Professional Documents
Culture Documents
VOLUME OF WATER
IN THE STOOLS
LOOSE WATERY
1
HYPERSECRETION
WATER
•MALDIGESTION
•HYPEROSMOLAR
MALABSORPTION •PERISTALSIS
•AREA FOR
ABSORPTION
2
DIARRHOEA
- FREQ. ≥ 3X / DAY
- CHANGING OF CONSISTENCY
- WITH/ WITHOUT VOMITING
- WITH/ WITHOUT BLOODY STOOL
SEVERE
ACUTE WATERY DYSENTERY PERSISTENT
DIARRHOEA MALNUTRITION
FORM
3
BABIES FED ONLY BREAST MILK OFTEN
FREQUENT PASSING OF FORMED STOOLS
( 5-6 x / DAY )
INFLAMMATION
NONINFLAMMATION - HORMONAL
- ANATOMICAL
- etc
VIRAL DIARRHOEA
6
PRACTICALY
7
CLASSIFICATION
1. AGE
2. ONSET
3. ETIOLOGY
4. SEVERITY
5. PATHOGENESIS
6. HOST DEFENCES
7. SOURCE OF INFECTION
8. EPIDEMIOLOGY
9. SITE OF PATHOLOGY
10. WHO ( 2OO5 )
8
1.AGE
-NEONATAL DIARRHOEA
-INFANTILE DIARRHOEA
-CHILDHOOD DIARRHOEA
2. ONSET
-ACUTE DIARRHOEA : < 7 DAYS (90-95%)
-PROLONGED DIARRHOEA: 7-14 DAYS
-CHRONIC DIARRHOEA : > 14 DAYS
3. ETIOLOGY
-INFLAMMATION : INFECTION/NON INFECTION
-NON INFLAMMATION
9
4. SEVERITY( WHO, 1984)
-MILD DIARRHOEA : < 1x / 2 hours or < 5cc / KgBW /hours
5.HOST DEFENCE
-IMMUNOCOMPETENT
-IMMUNOCOMPROMISED
6. SOURCE OF INFECTION
-NOSOCOMIAL
-COMMUNITY
10
7. PATHOGENESIS
ABSORPTIVE/ SECRETORY
OSMOTIC
1. FASTING STOPS CONTINUES
2. STOOL OSM. 400 280
3. Na + 30 100
4. K+ 30 40
5. (Na+K)x 2 120 280
6. SOLUTE GAP 280 0
11
8. EPIDEMIOLOGI
-ENDEMIC
-EPIDEMIC
-MIXED
9. SITE OF PATHOLOGY
12
10. WHO (2005)
13
MIKROORGANISMS
GASTRIC ACID
MULTIPLICATION
COLONIZATION
ADHERENT
ENTEROTOXIN - INVASION
- DAMAGE
HYPERSECRETION MALABSORPTION
HYPERPERISTALIS
Defense • Dehydration
• Hypoglicemia
Starvation
Malnutrition
Self Limited
ELEKTROLIT
ELECTROLYTES Na+ ==>
Na+ atau atau
K+ ==>
K+
D Ca2+ ==>
Ca2+ ==> TETANY
Mg2+ ==>
Mg2+ ==> TETANY
I Zn ==>
Zn ==>ACRODERMATITIS
ACRODERMATITIS ENTEROPATHICA
ENTEROPATHICA
A
R BASE METABOLIC ACIDOSIS
R
H NUTRIENTS - HYPOGLYCEMIA
O - STARVATION
E - PCM
A
MUCOSAL - MALABSORPTION
INJURY - PROTEIN LOSING ENTEROPATHY.
- SENSITIZATION
- NEC
16
HYPOCALCEMIC
TETANY HYPOMAGNESEMIC
ALKALOTIC
LOSS OF WATER VIA STOOLS
DEHYDRATION
PLASMA WATER
1. LETHARGICS TO 7. HYPOTENSION
COMATOSE 8. WEAKNESS OF
2. SHUNKEN RADIAL PULSE
ANTERIOR 9. OLIGURIA/ANURIA
FONTANELLA 10.TURGOR
3. SHUNKEN EYES 11. COOL MOIST
4. ABSENT OF EXTREMITES
TEARS 12. BW
5. DRY OF MOUTH
AND TONGUE
6. TACHYCARDIA 19
DEHYDRATION
22
MANAGEMENT
ASSESSMENT TREATMENT
REHYDRATION MAINTENANCE
HOLLIDAY – CHOLERA
SEGAR COT
25
HOLLIDAY - SEGAR
10 kg 100 mL / kg
10 - 20 kg 1000 mL + 50 mL/ kg
for each > 10 kg
> 20 kg 1500 mL + 20 mL/ kg
for each > 20 kg
ORAL I.V.
1.ISOTONIC
2.Na+ equivalent with plasma (90 mEq/l)
3. GLUCOSE = 2 - 3%
4. K+ ( higher than plasma 20 mEq/l )
5. BASE = 30 - 48 mEq/L
28
• CHO
• Peptide Na+ LUMEN
• Amino Acid water
Na+
2K+ ENTEROCYTES
3Na+ BASEMENT
MEMBRANE
BLOOD VESSELS
LAMINA
PROPRIA
29
MECHANISM OF ACTION ORS
ORAL REHYDRATION SALTS (WHO)
PREVIOUS NEW
(mmol/L) (mmol/L)
Na 90 75
K 20 20
Cl 80 65
Citrat 10 10
Glukose 111 75
311 245
30
NEW (LOW OSMOLARITY) WHO ORAL
REHYDRATION SALTS
DIARRHOEA
RESOMAL(REHYDRATION SOLUTION FOR MALNUTRITION
33
INDICATION OF I.V FLUIDS
1. SEVERE DEHYDRATION
WITH/WITHOUT SHOCK
2. SEVERE DIARRHOEA
3. INTAKE BY MOUTH
4. GLUCOSE MALABSORPTION
5. ABDOMINAL DISTENTION /
PARALYTIC OBSTRUCTION
6. OLIGURIA / ANURIA FOR
SEVERAL HOURS
34
DEHYDRATION
A B C
A. NO SIGN OF DEHYDRATION
1. ORALIT
• < 2 years = 50 - 100 mL / x loose stool
• 2 – 10 years = 100 - 200 mL/ x loose stool
• older children : as much fluid as they want
2. GIVE THE CHILD MORE FLUIDS AND FOOD
THAN USUAL
INDICATION
• Ringer’s Lactate
• Ringer’s Acetate
37
C. SEVERE DEHYDRATION
38
ORALIT
• PREVENTION
• TREATMENT
• MAINTENANCE
DEHYDRATION DIARRHOEA
39
DIARHOEA
REHYDRATION
ANURIA/OLIGURIA ADEQUATE
URINE *
FLUIDS FLUIDS
NB : 1. * 1 cc / kg BB / jam
40
2. Oliguria : < 400 cc / m2 / hari
Renal Physiologic
Failure Oliguria
Lasix diuresis (-) diuresis (+)
Laboratorium
Urine osmolality <350 >500
(mOsm/kgH2O)
Na+ urin (mEq/l) > 40 <20
Fr. excr of Na+ >1% <1%
AFTER REHYDRATION
NO RETURN OR WORSENING
OF DIARRHOEA
TOLERANCE TEST
● BREASTMILK
● SUB BAGIAN GE BIKA FKUSU: FORMULA MILK STOPPED
● ≥ 4-6 MONTHS OF AGE : BREAST MILK + OTHER FOODS
● PROBLEM: < 4 MONTHS OF AGE WHO ARE NOT
BREASTFED
● MTBS : FORMULA MILK(-)
● WHO ( 2005 ) : FORMULA MILK CONTINUED
42
43
BUKU MANAJEMEN TERPADU BALITA SAKIT (MTBS) WHO
ANTIMICROBIAL
Acute Diarrhoea
(WHO)
1. Cholera
2. Shigellosis
3. Amoebiasis
4. Giardiasis
44
ANTIMICROBIAL (WHO)
45
SIDE EFFECT OF ANTIMICROBIAL
1. Bowel Movement
2. Stool Consistency
3. Cramps
47
Antidiarrheal
1.UNABSORBED 3. ADSORBENT :
ANTIMICROBIAL : -Kaolin/pektin
-Streptomycin -Charcoal
-Neomysin -Atapulgit / smectite
-Hydroxyquinoline
-Unabsorbed Sulfa 4. ANTISECROTORY:
- Salicylate Acid
2. ANTIMOTILITY : - Chlorpromazine
-- Loperamide
-- Diphenoxylate 5. TRIAL :
-Lactobacillus
-Fructooligosaccharide
IODOHIDROXY QUINOLINE
1. No benefit
2. In Japan Subacute Myelo Optic Neuropathy
OPIATES & SPASMOLYTICA
50
DIARRHOEA
DEHYDRATION COMPLICATION
REHYDRATION - ELECTROLYTES
IMBALANCE
-RINGER’S LACTATE - METABOLIC ACIDOSIS
-RINGER’S ACETATE - FEVER
-ORS - CONVULTION
- HYPOGLICEMIA
ELECTROLYTES - ACID BASE
INITIAL REHYDRATION
DIAGNOSIS TREATMENT
ELECTROLYTES – ACID BASE
INITIAL REHYDRATION
ISONATREMIA HYPONATREMIA
DEHYDRATION
DILUTIONAL
DIARRHOEA
METABOLIC ACIDOSIS
ANION GAP
NORMAL INCREASED
• STARVATION
LOSS OF HCO3-
• RENAL
HYPOPERFUSION
• TISSUE HYPOXIA
• SALICYLATE
INTOXICATION
• INBORN ERROR 54
ANION GAP = Na+ - (Cl + HCO3-)
NORMAL = 8 – 16 mEq/L
55
METABOLIC ACIDOSIS
1.NAUSEA, VOMITING & ANOREXIA
2.DEPRESSION OF CNS (COMA,
CONVULSION)
3.ARTERIAL DILATATION HYPOTENSION
4.CARDIAC CONTRACTILITY
5.HEART FAILURE
6.VENTRICULAR FIBRILLATION
7.O2 AFFINITY OF Hb ANOXIA
8.KUSSMAUL BREATHING HYPO-
CARBIA vasoconstriction Cerebral
Blood Flow drowsiness
DEHYDRATION + METABOLIC ACIDOSIS
REHYDRATION
pH , HCO3- , pCO2
APPOPRIATE NO APPROPRIATE
METABOLIC ACIDOSIS
pCO2 (c) > pCO2 (lab) pCO2 (c) < pCO2 (lab)
HCO3-
58
DOSAGE OF HCO3- ( mg)
HCO3- d ?
HCO3- d
= 20
H2CO3
CEREBRAL ACIDOSIS
AND DEPRESSION
SLOW RAPID
BRAIN : HCO3- + H+ H2O + CO2
MECHANISM OF PARADOXAL ACIDOSIS 61
vasodilatation ⇒ ICP↗↗
anoxia
62
BICARBONAT
1 mEq/kgBB/X
TO PREVENT
INTRACRANIAL • OVERSHOOT
BLOOD VESSEL METAB.ALKALOSIS
RUPTURE • ACIDOSIS
INTRACELLULARE
63
DEHYDRATION + HYPERNATREMIA
REHYDRATION
HYPERNATREMIA
( > 150 mEq/l)
- IVFD STOPPED
- PLAIN WATER
DEHYDRATION + HYPONATREMIA
REHYDRATION
HYPONATREMIA
( < 135 mEq/L)
REHYDRATION
HYPOKALEMIA HYPERKALEMIA
Renal Function
Diarrhoea (+) Diarrhoea
Acute Renal Failure
RL ECG
Fluids
N abN
Restriction
K+ oral K+ drip
(upto 3 mEq / kgBW / day)
FEVER
TEMPERATURE DOWN
COOLING DRUGS
- Unclothed 1. Paracetamol :
- Wipe of sweat 30 mg/Kg/day - 3 doses
- Fanning 2. - Acetyl Salicylic Acid
- Tepid sponging - Mefenamic Acid
No recommended
CONVULSION
Diazepam: 1 mg/Kg/day
3 - 4 doses iv/per rectal
Coma
Alert
V. CHOLERAE
O1 Non O1
(Non Agglutinable)
- Biotip - Eltor
- Classic
- Serotip - Ogawa
- Inaba
- Hikojima O2 - 138 O139
O140 - 142
“Bengal Strain”
69
ENTEROTOXIN
Adenyl Cyclase
C - AMP
Secretion of Cl-
in Crypt Cells
Absorption
Bowel Lumen
Villi
Secretion
Crypt
V. CHOLERAE
JEJUNUM
- COPIOUS DIARRHOEA
- FISHY RICE WATER STOOLS
- FEVER (-)
- ABDOMINAL PAIN (-)
- RAPID DEHYDRATION & SHOCK
- BIOCHEMICAL (+)
- HISTOLOGY (-)
DIAGNOSIS
Fecal Sodium
( 88 – 101 mEq/ L)
FEEDING
ANTIMICROBIAL Tetracycline or
Doxycycline
DYSENTERY SINDROME = BLOODY DIARRHOEA
1. DYSENTERY
- BACILLARY
- AMOEBIC
2. Enterocolitis
- Cows milk allergy
3. Trichuriasis
S. DYSENTERIAE
S. FLEXNERI
S. BOYDII
S. SONNEI
COLON
SHIGELLA
INHIBITION OF
PROTEIN SYNTHESIS
CYTOTOXIC
SHIGELLA
2. FEEDING
3. - SELF LIMITED
- SEVERE • TMP - SMX
• Cefixime:
8 mg/kg/day
2 doses
• nalidixic acid
• ampisilin
SALMONELLOSIS
80
INDICATION OF ANTIMICROBIAL
TREATMENT IN SALMONELLA
GASTROENTERITIS
1. 3 MONTHS OF AGE
2. OLD DEBILITATED PATIENT
3. DYSENTERY FORM ESPECIALLY
ILLNESS > 5 DAYS
4. IMMUNOCOMPROMISED : STEROID,
MALIGNANCY
5. BACTERIAEMIA
ACUTE DIARRHOEA PERSISTENT DIARRHOEA
=MALNUTRITION
=IRON DEFICIENCY
=ANTIBIOTICS
=COW’S MILK
=INFECTION
82
MALABSORPTION OF NUTRIENT
PEM
BACTERIAL OVERGROWTH
AND INFECTION
DECREASED
INEFFECTIVE VILLOUS REPAIR
ENTERIC HORMONE
INCREASED ABSORPTION OF
NATIVE FOREIGN PROTEIN
83
DEGREE OF DEHYDRATION
84
GOLD STANDART DEGREE F
DEHYDRATION
X-Y
x 1OO %
X
85
A. X= 10 Kg 10-9,25
x 100 %= 7,5 %
Y= 9,25 Kg 10 (Some dehydration)
Fluid defisit= 10-9,25=0,75 Kg=750 cc