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WHEN WARTEG

GIVES HIM MORE


GROUP 7
CASE 1B
Mr. Surip, a 26-year-old previously healthy male, has
been in Jakarta for about 2 weeks since he came home from
his study in the States. Ever since, he has eaten any kinds of
Indonesia food, and warteg is always his favorite, especially
the one across his old school.
Today, Mr. Surip presents to your clinic reporting a 2-day
history of watery diarrhea and he has noticed that theres
blood in his stool. He has up to 8 bowel movements per day.
He has had intermmittent abdominal cramps as well. For the
past 2 days, he also feels nauseated, but no vomiting. His
vital signs are normal, his bowel souds are hyperactive and
the remainder of the physical exam is remarkable only for
mild, diffuse abdominal tenderness.
Learning Objective
Able to explain about nausea
Able to explain about definition of diarrhea
Able to explain about epidemiology of diarrhea
Able to explain about etiology of diarrhea
Able to expalin about sign and symtomp of diarrhea
Able to explain about classification of diarrhea
Able to explain about patophysiology of diarrhea
Able to explain about diagnostic test to confirm the caused of
diarrhea
Able to explain about complication of diarrhea
Able to explain about therapy pharmacology and non
pharmacology of diarrhea
Able to know differential diagnosis of diarrhea
The esophagus, stomach, large and small intestine, aided by the
liver, gallbladder and pancreas convert the nutritive
components of food into energy and break down the non-
nutritive components into waste to be excreted.
NAUSEA
Is the sensation that there is a need to vomit.
Nausea can be acute and short-lived, or it
can be prolonged. When prolonged, it is a
debilitating symptom. Nausea (and vomiting)
can be psychological or physical in origin. It
can originate from problems in the brain or
organs of the upper gastrointestinal tract
(esophagus, stomach, small intestine, liver,
pancreas, and gallbladder).
It also may be caused by pain, motion,
medications and diseases of many non-
gastrointestinal organs of the body.
Therefore, the diagnosis of the cause of
prolonged nausea may not be easy. All
stimuli that cause nausea work via the
vomiting center in the brain which gives rise
to the sensation of nausea and coordinates
the physical act of vomiting.
DIARRHEA
What is diarrhea?
Diarrhea is loose, watery stools. A person
with diarrhea typically passes stool more
than three times a day.
classification
Episode
Diarhea acute (<15days)

Diarhea chronic (>15days)

Mechanism and pathofisiology


Diarhea osmotic

Diarhea sekretoric

Etiology
Diarhea infection

Diarhea non infection

Function
Diarhea organic

Diarhea fungisional
Vibrio cholera Salmonella

Shigella

Campylobacter jejuni E. coli


1. E coli Enteropatogenik
(EPEC)
Cause by baby`s,especially in developing
country
Wattery diarhea,self-limited but can be
chronic diarhea
2. E coli Enterotoksigenik
(ETEC)
Traveller`s diarhea
Strain which produces eksotoksin which hot
resistantsubunit B binds at brushborers
epitelial intestine Gangliosida dan facilitate influx
subunit A into cell,then activated adenil
cyclaseincreased Camp
consentrationwater&cl-
hypersecretionblocked natrium
reabsroptionintestine lumen
strachinghypermotilitydiarhea
2. E coli Enterotoksigenik
(ETEC)
Strain which produces enterotoksin,hot
resistant sTa(BM 1500-4000)
sTa activate Guanil cyclase in enteric epitel
cell and stimulate fluid secretions
3. E coli Enterohemoragik
(EHEC)
Produces verotoxin
Caused colitic ulcerative, severe diarhea,
hemolitic uremic syndrom.
4. E coli Enteroagregratif
(EACE)
Caused acute and chronic diarhea et
developing country
Transmission by foods
Pathofisology acute diarhea
Osmotic diarheaintralumen osmotic
pressure of intestine ,caused by
medications,chemistry substance which
hiperosmotic,general malabsorbtion,defect in
intestine mucuos
Secretoric diarheasecretion of water dan
electrolit from intestine ,absrobtion caused
by enterotoxin V.cholerae,E.coly,Laksatif
drugs
Bile malabsrobtion and lipid
malsbsorbtiondefectife reabsropbtion of bile
salts
Defect exchange anion/active transport electrolit
at enterositblocked transport active
mechanisme Na+ k+ ATP ase at enterosit and
abnormal Na+ absorbtion
Motility& abnormal intestine transit
timehipermotility, inregularity intestine motility
causes abnormal absorbtion in
intestine(DM,pasca vagotomi,hipertyroid)
Intestine permeability defectabnormal
permeability of intestine epitel spesific
membrane disorder
Inflamantory diarheadamage mucosa
intestine,causes mucous excess >>,water
and electrolit exudation into lumen,water and
electrolit absrobtion defect
Infectious diarheaclassified by
invasif (damaged mucosa)ulseration and
necrotic at wall of intestine
non invasif(non mucosa damaged)produce
toxins which string at mucosa intestine
What are the symptoms of
diarrhea?
Cramping
abdominal pain
Bloating
Nausea
an urgent need to use the bathroom

Depending on the cause, a person may have a


fever or bloody stools.
Diarrhea: Clinical
Manifestation
Diarrhea: watery, bloody, mucous
Fever
Vomiting
Respiratory symptoms
Dehydration
Metabolic acidosis
Electrolyte imbalance: hyponatraemia, hypokalaemia,
hyponatraemia
Hypoglycemia
Lactose intolerance
How is the cause of diarrhea
diagnosed?
Medical history and physical examination. eating habits and
medication use and will examine for signs of illness.
Stool culture. A sample of stool is analyzed in a laboratory to check for
bacteria, parasites, or other signs of disease and infection.
Blood tests. Blood tests can be helpful in ruling out certain diseases.
Fasting tests. To find out if a food intolerance or allergy is causing the
diarrhea, the doctor may ask you to avoid lactose, carbohydrates,
wheat, or other foods to see whether the diarrhea responds to a change
in diet.
Sigmoidoscopy. For this test, the doctor uses a special instrument to
look at the inside of the rectum and lower part of the colon.
Colonoscopy. This test is similar to a sigmoidoscopy, but it allows the
doctor to view the entire colon.
Imaging tests. These tests can rule out structural abnormalities as the
cause of diarrhea.
How is diarrhea treated?
Absorbents: attapulgite & polycarbophil
Anti-motility medications: Loperamide &
Diphenoxylate
Bismuth compounds: Pepto-Bismol
Tips About Food
Until diarrhea subsides, try to avoid caffeine, milk
products, and foods that are greasy, high in fiber, or
very sweet. These foods tend to aggravate diarrhea.
As you improve, you can add soft, bland foods to your
diet, including bananas, plain rice, boiled potatoes, toast,
crackers, cooked carrots, and baked chicken without the
skin or fat. For children, the pediatrician may also
recommend a bland diet. Once the diarrhea has
stopped, the pediatrician will likely encourage children to
return to a normal and healthy diet if it can be tolerated.
Preventing Travelers
Diarrhea
Do not drink tap water or use it to brush your teeth.
Do not drink unpasteurized milk or dairy products.
Do not use ice made from tap water.
Avoid all raw fruits and vegetables, including lettuce and
fruit salads, unless they can be peeled and you peel
them yourself.
Do not eat raw or rare meat and fish.
Do not eat meat or shellfish that is not hot when served.
Do not eat food from street vendors.
Diarrhea medications
Medication
Aeromonas species: Use cefixime and most third-generation and
fourth-generation cephalosporins.
Campylobacter species: Erythromycin.
C difficile: use oral metronidazole or vancomycin.
C perfringens: Do not treat with antibiotics.
Cryptosporidium parvum: Nitazoxanide.
Entamoeba histolytica: Metronidazole, iodoquinol or paromomycin
E coli: Trimethoprim-sulfamethoxazole (TMP-SMX), second-
generation or third-generation cephalosporin.
G lamblia: Metronidazole or nitazoxanide.
Plesiomonas species: TMP-SMX, cephalosporin.
Salmonella species: TMP-SMX, ceftriaxone and cefotaxime
Shigella species: TMP-SMX, Cefixime, ceftriaxone, and cefotaxime
V cholerae: Doxycycline, and erythromycin.
Yersinia species: TMP-SMX, cefixime, ceftriaxone, and cefotaxime.[6]
Differential dignosis

Crohn`s disease
Hemoroid
Colitis ulserativa
Infection
Pathobiology Diarrhea

Hemorrhagic E.coli 1-3+,initially


watery,quickly blood

Campylobacter 1-4+,watery or bloody

Aeromonas 1-4+,watery or bloody

Shigella 1-2+,bloody

Vibrio sp. 3-4+,watery


Complication
Hypokalemia
Hypovolaemic shock
Sodium levels low(urine)
Depletional hyponatraemia
Dehydration
COMPLICATIONS

Diarrhea Water Dehydration


Potassium Hypokalaemia
Natrium Hyponatraemia
Bicarbonate Acidosis
Nutrient Hypoglycemia
Dehydration
Dehydration means your body does not have
as much water and fluids as it should.
Dehydration can be caused by losing too
much fluid, not drinking enough water or
fluids, or both. Vomiting and diarrhea are
common causes.
Scoring System
Degree of dehydration
Score 0 1 2
General condition Healthy Irritability, Delirium, coma
sleepy, or shock
Skin elasticity Normal apathy Very decreased
Decreased Very sunken
Eye Normal
Fontanel (ubun2) Normal Sunken(ckung Very sunken
)
Mouth Normal Dry & cyanotic
Sunken > 140
Pulse Normal
Dry
120-140
Amount of score: 0- 2 Mild dehydration
3- 6 Moderate dehydration
7-12 Severe dehydration

Maurice King, 1974


Dehidration grade
Based on:
1. Clinic manifestations: mild ,moderate,and
severe
2. BJ Plasma: on dehidration,Bj increased
a. Severe dehidration : 1,032-1,040
b. Moderate dehidration: 1,028- 1,032
c. Mild dehidration : 1,025- 1,028
3. Cenral Venous pressure(CVP) measurement
Shock or dehidrations,if CVP less than +4 cm
H2O
CONCLUSIONS

Based on the clinic symptomps which found on


Mr.Surip , watery stool and after 2 days
theres blood in his stool, bowel movements
8x/days, intermittent abdominal cramping, 2
days later he feels nausea but not vomitting.
His vital signs normal, his bowel sounds are
hyperactive and diffuse abdominal tenderness,
maybe he had diarrhea by infection
Suggestion

Better he should take a further medical


diagnostic to make sure the diagnosis. For
patient and the food seller to give more
attention for the sanitation and hygienity from
food and beverages that been served.
References
Fauci AS, Braunwald E, Kasper DL, Hauser SL,
Longo DL, et al, editors. Harrisons principle of
internal medicine. 17th ed. USA: Mc. Graw Hill
medical, 2008.
Sudoyo AW, Setiyohadi B, et al, editor. Buku ajar
ilmu penyakit dalam. Ed 4. Jilid 1. Jakarta: pusat
penerbitan ilmu penyakit dalam FKUI,2006.
Brooks GF, Butel JS, Morse SA. Lange Jawetz,
Melnick & Naelbergs Medical Microbiology. 23rd ed.
USA: Mc Graw Hill medical,2004.

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