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D E P A R T M E N T O F C H I L D H E A L T H
U N I V E R S I T A S P AD J A D J A R A N
H A S A N S A D I K I N H O S P I T A L B A N D U N G
2 0 1 6
DIARRHEA
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Diarrheal diseases account for 1 in 9 child
deaths worldwide, making diarrhea the
second leading cause of death among
children under the age of 5.
Despite these sobering statistics, strides
made over the last 20 years have shownthat, in addition to rotavirus vaccination
and breastfeeding, diarrhea prevention
focused on safe water and improved
hygiene and sanitation is not only possible
oday, only !9 per cent of children withdiarrhoea in developing countries receive
the recommended treatment, and limited
trend data suggest that there has been
little progress since 2000
Diarrhea kills 2,195 children every daymore than AIDS, malaria, and measlescombined
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DEFINITION OF DIARRHEA
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A
T
H
W
A
Y
S
T
O
D
I
A
R
R
H
E
A
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CLASSIFICATION OF DIARRHEA
Diarrhea Dra!i"# Me$ha#i%&
1' A$!e (iarrhea ) * 1+ (a,% - 1' Se$re!"r, (iarrhea
2' Per%i%!e#! (iarrhea ) . 1+ (a,% - 2' I#/a%i/e (iarrhea
D,%e#!eri"r& N"# D,%e#!eri"r&
' O%&"!i$ (iarrhea
Diarrhea 3i!h %e/ere &a4#!ri!i"# )&ara%&% "r 53a%hi"r5"r-
!he &ai# (a#7er% are %e/ere %,%!e&i$ i#e$!i"#8 (eh,(ra!i"#8 hear!ai4re a#( /i!a&i# a#( &i#era4 (ei$ie#$,'
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ETIOLOG9
INFECARBOH9DRATE MALABSORPTIONALERGFOOD POISONING
Sumber: Burkhart DM.1999.2 Arvola.1999.9 Ladinsky M. 2000.10
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S flexneri
S. dysenteriae Camilobacter
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! coli
Salmonella
Am"ba
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SECRETOR9 DIARRHEA
"ccur due to active en#yme adenil
cyclase, which would convert
adenosine triphosphate $%&'cyclic
adenosinemonophosphate $c%(&'.
%ccumulation of intracellular c%(&
causes active secretion of water,
chloride ion, sodium, potassium, and
bicarbonate into the intestinal lumen.
%denil cyclase is activated by a to)inproduced by microorganisms*
+ibrio cholerae, nteroto)igenic
schericia colli $-', higella,
-lostridium, almonella, and
-ampylobacter
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SECRETOR9 DIARRHEA
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INVASIVE DIARRHEA
he e)istence of the invasion of microorganisms
into the intestinal mucosadamage to the
intestinal mucosa. /nvasive diarrhea caused by
viruses, bacteria, or parasites.
here invasive diarrhea in 2 forms, namely*
2.1
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INVASIVE DIARRHEA
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OSMOTIC DIARRHEA
-aused by high osmotic pressure inside
intestinal lumen draw fluid from the intracellular into the
intestinal lumencause watery diarrhea.
"smotic diarrhea is most often caused by carbohydrate
malabsorption.actose is fermented by the en#yme lactase would
absorbed in the small intestine.
/n case this disakaridase en#yme deficiency, the
accumulation of lactose in the intestinal lumen will causethe high osmotic pressure, causing diarrhea.
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DEPARTMENT OF HEALTH IMPLEMENTED : PILLARS OF THE MANAGEMENT OF DIARRHEA
Reh,(ra!i"# %i#7 !he #e3 ORS
Sumber: Subagyo B. 2010.12dan Basis !!!
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ASSESSMENT OF THE CHILD ;ITH DIARRHEA
% child with diarrhea should be assessed for
dehydration
bloody diarrhea, persistent diarrhea
malnutrition and serious nonintestinal infections
so that an appropriate treatment plan can beimplemented.
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HISTOR9
< A%5 !he &"!her "r "!her $are!a5er a="!
duration of diarrheapresence of blood in the stoolnumber of watery stools per day
number of episodes of vomiting swollen diaper rashpresence of fever, cough, or other important
problems $e3.convulsions, recent measles'preillness feeding practicestype and amount of fluids $including breast milk' and
food taken during the illnessast mi)iy, weight before..drugs or other remedies takenimmuni#ation history.
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PH9SICAL E>AMINATION
4irst, check for signs and symptoms of dehydration.
< Look "r !he%e %i7#%
eneral condition* is the child alert restless or irritable
lethargic or unconscious6%re the eyes normal or sunken6
7hen water or "8 solution is offered to drink, is it
taken normally or refused, taken eagerly, or is the child
unable to drink owing to lethargy or coma6
< Feel !he $hi4( !" a%%e%%
kin turgor. 7hen the skin over the abdomen is
pinched and released, does it flatten immediately,
slowly, or
very slowly $more than 2 seconds'6
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PH9SICAL E>AMINATION
hen, check for signs of other important problems.
< L""5 "r !he%e %i7#%
Does the childs stool contain red blood6
/s the child malnourished6 8emove all upper body clothing to observe the shoulders,
arms, buttocks and thighs, for evidence of marked muscle wasting $marasmus'. ookalso for oedema of the feet if this is present with muscle wasting, the child is severely
malnourished. /f possible, assess the childs weightforage, using a
growth chart , or weightforlength. %lternatively, measure the midarm circumference
/s the child coughing6 /f so, count the respiratory rate to determine whether breathing
is abnormally rapid and look for chest indrawing.
< Ta5e !he $hi4(?% !e&@era!re
4ever may be caused by severe dehydration, or by a nonintestinal infection such as
malaria or pneumonia.
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PH9SICAL E>AMINATION DEHIDRATION
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DEH9DRATIONTHE DEGREE OF DEH9DRATION IS GRADED ACCORDING TO SIGNS ANDS9MPTOMS THAT REFLECT THE AMOUNT OF FLUID LOST
I# ear4, %!a7e% A% (eh,(ra!i"# i#$rea%e% I# %e/ere (eh,(ra!i"#
there are no signsor symptoms.
:
signs and symptoms develop./nitially these include*-hirst-restless or irritable behaviour-decreased skin turgor-sunken eyes-and sunken fontanelle
$in infants'.
these effects become morepronounced and the patientmay develop evidence ofhypovolaemic shockincluding*-Diminished consciousness-lack of urine output-cool moist e)tremities-a rapid and feeble pulse $the radial pulse may be undetectable'
-low or undetectable blood pressure-peripheral cyanosis.Death follows soon ifrehydration is not started3uickly.
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ASSESSMENT OF DIARRHEA PATIENTSFOR DEH9DRATION
EVALUATION A B C
CONDITION ;e448 a4er! Re%!4e%%8 irri!a=4e Le!har7i$ "r #$"#%$i"%
E9ES N"r&a4 S#5e# S#5e#
TEAR P"%i!i/e Ne7a!i/e Ne7a!i/e
ORAL MUCOSAL AND
TONGUE
M"i%! Dr, Ver, (r,
THIRST Dri#5% #"r&a44,8 #"! !hir%!, Thir%!,8 (ri#5% ea7er4, Dri#5% @""r4,8 "r #"! a=4e !"
(ri#5
SKIN PINCH G"e% =a$5 i$54, G"e% =a$5 %4"34, G"e% =a$5 /er, %4"34,
E>AMINATION RESULTS NO DEH9DRATION SOME DEH9DRATIONI 1 3i!h 1 "r &"re %i7#%
i# B
SEVERE DEH9DRATIONI 1 3i!h 1 "r &"re %i7#%
i# C
TREATMENT PLAN A PLAN B PLAN C
FLUID DEFICIT * : " ="(, 3! "r * :0
&457 ="(, 3!
:10 " ="(, 3! "r :0100
&457 " ="(, 3!
10 " ="(, 3! "r 100
&457 " ="(, 3!
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MANAGEMENT OF ACUTE DIARRHEA);ITHOUT BLOOD-
The "=e$!i/e% " !rea!&e#! are !"
&revent dehydration
reat dehydration when present &revent malnutrition
8educe duration and severity of diarrhea and occurence of
future episodes by giving supplemental #inc
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TREATMENT PLAN A
H"&e !hera@, !" @re/e#! (eh,(ra!i"# a#( &a4#!ri!i"#-hildren with no signs of dehydration need e)tra fluid and salt to
replace their losses of water and electolytes due to diarrhea.
F4i(% !" =e 7i/e#; "8; alted drinks eg. salted rice water or salted yoghurt drink
; +egetable or chicken soup with salt
;
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TREATMENT PLAN A
H"3 &$h !" 7i/e
; ive as much fluid as the child wants until diarrhea stops; -hildren ? 2 years of age * 50100 ml of fluid
; -hildren 2 years 10 years * 100200 ml
; "lder children and adults * %s much as they want;ha! ee(% !" 7i/e
he infants usual diet should be continued during diarrhea
and increased afterwards. @reastfeeding should always be
continued.I#$ %@@4e&e#!
$1020 mg' every day for 10 to 1A days should be given.
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C"#!i#e !" ee( !he $hi4(8 !" @re/e#! &a4#!ri!i"#/n general, foods suitable for a child with diarrhea are the same as
those re3uired by healthy children.
Ta5e !he $hi4( !" a hea4!h 3"r5er i !here are %i7#% "(eh,(ra!i"# "r "!her @r"=4e&%
The &"!her %h"4( !a5e her $hi4( !" a hea4!h 3"r5er i !he
$hi4( ; starts to pass many watery stools
; has repeated vomiting
; becomes very thirsty
; is eating or drinking poorly ; develops a fever
; has blood in the stool or
; the child does not get better in three days.
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TREATMENT PLAN B
A7e * + &!h% +11 &!h% 122&!h%
2+ ,ear% :1: ,ear% 1: ,ear%"r "4(er
;ei7h! * : 57 :' 57 10' 57 111:' 57 162' 57 0 57 "r
&"re
&4 200+00 +00600 60000 001200 12002200 2200+000
B%ge should be used only if weight is not known.
Ora4 reh,(ra!i"# !hera@, "r $hi4(re# 3i!h %"&e(eh,(ra!i"#"8 C inc supplementation
A&"#! " ORS !" =e 7i/e# i# 1%! + h"r%
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Age < 1 years : 300ml
Age 1-5 years : 600
ml Age > 5 years :
1200 ml
Adult : 2400
Ora4 reh,(ra!i"# !hera@, "r$hi4(re# 3i!h %"&e (eh,(ra!i"#
Jumlah
oralit :75
ml/kgdalam 3
!am"ertama
S"mber# $%&.2''5.(
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TREATMENT PLAN B
%ppro)imate amount of "8 re3uired $in ml' can also becalculated by multiplying the patients weight in kg by E5 /f
more "8 is re3uired, give more.
)cept for breast milk, food should not be given during the
initial A hour rehydration period.
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TREATMENT PLAN B
%fter A hours, reassess the child and decide what treatment
to be given ne)t as per rade of dehydration.
-hildren who continue to have some dehydration even afterA hours should receive "8 by nasogastric tube or 8
intravenously $E5 mlFkg in A hours'.
/f abdominal distension then oral rehydration should be
withheld and only /+ rehydration should be given.
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TREATMENT PLAN C
A7e Fir%! 7i/e 0 &457 # The# 7i/e 0 &457 i#/nfants 1 hour B 5 hours
"lder children !0 min B 2G hours
F"r @a!ie#!% 3i!h %e/ere (eh,(ra!i"#
&referred treatment is rapid intravenous rehydration. ive 100 mlFkg 8 or
normal saline solution as follows*
B 8epeat once if pulses are weak or not detectable.
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TREATMENT PLAN C
8eassess patient every 12 hours.
/f hydration is not improving, give the /+ drip more
rapidly.
%fter completion of /+ fluids, reassess the patient andchoose the appropriate treatment &lan $%, @ or -'.
/f /+ therapy is not available, then "8 by nasogastric
tube or orally at 20 mlFkgFhour for H hours $total of
120Fkg' should be given./f abdomen becomes swollen or the child vomits
repeatedly, then "8 should be given more slowly.
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PREVENTING DIARRHEA8 SAVING LIVES
R"!i#e /a$$i#a!i"#
&rovide rotavirus vaccine.
I&@r"/e( h,7ie#e
7ash hands when appropriate.
Sae 3a!era(ea!e %a#i!a!i"#
reat water before use anddispose of waste safely.
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