DIARRHEA

BY : HASRI SALWAN
Diarrhea
Definition
( WHO): loose of semisolid/ liquid stool, frequency ≥
3x / day with / without blood or mucus
Mother: change of consistency and frequency
defecation
Acute Diarrhoea : ≤ 14 days & < 4 x / month
Chronic Diarrhoea : Persistence and Chronic
Diarrhoea
Konsistensi
konstipasi

Konsistensi
diare
Frekuensi BAB normal
Hal yang berkaitan dengan difinisi
Perubahan konsistensi dan frekuensi BAB.
Pada bayi (terutama yang dapat ASI)
frekuensi BAB bisa sampai 8-12 x/hari.
Monitor: peningkatan BB
Epidemiology:
Diarrhoea:
One of causes morbidity & mortality child
Indonesia: morbidity rate: 200–400 permil
70-80%: child < 5 year 
die: 350.000-500.000 child / year
 Penyebab Kematian Bayi 0-11 bulan
Tidak diketahui Tetanus, 1.7
penyebabnya, 3.7 % %
Meningtis,
4.5 %

Kelainan Kongenital,
5.7 %

Pneumonia, Masalah
12.7 % Neonatal
46,2 %

Diare,
15 %
Masalah neonatal :
-Asfiksia
-BBLR
-Infeksi, dll
Sumber : Riskesdas 2007
Kematian 1-11 bulan menurut Riskesdas 2007
 Penyebab Kematian Balita 0-59 bulan

Tidak diketahui Tetanus, 1.5

penyebabnya, 5.5 % %

Meningtis,
5.1 %

Kelainan Kongenital,
4.9 %
Masalah
Neonatal
Pneumonia, 36 %
13.2 %

Masalah neonatal :
-Asfiksia
Diare, 17.2 -BBLR
%
-Infeksi, dll
Sumber : Riskesdas 2007
Penyebab kematian umur 1-4 tahun
ANGKA KESAKITAN
Aetiology (1):
85%: Rotavirus, ETEC, microorganism none
15% other causes: other bacterium, other
virus, parasite, malabsorption, food
allergy, food poisoning, immunodeficiency,
etc
Aetiology (2):
 80% infection  rotavirus:  30% in
society  50% in hospital
 10% food ( poisoning, malabsorption,
allergic)
 10% etc
Microorganisms caused diarrhoea :

1. Virus : Rotavirus, virus Norwalk, Norwalk

like virus, Astrovirus, Calcivirus,
Adenovirus.
2. Bacteria : Escherichia coli (EPEC, ETEC,
EHEC, EIEC), Salmonella, Shigella, Vibrio
cholera 01, Clostridium difficile,
Aeromonas hydrophilia, Plesiomonas
shigelloides, Yersinia enterocolitis,
Campilobacter jejuni, Staphilococcus
aureus, Clostridium botulinum
3. Parasite : Entamoeba histolytica, Dientamoeba
fragilis, Giardia lamblia, Cryptosporidium
parvum, Cyclospora sp, Isospora belli,
Blastocystis hominis, Enterobius vermicularis.
4. Worms : Strongiloides stercoralis, Capillaria
philippinensis, Trichinella spiralis.
5. Mushroom : Candidiasis, Zygomycosis,
Coccidioidomycosis
 STRUCTURE OF CELL MEMBRANE

Protein
integral

Protein peripheral
Lipid
STRUKTUR MEMBRAN SEL

Reseptor

Protein perantara
Lipid
 PATHWAY TRANSPOR PASS MEMBRANE

energi
LIPID
DOUBLE
LAYER

Simple diffusion
Active transport
Modulated diffusion

Water soluble material

Lipid soluble material
 ABSORPTION MECHANISME

Intra Lumen Glc Na

H K
Microvilli
Co-transfor
Difussion
Na Cl Na Cl
Solvent drag
Enterocite
Nucleus
Tight junction
Na pump

Na
Lamina propia
Other mechanisms influence the absorption &
secretion
1. Form of the vascular architect of villus: absorptive
2. Rule of: intracellular enzyme, neurohormonal. hormonal,
immunologic
3. Acid-base balance
4. food intraluminal
Secretion vs absorption: active secretion of Cl &
bicarbonate
 ABSORPTION

villus

cript

SECRETION
 Mechanism of Self limited diarrhoae

• Epithelial barrier, mucus layer with Ab and antimicrobial

and antiviral substance (lysozime and interferon)
• Immunology actions  mediator-mediator .
• Lymphoid tissue
• Fastest Renewal  diarrhoea recovery average in 3-5 day
Pathophyisiology:
Diarrhoea :
accumulation of water + electrolyte in lumen
3 mechanisms:
( 1) secretory diarrhoea
( 2) osmotic diarrhoea
( 3) cytotoxic / inflammatory diarrhoea
Secretory Diarrhoea

Bacteria produces toxin

Effect of toxin: activating intracellular
protein  stimulate electrolyte and water
secretion watery diarrhoea
 Entero
toksin celah
protein
bagi
Transpor
Reseptor elektrolit

Protein perantara
(second mesenger)
(2) osmotic diarrhoea

Enzyme system insufficient or Short Bowel

syndrome  food is digested partially 
osmotic burden intraluminal  bacterium
decompose the pigswill become the short
chain fatty acid and other material 
diarrhoea
Proses defisiensi
laktase
Gambaran klinik intolerasi laktosa :
• Fese berbau asam dan berbuih
• Meteorismus ringan
• Flatulens/sering flatus/ keluas gas
• Eritema natum/Diaper rash.
• Abdominal pain,cramp,disekitar area
periumbilikal, atau kuadrant bawah.
(3) cytotoxic/inflammatory diarrhoea
Cytotoxic: Viral, inflammatory : allergy, IBD
Viral  invasive and cytotoxic  damage entrocytes
at villus  villus atrophy (Absorption decrease)
 crypt hyperplasia (secretion increase) 
mixed diarrhoea
Inflammation  (1) immune cells  cytokines +
chemokines + prostaglandins  induce secretion
and activate enteric nerves (2) metaloproteins
destroyed entrocytes at villus  (Absorption
decrease)  crypt hyperplasia (secretion
increase)  mixed diarrhoea
Absorption decrease  immature entrocyte with
insufficient disacharidase and peptide hydrolase.
Diarrhoea
Gambaran villi usus
Patofisiologi rota virus

Virus
menyerang
entrosit di
leher villus
Stool Form
• secretory diarrhoea : watery, high level
electrolyte
• osmotic diarrhoea : semisolid, low level
electrolyte
• cytotoxic / inflammatory diarrhoea : mix
Pathogenesis
loss of water & electrolyte 
 Dehydration  death
 imbalance of electrolyte and acid-base
 hypoglycemia, under/malnutrition,
 shock, etc
Clinical manifestation
Alertness: irritable, weak / lethargy
Thirsty, nausea, vomiting,
Pulse: quick, weak.
Respiratory rate: quick, kausmall
Fontanel : sunken
Eyes: sunken, no tear
Mouth: dry mucosa
Turgor: diminish (> 1 second) , Swollen
erythema natum,
Mostly take place: 3 – 5 day
Clinical form Classification
Clinical : acute diarrhoea, cholera, dysentery
Severity of dehydration:
without dehydration, mild-moderate dehydration,

and severe dehydration

Type of dehydration:
isotonic, hypotonic, hypertonic
Clinical complicated:
complicated and uncomplicated
Clinical Form: antimicrobial usage
differed to : acute diarrhoea,
cholera, dysentery
Cholera : clinical manifestation typically,
child > 3 year ( especially > 5 year),
outbreaks accident
Dysentery: Diarrhoea with blood and or pus
 bloody stool
Acute diarrhoea: non cholera and non
dysentery.
Antimicrobial
• Limited
• WHO and National Health Department :
cholera and dysentery
• Considerable to invasive diarrhoea
• Other indicated: suspect cholera, suspect
shigelosis, proven amubiasis, proven
giardiasis, and bacterial overgrowth
Other indication of Antibiotic:
• Invasive diarrhoea: leucocyte stool = 10 /
hpf ?, temperature > 38,5 oC
• Meteorismus
• With other disease (need for antibiotic)
Acute diarrhoea with complicated disease,
rehydration is given in 24 hours.
Complicated disease:
heart disease, BP, bronchiolitis, meningitis,
encephalitis, NS, ANS, malnourish
WHO: term unknown.
Determining degree of dehydration

1. Clinical feature
2. IMCI/MTBS, practical and easy to
applied
3. P2 Diarrhoea = Programe National
Diarrhoeal Diseases Control Program
(CDD)
4. Maurice King Score
5. etc
General clinical manifestation
Clinical form based on MCI/ MTBS

• Acute
• Persistent
• Disentry
Clinical form based on
WHO/Depkes : RSUD kab (district
hospital)
1. Acute
2. Persistent
3. Disentry
4. cholera
5. + severe malnourish
6. AAD (antibiotic associated diarrhea)
7. Intusuception
Bagaimana diagnosis kolera ?

•Feses air cucian beras

•Feses bau sperma/”bayclin”
•BAB perfuse
•Tangan seperti wanita
tukang cuci
•Muka seperti orang tua
 Anak > 3 tahun

Menyerang orang
dewasa kemudian
anak-anak
 acute chronic

Acute prolong persistent chronic

Acute
Dysentri >< INTUSUCCEPTION
cholera
Clinical form based on IMCI/ MTBS

• Acute
• Persistent
• Disentry
IMCI: Does the child have diarrhoea?

IF YES, ASK:
• For how long?
• Is there blood in the stool?
1. How long ? < 14 days: acute, ≥ 14 days: persistent
2. Bloody stool? No: (dx: = 1), yes: disentry
Classification: degree of dehydration  general
apprerance, sunken eye, thristhy, turgor. Classification
dehydration (without, some = mild to moderate, severe)
MTBS = IMCI
General clinical manifestation
P2 Diare program = National Diarrhoeal
Diseases Control Program (CDD)
TREATMENT
WHO:
(1) giving solution: prevent & treat dehydration
(2) diet: continue especially breast feeding
(3) drug: no AB,
except for cholera and bloody stool
WHO recommend : Zinc,
not yet: Probiotik And prebiotik
(4) education
1. giving solution: to prevent or to treat
dehydration
2 option: peroral and parenteral (intravenously)
To prevent dehydration: without dehydration
(peroral)
To treat dehydration:
mild-moderate dehydration (peroral)
and severe dehydration (parenteral)
 Solid mass
40%
Intravasculler Intracelluler
Diartr 5%
hea
albumin

Intertitiel 40%

15%
 Solid mass
Diarrhea 40%
Na 50-60 Intravasculer
Intraceluller
K 28 5%
Alb (-) Albumin, Na

Intertitiel 40%
Na
15% K
 dehidrasi Solid mass
40%
Intraceluller
Diare Intravasculer
albumin
Intertitie
l
rehydratio Solid mass
n 40%
Intraceluller
IVFD Intravasculer
albumin
Intertitie
l

Need
time
Peroral

• more beneficial compared to parenteral

(cheap, frequency and duration of diarrhoea:
decrease)
• Given in : without and mild-moderate
dehydration
• In especially situation: can be given by NGT
(≤ 20 ml/kgBW/hour)
• Home based solution, ORS, renalyte,
pedialyte, etc
ORS Composition

Reduced Grams/litre Reduced Mmol/L

Osmolarity ORS Osmolarity ORS

Sodium Chloride 2.6 Sodium Chloride 75

Anhidrous 13.5 Anhidrous 75
Glukose Glukose
Potassium 1.5 chloride 65
chloride
Trisodium citrate, 2.9 Potassium 20
dihydrate
citrate 10
Total Osmolarity 245
Parenteral/Intravenously

• Given in: severe dehydration (when oral

administration unable to answer the
demand , and mild-moderate dehydration is
fail to rehydrate with oral solution
• After rehydration is reached, as soon as
possible ( 4-6 hours) change to oral solution.
• Kind of intravenous solution : kristalolid ( RL,
Nacl, Nacl+Dektrose)
Parenteral/Intravenously

Severe dehydration:
WHO: RL
< 1 year: 30 ml / 1 hour  70 ml / 5 hours
≥ 1 year: 30 ml / 0,5 hour  70 ml / 2,5 hours
RSCM/ FKUI: KAEN 3B
< 1 year: 30 ml / 1 hour  70 ml / 5 hours
≥ 1 year: 30 ml / 0,5 hour  70 ml / 2,5 hours
RSMH/ FK UNSRI: RL
30 ml/hour  120 ml/4 hours
Principle of solution therapy for 1 day
Giving solution for:
• PWL (mild-moderate: 75 ml, severe 125 ml)
• CWL (± 100 ml)
• IWL (± 25 ml)
Or
1. maintaince solution (depend on BW, ± 100 ml)
2. PWL (mild-moderate: 75 ml, severe 125 ml)
3. CWL (depend on frequency diarrhoea)
Degree of dehydration
• There are many type how to know
dehydration degree
• WHO : IMCI (MTBS) and P2 Diarre
• Classification of dehydration 
management of rehydration
• There are 3 types of dehydration:
without, mild to moderate, and severe
Giving solution
Loss of Body Weight

0% 5% 10% 15%
Ex : normal BW 10 kg, if diarrhea 9 kg :
loss of BW 10%
Dehydration
No,Mild, moderate, severe, shock,death
No, Mild-moderate, severe, shock,death
Rehydration
Mild-moderate : (5%+10%):2 = 7,5% = 75 ml/kgBW
Severe : WHO 10% (100ml/kgBW), FK Unsri = 12%
Diarrhea:
Without dehydration:
• Oral: home base solution, pedialyte, oralyte/
renalyte with high consumption of plain water.
• IVFD (failure orally for CWL rehydration) :
Estimation, there is dehydration in 24 hours : [D5%
10:4:7, KAEN 3A with drops/min 1,5-2x BW
(kg)/min (150-200ml/kgBW/day) if estimation mild
to mederate dehydration AND 2,5x BW(kg)/min
(250ml/kgBW/day) if estimation severe
dehydration], KAEN 3B ( hypokalemia case).
Peroral

• more beneficial compared to parenteral

(cheap, frequency and duration of diarrhoea:
decrease)
• Given in : without and mild-moderate
dehydration
• In especially situation: can be given by NGT
(≤ 20 ml/kgBW/hour)
• Home based solution, ORS, renalyte,
pedialyte, etc
Parenteral/Intravenously

• Given in: severe dehydration (when oral

administration unable to answer the
demand , and mild-moderate dehydration is
fail to rehydrate with oral solution
• After rehydration is reached, as soon as
possible ( 3-6 hours) change to oral solution.
• Kind of intravenous solution : kristalolid ( RL,
Nacl, Nacl+Dektrose)
Parenteral/Intravenously

Severe dehydration:
WHO: RL
< 1 year: 30 ml / 1 hour  70 ml / 5 hours
≥ 1 year: 30 ml / 0,5 hour  70 ml / 2,5 hours
RSCM/ FKUI: KAEN 3B
< 1 year: 30 ml / 1 hour  70 ml / 5 hours
≥ 1 year: 30 ml / 0,5 hour  70 ml / 2,5 hours
RSMH/ FK UNSRI: RL
30 ml/hour  120 ml/4 hours
The important thing is MONITORING each hour
Principle of solution therapy for 1 day
(slowly rehydration
ONLY for complicated diarrhea (diarrhea with DC, pneumonia,
bronkiolitis, severe malnourish, encephalitis, meningitis, NS,
neonate)
Severe malnourish : orally for 12 hours
Giving solution for:
• PWL (mild-moderate: 75 ml, severe 125 ml)
• CWL (± 100 ml)
• IWL (± 25 ml)
Or
1. maintaince solution (depend on BW, ± 100 ml)
2. PWL (mild-moderate: 75 ml, severe 125 ml)
3. CWL (depend on frequency diarrhoea)
Vomit case without dehydration:
Acid vomit (low pH) :
Peroral: home base solution
IVFD
- D5% 1/5 NS (+ KCl 7,46% 5-10ml perkolf),
- KAEN 4A (+ KCl 7,46% 5-10ml perkolf),
- D5% ¼ NS (+ KCl 7,46% 5-10ml perkolf),
- KAEN 1B (+ KCl 7,46% 5-10ml perkolf).
Chronic : D5/10% ½ NS or NS
Billous vomiting (high pH) without
dehydration:
Peroral: Renalyte, ORS (oralyte) .
IVFD: D5% 10:4:7 , KAEN 3A, KAEN 3B.
Don,t know (acid or billous) : D5% 10:4.
Vomit with complete cyclus (nausea/
preejeksi, retching, and expultion) =
billous vomiting
Vomit + diarrhea = diarrhea cases
With dehydration:
• Billous vomiting = Management of
diarrhea
• Acid vomiting : NaCl 0,9%
• To know degree of dehydration =
diarrhea
• Electrolyte meassurement = after
rehidration or before and after
rehydration
 If > 10 kg it means BW equal with maintenace
solution, ex BW 20 kg maintenance 15
drops/minutes, estimate there is severe
dehydration in 24 hours, we give 2,5 x 15 drops/min
 IMPORTANT!!!
Rehydration in Mild to moderate dehydration :
Orally is better than parenterally :
1. cheaper, easier
2. Frequency and duration diarrhea: Per orally is
more decrease than per parenterally
3. In dehydration there is increasing ADH
secresion. ADH make retention of water is more
responsive than retention of electrolyte
2. Diet

• Breast feeding continued

• continue to eat and drink as usual:
portion > usual
• Do not consume the stimulating food
• Consume food with potassium high
• Baby consumes formula milk, change:
LLM/BL/LF if there is lactose
intolerance
 Seng (Zinc)
Mikronutrien esensial
Berperan dlm :
• proses pertumbuhan dan diferensiasi sel
• menjaga stabilitas dinding sel
• Ikut proses ekspresi gen dan pengaturan ion
intraseluler.
• Meningkatkan sisstem imun spesifik/nonspesifik
Seng dalam pengobatan & pencegahan diare
• Seng menurunkan insidens diare akut dan
persisten antara 14-65%
• Seng menurunkan insiden diare 2-3 bln yad
• Seng memperpendek durasi dan mengurangi
proporsi diare yg menjadi kronik
• Seng mengembalikan nafsu makan anak
Sediaan: tablet atau sirup
Dosis: 2- 6 bl: 10 mg, > 6 bulan : 20 mg
Diberikan selama 10-14 hari