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

SEVERE
ACUTE WATERY DYSENTERY PERSISTEN
MALNUTRITIO
DIARRHOEA FORM T
N

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

 INFECTIO - VIRAL
N - FUNGAL
- BACTERIA
- PARASITES
INFLAMMATIO
N

NON - ALLERGY
DIARRHOEA
INFECTION - etc

NONINFLAMMATIO
- HORMONAL
N
- 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

•
LIQU
ID
STOO
LS ≥
3x/D
AY,
•
WITH
/WIT
HOU
T
VOM
 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 INFEKSI
NON INFECTION
-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 Limited
∙ Water & Electrolytes
∙ Diets
 WATER DEHYDRATION
ELEKTROLYT
ELEKTROLIT Na+ 🡪
==>
Na+ or 🡪 atau 🡪
ES K+ ==>K+🡪 🡪
D Ca2+ ==> 🡪 🡪 ==> TETANY
Ca2+
Mg2+ ==> 🡪 🡪 ==> TETANY
Mg2+
I Zn ==> ACRODERMATITIS ENTEROPATHICA
Zn 🡪 ==>ACRODERMATITIS
A 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
 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 OBJECTIVES OF TREATMENT ACUTE 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.

• RINGER’S LACTATE
ORS*
(ORAL • RINGER’S ACETATE
@
IT )
* 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

• Ringer’s Lactate
• Ringer’s 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/ ½
hours
* repletion = 70 mL/kgBW/2½
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
Excretion of
Na+
 FEEDING

1. AFTER REHYDRATION
2. < 4 MONTHS
- BREASTMILK (+)
- BREASTMILK (-) ==>
????
3. > 4 MONTHS
- BREASTMILK
- RICE PORRIDGE
- BANANAS
- FISHES
- “TAHU, TEMPE”
- FORMULA MILK 🡪 STOP