Diare Akut dan Kronis

7/27/2019 Diare Akut dan Kronis

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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

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


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?

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