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  • DIARRHOEA

    IN PEDIATRICS

    ATAN BAAS SINUHAJI

    1

    ATAN BAAS SINUHAJI

    SUB DIVISION OF PEDIATRICS GASTROENTERO-HEPATOLOGY

    DEPARTMENT OF CHILDHEALTH

    SCHOOL OF MEDICINE,UNIVERSITY OF SUMATERA UTARA

    ADAM MALIK HOSPITAL MEDAN

  • DIARRHOEA

    VOLUME OF WATER

    IN THE STOOLS

    2

    IN THE STOOLS

    LOOSE WATERY

  • STOOL

    WATER 75-80 %

    3

    STOOL

    NON WATER

    Difference of only 10 % in hydration marked change

    in stool consistency

  • WATER

    HYPERSECRETION

    4

    WATER

    MALABSORPTION

    •MALDIGESTION

    •HYPEROSMOLAR

    •PERISTALSIS

    •AREA FOR

    ABSORPTION

  • DIARRHOEA

    - FREQ. ≥ 3X / DAY

    - CHANGING OF CONSISTENCY

    - WITH/ WITHOUT VOMITING

    - WITH/ WITHOUT BLOODY STOOL

    5

    ACUTE WATERY

    DIARRHOEA DYSENTERY

    FORM

    PERSISTENT

    < 14 DAYS BLOODY

    DIARRHOEA > 14 DAYS

    SEVERE

    MALNUTRITION

  • BABIES FED ONLY BREAST MILK OFTEN

    FREQUENT PASSING OF FORMED STOOLS

    ( 5-6 x / DAY ) ( 5-6 x / DAY )

    THIS ALSO NOT DIARRHOEATHIS ALSO NOT DIARRHOEA

  • INFLAMMATION

    INFECTION - VIRAL

    - FUNGAL

    - BAKTERIA

    - PARASITE

    - ALLERGYDIARRHOEA

    NONINFLAMMATION

    NON INFECTION - ALLERGY

    - etc

    - HORMONAL

    - ANATOMICAL

    - etc

  • VIRAL DIARRHOEA

    1. ROTAVIRUS ���� 6 MONTHS TO 2.5 YEARS

    2. NORWALK VIRUS

    3. ENTERIC ADENOVIRUS

    4. ASTROVIRUS

    5. CALICI VIRUS

    8

    5. CALICI VIRUS

    6. CORONA VIRUS

    7. SMALL ROUND VIRUS

    - PARVOVIRUS LIKE AGENT

    - MINI ROTAVIRUS

    - MINI REOVIRUS

  • PRACTICALY

    -LIQUID STOOLS ≥ 3 X/ DAY

    -WITH/ WITHOUT VOMITING

    -WITH/ WITHOUT MUCOUS/

    BLOOD IN THE STOOLS

    9

  • CLASSIFICATION

    1. AGE

    2. ONSET

    3. ETIOLOGY

    4. SEVERITY

    5. PATHOGENESIS

    10

    5. PATHOGENESIS

    6. HOST DEFENCES

    7. SOURCE OF INFECTION

    8. EPIDEMIOLOGY

    9. SITE OF PATHOLOGY

    10. WHO ( 2OO5 )

  • 1.AGE

    -NEONATAL DIARRHOEA

    -INFANTILE DIARRHOEA

    -CHILDHOOD DIARRHOEA

    2. ONSET

    -ACUTE DIARRHOEA : < 7 DAYS (90-95%)

    -PROLONGED DIARRHOEA: 7-14 DAYS

    11

    -PROLONGED DIARRHOEA: 7-14 DAYS

    -CHRONIC DIARRHOEA : > 14 DAYS

    3. ETIOLOGY

    -INFLAMMATION : INFECTION/NON INFECTION

    -NON INFLAMMATION

  • 4. SEVERITY( WHO, 1984)

    -MILD DIARRHOEA : < 1x / 2 hours or < 5cc / KgBW /hours

    -SEVEREDIARRHOEA: > 1x / 2 hours or > 5 cc/KgBW/hours

    5.HOST DEFENCE

    -IMMUNOCOMPETENT

    -IMMUNOCOMPROMISED

    12

    -IMMUNOCOMPROMISED

    6. SOURCE OF INFECTION

    -NOSOCOMIAL

    -COMMUNITY

  • 7. PATHOGENESIS

    ABSORPTIVE/ SECRETORY

    OSMOTIC

    1. FASTING STOPS CONTINUES

    2. STOOL OSM. 400 280

    3. Na + 30 100

    13

    3. Na 30 100

    4. K+ 30 40

    5. (Na+K)x 2 120 280

    6. SOLUTE GAP 280 0

  • 8. EPIDEMIOLOGI

    -ENDEMIC

    -EPIDEMIC

    -MIXED

    14

    9. SITE OF PATHOLOGY

    -SMALL INTESTINE : CHOLERA, ETEC, ROTAVIRUS

    AND G. LAMBLIA DIARRHOEA

    -LARGE INTESTINE: SHIGELLOSIS, AMOEBIASIS

    -BOTH : CAMPYLOBACTERIOSIS, SALMONELLOSIS

  • 10. WHO (2005)

    -ACUTE WATERY DIARRHOEA

    -PERSISTENT DIARRHOEA

    -DYSENTERY DIARRHOEA

    -DIARRHOEA WITH SEVERE MALNUTRITION

    15

  • MIKROORGANISMS

    GASTRIC ACID

    MULTIPLICATION

    COLONIZATION

    ADHERENT

    16

    - INVASION

    - DAMAGE

    ENTEROTOXIN

    MALABSORPTIONHYPERSECRETION

    HYPERPERISTALIS

    DIARRHOEA

    PATHOGENESIS OF ACUTE INFECTIOUS DIARRHOEA

    COLONIC SALVAGE

  • DIAREDIARE

    Cleasing effect • Pathogens

    Defense

    Loss of • Water and Electrolytes • Nutrients

    17

    Defense

    Self LimitedSelf Limited

    •••• Water and Electrolytes

    •••• Diets

    •••• Water and Electrolytes

    •••• Diets

    • Dehydration

    • Hypoglicemia

    Starvation

    Malnutrition

  • D

    I

    A

    R

    R

    WATER DEHYDRATION

    BASE METABOLIC ACIDOSIS

    ELEKTROLIT Na+ ==> � atau �

    K+ ==> �

    Ca2+ ==> �

    Mg2+ ==> �

    Zn ==> ACRODERMATITIS ENTEROPATHICA

    ELECTROLYTES Na+ � atau �

    K+ �

    Ca2+ � ==> TETANY

    Mg2+ � ==> TETANY

    Zn � ==>ACRODERMATITIS ENTEROPATHICA

    18

    R

    H

    O

    E

    A

    NUTRIENTS - HYPOGLYCEMIA

    - STARVATION

    - PCM

    MUCOSAL

    INJURY

    - MALABSORPTION

    - PROTEIN LOSING ENTEROPATHY.

    - SENSITIZATION

    - NEC

  • TETANY

    HYPOCALCEMIC

    HYPOMAGNESEMICTETANY HYPOMAGNESEMIC

    ALKALOTIC

  • LOSS OF WATER VIA STOOLS

    DEHYDRATION

    PLASMA WATER

    FEVER HEMOCONCENTRATION HYPOVOLEMIAFEVER HEMOCONCENTRATION HYPOVOLEMIA

    SHOCK RBF* SYMPATH. DISCHARGE

    - HEART RATE

    - VASOCONSTRICTION

    COMA ARF**

    * Renal Blood Flow

    ** Acute Renal Failure

  • SIGNS OF DEHYDRATION

    1. LETHARGICS TO

    COMATOSE

    2. SHUNKEN

    ANTERIOR

    7. HYPOTENSION

    8. WEAKNESS OF

    RADIAL PULSE

    9. OLIGURIA/ANURIA

    21

    ANTERIOR

    FONTANELLA

    3. SHUNKEN EYES

    4. ABSENT OF

    TEARS

    5. DRY OF MOUTH

    AND TONGUE

    6. TACHYCARDIA

    9. OLIGURIA/ANURIA

    10.TURGOR

    11. COOL MOIST

    EXTREMITES

    12. BW

  • DEHYDRATION

    VOLUME PLASMA SODIUM

    -SOME DEHYDRATION

    = 5 - 10 % BB

    -SEVERE DEHYDRATION

    = > 10% BB

    • ISONATREMIA

    = 135 - 150 mEq/L

    • HYPO/HYPER

    NATREMIA

  • THE OBJECTIVE OF TREATMENT ACUTE DIARRHOEA

    DEHYDRATION PROTEIN CALORI MALNUTRITION

    PREVENTION TREATMENT

    DURATION,

    SEVERITY,

    EPISODES

    23 WATER & ELECTROLYTES FEEDING ZINC

  • A NEW EPISODE OF DIARRHOEA

    24

    DIARRHOEA OCCUR AFTER TWO FULL DAYS

    WITHOUT DIARRHOEA

  • MANAGEMENT

    ASSESSMENT TREATMENT

    1. Degree of 1. Water & elektrolytes

    25

    1. Degree of

    Dehydration

    2. Associated :

    • Malnutrition

    • Pneumonia

    • etc

    1. Water & elektrolytes

    2. Diets

    3. Drugs

    - Zinc

    - anti microbial

    - Symptomatic

    - antidiarrhoeal

  • NO SIGN OF NO SIGN OF

    DEHYDRATIONDEHYDRATION

    SOME SOME

    DEHYDRATIONDEHYDRATION

    SEVERE SEVERE

    DEHYDRATIONDEHYDRATION

    CONDITION CONDITION WELL, ALERTWELL, ALERT RESTLESS / RESTLESS /

    IRRITABLEIRRITABLE

    LETHARGIC, LETHARGIC,

    FLOPPY, COMAFLOPPY, COMA

    EYESEYES NORMALNORMAL SUNKENSUNKEN SUNKENSUNKEN

    DEGREE OF DEHYDRATION (WHO,2005)

    THIRSTTHIRST NORMALLY, NOT NORMALLY, NOT

    THIRSTYTHIRSTY

    THIRSTY, DRINK THIRSTY, DRINK

    EAGERLYEAGERLY

    DRINKS POORLYDRINKS POORLY

    SKIN TURGOR SKIN TURGOR QUICKLYQUICKLY SLOWLYSLOWLY VERY SLOWLYVERY 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

    27

    INITIAL REPLETION NORMAL

    HOLLIDAY –

    SEGAR

    CHOLERA

    COT

    ABNORMAL+

  • 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> 20 kg 1500 mL + 20 mL/ kg

    for each > 20 kg

    NB : 100 mL ≡ 2,5 mEq Na+

    ≡ 2 mEq K+

    ≡ 100 calori

  • REHYDRATION

    ORAL I.V.

    29

    ORS*

    ( ORALIT@)

    • RINGER’S LACTAT

    • RINGER’S ACETATE

    * Oral Rehydration Salts

  • PREVIOUS STANDART WHO ORAL

    REHYDRATION SALTS (ORS)

    1.ISOTONIC

    2.Na+ equivalent with plasma (90 mEq/l)

    3. GLUCOSE = 2 - 3%

    30

    3. GLUCOSE = 2 - 3%

    4. K+ ( higher than plasma →→→→ 20 mEq/l )

    5. BASE = 30 - 48 mEq/L

  • Na+

    2K+ ENTEROCYTES

    LUMEN • CHO

    • Peptide

    • Amino Acid

    Na+

    water