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ACUTE DIARRHEA
DR. Dr. A. A. Gede Budhitresna, Sp.PD, FINASIMLecture Block Gastroenterology
Faculty of Medicine Warmadewa University 2011
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Acute Diarrhea
Acute diarrhea is a disease characterized by changes inthe character and frequency of stool.
It can be defined as the passage of a greater number ofstools of decreased form from the normal lasting less
than 14 days.Generally associated with other signs or symptomsincluding nausea, vomiting, abdominal pain and cramps,increase in intestinal gas-related complaints, fever,passage of bloody stools (dysentery), tenesmus(constant sensation of urge to move bowels), and fecalurgency. (1)
(1) Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology.American Journal of Gastroenterology. 1997 Nov;92(11):1962-75.
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Patofisiologi
Diare Osmotik: bahan makanan yang tidak dapatdiabsorpsi sehingga terjadi hiperosmolaritas
Diare Sekretorik: terjadi gangguan transporelektroklit baik absorpsi yang berkurang atau
sekresi yang meningkat melalui dinding ususDiare Eksudatif: akibat inflamasi menimbulkankerusakan mukosa usus halus maupun usus besar
Diare Hipermotilitas: gangguan motilitas yang
menimbulkan transit usus menjadi cepat
PGI, 2009. Konsensus Penatalaksanaan Diare Akut Pada Dewasa di Indonesia
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Etiologi
Infeksi:Virus (rotavirus, adenovirus,Norwalk virus), Bakteri (vibrio cholera,eschericia coli, salmonella, shigella,
campilobacter), Parasit (giardia lamblia,cryptosporidium, entamoeba histolytica)
Non-infeksi: keracunan makanan, obat-
obatan dan toksisn, sindroma usus iritabel,alergi makanan, defisiensi laktosa
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Diagnosis
History
Physical examination
Diagnostic: Stool examination (mucus,blood, leukocytes, stool cluture), Blood
examination (ureum, creatinine, blood gas
analyse), colonoscopy/sigmoidoscopy
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Diagnosis
Complete blood count can be obtained to lookfor anemia, hemoconcentration, or an abnormalwhite blood cell count. (4)
Measurements of serum electrolyteconcentrations and blood urea nitrogen andserum creatinine levels can be used todetermine the extent of fluid and electrolytedepletion and its effect on renal function. (4)
(4) Sleisenger and Fordtrans Gastrointestinal and Liver Disease. 8th edition. 2006. Feldman, Mark
MD. Volume II. p169.
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Acute Diarrhea
Perform initial assessment
Dehydration
Duration (>1 day)Inflammation (indicated by fever, presence
of blood in stool, tenesmus)
(2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The New England
Journal of Medicine. 2004; 350:38-47.
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Acute Diarrhea
Provide symptomatic treatment
Rehydration
Treatment of symptoms (if necessary,loperamide if diarrhea is not inflammatory
or bloody) (2)
(2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The New England
Journal of Medicine. 2004; 350:38-47
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Acute Diarrhea
Initial rehydrationThe most common risk with diarrheal illnesses isdehydration.
The critical initial treatment must include rehydration,
which can be accomplished with an oral glucose orstarch-containing electrolyte solution in the vast majorityof cases.
Although many patients with mild diarrhea can preventdehydration by ingesting extra fluids (such as clear
juices and soups), more severe diarrhea, postural light-headedness, and reduced urination signify the need formore rehydration fluids. (2)
(2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. TheNew England Journal of Medicine. 2004; 350:38-47.
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Dehydration
Mild (3-5%)
Normal or increased pulse
Decreased urine output
Thirsty
Normal physical exam
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Dehydration
Moderate (7-10%)
Tachycardia
Little/no urine output
Irritable/lethargic
Sunken eyes/fontanelle
Decreased tears
Dry mucous membranes
Skin- tenting, delayed cap refill, cool, pale
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Dehydration
Severe (10-15%)
Rapid, weak pulse
Decreased blood pressure
No urine output
Very sunken eyes/fontanelle
No tears
Parched mucous membranes
Skin- tenting, delayed cap refill, cold, mottled
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Physical Examinations
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Rehidrasi
Rehidrasi cairan dan elektrolit
Oral: cairan garam gula, oralit, pedialyte
Diberikan pada pasien dengan diare
akut tanpa komplikasi/dehidrasi ringan
Intravena
Diberikan pada pasien dengan
dehidrasi sedang-berat/komplikasi
Cairan intravena: Ringer laktat/asetat
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Rehidrasi
Evaluasi dan Penatalaksanaan Dehidrasi
Dehidrasi minimal: kebutuhan cairan = 103/100
X 30-40 cc/kgBB/hari
Dehidrasi ringan-sedang: kebutuhan cairan=
109/100 X 30-40 cc/kgBB/hari
Dehidrasi berat: kebutuhan cairan = 112/100 X
30-40 cc/kgBB/hariDalam satu jam pertama berikan 50% defisit cairan, kemudian 3
jam berikutnya diberikan sisa defisit, selanjutnya diberikan sesuai
kehilangan cairan melalui feses
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Terapi Etiologik
Infeksi
Bakteri, Virus, Parasit , Jamur diberikan
antinya berdasarkan evidence/biakan
Non-Infeksi
Intoleransi glukosa, alergi makanan,
intoleransi makanan, sindrom usus
iritabel, tirotoksikosis fase akut, penyakit
inflamasi usus
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(2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The New England Journal of Medicine. 2004; 350:38-47
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Acute Diarrhea
Prevention of Dehydration
It is recommended that continued use of the
patients preferred, usual, and appropriate diet
be encouraged to prevent or limit dehydration.
Regular diets are generally more effective than
restricted and progressive diets, and in
numerous trials have consistently produced areduction in the duration of diarrhea. (5)(5) Cincinnati Childrens Hospital Medical Center. Evidence-based clinical care guideline for acute gastroenteritis (AGE) in children aged 2 months through 5
years. Cincinnati (OH): Cincinnati Childrens Hospital Medical Center; 2006 May. 15 p. [50 references].
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Dont Forget It
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Acute Diarrhea
The use of dietconsisting of bananas, rice,apple, and toast with avoidance of milk products(since a transient lactase deficiency may occur)is commonly recommended, although supportingdata are limited. (3)
Clear liquids are not recommended as asubstitute for oral rehydration solutions (ORS) orregular diets in the prevention or therapy ofdehydration. (5)
(3) Practice Guidelines for the Management of Infectious Diarrhea. Infectious diseases Society of America. Clinical Infectious Diseases 2001;32:33150.
(5) Cincinnati Childrens Hospital Medical Center. Evidence-based clinical care guideline for acute gastroenteritis (AGE) in children aged 2 months through 5years. Cincinnati (OH): Cincinnati Childrens Hospital Medical Center; 2006 May. 15 p. [50 references].
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Acute Diarrhea
Oral Feeding Following Rehydration
> It is recommended that giving the patients usual dietbe started at the earliest opportunity after an adequatedegree of rehydration is achieved. (5)
On-going IV or NG Fluids following Rehydration
> It is recommended that maintenance IV fluids or NGORS be given:
when unable to replace the estimated fluid deficit and keep up
with the on-going losses using oral feedings alone, and/or toseverely dehydrated patient with obtunded mental status
(5) Cincinnati Childrens Hospital Medical Center. Evidence-based clinical care guideline for acute gastroenteritis (AGE) in children aged 2 monthsthrough 5 years. Cincinnati (OH): Cincinnati Childrens Hospital Medical Center; 2006 May. 15 p. [50 references].
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Acute Diarrhea
Stratify subsequent management according to
clinical and epidemiologic features
Epidemiologic clues:
Food, antibiotics, sexual activity, travel, day-care
attendance, other illnesses outbreaks, season
Clinical clues:
Bloody diarrhea, abdominal pain, dysentery, wasting,
fecal inflammation. (2)
(2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The New England Journal of Medicine. 2004;
350:38-47
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Acute Diarrhea
When to admit?
Unstable
Severely dehydrated
Bloody diarrhea
Persistent Vomiting
No improvement after initial hydration or
symptoms exacerbate/ overall condition getsworse
(6) World Gastroenterology Organisation (WGO). WGO practice guideline: acute diarrhea. Munich, Germany: World Gastroenterology Organisation (WGO);
2008 Mar.
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(2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The New England Journal of Medicine. 2004; 350:38-47
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Immunocompromised patients
If symptoms recur or are uncontrolled despite hydration
and antimicrobial treatment....
If evidence of colitis is present,
Do:
Proctosigmoidoscopy with biopsy of lesions with
attention to CMV, mycobacteria, Adenovirus, Fungi,
Herpes simplex
(1) Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology. American
Journal of Gastroenterology. 1997 Nov;92(11):1962-75.
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Immunocompromised
patientsIf symptoms recur or are uncontrolled despite
hydration and antimicrobial treatment....
If evidence of colitis is NOT present,
Do:
-Gastroduodenoscopy with biopsy, Smears and
culture for special parasites plus
proctosigmoidoscopy
(1) Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology. American
Journal of Gastroenterology. 1997 Nov;92(11):1962-75.
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Acute Diarrhea
When to discharge?
Stable Vital signs
Maintains a sufficient fluid intake
Able to eat meals adequately
Able to take medications (if still indicated)
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Patient Education
Consequently, microbial studies should not beneeded to justify careful attention to hygiene.
Select populations may require additionaleducation about food safety, and health careproviders can play an important role in providingthis information. (3)
(3) Practice Guidelines for the Management of Infectious Diarrhea. Infectious diseases Society of America. ClinicalInfectious Diseases 2001; 32:33150.
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APPROACH TO A PATIENT
WITH CHRONIC DIARRHEA
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CLASSIFICATION
Acute diarrhea
Chronic diarrhea
4 weeks cut off point
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CAUSES
Chronic Fatty Diarrhea malabsorptionsyndromes
Chronic Inflammatory Diarrhea
Chronic Watery Diarrhea
Secretory Diarrhea
Osmotic Diarrhea
Drug-Induced Diarrhea
Infectiuos diarrhea
Functional diarrhea :Irritable Bowl Disease
http://www.fpnotebook.com/GI18.htmhttp://www.fpnotebook.com/GI19.htmhttp://www.fpnotebook.com/GI20.htmhttp://www.fpnotebook.com/GI20.htmhttp://www.fpnotebook.com/GI20.htmhttp://www.fpnotebook.com/GI187.htmhttp://www.fpnotebook.com/GI187.htmhttp://www.fpnotebook.com/GI187.htmhttp://www.fpnotebook.com/GI187.htmhttp://www.fpnotebook.com/GI20.htmhttp://www.fpnotebook.com/GI20.htmhttp://www.fpnotebook.com/GI20.htmhttp://www.fpnotebook.com/GI19.htmhttp://www.fpnotebook.com/GI18.htm -
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Infectious Diarrhea
Endocrine diarrhea
Functional Diarrhea (diagnosis of exclusion) Irritable Bowel Syndrome
http://www.fpnotebook.com/GI21.htmhttp://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/GI2.htmhttp://www.fpnotebook.com/GI2.htmhttp://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/GI21.htm -
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HISTORY
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AGE
Young patients
Inflammatory Bowel Disease
Tuberculosis
Functional bowel disorder (Irritable bowel)Older patients
Colon Cancer
Diverticulitis
http://www.fpnotebook.com/GI82.htmhttp://www.fpnotebook.com/LUN198.htmhttp://www.fpnotebook.com/GI54.htmhttp://www.fpnotebook.com/GI89.htmhttp://www.fpnotebook.com/GI89.htmhttp://www.fpnotebook.com/GI54.htmhttp://www.fpnotebook.com/LUN198.htmhttp://www.fpnotebook.com/GI82.htm -
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DIARRHEA PATTERN
Diarrheaalternates with Constipation
Colon Cancer
Functional bowel disorder (Irritable bowel)
Intermittent Diarrhea Diverticulitis
Malabsorption
Functional bowl disorders
Persistent Diarrhea Inflammatory Bowl Disease
http://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/GI8.htmhttp://www.fpnotebook.com/GI54.htmhttp://www.fpnotebook.com/GI54.htmhttp://www.fpnotebook.com/GI8.htmhttp://www.fpnotebook.com/GI16.htm -
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DIURNAL VARIATION
No relationship to time of day: Infectious Diarrhea
Morning Diarrhea and after meals Gastric cause
Functional bowel disorder (e.g. irritable bowel) Inflammatory Bowel Disease
Nocturnal Diarrhea (always organic) Diabetic Neuropathy
Inflammatory Bowel Disease
http://www.fpnotebook.com/GI21.htmhttp://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/GI82.htmhttp://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/END111.htmhttp://www.fpnotebook.com/GI82.htmhttp://www.fpnotebook.com/GI82.htmhttp://www.fpnotebook.com/END111.htmhttp://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/GI82.htmhttp://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/GI21.htm -
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WEIGHT LOSS
Despite normal appetite Hyperthyroidism
Malabsorption
Associated with fever
Inflammatory Bowel Disease
Weight loss prior to Diarrhea onset
Pancreatic Cancer
Tuberculosis Diabetes Mellitus
Hyperthyroidism
Malabsorption
http://www.fpnotebook.com/END230.htmhttp://www.fpnotebook.com/GI82.htmhttp://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/GI65.htmhttp://www.fpnotebook.com/LUN198.htmhttp://www.fpnotebook.com/END12.htmhttp://www.fpnotebook.com/END230.htmhttp://www.fpnotebook.com/END230.htmhttp://www.fpnotebook.com/END12.htmhttp://www.fpnotebook.com/LUN198.htmhttp://www.fpnotebook.com/GI65.htmhttp://www.fpnotebook.com/GI16.htmhttp://www.fpnotebook.com/GI82.htmhttp://www.fpnotebook.com/END230.htm -
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STOOL CHARACTERISTICS
Water:Chronic Watery Diarrhea
Blood, pus or mucus:ChronicInflammatory Diarrhea
Foul, bulky, greasy stools:Chronic Fatty
Diarrhea
http://www.fpnotebook.com/GI20.htmhttp://www.fpnotebook.com/GI19.htmhttp://www.fpnotebook.com/GI19.htmhttp://www.fpnotebook.com/GI18.htmhttp://www.fpnotebook.com/GI18.htmhttp://www.fpnotebook.com/GI18.htmhttp://www.fpnotebook.com/GI18.htmhttp://www.fpnotebook.com/GI19.htmhttp://www.fpnotebook.com/GI19.htmhttp://www.fpnotebook.com/GI20.htm -
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MEDICATION AND DIETARY INTAKE
Drug induced diarrhea
Food borne illness
waterborne illnessHigh fructose corn syrup
Excessive sorbitol or mannitol
Excessive coffee or other caffeine
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TRAVEL
Travelers diarrhea
Infectious diarrhea
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ASSOCIATED SYMPTOMS
Abdominal pain
Alternating constipation
TenesmusUnintentional wt. loss
Fever
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PHYSICAL EXAMINATION
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GPE
General appearance and mental status
Vital signs
Body weight
Orthostasis- volume depletion,autonomicdysfunction
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exophthalmos (hyperthyroidism)
aphthous ulcers (IBD and celiac disease)
lymphadenopathy (malignancy, infection
or Whipple's disease)
enlarged or tender thyroid (thyroiditis,
medullary carcinoma of the thyroid
clubbing (liver disease, IBD, laxativeabuse, malignancy)
SKIN LESIONS
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SKIN LESIONS
dermatitis herpetiformis (celiac disease)
erythema nodosum and pyoderma gangrenosum(IBD)
hyperpigmentation (Addison's disease)flushing (carcinoid syndrome)
migratory necrotizing erythema (glucagonoma).
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ABDOMINAL EXAMINATION
Surgical scars
abdominal tenderness
MassesHepatosplenomegaly
Borborygmus onauscultation
malabsorption bacterial overgrowth
obstruction, or rapidintestinal transit.
PERINEAL AND RECTAL
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PERINEAL AND RECTAL
EXAMINATION
Signs of incontinence skin changes from chronic irritation,
gaping anus,
weak sphincter tone.Crohn's disease perianal skin tags
Ulcers
fissures abscesses
Fistulas
stenoses.
Fecal impaction or masses might be noted.
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INVESTIGATIONS
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Always Remember
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BLOOD TESTS
CBC
TSH
Serum electrolytes
Serum albumin
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STOOL EVALUATION
Stool pH (
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Fecal fat (abnormal if >14 grams/24 hours)
Stool ova and parasites (2-3 samples)
Giardia lamblia antigen
Indicated for diarrhea >7 days and >10stools/day
Clostridium difficle toxin
Indicated if recent antibiotics or hospitalizatio
Consider testing stools for laxative abuse
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ENDOSCOPY
PROCTOSIGMOIDOSCOPY
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TREATMENT
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NON-SPECIFIC THERAPIES
Dietary modifications
Smaller, more frequent meals
Dec. carbohydrates Dec. fat intake
Avoidance of milk
Avoid sorbitol and mannitol
Opioids and Opioid agonist
Loperamide first line therapy
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SPECIFIC THERAPIES
Clonidine
Diabetic diarrhea
moderate and severe diarrhea-predominant IBSSomatostat in
refractory diarrhea
AIDS,
post chemotherapy,and hormone secreting tumors.
Antimikrobial- empirik fluroquinolon
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Think About
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Any questions?