Case 2B (group 8) blok GIT

CASE : 2B

GROUP 8TUTOR : dr. Zita

BLOK : GIT

FACULTY OF MEDICINETARUMANAGARA UNIVERSITY

Group List Tutor : dr. Zita Leader : Kevin Barnabas Malingkas Secretary : Nancy Scriber : Amelia Febriana Handjaja Member:

- Megawati Lohanatha

- Anggelina Angkola

- Meida Astriani

- Johan Yap

- Anggi Zerlina Darwin

- Maria N.E. Bagul

- Marcelly Raymando Salyo

- Angelia

- Ahmad Farid Haryanto

Problem 2B (child)A 3-year-old boy is brought to the emergency room with fever, vimiting, and diarrhea for the past day. He has not been able to keep anything down by mouth and has had profuse, very watery stools. He attends day care, an several of his classmates have been out sick recently as well. Not adult members of the household have been ill. He has no significant past medical history. On examination, vital sign : temperature 37,9°C, heart rate 120 bpm, blood pressure 70/50 mmHg and capillary refill is more than 2 seconds. Current body weight is 12 kg. Two weeks ago his body weight was 14 kg. Mucous membranes are dry, and eyes appear somewhat sunken. Abdomen has active bowel sounds and is non tender. Stool is watery and pale. The stool tests negative for blood, possitive for fecal leucocytes and fungi.

Learning Objective :

Able to explain about diarrhea in childrenAble to explain about fluid and electrolite

balance

DIARRHEA

Diarrhea

Frequency of bowel movements. •Absolute diarrhea is having more bowel movements than normal.

•Thus, since among healthy individuals the maximum number of daily bowel movements is approximately three

•Diarrhea can be defined as any number of stools greater than three.

•Relative diarrhea is having more bowel movements than usual.

Consistency of stools •the consistency of stool can vary considerably in healthy individuals depending on their diets.

•Stools that are liquid or watery are always abnormal and considered diarrheal..

A. Definition :

Epidemiology

• Most cases of acute infectious diarrhea are caused by viruses

• Bacterial pathogens isolated in 1-6% of cases

• Limitation of hospital based survey:

- 22% examined- 5% submitted stool

RISK FACTOR

Other factor

Nutrition Hygiene Sanitation

Social Culture

Germ caused

diarrhea COMMUNITY

Patient

Human that carier the germ

Compact inhabitant

Social Economi

Health people

ETIOLOGY

Phsycology : afraid, worried

Viruses : Enterovirus, adenovirus, rotavirus Enteral Infection

Bacteria : Vibrio, E. coli, Shigella, Salmonella, Campylobactr, Yersinia, Aeromonas

Protozoa : G. Lamblia, E. Histolitica, Isospora belli

Parasites Helmin : Ascaris, Trichuris, Oxyyuris, Strongyloides

Fungal : Candida albicans

Parenteral Infections : Tonsilofaringitis, Bronkopneumonia,

Morbilli

Infection

Malabsorption : Carbohydrate, Lipid, Protein

Food : out-of-date, poisonous

Allergic

Immunodeficiency

Caused of diare

Any number of viruses can cause diarrhea,as well as

vomitting,abndominal pain,fever an chills.

Pathophysiology

•Viruses injure the absorptive surface of mature villous cells,resulting in decreased fluid absorption and dissacharidase deficiency.•Bacteria produce intestinal injury by directly invading the mucosa,damaging the villous surface or releasing toxin.

Viral infectious

ROTAVIRUS• Most common cause of viral gastroenteritis.• Usually occurs between 3 months and 3yrs of age. Although

most common during wintermonths, it may occur year round.• Clinical manifestations:

– Diarrhea– Fever and vomiting. – Blood is not usually found in stools– Usually lasts for few days and up to 1 wk.

• Detection of rotavirus antigen in stoolby enzyme immunoassay is diagnostic.

Viral infectiousADENOVIRUS• Adenoviruses may be associated with acute gastroenteritis,

especially in children <2 yrsof age.• Illness usually occurs during summer.• Diagnosed by: stool viral culture.

NORWALK-VIRUS• Usually cause epidemics in school-aged children or

adults.• Infection usually comes from contaminated wateror food.• Clinical manifestations: (usually last several days)

• Cramping abdominal pain• vomiting,and low-grade fever

• Diagnosed by: stool viral culture.

Bacteria can also responsible for diarrhea.accompanied by

cramps,blood in his stool and fever.

Bacterial infection

Parasitic can also cause diarrhea.symptoms may include gas,bloating and greasy stools.

Entamoeba histolytica

• Although many species of amoeba exist, only E. histolytica is clearly pathogenic. Transmission occurs by fecal contamination of food or water. Infection is endemic throughout the world, especially where poor sanitation exists.

• Clinical manifestations :– Diarrhea (with blood & mucus)– Abdominal pain / acute colitis with abdominal cramps,

• Diagnosis is usually made by identification of cysts or trophozoites in stool. Serology also may be helpful,particularly with diagnosis of extraintestinal amebiasis and liverinvolvement.

Strongyloides stercoralis

• This roundworm,2.5 mm in length, is endemic in southern U.S. and common in tropicsand Asia.

• Clinical manifestation:– Skin becomes red and pruritic after penetration by larvae, which usually

occurs on feet. – Diarrhea, – Vomiting– Abdominal pain– Cough and pneumonia after migration of larvae through lung scan– Peripheral eosinophilia may occur.

• Identification of larvae in stool isdiagnostic.

Ascaris lumbricoides

• Clinical manifestations:• Can be asymptomatic• Mild diarrhea• Intermittent epigastric pain• Anorexia• Vomiting

• Diagnosed: by identifying whitish-brown Ascaris worm,20–40 cm in length, or finding Ascaris eggs on microscopic exam of stool is diagnostic.

Hookworm Infection

• Adult hookworms (N. americanus and A. duodenale)• Clinical manifestations:

– Red, pruritic lesions on feetor between toes where larvae penetrate. – Diarrhea– Vomiting– Abdominal pain– Anemia from GI blood loss– Peripheral eosinophilia.

• Detecting hookworm eggs on stool smear is diagnostic.

Trichuris trichiura

• T. trichiura,4-cm long whipworm, occurs most commonly in tropical areas but is also found in subtropical areas (e.g., southern U.S.).

• Clinical manifestations:– Most individuals are asymptomatic– Diarrhea– Tenesmus– Weight loss– Anemia– Peripheral eosinophilia

• Diagnosed: by seeing eggs on microscopic stool examis diagnostic.

Fungal infectious

Candida sp• C. albicans is most common cause of Candida enteritis• Characterized by watery diarrhea and abdominal pain.• Predisposing factors :prolonged antibiotic or

immunosuppressive therapy yeast forms are ubiquitous and occur in fecal flora of normal persons, their presence alone is not diagnostic.

• Definitive diagnosis requires demonstration of intestinal mucosal invasion by Candida on biopsy or isolation of Candida from ulcerative lesions.

Types of diarrhea

Osmotic diarrhea

• osmotic force that acts in the lumen to drive water into the gut (caused by hyperosmotic drugs (MgSO4, Mg(OH)2), malabsorption, defect in mucosal absorption (disacharide deficiency, glucose/galactose malabsorption)

Secretory diarrhea

• increase in the active secretion • inhibition of absorption. • The most common cause of this type of

diarrhea is a cholera toxin that stimulates the secretion of anions, especially chloride ions.

• Inflammatory and Infectious Diarrhea• • The epithelium of the digestive tube is protected from insult by a number of

mechanisms constituting the gastrointestinal barrier, but like many barriers, it can be breached. Disruption of the epithelium of the intestine due to microbial or viral pathogens is a very common cause of diarrhea in all species. Destruction of the epithelium results not only in exudation of serum and blood into the lumen but often is associated with widespread destruction of absorptive epithelium. In such cases, absorption of water occurs very inefficiently and diarrhea results. Examples of pathogens frequently associated with infectious diarrhea include:

• Bacteria: Salmonella, E. coli, Campylobacter • Viruses: rotaviruses, coronaviruses, parvoviruses (canine and feline), norovirus • Protozoa: coccidia species, Cryptosporium, Giardia • The immune response to inflammatory conditions in the bowel contributes

substantively to development of diarrhea. Activation of white blood cells leads them to secrete inflammatory mediators and cytokines which can stimulate secretion, in effect imposing a secretory component on top of an inflammatory diarrhea. Reactive oxygen species from leukocytes can damage or kill intestinal epithelial cells, which are replaced with immature cells that typically are deficient in the brush border enyzmes and transporters necessary for absorption of nutrients and water. In this way, components of an osmotic (malabsorption) diarrhea are added to the problem.

• Diarrhea Associated with Deranged Motility• • In order for nutrients and water to be efficiently absorbed,

the intestinal contents must be adequately exposed to the mucosal epithelium and retained long enough to allow absorption. Disorders in motility than accelerate transit time could decrease absorption, resulting in diarrhea even if the absorptive process per se was proceeding properly.

• Alterations in intestinal motility (usually increased propulsion) are observed in many types of diarrhea. What is not usally clear, and very difficult to demonstrate, is whether primary alterations in motility are actually the cause of diarrhea or simply an effect.

Classsification : OrgansStool Characteristics Small Bowel Large Bowel

Appearance Watery Mucoid and/or bloody

Volume Large Small

Frequency Increased Highly increased

Blood Possibly positive but never gross blood

Commonly grossly bloody

pH Possibly <5.5 >5.5

Reducing substances Possibly positive Negative

WBCs <5/high power field Commonly >10/high power field

Serum WBCs Normal Possible leukocytosis

Sign and Symtomp Inadult :

Your diarrhea persists beyond three days

You become dehydrated — as evidenced by excessive thirst, dry mouth or skin, little or no urination, severe weakness, dizziness or lightheadedness, or dark-colored urine

You have severe abdominal or rectal pain

You have bloody or black stools You have a temperature of more

than 102 F (39 C), or signs of dehydration despite drinking plenty of liquids

In children, particularly young children, diarrhea can quickly lead to dehydration. Hasn't had a wet diaper in three

or more hours Has a fever of more than 102 F

(39 C) Has bloody or black stools Has a dry mouth or cries without

tears Is unusually sleepy, drowsy,

unresponsive or irritable Has a sunken appearance to the

abdomen, eyes or cheeks Has skin that doesn't flatten if

pinched and released

• Chronic diarrhea. With chronic diarrhea, the focus usually shifts from dehydration and infection (with the exception of Giardia, which occasionally causes chronic infections) to the diagnosis of non-infectious causes of diarrhea. (See the prior discussion of common causes of chronic diarrhea.)

• This may require X-rays of the intestines (upper gastrointestinal series or barium enema), or endoscopy (esophagogastroduodenoscopy or EGD, or colonoscopy) with biopsies.

• Fat malabsorption can be diagnosed by measuring the fat in a 72 hour collection of stool.

• Sugar malabsorption can be diagnosed by eliminating the offending sugar from the diet or by performing a hydrogen breath test. Hydrogen breath testing also can be used to diagnose bacterial overgrowth of the small intestine.

Chronic diarrhea

Treatment For Diarrhea in ChildWHO susgests some treatment for diarrhea in

child,such as:a. Rehidrationb. Breast feeding while diarrhea and recovery phase.c. Do not use anti diarrhea drugs

antibiotics just given for patient with cholera and dysentri caused by shigella, and metronidazole given for patient with giardiasis and amebiasis.

COMPLICATIONS

• Diarrhea Water Dehydration Potassium Hypokalaemia Natrium Hyponatraemia Bicarbonate Acidosis Nutrient Hypoglycemia

Prevention

• Breastfeeding• Improving food sapling• Using plenty of clean water• washing hands• Using a household toilet• How to dispose of feces is good and right• Measles immunization

Complications• Kidney failure• Coma • Shock • Heat-related illnesses & associated complications • Electrolyte abnormalities

– In dehydration, electrolyte abnormalities may occur since important chemicals (like sodium and potassium) are lost from the body through sweat.

– If rehydration is done too slowly :--> hypotensive & in shock for too long

– If done too quickly :--> water and electrolyte concentrations within organ cells can be negatively affected --> causing cells to swell --> die.

FLUID AND ELECTROLITE BALANCE

Total Body Fluid by CompartmentTotal Body Water

Electrolyte Composition of Body Fluid Compartments

HOMEOSTATIC REGULATION

ADH H2O

HOMEOSTATIC

RBF

RENIN

ANGIOTENSIN

ALDOSTERONOSMOLALITYReabs Na hemoconsentration

Permeability TD reabs h2o

Composition of Parenteral Fluids (mEq/L)

FluidFluid Na+Na+ K+K+ Ca2+Ca2+ Cl-Cl- HCO3-HCO3- pHpHECFECF 142142 44 55 103103 2727 7.47.4

LRLR 130130 44 2.72.7 109109 2828 6.56.5

.9% NaCl.9% NaCl 154154 154154 4.54.5

.45% NaCl.45% NaCl 7777 7777 4.54.5

.2% NaCl.2% NaCl 3030 3030 4.54.5

3% NaCl3% NaCl 513513 513513 4.54.5

5% NaCl5% NaCl 855855 855855 4.54.5

5% Albumin5% Albumin 145145 7.47.4

Composition of GI Fluids (mEq/L)

SourceSource Daily LossDaily Loss Na+Na+ K+K+ Cl-Cl- HCO3-HCO3-

SalivaSaliva 10001000 30-8030-80 2020 7070 3030

GastricGastric 1000-20001000-2000 60-8060-80 1515 100100 00

PancPanc 10001000 140140 5-105-10 60-9060-90 40-10040-100

BileBile 10001000 140140 5-105-10 100100 4040

SBSB 2000-50002000-5000 140140 2020 100100 25-5025-50

LBLB 200-1500200-1500 7575 3030 3030 00

SweatSweat 200-1000200-1000 20-7020-70 5-105-10 40-6040-60 00

Dehydration

• The body needs the correct amount of water and electrolytes (salts) to function properly.

• Diarrhea causes excess loss of fluids and essential electrolytes from the body. When fluid lost in the stools is not replaced, diarrhea can lead to dehydration (abnormally low water content in the body).

• Dehydration can be a life-threatening complication of diarrhea for some individuals, especially infants, small children and elderly people

Dehydration can be categorized according to osmolarity and severity. Serum sodium is a good surrogate marker of osmolarity assuming

the patient has a normal serum glucose. Dehydration may be isonatremic (130-150 mEq/L), hyponatremic

(<130 mEq/L), or hypernatremic (>150 mEq/L). Isonatremic dehydration is the most common (80%).

Hypernatremic and hyponatremic dehydration each comprise 5-10% of cases.

Variations in serum sodium reflect the composition of the fluids lost and have different pathophysiologic effects.

• Isonatremic (isotonic) dehydration occurs when the lost fluid is similar in sodium concentration to the blood. Sodium and water losses are of the same relative magnitude in both the intravascular and extravascular fluid compartments.

• Hyponatremic (hypotonic) dehydration occurs when the lost fluid contains more sodium than the blood (loss of hypertonic fluid). Relatively more sodium than water is lost. Because the serum sodium is low, intravascular water shifts to the extravascular space, exaggerating intravascular volume depletion for a given amount of total body water loss.

• Hypernatremic (hypertonic) dehydration occurs when the lost fluid contains less sodium than the blood (loss of hypotonic fluid). Relatively less sodium than water is lost. Because the serum sodium is high, extravascular water shifts to the intravascular space, minimizing intravascular volume depletion for a given amount of total body water loss.

Assessment of Dehydration

Scoring System Degree of dehydration

Score 0 1 2General condition

Skin elasticityEyeFontanelMouthPulse

Healthy

NormalNormalNormalNormalNormal

Irritability, sleepy, apathyDecreasedSunkenSunkenDry120-140

Delirium, coma or shockVery decreasedVery sunkenVery sunkenDry & cyanotic> 140

Amount of score: 0- 2 Mild dehydration 3- 6 Moderate dehydration 7-12 Severe dehydration

Maurice King, 1974

Treatment of Dehydration

Complications

• Kidney failure• Coma• Shock• Heat-related illnesses and associated

complications • Electrolyte abnormalities

04/22/23

Conclusion

• Probably this patient got acute secretoric diarrhea caused by fungal infection.

• Probably this patient got moderate dehydration.

Prevention

Wash your hands frequently, especially after using the toilet, changing diapers.

Wash your hands before and after preparing food.

Wash diarrhea-soiled clothing in detergent and chlorine bleach.

Never drink unpasteurized milk or untreated water.

Drink only bottled water. Proper hygiene. Give ORS for the dehydration.

Daftar Pustaka

• Suraatmaja Sudaryat. Gastroenterologi Anak. Sagung Seto. 2007• Hadi, Sujono. Gastroenterologi. Bandung. 1995• Fauci, Braunwald, dkk. Harrison’s Manual of Medicine. Edisi 17. USA: Mc Graw Hill, 2008.• Fauci, Braunwald, dkk. Harrison’s Priciples of Internal Medicine. Edisi 17. USA: Mc Graw Hill, 2008.• Kliegman RM, Berhman RE, Jensin HB.Nelson’s Text book of Pediatrics. Edisi 16. Philadelphia: WB

Saunders Co, • L Katthleen Mahan, Sylvia Escott-Stump. Krause’s Food & Nutrition Therapy. Edisi 12. Kanada:

Saunders Elvesier, 2008.• Arthur C Guyton, John E Hall. Buku Ajar Fisiologi Kedokteran. Edisi 11. Jakarta: EGC, 2007. • Ronald A Sacher, Richard A McPherson. Tinjauan Klinis Hasil Klinis Pemeriksaan Laboratorium. Edisi

11. Jakarta: EGC, 2004.• Laurence Brunton, Keith Parker, Donald Blumenthal, Iain Buxton. Goodman & Gilman’s Manual of

Pharmacology and Therapeutics. Amerika Serikat: Mc Graw Hill, 2007.• Betram G Katzung. Basic And Clinical Pharmacology. Edisi 10. Singapore: Mc Graw Hill Lange, 2007.• Gunawan SG, Setiabudy R, Nafrialdi, Elisabeth, editor. Farmakologi dan Terapi. Edisi 5. Jakarta:

FKUI, 2007.• http://forestry.about.com• http://www.womenshealthapta.org• http://www.emedicinehealth.com• http://www.wrongdiagnosis.com • www.articlebase.com