DIARRHOEA
Atan Baas Sinuhaji
Department of ChildHealth
School of Medicine,University Of Sumatera Utara
Medan
Causes of death among
infants and children in Indonesia
Age < 1 years old % Age < 5 years old %
( n = 173 ) ( n = 103)
1 Diarrhoea 31.4 Diarrhoea 25.2
2 Pneumonia 23.8 Pneumonia 15.5
3 Meningitis /encephalitis 9.3 Enterocolitis 10.7
4 Gastrointestinal disorders 6.4 Meningitis /encephalitis 8.8
5 Congenital heart disease and 5.8 Dengue 6.8
hydrochephalus
Basic health surveillance 2007
DIARRHOEA
VOLUME OF WATER IN
THE STOOLS
LOOSE WATERY
HYPERSECRETION
PERISTALSIS
WATER AREA FOR
ABSORPTION
MALABSORPTION
HYPEROSMOLAR
MALDIGESTION
DIARRHOEA
- FREQ. 3 X /DAY
- CHANGING OF CONSISTENCY
- WITH/ WITHOUT VOMITING
- WITH/WITHOUT BLOODY STOOL
ACUTE WATERY DYSENTERY SEVERE
PERSISTENT
DIARRHOEA FORM MALNUTRITION
BLOODY
< 14 DAYS > 14 DAYS
DIARRHOEA
BABIES FED ONLY BREAST MILK OFTEN
FREQUENT PASSING OF FORMED STOOLS
( 5-6 x / DAY )
THIS ALSO NOT DIARRHOEA
INFECTION - VIRAL
- FUNGAL
- BACTERIA
- PARASITES
INFLAMMATION
DIARRHOEA NON INFECTION - ALLERGY
- etc
NONINFLAMMATION - HORMONAL
- ANATOMICAL
- etc
VIRAL DIARRHOEA
1. ROTAVIRUS ==> 6 MONTHS to 2.5 YEARS
2. NORWALK VIRUS
3. ENTERIC ADENOVIRUS
4. ASTROVIRUS
5. CALICI VIRUS
6. CORONA VIRUS
7. SMALL ROUND VIRUS
- PARVOVIRUS LIKE AGENT
- MINI ROTAVIRUS
- MINI REOVIRUS
Etiology of diarrhoea in
Children
ROTAVIRUS
RNA
Fecal oral route
=persists for long periodes in low humidity environment
=relatively resistant to hand-soaps and common disinfectans
=inactivated by relatively high concentrations of alcohol,
chlorine or iodine
=transmission can occur before the onset of symptoms
and persists after symptoms subside
=villous atrophy
=NSP4 enterotoxin
PREVENTION
-BREAST FEEDING
-HAND WASHING
-GOOD HYGIENE
VACCINATION
PRACTICALITY
LIQUID STOOLS 3x/DAY,
WITH/WITHOUT VOMITING,
WITH/WITHOUTMUCOUS/BLOOD
CLASSIFICATION
1. AGE
2. ONSET
3. ETIOLOGY
4. SEVERITY
5. PATHOGENESIS
6. HOST DEFENSE
7. SOURCE OF INFECTION
8. EPIDEMIOLOGY
9. SITE OF PATHOLOGY
10.WHO (2005)
1.AGE
-NEONATAL DIARRHOEA : DIARRHOEA IN
NEONATES
-INFANTILE DIARRHOEA : DIARRHOEA IN
INFANTS
-CHILDHOOD DIARRHOEA : DIARRHOEA IN
CHILDREN
2. ONSET
-ACUTE DIARRHOEA : < 7 DAYS (90-95%)
- PROLONGED DIARRHOEA : 7-14 DAYS
- CHRONIC DIARRHOEA : > 14 DAYS
3. ETIOLOGY
-INFLAMMATION : INFECTION /
-RADANG : INFEKSI
NON INFECTION
/ NON INFEKSI
-NON RADANG
-NONINFLAMMATION
4. SEVERITY ( WHO, 1984)
-MILD DIARRHOEA : 1x / 2 hours or 5 mL / KgBW / hour
-SEVERE DIARRHOEA : > 1x / 2 hours or > 5mL/KgBW/hour
5.HOST DEFENSE
-IMMUNOCOMPETENT
-IMMUNOCOMPROMISED :AIDS, LEUKEMIA, etc.
6. SOURCE OF INFECTION
-NOSOCOMIAL : INFECTION IN HOSPITAL
-COMMUNITY
7. PATHOGENESIS
ABSORPTIVE/OSMOTIC SECRETORY
1. FASTING STOPS CONTINUES
2. STOOLS OSM. 400 280
3. Na + 30 100
4. K+ 30 40
5. (Na+K)x 2 120 280
6. SOLUTE GAP 280 0
8. EPIDEMIOLOGY
-ENDEMIC : PRESENT AT ALL TIMES
-EPIDEMIC : OUTBREAK
-MIXED
9. SITE OF PATHOLOGY
-SMALL INTESTINAL: CHOLERA, ETEC,
ROTAVIRUS & G. LAMBLIA
DIARRHOEA
-LARGE INTESTINAL: SHIGELLOSIS, AMOEBIASIS
-BOTH : CAMPYLOBACTERIOSIS,
SALMONELLOSIS
10. WHO (2005)
-ACUTE DIARRHOEA
-PERSISTENT DIARRHOEA
-DYSENTERY FORM
-DIARRHOEA WITH SEVERE
MALNUTRITION
MICROORGANISMS
GASTRIC ACID
MULTIPLICATION
COLONIZATION
ADHERENT
ENTEROTOXIN - INVASION
- DAMAGE
HYPERSECRETION MALABSORPTION
HYPERPERISTALSIS
COLONIC SALVAGE DIARRHOEA
PATHOGENESIS OF ACUTE INFECTIOUS DIARRHOEA
DIARRHOEA
Cleansing Effect Loss Of
Pathogens Water & Electrolytes
Nutrients
Defense Dehydration
Hypoglycemia
Starvation
Malnutrition
Self
SelfLimited
Limited
Water
Water&&Electrolytes
Electrolytes
Diets
Diets
WATER DEHYDRATION
ELEKTROLIT
ELEKTROLYTES Na+ ==> atau
Na+ or
K+ ==>
K+ ==>
Ca2+
D Ca2+ ==> TETANY
Mg2+ ==>
I Mg2+
Zn ==> ==> TETANY
ACRODERMATITIS ENTEROPATHICA
A Zn ==>ACRODERMATITIS ENTEROPATHICA
R BASE ASIDOSIS METABOLIC
R
H NUTRIENTS - HYPOGLYCEMIA
O - STARVATION
E - PCM
A
MUCOSAL - MALABSORPTION
INJURY - PROTEIN LOSING ENTEROPATHY
- SENSITIZATION
- NECROTIZING ENTEROCOLITIS
HYPOCALCEMIC
TETANY HYPOMAGNESEMIC
ALKALOTIC
LOSS OF WATER VIA STOOLS
DEHYDRATION
PLASMA WATER
FEVER HEMOCONCENTRATION HYPOVOLEMIA
SHOCK RBF* SYMPATH. DISCHARGE
COMA ARF** - HEART RATE
- VASOCONSTRICTION
* Renal Blood Flow
** Acute Renal Failure
SIGNS OF DEHYDRATION
1. LETHARGIC TO 7. WEAKNESS OF
COMATOSE RADIAL PULSE
2. SUNKEN 8. HYPOTENSION
ANTERIOR 9. THIRSTY
FONTANELLA 10. TURGOR
3. SUNKEN EYES 11. COOL MOIST
4. ABSENT OF EXTREMITIES
TEARS 12. OLIGURIA/ANURIA
5. DRY OF MOUTH & 13. BW
TONGUE
6. HR
DEHYDRATION
VOLUME PLASMA SODIUM
SOME DEHYDRATION ISONATREMIA
= 5 - 10 % BB = 135 - 150 mEq/L
SEVERE DEHYDRATION
= > 10% BB HYPO/HYPER
NATREMIA
THE
THEOBJECTIVES
OBJECTIVESOF
OFTREATMENT
TREATMENTACUTE
ACUTEDIARRHOEA
DIARRHOEA
DEHYDRATION PROTEIN CALORY DURATION, SEVERITY
MALNUTRITION EPISODES
PREVENTION TREAT
WATER & ELECTROLYTES FEEDING ZINC
MANAGEMENT
ASSESSMENT TREATMENT
1. Degree of 1. Water & electrolytes
Dehydration 2. Diets
2. Associated : 3. Drugs
Malnutrition - Zinc
Pneumonia - antimicrobial
etc - Symptomatic
DEGREE OF DEHYDRATION (WHO,2005)
NO SIGN OF SOME SEVERE
DEHYDRATION DEHYDRATION DEHYDRATION
CONDITION WELL, ALERT RESTLESS / LETHARGIC,
IRRITABLE FLOPPY, COMA
EYES NORMAL SUNKEN SUNKEN
THIRST NORMALLY, NOT THIRSTY, DRINK DRINKS POORLY
THIRSTY EAGERLY
SKIN TURGOR QUICKLY SLOWLY VERY SLOWLY
NB : 1. READING FROM RIGHT TO LEFT
2. CONSIDERED SEVERE OR SOME DEHYDRATION IF TWO OR
MORE OF THE SIGN ARE PRESENT
FLUIDS TREATMENT
REHYDRATION MAINTENANCE
INITIAL REPLETION NORMAL + ABNORMAL
HOLLIDAY CHOLERA
SEGAR COT
HOLLIDAY - SEGAR
10 kg 100 cal / kg
10 - 20 kg 1000 cal + 50 cal/ kg
for each > 10 kg
> 20 kg 1500 cal + 20 cal/ kg
for each > 20 kg
NB : 100 cal 100 ml water
2,5 mEq Na+
2 mEq K+
REHYDRATION
ORAL I.V.
RINGERS LACTATE
ORS*
(ORALIT@) RINGERS ACETATE
* Oral Rehydration Salts
PREVIOUS STANDARD WHO
ORAL REHYDRATION SALTS
(ORS)
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
CHO
Peptide
Na+ LUMEN
Amino Acid water
Na+
2K+ ENTEROCYTES
3Na+ BASEMENT
MEMBRANE
BLOOD VESSELS
LAMINA
PROPRIA
ORAL REHYDRATION SALTS
(WHO)
PREVIOUS NEW
(mmol/L) (mmol/L)
Na 90 75
K 20 20
Cl 80 65
Citrat 10 10
Glucose 111 75
311 245
NEW (LOW OSMOLARITY) WHO
ORAL REHYDRATION SALTS
STOOL OUTPUT = 20%
VOMITING = 30%
THE NEED FOR SUPPLEMENTAL I.V
FLUID = 33%
LUMEN USUS P.DARAH INTERSTISIAL
ORALIT
LARUTAN GULA
LGG LARUTAN GARAM
@
DHF
DIARE @
Larutan Garam Gula
INDICATION OF I.V FLUIDS
1. SEVERE DEHYDRATION
WITH/WITHOUT SHOCK
2. SEVERE DIARRHOEA
3. INTAKE BY MOUTH
4. GLUCOSE MALABSORPTION
5. ABDOMINAL DISTENSION /
PARALYTIC OBSTR.
6. OLIGURIA / ANURIA FOR
SEVERAL HOURS
DEHYDRATION
NO SIGN OF SOME SEVERE
< 5% 5 - 10% > 10%
A B C
A. NO SIGN OF DEHYDRATION
1. ORALIT
< 2 years = 50 - 100 mL / X loose stool
2 years = 100 - 200 mL / X loose stool
2. GIVE THE CHILD MORE FLUIDS &
FOODS THAN USUAL
PREVENTION OF DEHYDRATION
3. GIVE SUPPLEMENTAL ZINC (<6 months=10
mg/day;> 6 months =20mg/day) for 10-14 days
B. SOME DEHYDRATION
ORALIT 75 mL/kg BW /3 or 4
hours
INDICATION
Ringers Lactate
Ringers Acetate
C. SEVERE DEHYDRATION
100 mL/ kgBW/3-6 hours
< 1 year * initial = 30 mL/kgBW/ 1
hour
* repletion= 70 mL/kgBW/5
hours
> 1 years* initial = 30 mL/kgBW/
hours
* repletion = 70 mL/kgBW/2
hours
ORALIT
PREVENTION
TREATMENT
MAINTENANCE
DEHYDRATION DIARRHOEA
DIARRHOEA
REHYDRATION
ANURIA/OLIGURIA ADEQUATE
URINE *
RENAL PHYSIOLOGIC NO
FAILURE OLIGURIA PROBLEM
FLUIDS FLUIDS
NB : 1. * 1 mL / kg BW / hour
2. Oliguria : < 400 mL / m2 / day
Renal Physiologic
Failure Oliguria
Lasix@ diuresis (-) diuresis (+)
Laboratory
Urine osmolality <350 >500
(mOsm/kgH2O)
Na+ urine (mEq/l) > 40 <20
Fr. excr of Na+ >1% <1%
Fractional Na urine/Na plasma
Excretion of 100%
Na+ Cr . urine/Cr . plasma
FEEDING
1. AFTER REHYDRATION
2. < 4 MONTHS
- BREASTMILK (+)
- BREASTMILK (-) ==> ????
3. > 4 MONTHS
- BREASTMILK
- RICE PORRIDGE
- BANANAS
- FISHES
- TAHU, TEMPE
- FORMULA MILK STOP
