Download - 10. Diare Akut (Dr. Umar Zein)
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MANAGEMENT OF ACUTE DIARRHEA IN COMMUNITY
Umar Zein
Division of Tropical Diseases and Infections/
Health Office of Medan City
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Diarrhea describes bowel movements (stools) that are loose and watery. It is very common and usually not serious. Many people will have diarrhea once or twice each year. It typically lasts two to three days and can be treated with over-the-counter medicines.
Doctors classify diarrhea as "osmotic," "secretory" or "exudative."
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Definisi Diare
Buang air besar lembek/ cair bahkan dapat berupa air.
Frek. Lbh srg dari biasa (3x atau lebih)
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Definition of Diarrhea
Three or more stool motion/Day Stool weight >200 g Loose stool
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Diarrhea 9 liters of fluid enter the GI tract 4-5l absorbed in jejunum , 3-4 ileum, 800
ml in colon. Water transport follows Na & nutrient
active & passive transport . The basis for ORS treatment
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Mechanism of Diarrhea
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Clue for diagnosis
Acute versus chronic Small bowel versus large bowel Osmotic versus secretary Inflammatory versus fatty versus
secretory
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FAKTA
Diare merupakan penyebab utama ketidakhadiran kerja, karena diare mengganggu aktivitas penderita*: Menimbulkan rasa tidak nyaman Menghambat perjalanan Menimbulkan rasa malu dan stress Komplikasi kehilangan energi, lemas &
dehidrasi
*Wingate D et al. ; Alimentary Pharmacology Therapeutics 2001; 15; 16; 773-782
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Penyebab penyakit diare
PENYEBAB
PENYAKIT
DIARE
INFEKSI
MALABSORBSI
ALERGI
KERACUNAN
IMUNISASI DEFISIENSI
SEBAB2 LAIN
SHIGELLA
PARASIT
VIRUS
BAKTERIAI
BACILLUS CEREUS
CACING PERUT
PROTOZOA
ROTAVIRUS
BACILUS CEREUS
CLOSTRIDIUM PERFRICENS
ASCARIS
ENTAMURA HISTOLYTICA
NORWALK+NORWALK LIKE AGENT
CLOSTRIDIUM PEFRICENS
SALMONELLA
AEROMONASCAMFYLO-BACTER
GOLONGAN VIBRIO
STAPHILOCOC USAURFUS
E.COLI
BLASTISSISTIS HUMINIS
CRYPTO SPARIDUM
STRONGY-LOIDES
BALANTIDIUM COLI
TRICHURIS
GIARDA LAMBLIA
ADENOVIRUS
SAYUR-SAYURAN
BUAH-BUAHAN
ALGAE
IKAN
JASAD RENIK
KERACUNAN OLEH RACUN YANG
DIKANDUNG DN DIPRODUKSI
KERACUNAN BAHAN-BAHAN KIMIA
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Diare Akut
Masih merupakan masalah kesehatan masyarakat.
Angka kesakitan diare semua gol umur 280/1000 pddk/tahun, balita episodenya 1,5 kali pertahun.
Bisa KLB Dipengaruhi oleh lingk, gizi, sosial
ekonomi, perilaku masy.
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JENIS DIAREDiare akut: < 14 hari (< 7hari) akibatnya
dehidrasi. Sindroma Disentri: disertai darah dan
lendir dalam tinja. Diare persisten: > 14 hr terus menerus
akibatnya BB turun dan gangguan metabolisme
Diare dengan masalah lain: Infeksi lain, Malnutrisi, Malignancy, AIDS, Enteropati DM
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Allemand H et al. Gut 1996; 39 (Suppl 3): A173. General practitioners survey in France (4200 adults)
84%
42% 39%33%
25%13%
3%0%
20%
40%
60%
80%
100%
Nyeri abdomen
Sakit kepala
Muntah Demam Nyeri otot Nyeri sendi Dehidrasi
Diare sangat mengganggu aktivitas penderita
Gejala Penyerta Diare Akut Dewasa
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Karakteristik Non Inflamatory
Inflamatory Penetrasi
Gambaran Tinja
WateryVolume >>Leukosit (-)
Bloody, mukusVolume sedang
Leukosit PMN
MukusVolume sedikitLeukosit MN
Demam (-) (+) (+)
Nyeri Perut (-) (+) (+)/(-)
Dehidrasi (+++) (+) (+)/(-)
Tenesmus (-) (+) (-)
Komplikasi Hipovolemik Toksik Sepsis
Karakteristik 3 Tipe Diare Akut
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Mechanisms of diarrhea Disturbed intestinal solute transport,
water movement across intestinal wall. Secratory Osmotic Dysmotility Inflammatory
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Secretory Diarrhea Agent that binds to surface receptors ,
increasing cAMP,increased secretion. Watery ,large volume , normal
osmolality( 2* Na+K ) Persists during fasting,no stool leukocytes. Examples; cholera, toxigenic
E.coli,carcinoid ,VIP, congenital chloride diarrhea,Clostridium difficile,cryptosporidium.
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Osmotic Diarrhea Occurs after ingesting a poorly absorbed
solute . Stools are of less volume, acidic, reducing
substances, high osmolality > 2* Na + K. Stops with fasting , increased breath
hydrogen with malabsorption,no stool leukocytes.
Examples : lactase deficiency , glucose-galactose malabsorption,lactulose, laxative abuse.
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Motility Diarrhea Increased motility :
decreased transit time. Stimulated by gastro-colic reflex Irritable bowel syndrome Thyrotoxicosis Post vagotomy Infections
Decreased motility: Stasis : bacterial overgrowth. Pseudo-obstruction, blind loop
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Inflammatory Inflammation . Decreased mucosal surface area &/Or
colonic reabsorption. Blood & increased WBC`s in stool. Infectious gastroenteritis Dysentery
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Clinical Features
Diarrhoea Watery Bloody
Cramping abdominal pain
Nausea, +/- Vomiting Fever Loss of appetite Lethargy Shock
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EPIDEMIOLOGI
Kuman menyebar: fecal-oral Perilaku sgt mempengaruhi: tdk
memberi ASI 4- 6 bln, tdk mencuci tangan, air minum dan makanan yang tercemar, botol susu pd anak.
Faktor dominan: sarana air bersih dan pembuangan tinja
Faktor lain: gizi buruk, penyakit infeksi spt campak.
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WHO memperkirakan ada sekitar 4 miliar kasus diare akut setiap tahun dengan mortalitas 3-4 juta pertahun.
Bila angka itu diterapkan di Indonesia, setiap tahun sekitar 100 juta episode diare pada orang dewasa per tahun
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Di Amerika Serikat, diperkirakan 211-375 juta kasus diare terjadi setiap tahunnya yang mana 73 juta kasus diantaranya berkonsultasi ke dokter, 1,8 juta kasus opname di rumah sakit dan 3.100 kasus diantaranya mengalami kematian
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Di kota Medan, tercatat 42.050 kasus diare yang berobat ke 39 Puskesmas dan RS Dr. Pirngadi sepanjang tahun 2006.
Tahun 2007, 37.456 kasus diare, 10 meninggal
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PENYEBAB
Infeksi: bakteri, virus, parasit. Malabsorpsi Allergi Keracunan Immuno defisiensi Penyebab lain : stress emosional, dll. Yang sering ditemukan : infeksi dan
keracunan.
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What Causes Diarrhea?
The most common cause of diarrhea is a virus that infects the gut. The infection usually lasts for two days and is sometimes called "intestinal flu." Diarrhea may also be caused by:
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PENYEBAB DIARE AKUT
0 10 20 30 40 50 60
Others
Parasit
Obat-obatan
G.Sal.Cerna
Bakteri
Virus
Sumber : Marcel Simadibrata
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Etiologi Diare Akut pada orang Dewasa
Non infeksi/Saluran cerna
(26%)
Viral(51%)
‘DrugInduced’(8%)
Bakterial (7%)
Parasitik (1%)
Tidak diketahui (6%)
Lain-lain (5%)
Sumber : Allemand H et al. Gut 1996; 39 (Suppl 3): A173. General practitioners survey in France (4200 adults)
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There are many dietary changes that can be made to prevent or reduce diarrhea. Foods to avoid include:
whole grain breads and cereals fresh or frozen fruits (except banana) dried fruits fruit juices with pulp and prune juice raw vegetables canned onions, corn, olives, pickles, and Brussels sprouts fatty foods dried beans rich desserts milk and milk products alcohol and caffeinated coffee and tea spicy foods fried foods
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Diare Virus
Paling sering terjadi Penyebab utamanya oleh 4 kelompok
virus:1. Norwalk virus2. Rotavirus3. Enteric adenovirus4. Astroviruses
Spektrum klinis: ringan, diare cair sampai dengan mual berat, muntah, dan demam.
Dapat sembuh dengan sendirinya Terapi suportif : rehidrasi.Southwick FS : Infectious Diseases, McGraw Hill 2003
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Chemotherapy drugs, hormones, and biological response modifiers that frequently cause diarrhea include:
Dactinomycin Daunorubicin Diethylstilbestrol diphosphate Doxorubicin Fluorouracil Flutamide Hydroxyurea Interferon Interleukin-2 (aldesleukin) Irinotecan Methotrexate Nitrosoureas Thioguanine
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Foto Vili
Vili – vili usus
Permukaan vili
Sel parietal
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Pada kondisi normal terjadi keseimbangan absorbsi & sekresi cairan
Infeksi mukosa saluran cerna menyebabkan pelepasan epitel saluran cerna
Sel epitel kripta bermigrasi menuju permukaan vili, sel ini bersifat immature, yg menyebabkan fungsi penyerapan cairan tidak dapat berlangsung sempurna, sehingga terjadi diare
Etiologi Diare Virus
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Diare Bakteri
1. Bakteri non-invasif (Enterotoksigenik) Tidak merusak mukosa V. Cholerae, ETEC, Cl. Perfringens
2. Bakteri Enterovasif Kerusakan dinding usus (nekrosis & ulkerasi) Diare sekretorik eksudatif EIEC, EHEC, Salmonella, Shigella
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VIBRIO CHOLERAE Kuman sudah menempel pada usus halus
dan memproduksi toksin kolera yang kemudian terikat pada reseptor terjadi peningkatan AMP siklik, pengeluaran klorida dan air
VIBRIO PARAHAEMOLYTICUS Memproduksi enterotoksin yang
menyebabkan inflamasi dan watery diarrhea
Southwick FS : Infectious Diseases, McGraw Hill 2003
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Kolera
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7 EXPERTS : Alimentary Pharmacology & Therapeutic 2001
DIARE BUKAN MEKANISME PERTAHANAN Mekanisme diare tidak bisa melepaskan
patogen yang sudah melekat di fimbrae usus. Diare tidak bisa mengurangi sekresi cairan
yang disebabkan oleh toksin, karena diare tidak dapat mengeluarkan toksin yang sudah melekat kuat di mukosa usus.
Pada keadaan diare usus tidak dapat melakukan absorsi cairan dengan baik, karena sel-sel epitelnya sudah dirusak oleh mikroorganisme.
Tidak terjadi pengurangan jumlah patogen pada pasien AIDS yang menderita diare
Tidak semua diare disebabkan oleh patogen.
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Tipe Diare karena Enteropatogen
Enteropatogen Acute Watery
Disentri Persisten
Bakteri :
V.choleraeETEC, EPECEIECEHECShigella,SalmonellaC.jejuni,Y.enterocliticaC.defficileM.tuberculosaAeromonas
(+)(+)(+)(+)(+)(+)(+)(-)(-)
(-)(-)(+)(+)(+)(+)(+)(+)(+)
(-)(-)(-)(+)(+)(+)(+)(+)(-)
Modifikasi dari : Sirivichayakul C : Acute Diarrhea in Children, In : Tropical Pediatrics for DTM&H 2002, Faculty of Tropical Medicine, Mahidol Univesity, Bangkok, Thailand,1-13.
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Virus : (+) (-) (-)
Protozoa :G.lambliaE.histolyticaC.parvumMicrosporidium sppIsospora belliCyclospora cayatenensis
(+)(+)(+)(+)(+)(+)
(-)(+)(-)(-)(-)(-)
(+)(+)(+)(+)(+)(+)
Cacing :Strongyloides stercoralisSchistosoma sppCapilaria philippinensisTrichuris trichuria
(-)(-)(+)(-)
(-)(+)(-)(+)
(+)(+)(+)(+)
Enteropatogen Acute Watery
Disentri Persisten
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TATA LAKSANA
Mencegah terjadinya dehidrasi: terapi cairan: oral (oralit, LGG, cairan lain yang dianjurkan), intra vena
Memberi makanan: ASI, makanan lunak sedikit-sedikit tp sering.
Mengobati masalah lain.
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Pengobatan Diare Akut Dewasa1. Pengaturan Diet
• Hindari:– Produk olahan susu– Kadar lemak tinggi– Makanan merangsang
• Karbohidrat sederhana (nasi/roti) protein lemak
2. Cairan Oral• Untuk dewasa sehat, minum sesuai rasa
haus– WHO – Oral Rehydration Salts Solution– Oralit
• Subsitusi cairan + elektrolit dianjurkan hanya untuk anak/usia lanjut atau dehidrasi sedang/berat
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Pengobatan Diare Akut Dewasa
3. Obat Non Spesifik• Arang aktif kurang efektif• Kaolin & Pektin :
meningkatkan konsistensi feses tidak mengurangi rasa mules & frekuensi diare tidak mempersingkat lama diare.
• Preparat Laktobasilus tidak terbukti efektifitasnya untuk terapi Diare Akut.
• Attapulgite aktif : kurang efektif, hanya untuk diare yang ringan dan non spesifik
• Bismuth Subsalicylate– Kurang efektif dalam menurunkan frekuensi dan
mempersingkat waktu diare
Wingate D et al. ; Alimentary Pharmacology Therapeutics 2001; 15; 16; 773-782
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Pengobatan Diare Akut Dewasa4. Obat Antimotilitas
• Opiat alam (Codeine), Diphenoxylate (+ Atropine) : tidak dianjurkan lagi
• Loperamide – Antimotilitas dan antisekretori– Tidak dianjurkan pemakaian pada anak < 2
tahun– Stop bila gejala menetap dalam 48 jam– Dapat dikombinasi dengan Antimikroba
pada diare yang disebabkan bakteri
Wingate D et al. ; Alimentary Pharmacology Therapeutics 2001; 15; 16; 773-782
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Pengobatan Diare Akut Dewasa5. Obat Antimikroba :
• Diare encer > 3x / 8 jam + mual, muntah, mules, demam dan darah pada feses → cari etiologi
• Kombinasi Loperamide dan antimikroba dosis tepat, mempersingkat lama diare Fluoroquinolone : 1 - 3 hari Ciprofloxacin 2 x (250-500)mg Ofloxacin 2 x (200-400)mg Norfloxacin 2 x 400 mg Fleroxacin 1 x 400 mg TMP/SMX 2x2 tablet (160 mg TMP/
800mg)Wingate D et al. ; Alimentary Pharmacology Therapeutics 2001; 15; 16; 773-782
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Pedoman Pengobatan Mandiri Diare Akut Dewasa
Kriteria Bila tidak terlambat → aman, efektif
pada keadaan :1. Diare mendadak2. Sehat3. Umur > 12 tahun, < 75 tahun4. Tanpa gejala :
Disentri ( suhu 38,5 ºC, + darah ) Muntah-muntah Dehidrasi yang jelas
Wingate D et al. ; Alimentary Pharmacology Therapeutics 2001; 15; 16; 773-782
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Pedoman Pengobatan Mandiri Diare Akut Dewasa
Membawa “travel kit” yang berisi antara lain obat anti diare yang dianjurkan
Sasaran Pedoman Ahli farmasi, petugas apotek Dokter umum, perawat Penasehat biro perjalanan
Penderita Di rumah Dalam perjalanan
Wingate D et al. ; Alimentary Pharmacology Therapeutics 2001; 15; 16; 773-782
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PENCEGAHAN
Memberikan ASI Memperbaiki makanan pendamping Menggunakan air bersih yang cukup Mencuci tangan Menggunankan jamban Membuang tinja bayi yang benar Memberikan immunisasi campak
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ASI EKSKLUSIF
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CUCI TANGAN
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Cuci Tangan
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KESIMPULAN
Diare akut merupakan masalah yang sering terjadi dan umumnya dapat diobati sendiri oleh pasien meskipun sebagian pasien memerlukan pertolongan medik.
Dengan memahami gejala klinik serta karakteristik diare, kita dapat memperkirakan penyebab diare akut dewasa dan memberikan pengobatan yang tepat
Penatalaksanaan meliputi rehidrasi, antimotilitas, pengaturan diet, dan antibiotik sesuai indikasi.