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WHEN WARTEG
GIVES HIM MORE
GROUP 7
Fasilitator : dr. Kumala Dewi Darmawi
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Name NIM
STEPHANIE
WIBISONO
405070001 SCRIBER
LISA WIBOWO 405070004 MEMBER
ANDI SURYA JAYA 405070010 MEMBER
CLAUDIO UDJAJA 405070011 MEMBER
FAJAR PERMATA SARI 405070032 MEMBER
JACKY TANZIL 405070061 MEMBER
CHASTINE FAUSTINA 405070070 MEMBER
DIAN WIJAYANTI 405070076 MEMBER
ELLEN ARISTIKA G. 405070083 MEMBER
RITCHIE SANTOSO 405070115 LEADER
FERDY SANJAYA 405070118 MEMBER
HARI DARMAWAN LEE 405070155 SECRETARY
Fasilitator : dr. Kumala Dewi Darmawi
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CASE 1B
Mr. Surip, a 26-year-old previously healthy male, hasbeen in Jakarta for about 2 weeks since he came home fromhis study in the States. Ever since, he has eaten any kinds ofIndonesia food, and wartegis always his favorite, especiallythe one across his old school.
Today, Mr. Surip presents to your clinic reporting a 2-dayhistory of watery diarrhea and he has noticed that theresblood in his stool. He has up to 8 bowel movements per day.He has had intermmittent abdominal cramps as well. For thepast 2 days, he also feels nauseated, but no vomiting. Hisvital signs are normal, his bowel souds are hyperactive and
the remainder of the physical exam is remarkable only formild, diffuse abdominal tenderness.
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Learning Objective
Able to explain about nausea
Able to explain about definition of diarrhea
Able to explain about epidemiology of diarrhea
Able to explain about etiology of diarrhea
Able to expalin about sign and symtomp of diarrhea
Able to explain about classification of diarrhea Able to explain about patophysiology of diarrhea
Able to explain about diagnostic test to confirm the caused ofdiarrhea
Able to explain about complication of diarrhea
Able to explain about therapy pharmacology and nonpharmacology of diarrhea
Able to know differential diagnosis of diarrhea
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The esophagus, stomach, large and small intestine, aided by theliver, gallbladder and pancreas convert the nutritivecomponents of food into energy and break down the non-nutritive components into waste to be excreted.
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NAUSEA
Is the sensation that there is a need to vomit.
Nausea can be acute and short-lived, or it
can be prolonged. When prolonged, it is a
debilitating symptom. Nausea (and vomiting)can be psychological or physical in origin. It
can originate from problems in the brain or
organs of the upper gastrointestinal tract(esophagus, stomach, small intestine, liver,
pancreas, and gallbladder).
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It also may be caused by pain, motion,
medications and diseases of many non-
gastrointestinal organs of the body.
Therefore, the diagnosis of the cause ofprolonged nausea may not be easy. All
stimuli that cause nausea work via the
vomiting center in the brain which gives riseto the sensation of nausea and coordinates
the physical act of vomiting.
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DIARRHEA
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What is diarrhea?
Diarrhea is loose, watery stools. A person
with diarrhea typically passes stool more
than three times a day.
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classification
Episode Diarhea acute (15days)
Mechanism and pathofisiology Diarhea osmotic
Diarhea sekretoric
Etiology Diarhea infection
Diarhea non infection
Function Diarhea organic
Diarhea fungisional
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Campylobacter jejuni E. coli
Vibrio cholera Salmonella
Shigella
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1. E coli Enteropatogenik (EPEC)
Cause by baby`s,especially in developing
country
Wattery diarhea,self-limited but can be
chronic diarhea
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2. E coli Enterotoksigenik (ETEC)
Traveller`s diarhea
Strain which produces eksotoksin which hotresistantsubunit B binds at brushborersepitelial intestine Gangliosida dan facilitate influx
subunit A into cell,then activated adenilcyclaseincreased Campconsentrationwater&cl-hypersecretionblocked natriumreabsroptionintestine lumenstrachinghypermotilitydiarhea
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Strain which produces enterotoksin,hot
resistant sTa(BM 1500-4000)
sTaactivate Guanil cyclase in enteric epitel
cell and stimulate fluid secretions
2. E coli Enterotoksigenik (ETEC)
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3. E coli Enterohemoragik (EHEC)
Produces verotoxin
Caused colitic ulcerative, severe diarhea,
hemolitic uremic syndrom.
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4. E coli Enteroagregratif (EACE)
Caused acute and chronic diarhea et
developing country
Transmission by foods
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Pathofisology acute diarhea
Osmotic diarheaintralumen osmoticpressure of intestine ,caused bymedications,chemistry substance which
hiperosmotic,general malabsorbtion,defect inintestine mucuos
Secretoric diarheasecretion of water danelectrolit from intestine ,absrobtion caused
by enterotoxin V.cholerae,E.coly,Laksatifdrugs
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Bile malabsrobtion and lipidmalsbsorbtiondefectife reabsropbtion of bilesalts
Defect exchange anion/active transport electrolit
at enterositblocked transport activemechanisme Na+ k+ ATP ase at enterosit andabnormal Na+ absorbtion
Motility& abnormal intestine transit
time
hipermotility, inregularity intestine motilitycauses abnormal absorbtion inintestine(DM,pasca vagotomi,hipertyroid)
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Intestine permeability defectabnormal
permeability of intestine epitel spesific
membrane disorder
Inflamantory diarheadamage mucosaintestine,causes mucous excess >>,water
and electrolit exudation into lumen,water and
electrolit absrobtion defect
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Infectious diarheaclassified by
invasif (damaged mucosa)ulseration and
necrotic at wall of intestine
non invasif(non mucosa damaged)producetoxins which string at mucosa intestine
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What are the symptoms of diarrhea?
Cramping
abdominal pain
Bloating
Nausea an urgent need to use the bathroom
Depending on the cause, a person may have afever or bloody stools.
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Diarrhea: Clinical Manifestation
Diarrhea: watery, bloody, mucous
Fever
Vomiting
Respiratory symptoms
Dehydration Metabolic acidosis
Electrolyte imbalance: hyponatraemia, hypokalaemia,hyponatraemia
Hypoglycemia
Lactose intolerance
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How is the cause of diarrhea
diagnosed? Medical history and physical examination.eating habits and
medication use and will examine for signs of illness.
Stool culture.A sample of stool is analyzed in a laboratory to check forbacteria, parasites, or other signs of disease and infection.
Blood tests.Blood tests can be helpful in ruling out certain diseases.
Fasting tests.To find out if a food intolerance or allergy is causing the
diarrhea, the doctor may ask you to avoid lactose, carbohydrates,wheat, or other foods to see whether the diarrhea responds to a changein diet.
Sigmoidoscopy.For this test, the doctor uses a special instrument tolook at the inside of the rectum and lower part of the colon.
Colonoscopy.This test is similar to a sigmoidoscopy, but it allows the
doctor to view the entire colon. Imaging tests.These tests can rule out structural abnormalities as the
cause of diarrhea.
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How is diarrhea treated?
Absorbents: attapulgite & polycarbophil
Anti-motility medications: Loperamide &
Diphenoxylate
Bismuth compounds:Pepto-Bismol
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Tips About Food
Until diarrhea subsides, try to avoid caffeine, milkproducts, and foods that are greasy, high in fiber, orvery sweet. These foods tend to aggravate diarrhea.
As you improve, you can add soft, bland foods to your
diet, including bananas, plain rice, boiled potatoes, toast,crackers, cooked carrots, and baked chicken without theskin or fat. For children, the pediatrician may alsorecommend a bland diet. Once the diarrhea hasstopped, the pediatrician will likely encourage children to
return to a normal and healthy diet if it can be tolerated.
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Preventing Travelers Diarrhea
Do not drink tap water or use it to brush your teeth.
Do not drink unpasteurized milk or dairy products.
Do not use ice made from tap water.
Avoid all raw fruits and vegetables, including lettuce and
fruit salads, unless they can be peeled and you peelthem yourself.
Do not eat raw or rare meat and fish.
Do not eat meat or shellfish that is not hot when served.
Do not eat food from street vendors.
Di h di i
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Diarrhea medications Medication
Aeromonasspecies: Use cefixime and most third-generation and
fourth-generation cephalosporins.
Campylobacterspecies: Erythromycin.
C difficile:use oral metronidazole or vancomycin.
C perfringens:Do not treat with antibiotics.
Cryptosporidium parvum:Nitazoxanide. Entamoeba histolytica:Metronidazole, iodoquinol or paromomycin
E coli:Trimethoprim-sulfamethoxazole (TMP-SMX), second-
generation or third-generation cephalosporin.
G lamblia:Metronidazole or nitazoxanide.
Plesiomonasspecies: TMP-SMX, cephalosporin.
Salmonellaspecies: TMP-SMX, ceftriaxone and cefotaxime
Shigellaspecies: TMP-SMX, Cefixime, ceftriaxone, and cefotaxime
V cholerae:Doxycycline, and erythromycin.
Yersiniaspecies: TMP-SMX, cefixime, ceftriaxone, and cefotaxime.[6]
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Differential dignosis
Crohn`s disease
Hemoroid
Colitis ulserativa
Infection
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Pathobiology Diarrhea
Hemorrhagic E.coli 1-3+,initially
watery,quickly blood
Campylobacter 1-4+,watery or bloody
Aeromonas 1-4+,watery or bloody
Shigella 1-2+,bloody
Vibrio sp. 3-4+,watery
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Complication
Hypokalemia
Hypovolaemic shock
Sodium levels low(urine)
Depletional hyponatraemia
Dehydration
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COMPLICATIONS
Diarrhea WaterDehydration
Potassium Hypokalaemia
Natrium HyponatraemiaBicarbonateAcidosis
Nutrient Hypoglycemia
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Dehydration
Dehydration means your body does not have
as much water and fluids as it should.
Dehydration can be caused by losing too
much fluid, not drinking enough water orfluids, or both. Vomiting and diarrhea are
common causes.
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Scoring System
Degree of dehydrationScore 0 1 2
General condition
Skin elasticity
Eye
Fontanel (ubun2)
Mouth
Pulse
Healthy
Normal
Normal
Normal
Normal
Normal
Irritability,sleepy, apathy
Decreased
Sunken(ckung)
Sunken
Dry
120-140
Delirium, coma orshock
Very decreased
Very sunken
Very sunken
Dry & cyanotic
> 140
Amount of score: 0- 2 Mild dehydration3- 6 Moderate dehydration7-12 Severe dehydration
Maurice King, 1974
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Dehidration grade
Based on:
1. Clinic manifestations: mild ,moderate,andsevere
2. BJ Plasma: on dehidration,Bj increased
a. Severe dehidration : 1,032-1,040b. Moderate dehidration: 1,028- 1,032
c. Mild dehidration : 1,025- 1,028
3. Cenral Venous pressure(CVP) measurementShock or dehidrations,if CVP less than +4 cm
H2O
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CONCLUSIONS
Based on the clinic symptomps which found on
Mr.Surip , watery stool and after 2 days
theres blood in his stool, bowel movements8x/days, intermittent abdominal cramping, 2
days later he feels nausea but not vomitting.
His vital signs normal, his bowel sounds arehyperactive and diffuse abdominal tenderness,
maybe he had diarrhea by infection
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Suggestion
Better he should take a further medical
diagnostic to make sure the diagnosis. For
patient and the food seller to give more
attention for the sanitation and hygienity fromfood and beverages that been served.
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References
Fauci AS, Braunwald E, Kasper DL, Hauser SL,
Longo DL, et al, editors. Harrisons principle of
internal medicine. 17thed. USA: Mc. Graw Hill
medical, 2008.
Sudoyo AW, Setiyohadi B, et al, editor. Buku ajar
ilmu penyakit dalam. Ed 4. Jilid 1. Jakarta: pusat
penerbitan ilmu penyakit dalam FKUI,2006.
Brooks GF, Butel JS, Morse SA. Lange Jawetz,Melnick & Naelbergs Medical Microbiology. 23rded.
USA: Mc Graw Hill medical,2004.
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