-) Protein (-) Waste material more than water Blood (-) Pus (-) WBC : 0-5/WF RBC (-) Normal Normal Shift to the left - acute Normal Normal Normal Normal Diarrhea Normal Normal Normal Normal

Urine

Faeces

Microscopic

e. Working Diagnostic Definition A familiar phenomenon with unusually frequent or unusually liquid bowel movements, excessive watery evacuations of fecal material. The opposite of constipation. Diarrhea is a common symptom that can range in severity from an acute, self-limited annoyance to a severe, life-threatening illness. The frequency and consistency of bowel movements vary within and between individuals. Some individuals may normally defecate as many as three times a day, while others only two to three times per week. Diarrhea is defined as increased volume, fluidity, or frequency of fecal discharges compared with the patients normal stools. Clinical features vary greatly depending on the cause, duration, and severity of the diarrhea, on the area of bowel affected, and on the patients general health. Etiology

In this case : Acute diarrhea caused by ROTAVIRUS Rotavirus infection is an infection of the digestive tract. It is the most common cause of severe diarrhea in infants and young children. The infection is caused by group A rotaviruses, which are wheel-shaped viruses. Rotavirus spreads very easily. The virus is transmitted by hand-to-mouth contact with stool from an infected person. The virus can be passed from one person to another by touching a hand contaminated by the virus. The virus can also be transmitted by merely touching a surface or object that has been contaminated by an infected person. The virus then enters the body through contact with the mouth. Children can spread rotavirus both before and after they develop symptoms. Rotavirus infection usually starts with fever and vomiting, followed by diarrhea. The diarrhea can be mild to severe and generally lasts 3-9 days. And the illness usually begins 3 days after exposure. Most children with rotavirus diarrhea recover on their own, but some children become very ill with severe vomiting, diarrhea, and loss of fluids (dehydration). Children with

severe diarrhea can lose body fluids very quickly and may need to be hospitalized for special therapy to replace fluids and restore chemical balance. The seriousness of infection generally decreases with the number of infections. First infections tend to be the most severe. The infection can be diagnosed by a laboratory test on a stool sample. Antibody of anti rotavirus which called immunoglobulin A and M, is being excreted in faeces after the day of rotavirus infection. This antibody test was still positive until 10 days after the first infection, and could be much longer if the recurrent infection is present. So that, antibody examination could be used to diagnose the rotavirus. Risk Factor Every child is likely to be infected with rotavirus at least once in the first 5 years of life. Severe diarrhea and dehydration occur mainly in children aged 3 to 35 months. Children who have been infected once can become infected again. Older children and adults can also get rotavirus infection. Young children can pass the virus to their older brothers and sisters. In adults in the United States, rotavirus infections sometimes cause diarrhea in travelers, persons caring for children with rotavirus diarrhea, and the elderly. Pathophysiology DIARRHEA: Three mechanisms of diarrhea : 1. Bcretory diarrhea Bacteria produces toxin Effect of toxin: activating intracellular protein stimulate electrolyte and water secretion watery diarrhea 2. Osmotic diarrhea Enzyme system insufficient or Short Bowel syndrome

Food is digested partially

Osmotic burden intraluminal

Bacterium decompose the pigswill become the short chain fatty acid and other material Diarrhea

3. Cytotoxic / inflammatory diarrhoea Viral, inflammatory : allergy, IBD Viral invasive and cytotoxic damage entrocytes at villus villus atrophy (Absorption decrease) crypt hyperplasia (secretion increase) mixed diarrhoea Inflammation immune cells cytokines + chemokines + prostaglandins induce secretion and activate enteric nerves metaloproteins destroyed entrocytes at villus Absorption decrease crypt hyperplasia (secretion increase) mixed diarrhea immature entrocyte with insufficient disacharidase and peptide hydrolase Absorption decrease

Stool forms :

secretory diarrhoea osmotic diarrhoea cytotoxic / inflammatory diarrhoea

: watery, high level electrolyte : semisolid, low level electrolyte : mix

ROTAVIRUS : ROTAVIRUS Mature erythrocyte in the tip of villi of small intestine Change of structure of mucous of small intestine Shorten of villi & infiltrate of mononuclear inflammatory cell in lamina propria Rotavirus attatch and come into epitel cell Destruction of the cell Replace by criptus cell Criptus cell immature Canr absorb well Diarrhea Loss of fluid Loss of electrolyte PGE2 Anterior hypothalamus Elevated thermoregulator Set point Increase heat conservation Increase heat production Fever Dehydration No tears drop Dry mouth Turgor pressure Hollow eyes Less of urinate

ROTAVIRUS : shorten the villi decreased absorbtion

DIARRHEA

More criptus increased secretion VOMITING : Process of vomit : 1.Nausea 2.Retching 3.Vomiting Central of vomiting : region postrema medulla oblongata in base of 4th ventricle

Near from central of salivation and respiration -> hypersalivation and movement of respiration Iritation of gastrointestinal tract / much of distention Antiperistaltis in illeum Move inward and up to Push the content material of intestine back to duodenum & gaster Dilatation of pper region of GI & duodenum Hard instriction contraction in duodenum and gaster caused the relaxation of lower oesophagus sphincter The vomit move to oesophagus Moved out by the movement of abdomen musles e. Management 1. Criteria of being hospitalized : Clinical feature MTBS ( Managemen Terbantu Bayi Sakit ) General appearance : normal, weak, nervous, lethargy Eyes lid : sunken Sense of thirsty : without dehydration, mild-moderate dehydration, severe dehydration Turgor : > 1 second [If two of these is present means lets get hospitalized] P2 Diarrhoea = Programe National Diarrhoeal Diseases Control Program (CDD) Key points : (WHO) 1. Giving solution: prevent & treat dehydration Peroral :

2.

3.

more beneficial compared to parenteral (cheap, frequency and duration of diarrhoea: decrease) Given in : without and mild-moderate dehydration In especially situation: can be given by NGT ( 20 ml/kgBW/hour) Home based solution, ORS, renalyte, pedialyte, etc

Parenteral (intravenously) :

Given in severe dehydration (when oral administration unable to answer the demand , and mild-moderate dehydration is fail to rehydrate with oral solution After rehydration is reached, as soon as possible ( 4-6 hours) change to oral solution. Kind of intravenous solution : kristalolid ( RL, Nacl, Nacl+Dektrose)

To prevent dehydration : without dehydration(peroral) To treat dehydration : mild-moderate dehydration (peroral) and severe dehydration ( parenteral ) 2. Diet Continue especially breast feeding, bananas, rice, applesauce, and toast diet.

3. Drug No antibody, except for cholera and bloody stool. WHO recommend : Zinc Not yet clinically relevant : Probiotik And prebiotik 4. Education Education is most important for prevention and treatment. Proper ORT prevents dehydration, and early refeeding speeds recovery of intestinal mucosa. Emphasize proper hygiene and food preparation practices to prevent future infections and spread. f. Prognosis With proper management, prognosis is very good. g. Complication Hypokalaemia Hypovolaemic shock Sodium levels low (urine) Depletional hyponatraemia Hypernatraemia Hypophosphataemia Hypomagnesemia Dehydration Faecal incontinence h. Prevention 1.Oral rotavirus immunization : Oral rotavirus vaccine is the best way to protect infants and children against rotavirus disease. The vaccine will not prevent diarrhoea and vomiting caused by other infections but is very good at preventing severe diarrhoea and vomiting caused by rotavirus. The oral (swallowed by mouth) rotavirus vaccine used is called RotaTeq. RotaTeq is a live weakened virus vaccine. The vaccination course of RotaTeq consists of three doses and is recommended to be given at the same time as other vaccines included on the National Immunisation Program at two, four and six months of age. The first dose of RotaTeq should be given no later than 12 weeks of age and the third dose should be given by 32 weeks of age. The rotavirus vaccine is generally well tolerated. Reactions to the rotavirus vaccine are much less frequent than the likelihood of the disease and include: Common side effects: Fever Diarrhoea (in the week after rotavirus vaccination) Vomiting (in the week after rotavirus vaccination) Extremely rare side effect: Anaphylaxis (severe allergic reaction)

2. Other than vaccination, there is no effective way to completely eliminate rotavirus infection or its spread. Washing with soaps or cleansers does not kill the virus but will help reduce the spread of infection. Wash hands after using the toilet, after helping a child use the toilet, after diapering a child, and before preparing or serving food.

CHAPTER III CONCLUSION

Budi, a 12 months boy, suffered from acute diarrhea and severe dehydration caused by suspect rotavirus.