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7/30/2019 Kuliah Tk IV Fkui Diarrhoea
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DIARRHEAPRAMITA G. DWIPOERWANTORODivision of Gastroenterology Child Health Department
Medical Faculty - University of Indonesia
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INTRODUCTION
Global problem morbidity & mortality
Definition: - Frequency & consistency
- Acute diarrhea
Dysentery
Persistent diarrhea
- Osmotic diarrhea
Secretory diarrhea
- Chronic diarrhea
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EPIDEMIOLOGY
Transmission of agents cause diarrhea
Routes of transmission
Behaviours
the risk of diarrhea Host factors susceptibility to diarrhea
Age
Seasonality
Asymptomatic infections
Epidemic
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BEHAVIOURS
Failing to breast-feed for the first 4-6 mos
Failing to continue breast-feeding 1 yr
Using infant feeding bottles Storing cooked food at room temperature
Drinking water contaminated w/ fecal
Failing to wash hands
Failing to dispose of faeces hygienically
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HOST FACTORS
Undernutrition
Current or recent measles Immunodeficiency or immunosuppresion
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HOST - malnutrition- immune deficiency
ENVIRONMENT AGENT
- sanitation - bacteria- hygiene - viruses
- protozoa
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ETIOLOGY
General considerations
Pathogenetic mechanisms: Viruses patchy epithelial cell destruction &
villous shortening Bacteriamucosal adhesion, invasion, toxin
Protozoamucosal adhesion,microabcess/ulcers
Important enteropathogens Rotavirus, ETEC, Shigella, C.jejuni, V.cholerae
01 Salmonella, Cryptosporidium
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Normal intestinal fluid balance
Oral intake (1-2L/day)
+ saliva (1.5L)
+ stomach + pancreas + liver (5-6L)
Jejunum 9L enter the small intestine/day
H2O + Na+,Cl-,K+ simultaneously absorbed
(8L/d) Ileum HCO3- excreted
1-1.5L enter colon/day
Colon
Na+ & Cl- absorbed
K+ & HCO3- excreted
100-200mls of water being excreted each day in formed stool
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Intestinal absorption of water & electrolytes
Absorption osmotic gradients solutes (Na+)
are actively absorbed from the bowel by the
villous epithelial cells
Mechanisms of Na+ absorption: Linked to the absorption of Cl-
Absorbed directly as sodium ion
Exchanged for hydrogen ion
Linked to the absorption of organic materials (glucose
/ amino acids)
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Intestinal secretion of water & electrolytes
Occurs in the crypts of the small bowel epithel NaCl is transported from ECF into the epithelialcells across its basolateral membrane
Na
+
pumped back
ECF by Na-K-ATPase Secretory stimuli the ability of Cl- to pass
through the luminal membrane of the crypt cells ion enter the bowel lumen
Movement of chloride ion osmotic gradient water & electrolytes flow passively from ECF intolumen through intercellular channels
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Pathophysiology
Mechanism of watery diarrhea:
Secretory diarrhea &/or osmotic diarrhea
Consequences of watery diarrhea: Isotonic dehydration
Hypertonic (hypernatraemic) dehydration
Hypotonic (hyponatraemic) dehydration
Base deficit acidosis (metabolic acidosis)
Potassium depletion
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SECRETORY DIARRHEA
Pathogen (eg: Yersinia)
produces
Toxins ATP
attached activates breakdown into
cAMPepithelium causes
of bowel
More secretion of chloride
andLoses absorption of sodium
Water, potasium & bicarbonate flow into the bowel
Watery stool with sodium, potasium, chloride & bicarbonate
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Invasive enteropathogens: Shigella
EIEC (Enteroinvasie E. coli)
C. jejuni
Salmonella
E. histolytica
Y. enterocolica
Enteropathogen causing secretory
diarrhea: V. cholerae 01
Enterotoxigenic E. coli (ETEC)
V. cholera non 01
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Mechanism of diarrhea in lactose
intolerance
BOWEL LUMEN
lactose
not absorbed
fermented bacteria
organic acid + gas
increased osmotic pressure
fluid dragged into lumen
diarrhea
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Composition of electrolytes in stool
Etiology Electrolytes (mmol/L) Osmolarity
(mosmol)Na K Cl HCO3
Cholera
Rotavirus
ETEC
Oralit WHO
88
37
53
90
30
38
37
20
86
22
24
80
32
6
18
30
300
300
300
300
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DIARRHEA MANAGEMENT
Assessing a child for dehydration: Ask,look, and feel for signs of dehydration
Condition & behaviour, eyes, tears, mouth & tongue
thirst, skin pinch
Anterior fontanelle, arms & legs, pulse, breathing
Determine the degree of dehydration
Select a treatment plan: C: Severe dehydration (loss of >10% of Body Weight)
B: Some dehydration (loss of 5-10% of BW) A: No signs of dehydration (loss of
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Signs & symptoms of some
dehydration
Restless, irritable
Sunken eyes
No tears when he cries vigorously
Dry mouth and tongue
Thirst drink eagerly
Slowly skin pinch (skin turgor)
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Signs & symptoms of severe dehydration
Floppy (listless), lethargic, or
unconscious
Very sunken & dry eyesNo tears when he cries
Very dry mouth & tongue
Is unable to drink / drink poorly Skin pinch: very slowly (take 2
seconds)
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DIARRHEA MANAGEMENT
Assessing the child for other problems
Dysentery
Persistent diarrhea
Under-nutrition
Feeding history
Physical findings: marasmic &/ kwashiorkor
Vitamin A deficiency
Fever
Measles vaccination status
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TREATMENT OF DIARRHEA
AT HOME (Plan A)
Prepare & give appropriate fluids for ORT
Feed a child with diarrhea correctlyRecognize when a child should be taken
to health worker
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TREATMENT OF DIARRHEA
Plan B: Manage in ORS corner
Continue breast-feeding
Give ORS 75mls/kg/3 hoursMonitor Tx & reassess the child
periodically until rehydration is complete
send home (Plan A)
Give ORS 10 mls/kg for each diarrhea
Resume giving foods other than BM after 4
hrs
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FAILURE OF ORT
The passage of many watery stools
Repeated vomiting
Increased thirst Failure to eat or drink normally
Severe dehydration
Meteorism Preparing & giving ORS not correctly
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WHEN TO TAKE THE CHILD TO A HEALTH WORKER
There is no improvement in 3 days
The passage of many watery stools
Repeated vomiting Increased thirst
Failure to eat or drink normally
Fever Blood in the stool
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INDICATION OF IV FLUID
Severe dehydration or with hypovolemia
Unable to drink (unconscious)
Persisted vomiting Prolonged oligouria or anuria
Other complications that influenced
ORS
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WHO ORS COMPOSITION
Contain
Sodium chloride
Three sodium citrate
(dihydrate)
Sodium bicarbonate
Potasium chloride
Glucose (anhydrate)
Gram/L
3.5
2.9
2.5
1.5
20.0
Composition
Sodium
Potasium
Chloride
Citrate
Bicarbonate
Glucose
Mmol/L
90
20
80
10
30
111
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COMPOSITION OF IV FLUID
Solution Glukosa
(g/L)
K+ Na+ Cl- Lactate/
Acetate
Hartmann / RL
DGaa
NaCl 0.9%
KaEN 3B
-
150
-
27
4
17.5
-
20
130
61
154
50
109
52
154
50
28
26
0
20
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TREATMENT FOR SEVERE DEHYDRATION
(PLAN C)
Give 100ml/kg:
*can be repeated if the pulse is still weak or unpalpable
Age 30ml/kg 70ml/kg
12 months
1 hour*
30min*-1hour
5 hours
2-2 hours
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ANTIBIOTICS FOR DIARRHEA
Cholera tetracycline or doxycycline
(if resistant: furazolidone, cotrimoxazole
or chloramphenicol may be used)
Dysentery (treated as shigellosis):
co-trimoxazole, ampicillin, nalidixid
acid
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ANTIPARASITIC FOR DIARRHEA
Amoebiasis metronidazole; if:
E. histolytica trophozoites containing RBC
(+) Bloody stools persist after tx for shigellosis
Giardiasis metronidazole; if:
Diarrhea more than 14 days Giardia containing stools
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MEDICATION NOT INDICATED FOR DIARRHEA
Sulphonamide
Neomycin & streptomycin
Clioquinol or oxyquinolone
Anti-peristaltic drug
Anti-vomiting drug
Kaolin
Steroid
Purgatif
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PREVENTION
Breast milk for the first 4-6 months of life
Avoiding the use of infant feeding bottles
Improving practices preparation & storage
of weaning foods Using clean water for drinking
Washing hands
Safely disposing of faeces
Measles vaccination Improving nutritional status weaning food