LONG CASE

ACUTE DIARRHEA MILD – MODERATE DEHYDRATION

Written by:
Lutfiana Ulfah Uswandi
1113103000042

Supervised by:
dr. Ulynar Marpaung, Sp. A

Faculty of Medicine UIN Syarif Hidayatullah Jakarta

Pediatric Department
Bhayangkara Tk. I R. Said Sukanto Hospital
2018

1
 PART I
CASE ILLUSTRATION

1.1 IDENTITY
Patient Identity
Name : Ch. MNR
Age : 4 year
Sex : boy
Religion : Islam
Address : Jl. Masjid RT 13/ RW 07 Susukan Ciracas Jakarta Timur
No. MR : 956057
Come : 18 april 2018
Financing : BPJS

Parent Identity
Father
Name : Mr. AS
Age : 30 y.o
Address : Depok
Job : Employee
Education : Senior High School
Salary : < 3.000.000 / month

Mother
Name : Mrs. N
Age : 27 y.o
Address : Depok
Job : Housewife
Education : Senior High School
Salary :-

2
1.2 ANAMNESIS

(Anamnesis performed as allo-anamnesis with father and mother of patient

at inpatient ward Anggrek 2 RS Bhayangkara Tk I R. Said Sukanto april 18,
2018).

Chief Complaint

Diarrhea since 3 days before entering hospital.

Additinaol Complaint

Fever, vomiting, and massa in abdomen

Present Illness History

Since 3 days before hospital admission patients diarrhea more than 10 times
per day. Urinary bowel movements, accompanied by a little dregs, yellowish-
green, visible mucus, no blood, and smell more rotten than the stool usually. The
patient's mother changed the diaper more than 4 times and the diaper was always
full of dilute feces. The patient's mother said her son's eyes were hollow, more
thirsty than usual, and more fussy. Bloated is denied, and does not appear pale.
Urination can come out but little and the color is more dense. Patients are also
difficult to feed. At that time the patient's parents immediately took to the health
center near his home and given syrup paracetamol, zinc, and ORS. According to
the patient's mother, the patient's condition does not improve.
Since 3 days before admission, ± 3 hours after diarrhea, the patient has a fever.
The fever arises slowly. Fever according to the patient's mother constantly. Fever
is not affected by time. Fever had dropped after the patient was given paracetamol
syrup from the Puskesmas.
Since 3 days before entering the hospital, the patient also experienced
vomiting. Vomiting ± 5 times a day. Vomiting especially when the patient is
given a drink or a meal. The contents of vomit in the form of food content that
patients eat. Fill the vomit like water as saliva when the stomach is empty. There
is no blood. In one vomit, the vomit volume is approximately ½ to ½ cup of star
fruit.

3
 One hour before hospitalization, the patient was taken by his parents to the
Susukan Community Health Center because of conditions that did not improve.
There the patient had a seizure for approximately 5 minutes. At that moment
suddenly the eyeball of the patient glared upward, his body stiff, no fetal, did not
respond if called, no foaming mouth and no bluish. Seizures lasted only once.
Patients have no fever while experiencing a seizure because the morning before
leaving already drank paracetamol syrup. This seizure is the first time. No history
has fallen before. As long as there is given the drug, but the patient does not know
the name of the drug given. Patients are encouraged to be referred. Then the
patient was referred to Bhayangkara Tk. I R. Said Sukanto.
At present, according to the patient's parents the condition is better, the child
appears calmer, not vomiting, appetite improves, diarrhea this morning 2 times,
the consistency of liquid with more dregs, yellow-green, foul, and the patient's
mother changing diapers every his child diarrhea. BAK can come out in light
yellow. Urine is clearer than before. Currently the patient has no fever, no
seizures, and no cold cough complaints. The patient is still fussy, and still seems
more thirsty than usual. According to the patient's mother, the patient's body
weight before diarrhea is 12 kgs.
Since birth, patient has mass in abdomen. Mass can in and out. Appears when
crying, defecate, and straining, lost if rest.

Past Illness History

The patient had never been hospitalized before. Patients occasionally cough
and runny nose but recover with medication from Puskesmas and diarrhea only
once less than 4 times per day and never more than 3 days. The patient was never
hospitalized. There is no history of drug and food allergies.

Family Illness History and Environment Condition

The patient lives at home with his mother, father, grandfather, and
grandmother. Currently the patient's father is also experiencing diarrhea.
However, it has been improved after taking medication from Puskesmas
Kelurahan. There isn’t family with HIV history.

4
Pregnancy and Delivery History
• Is the first pregnancy and birth with age at birth 23 years.
• The patient's mother has never been hospitalized for a particular illness
during pregnancy.
• A history of high fever or heat, swelling of the feet, hands, or face with
headache or seizures, old cough, vaginal discharge, red patches on the
body, contact with pets and animal feces are all denied. Rarely eat fresh
vegetables, satay, and roasted or baked foods. Consumption of drugs and
herbs during pregnancy is denied.
• The patient's mother does not have high blood pressure and diabetes
mellitus.
• Mother diligent patient to check her pregnancy to health center or midwife
on schedule.
• Patients born spontaneously in Puskesmas assisted by midwives in 39
weeks' pregnancy.
• Spontaneous, moonlit, crying, pale (-), blue (-), yellow (-), seizures (-), BL
3400 gr, PL 49 cm.

Growth and Development History

• Psychomotor development:
o Lifting the head: 1 month old
o Smile: 4 months of age
o Laughter: 1-2 months of age
o Head upright: 4 months of age
o Initiation of speech: 6 months of age
o Prone position: 6 months of age
o Eat yourself: age 5-6 months
o Sitting: 6 months of age
o Crawling: 7 months of age
o Standing: 13 months of age
o Walking: 15 months of age
o Teething: 8 months of age

5
 • Psychological status: Normal
• Conclusion: Status of growth and development is still within normal limits
and according to patient age.

• Food History
• Breast milk: given from birth and continued to children aged ± 1 year.
• Milk formula: given from birth, because the initial time of
breastfeeding does not come out. Currently formula milk is still given.
• Bananas: begin to be given when the patient is 6 months old in the
morning and afternoon.
• The patient has no difficulty eating.

Immunitation History
According to the information from the patient's mother, the patient
gets complete immunization according to the schedule at the Puskesmas.
At birth the patient is directly immunized at the maternity hospital and the
next immunization is always done at the Puskesmas.
Immunization Frequency Time

BCG 1 time 1 month old

Hepatitis B 3 times 0,1,6 months old

DPT 3 times 2,4,6 months old

Polio 4 times 0,2,4,6, months old

Hib 3 times 2,4,6 months old

1.3 PHYSICAL EXAMINATION

(Physical examination is done in the Anggrek Room 2 RS Bhayangkara Tk.I R.

Said Sukanto on Mei 18, 2018)

General situation : moderate pain

Awareness : compos mentis

6
Blood pressure : not measured

Pulse rate : 130x / min, regular, enough content, ekual on all four
extremities

Frequency of breath : 25x / min, irregular, sufficient depth, abdominal type,

nasal lobe (-), use of auxiliary muscle (-)

Tmperature : 37,5 C

Nutritional status :

Weight (BB) : 11 kg

Height (TB) : 84 cm

Head circumference (LK) : 47 cm

Upper arm circumference : 12 cm

BB / U according to WHO curve: z scores 0 ~ -2

BB / TB according to the WHO curve z scores 0 ~ -2

Head Toe Examination

Head : normosephal, deformity (-), closed fontanel

Hair : black, spread evenly, not easily revoked

Eye : round pupil, isokor, direct light reflex (+ / +), indirect light
reflex (+ / +), conjunctiva pale (- / -), jaundiced sclera (- / -), concave (+ / +)

ENT : Tonsil T1-T1, hypereemic pharynx (-), secretions from the ear

(-), sinus tenderness (-), septum deviation (-).

Mouth : good oral hygiene, dry lips mucosa.

Neck : stiff neck (-), stiff neck (-), KGB not palpable.

Thorax :

7
Lung :

I: dynamic static-dynamic exposure chest, retracting wall chest (-), epigastric

retraction (-), suprasternal retraction (-), use of auxiliary muscle (-), venektasi (-)

P: symmetrical chest expansion.

P: The whole Sonor is roomy.

A: vesicular + / +, ronkhi (- / -), wheezing (- / -)

Cardiac :

I: ikcus cordis not visible

P: ikcus kordis palpated between the ribs 5 left midclavicular linea

P: -

A: normal I-II heart sound, murmur (-), gallop (-)

Abdomen :

I: limp, distension (+), venektasi (-), scarring, hernia umbilical (+)

A: bowel sounds (+) / increases

P: supel, tenderness (-), liver and spleen are not palpable, turgor slightly slow,
mass (-)

P: -

Genitalia : 555

Anus : erythema natum (-)

Extremities : warm acral, CRT <2 sec, grated BCG (+), edema (-),

pitting edema (-), wasting (-), baggy pants (-)

Neurological Status

Motoric: 5555 5555

5555 5555

8
Spasm (-), clonus (-), physiological reflex (+), pathological reflex (-)

1.4 LABORATORIUM

18/04/2018
Kind of Check Value Normal Value
Peripheral Blood Exam.
Hemoglobin 11,6 g/dL 13-16
Leukocyte 17.500 u/L 5.000-10.000
Hematocrit 33% 40-48
Trombocyte 332.000 150.000-450.000
Electrolite
Natrium 126 mEq/L 135-145
Kalium 2,4 mEq/L 3,5-5,0
Chlorida 99,8 mEq/L 120-130
GDS 87 mg/dl < 200
Serology Widal
Thypi O Negatif Negatif
Parathypi AO + 1/80* Negatif
Parathypi BO Negatif Negatif

9
Parathypi CO + 1/80 Negatif
Thypi H Negatif Negatif
Parathypi AH Negatif Negatif
Parathypi BH Negatif Negatif
Parathypi CH Negatif Negatif
FECES EXAM.
Macroscopis
Colour Green
Konsistensi soft
Mucus +
Blood -
Microscopis
Leukocyte 4-6 /LPB
Eritrosit 0-2 /LPB
Worm egg
Ascaris Sp - /LPB
Anchilostoma Sp - /LPB
Trichuris Sp - /LPB
Oxyuris Sp - /LPB
Lain-lain - /LPB
Complete urine
Colour Yellow
Kejernihan Murky
pH 6.0 5 – 8.5
Specific Gravity 1.020 1.000 – 1.030
Protein - Negatif
Bilirubin - Negatif
Glucose - Negatif
Ketone - Negatif
Blood - Negatif
Nitrit - Negatif

10
Urobilinogen 0,1 0,1-1,0 IU
Leukocyte - Negatif
Sedimen
Leukosit - 0-5
Eritrosit - 1-3
Epitel cell -
Sylinder -
Cristal -

1.5 REGISTER PROBLEM

1. Diarrhea with acute mild-to-moderate dehydration
2. Hyponatremia
3. Hypokalemia
4. History of seizures ec. metabolic disorders
5. Hernia umbilical (+)
1.6 TREATMENT ON EMERGENCY DEPARTMENT
- Pro hospitalization with Pediatrician.
- IVFD NaCl 0.9% 500 cc + KCl 10 mEq for 12 hours followed by NaCl 0.9%
500 cc.
- Lacto B 1 x 1 Sachet PO
- Zinc Kid Syrup 1 x CTH 1 PO
- Paracetamol syrup 4 x CTH 1 PO
- Inj. Cefotaxime 2 x 550 mg IV
- Continue breastfeeding and MPASI
1.7 FOLLOW UP

19 April 2018 (Day Care: II)

S: Fever up and down, diarrhea (+) 3x this morning, consistency of liquid with
more dregs, greenish yellow, foul odor, no mucus and blood, the patient's mother
had to change diapers every child diarrhea. Vomitus (-). Seizures (-).

O: Awareness: compos mentis General Condition: moderate pain.

Vital signs: HR: 108x / m RR: 28x / m T: 370C

11
Anthropometry: BB: 11 kg TB: 84 cm

Head: normosefal, deformity (-), closed fontanel

Hair: black, spread evenly, not easily revoked

Eyes: round pupils, isocores, direct light reflex (+/ +), indirect light reflex (+ / +),
pale conjunctiva (- / -), jaundiced sclera (- / -), sunken eyes (- / -)

ENT: Tonsil T1-T1, hypereemic pharynx (-), secretions from the ear (-), sinus
tenderness (-), septum deviation (-).

Mouth: good oral hygiene, dry lips mucosa.

Neck: stiff neck (-), stiff neck (-), KGB not palpable enlarged.

Thorax:

Lung:

I: dynamic-symmetric chest expansion, chest wall retraction (- / -), epigastric

retraction (-), suprasternal retraction (-), use of respiratory muscle (-), venektasi

(-)

P: symmetrical chest expansion.

P: The whole Sonor is roomy.

A: vesicular + / +, ronkhi (- / -), wheezing (- / -)

Heart:

I: the cordic iktus is not visible

P: ikcus kordis palpated between the ribs 5 left midclavicular linea

P: -

A: normal I-II heart sound, murmur (-), gallop (-)

Abdomen:

I: weakness, distension (+), venektasi (-), scarring (-), hernia umbilical (+)

12
A: bowel sounds (+) / increases.

P: supel, tenderness (-), liver and spleen are not palpable, turgor is good, mass (-)

P: -

Genitalia: within normal limits

Anus: erythema natum (-)

Extremities: warm acral, CRT <2 sec, grated BCG (+), edema (-),

pitting edema (-), wasting (-), baggy pants (-)

Supporting investigation:

Laboratory Examination April 19, 2018

Electrolite Result Normal Value

Natrium 131 mmol/l 135 - 145

Kalium 2,4 mmol/l 3,5 - 50

Chlorida 99 mmol/l 98 – 108

A:

1. Diarrhea with acute mild-to-moderate dehydration

2. Hyponatremia
3. Hypokalemia
4. History of seizures ec. metabolic disorders
5. Hernia umbilical

P:

- IVFD KaEn 3B 1.000 ml + KCl 10 mEq

- Zinc Kid Syrup 1 x 20 mg PO

- Paracetamol Syrup 4 x 125 mg PO

13
- Inj. Cefotaxime 2 x 500 mg (II) IV

20 April 2018 (Day Care: III)

S: Diarrhea 1x, consistency of liquid with more dregs, the smell is not too rotten,
mucus (-), blood (-), change diapers once, nausea (-), vomiting (-), fever (-). Eat
drinking smoothly.

O: Awareness: compos mentis General Condition: moderate pain.

Vital signs: HR: 101x / m RR: 24x / m T: 370C

Anthropometry: BB: 11.5 kg TB: 84 cm

Head: normosefal, deformity (-), closed fontanel

Hair: black, spread evenly, not easily revoked

Eyes: round pupils, isocores, direct light reflex (+/ +), indirect light reflex (+ / +),
pale conjunctiva (- / -), jaundiced sclera (- / -), sunken eyes (- / -)

ENT: Tonsil T1-T1, hypereemic pharynx (-), secretions from the ear (-), sinus
tenderness (-), septum deviation (-).

Mouth: good oral hygiene, moist lips mucosa.

Neck: stiff neck (-), stiff neck (-), KGB not palpable enlarged.

Thorax:

Lung:

I: dynamic-symmetric chest expansion, chest wall retraction (- / -), epigastric

retraction (-), suprasternal retraction (-), use of respiratory muscle (-), venektasi

(-)

P: symmetrical chest expansion.

P: The whole Sonor is roomy.

A: vesicular + / +, ronkhi (- / -), wheezing (- / -)

14
Heart:

I: the cordic iktus is not visible

P: ikcus kordis palpated between the ribs 5 left midclavicular linea

P: -

A: normal I-II heart sound, murmur (-), gallop (-)

Abdomen:

I: weakness, distension (+), venektasi (-), scarring (-), hernia umbilical (+)

A: bowel sounds (+) / increases.

P: supel, tenderness (-), liver and spleen are not palpable, turgor is good, mass (-)

P: -

Genitalia: within normal limits

Anus: erythema natum (-)

Extremities: warm acral, CRT <2 sec, grated BCG (+), edema (-),

pitting edema (-), wasting (-), baggy pants (-)

Investigations April 20 2018

ELECTROLITE RESULT NORMAL VALUE

Natrium 130 mmol/l 135-145

Kalium 3,2 mmol.l 3,5 – 5,0

Chlorida 94 mmol.l 98 – 108

A:

1. Diarrhea with acute mild-to-moderate dehydration

2. Hyponatremia
3. Hypokalemia

15
 4. History of seizures ec. metabolic disorders
5. Hernia umbilical

P:

- IVFD NaCl 0,9% 500 for 12 hour and followed by KaEn 3B + KCl 10 mEq
- Zinc Kid Syrup 1 x 20 mg PO
- Paracetamol Syrup 4 x 125 mg PO
- Inj. Cefotaxime 2 x 500 mg (III) IV

21 April 2018 (Day Care: IV)

S: Fever (-), diarrhea (-), vomiting (-), seizures (-), eating and drinking smoothly.

O: Awareness: compos mentis General Condition: looks good.

Vital signs: HR: 100x / m RR: 24x / m T: 370C

Anthropometry: BB: 11.8 kg TB: 84 cm

Head: normosefal, deformity (-), closed fontanel

Hair: black, spread evenly, not easily revoked

Eyes: round pupils, isocores, direct light reflex (+/ +), indirect light reflex (+ / +),
pale conjunctiva (- / -), jaundiced sclera (- / -), sunken eyes (- / -), tears (+ / +).

ENT: Tonsil T1-T1, hypereemic pharynx (-), secretions from the ear (-), sinus
tenderness (-), septum deviation (-).

Mouth: good oral hygiene, moist lips mucosa.

Neck: stiff neck (-), stiff neck (-), KGB not palpable enlarged.

Thorax:

Lung:

I: dynamic-symmetric chest expansion, chest wall retraction (- / -), epigastric

retraction (-), suprasternal retraction (-), use of respiratory muscle (-), venektasi

(-)

16
P: symmetrical chest expansion.

P: The whole Sonor is roomy.

A: vesicular + / +, ronkhi (- / -), wheezing (- / -)

Heart:

I: the cordic iktus is not visible

P: ikcus kordis palpated between the ribs 5 left midclavicular linea

P: -

A: normal I-II heart sound, murmur (-), gallop (-)

Abdomen:

I: weakness, distension (+), venektasi (-), scarring (-), hernia umbilical (+)

A: bowel sounds (+) / increases.

P: supel, tenderness (-), liver and spleen are not palpable, turgor is good, mass (-)

P: -

Genitalia: within normal limits

Anus: erythema natum (-)

Extremities: warm acral, CRT <2 sec, grated BCG (+), edema (-),

pitting edema (-), wasting (-), baggy pants (-)

Investigations April 21 2018

Electrolite Result Normal Value

Natrium 136 mmol/l 135-145

Kalium 3,5 mmol.l 3,5 – 5,0

Chlorida 100 mmol.l 98 – 108

17
A:

1. Diarrhea with acute mild-to-moderate dehydration

2. Hyponatremia (Recovery)
3. Hypokalemia (Recovery)
4. History of seizures ec. metabolic disorders
5. Hernia umbilical

P:

- Discharge

1.8 PROGNOSIS
1 Ad vitam : bonam
2 Ad fungsionam : bonam
3 Ad sacntionam : dubia ad bonam

1.9 FOLLOW UP IN POLICLINIC

27 April 2018 (sixth day after hospitalized)

S: Fever (-), diarrhea (-), vomiting (-), seizures (-), eating and drinking smoothly.

O: Awareness: compos mentis General Condition: looks good.

Vital signs: HR: 100x / m RR: 24x / m T: 370C

Anthropometry: BB: 11.8 kg TB: 84 cm

Head: normosefal, deformity (-), closed fontanel

Hair: black, spread evenly, not easily revoked

Eyes: round pupils, isocores, direct light reflex (+/ +), indirect light reflex (+ / +),
pale conjunctiva (- / -), jaundiced sclera (- / -), sunken eyes (- / -), tears (+ / +).

18
ENT: Tonsil T1-T1, hypereemic pharynx (-), secretions from the ear (-), sinus
tenderness (-), septum deviation (-).

Mouth: good oral hygiene, moist lips mucosa.

Neck: stiff neck (-), stiff neck (-), KGB not palpable enlarged.

Thorax:

Lung:

I: dynamic-symmetric chest expansion, chest wall retraction (- / -), epigastric

retraction (-), suprasternal retraction (-), use of respiratory muscle (-), venektasi

(-)

P: symmetrical chest expansion.

P: The whole Sonor is roomy.

A: vesicular + / +, ronkhi (- / -), wheezing (- / -)

Heart:

I: the cordic iktus is not visible

P: ikcus kordis palpated between the ribs 5 left midclavicular linea

P: -

A: normal I-II heart sound, murmur (-), gallop (-)

Abdomen:

I: weakness, distension (+), venektasi (-), scarring (-), hernia umbilical (+)

A: bowel sounds (+) / increases.

P: supel, tenderness (-), liver and spleen are not palpable, turgor is good, mass (-)

P: -

Genitalia: within normal limits

Anus: erythema natum (-)

19
Extremities: warm acral, CRT <2 sec, grated BCG (+), edema (-),

pitting edema (-), wasting (-), baggy pants (-)

A:

1. Diarrhea with acute mild-to-moderate dehydration

2. Hyponatremia (Recovery)
3. Hypokalemia (Recovery)
4. History of seizures ec. metabolic disorders
5. Hernia umbilical

P:

- There is no medication
- Refer to surgeon to consider operating hernia
- Education

29 April 2018 at patient’s home

Patients refuse surgery because cost reasons.

20
 PART II

LITERATURE REVIEW

2.1. Diarrhea

Diarrhea is the second leading cause of death in children under five years
in the world, and is responsible for the deaths of 1.5 million children every year,
which is almost equal to one in five global child deaths.1,2 Diarrhea kills more
children compared with AIDS, malaria and measles combined.2 Indonesia also
places diarrhea as the second leading cause of death among children in the
country. According to the Indonesia Demographic and Health Survey (IDHS
1997) the prevalence of diarrhea in Indonesia is 10.4% and is the second highest
cause of death in children.3

Most children who die from diarrhea actually die from severe dehydration
and fluid loss, especially in under-five children and under-nourished children or
immunocompromised children. 2, 4

Definition

Diarrhea is defined as a change in the consistency of the stool becomes

more tender / liquid and accompanied by increased frequency of defecation. The
defecation can be / without mucus and blood.1,2 WHO defines diarrhea as
discharge of watery stool (which follows vessel form) with a frequency of 3 or
more in a 24 hour period.5 The episodes of diarrhea are distinguished to be acute
and persistent based on their duration. Acute diarrhea occurs suddenly and not
later than 14 days. Persistent diarrhea is defined as an episode of diarrhea that
occurs more than 14 days.

For infants and children, the amount of stool output is greater than 10g / kg
/ 24 hours or more than the adult limit of 200g / 24 hours. Diarrhea is a result of
disruption of intestinal and electrolyte fluid transport.2

21
Etiology

The most common cause is infectious agents, but other causes that cause
the same clinical manifestations should not be ignored. The causes of acute
diarrhea include 3.4

Table 1. Etiology of Acute Causes of Diarrhea3,4

Infeksi Infeksi usus (termasuk keracunan makanan)

Infeksi ekstra intestinal (otitis media akut,
infeksi saluran kemih, pneumonia)
Obat-obatan Antibiotika
Pencahar
Antasida yang mengandung magnesium
Withdrawal opiat
Obat-obatan lainnya
Alergi makanan atau Cow’s milk protein allergy (CMPA)
intoleransi
Alergi protein kedelai
Alergi makanan multipel
Metilxantin (kafein, teobromin, teofilin)
Kelainan proses Defisiensi enzim sukrase-isomaltase
cerna/absorpsi
Hipolaktase awitan lambat (atau tipe dewasa)
Defisiensi vitamin Defisiensi niasin
Defisiensi folat
Tertelan logam berat Co, Zn, cat
Kemoterapi atau radiasi yang
menginduksi enteritis

Functional anatomy of the intestinal mucosa2,6

Villus, the functional unit of the small intestine, multiplies the surface of
the digestion and absorption of the small intestinal mucosa. Enzyme digestion and

22
transport proteins are responsible for the movement of electrolytes in the intestinal
mucosa located in the brush border membrane of the villi cells. The
gastrointestinal tract epithelium is an epithel that can regulate the osmotic charge
into the small intestine. The tight link, the dynamic structure that occurs between
the epithelial cells, contributes to the movement of water and the overall
electrolyte.

The transport of electrolytes via small intestinal epithelial cells occurs

through several mechanisms, including glucose-sodium co-transporter. The
transport of this protein requires the presence of a sodium gradient along the brush
border membrane maintained by the Na, K + ATPase pump on the basolateral
enterocyte membrane.

The second mechanism is the electroneutral NaCl-coupled pathway which

involves a dual exchange mechanism by Na-H + exchanger and Cl-HCO3-
exchanger.

Patophysiology

Diarrhea results from an imbalance between absorption of water and

electrolytes with secretions. This change may occur either due to an osmotic force
in the lumen that draws water or the result of induced active secretion status on
enterocytes.3

Osmotic diarrhea

Osmotic diarrhea is caused by a substrate that can not be absorbed in the

gastrointestinal tract and is generally associated with intestinal damage.2,6 The
classical example of osmotic diarrhea is lactose intolerance caused by enzyme
deficiency so that lactose can not be absorbed in the small intestine and reaches
the colon in the intact state . The colonic bacteria then ferment the unabsorbed
lactose into short-chain organic acids, generating osmosis so that water is secreted
into the lumen. Another example is the consumption of carbonated beverages
containing excessive amounts of sugar beyond the transport capacity, especially in
infants, and the consumption of sorbitol and magnesium salts, both of which are
not absorbed. In general, osmotic diarrhea occurs when digestion and / or

23
absorption is problematic. Osmotic diarrhea ceases with fasting and has an acidic
pH.6

Secretory diarrhea

The mechanism of diarrheal diarrhea is the activation of intracellular

mediators such as cAMP, cGMP, and intracellular Ca2 +, which stimulates the Cl-
-active secretion of crypto cells and inhibits the absorption of neutral coupled
sodium chloride. This mediator interferes with paracellular flux ions due to toxin
injuries occurring in the tight junction.6 Classical examples of secretory diarrhea
caused by cholera and Escherichia coli enterotoxins that bind to enterocene
surface receptors (monocogioslioside GM1). Fragments of cholera toxin will then
enter the cell and activate adenylyl cyclase on the basolateral membrane through
interaction with protein G. This incident increases intracellular cAMP that
activates a specific protein which then generates chloride channel opening.6

E. coli will mediate secretory diarrhea by generating heat-labile toxin (LT)

and heat-stable toxin (ST) in the small intestine. LT action is similar to cholera
toxin and binds to the same surface receptor. Another cause of secretory diarrhea
is a vasoactive peptide that activates G protein-coupled receptors leading to an
increase in intracellular mediators.2

Secretory diarrhea usually has a lot of volume, the stool contains a lot of
water. Stool analysis showed high sodium and chloride (> 70 mEq / L). Secretory
diarrhea continues with fasting.6

The classical concept that only the bacterial diarrhea diarrhea diarrhea
begins to be challenged by the evidence that similar ion secretory pathways are
induced by viral agents and protozoa.6 Rotavirus produces nonstructural proteins
(NSP4) that can stimulate calcium-mediated chloride secretion. Secretory diarrhea
may also arise through a noninfectious process. Some hormones and
neurotransmitters are known to be involved in intestinal secretion as part of the
integrated neuroendocrine system in the intestinal response to external stimuli.

24
 Acute diarrhea, mainly caused by infection, is influenced by host factors
and causal factors. Host factor is the body's ability to defend itself against
organisms that can cause acute diarrhea, consisting of preventable factors or
internal environment of the gastrointestinal tract, including gastric acidity,
intestinal motility, immunity and intestinal microflora environment. Causal factors
are penetration power that can damage mucosal cells, the ability to produce toxins
that affect the secretion of small intestine fluids and the adhesiveness of germs.1

Infection diarrhea is divided into: 1

1. non-invasive (enterotoxigenic): bacteria that do not damage the mucosa, eg

Vibrio cholerae Eltor, Enterotoxigenic E.coli (ETEC), and Clostridium
perfringens. V.cholerae eltor secretes toxins bound to the small intestine
mucosa 15-30 minutes after production. This enterotoxin causes excessive
activity of the nicotinamide adenine dinucleotide in the walls of the
intestinal cells, thereby increasing the levels of adenosine 3 ', 5'cAMP in
cells that cause the active secretion of anion chloride into the intestinal
lumen followed by water, bicarbonate ions, sodium and potassium cations.
2. invasive (enterovasif): bacteria that damage the mucosa such as
Enteroinvasive E.coli (EIEC), Salmonella, Shigella, Yersinia,
C.perfringens type C. Diarrhea is caused by damage to the intestinal wall
in the form of necrosis and ulceration. The nature of the diarrhea is
exudative secretory. Diarrhea fluid can be mixed with mucus and blood.
Common causes of parasites are E.histolytica and G.lamblia.

Pathogenesis

Virus

Some types of viruses such as rotavirus, breed in the epithelium of the small
intestine, cause epithelial cell damage and villous shortening. The loss of villous
cells that normally have a function of absorption and temporary replacement by
epithelial cells that form immature crypts, causing the intestine to secrete water
and electrolytes. Damage to the villi may also be associated with loss of

25
disaccharidase enzyme, resulting in reduced absorption of the disaccharides
especially lactose. Healing occurs when the villi undergoes regeneration and the
vital epithelium becomes mature.1

Bacteria

• Adhesion in the mucosa. The bacteria that breed in the small intestine
must first stick to the mucosa to avoid sweeping. The attachment takes
place through the pili attached to the receptors on the intestinal surface.
This occurs for example in enterotoxigenic E.coli and V. Cholera 01.
In some circumstances, the mucosal attachment is associated with
intestinal epithelial changes that lead to a reduction in absorption
capacity or to cause fluid secretion.1
• Toxins that cause secretions. E. coli is enterotoxigenic, V. Cholerae 01
and some other bacteria secrete toxins that inhibit epithelial cell
function. This toxin reduces sodium absorption through the villi and
may increase the chloride secretion of the crypta, which causes the
secretion of water and electrolytes. Healing occurs when sick cells are
replaced with healthy cells after 2-4 days.1
• Mucosal invasion. Shigella, C jejuni, E coli enteroinvasife and
Salmonella can cause bloody diarrhea through invasion and mucosal
epithelial cell destruction. It occurs mostly in the colon and distal
portions of the ileum. Invasion may be followed by the formation of
superficial microabses and ulcers that cause red blood cells and white
blood cells or the presence of blood in the stool. The toxin produced by
this bacteria causes tissue damage and possibly also the secretion of
water and electrolytes from the mucosa.1

Protozoa

• Mucosal attachment. G.lamblia and Cryptosporidium attach to the

intestinal epithelium and cause shortening of the villi, which is likely
to cause diarrhea.

26
 • Mucosal invasion.E. Histolitica causes diarrhea by invading the
mucosal epithelium in the colon (or ileum) causing microabses and
ulcers. But this situation occurs when the strain is very fierce. In
humans, 90% of infections occur by non-malignant strains. In this case
there is no mucosal invasion and no symptoms / signs, although the
amoeba and trophozoite cysts may be present in the stool.1
2.2.DEHIDRASI

Severe diarrhea and limited oral intake can lead to dehydration.

Manifestations of dehydration include increased thirst, decreased urination, dark
urine, inability to sweat and orthostatic changes. In severe diarrhea, acute renal
failure may occur and mental status changes (confusion and dizziness). In all
children with diarrhea, hydration status is classified as severe, moderate, or
dehydrated dehydration.7

Table 2. Classification of dehydration severity in children with diarrhea according

to WHO7-

Klasifikasi Gejala atau tanda

Dehidrasi berat Dua atau lebih dari:
 Lethargi/tidak sadar
 Mata cekung
 Tidak dapat minum atau minum sedikit
 Cubitan pada kulit kembali sangat lambat (≥2 detik)
Dehidrasi ringan Dua atau lebih dari:
sedang  Gelisah, iritabilitas
 Mata cekung
 Minum seperti kehausan
 Cubitan kulit kembali dengan lambat
Tanpa dehidrasi Tidak cukup tanda untuk memenuhi klasifikasi dehidrasi
berat dan sedang

27
Dehydration according to clinical is divided into 3 levels:1

1. mild dehydration (fluid loss 2-5% BB): reduced turgor, hoarseness (vox
cholerica), the patient has not fallen in preshock.
2. Moderate dehydration (fluid loss 5-8% BB): bad turgor, hoarseness,
patient presyok or shock, rapid pulse, fast and deep breath.
3. Severe dehydration (loss of fluid 8-10% BB): signs of moderate
dehydration plus decreased consciousness (apathy to coma), stiff muscles,
cyanosis.

Management of diarrhea according to WHO7

Plan A

Diarrhea without dehydration

• More fluids are given to the child to prevent dehydration. House

liquids such as tajin water, coconut water, vegetable soup or yogurt can
be given. Soft liquids, liquids with artificial sweeteners, and high
glucose are avoided because they can cause osmotic diarrhea. As long
as there are no signs and symptoms of malabsorption during treatment,
termination of milk and dairy products is not recommended. Regular
use of lactose-free formula does not reduce the healing period.
• Oral rehydration solution WHO (Oral Rehydration Solution / ORS)
contains 3.5 g of NaCl, 2.5 g NaCO3, KCl 1.5 g, 20 g glucose in 1 liter
of water (Oralyte, Ottolite). Mother can be taught how to prepare a
salt-sugar liquid, 3 jumps of salt added with about a handful of sugar,
mixed with ½ liter of water. In elongated or severe diarrhea, rice-
containing ORS may be tried. This fluid is acceptable and improves
child nutrition.
• Restriction or cessation of food is not recommended. Children should
still be fed with nutrients and high calories to prevent malnutrition.
ASI continues. A mixture of cereals and nuts, fresh fruit juices and
bananas can be provided. When diarrhea stops, the child is given extra
food every day for one week to gain weight before illness.

28
 • Dangers should be explained to the mother and should be reported
immediately, excessive thirst, sunken eyes, fever, refusal to eat or
drink, dysentery, urinary defecation, seizures.

Plan B

Diarrhea with mild-moderate dehydration

• Determine the amount of ORS for the first 3 hours

• If the child wants more oralit from the above guidelines, provide
appropriate fluid loss in progress
• For children younger than 6 months who are not breastfeeding, also
give 100-200 ml of boiled water during this period
• Start feeding as soon as the child wants to eat
• Continue breastfeeding
• Provide a zinc tablet for 10 days

Show mother how to give oralit solution:

- Drink a little but often from cup / cup / glass

- If the child vomits, wait 10 minutes, then continue again more slowly
- Continue breastfeeding as long as the child wants

After 3 hours:

- Repeat the assessment and re-classification of dehydration degree

- Select an appropriate therapy plan to continue treatment

If mother forces to go home before treatment is complete:

- Show me how to prepare an ORS solution at home

- Show some of the many oral solutions that should be given at home to
complete 3 hours of treatment
- Describe the 4 rules of care:

29
1. Add extra fluids

2. Continue feeding

3. Give a zinc tablet for 10 days

4. When to return

Plan C

Diarrhea with severe dehydration

• Must be treated promptly with intravenous fluids due to emergencies,

Ringer Lactate or Normal Saline 0.9% given 100 ml / kg divided as
follows:
- <12 months first administration 30 ml / kg for 1 hour, followed by 70mg
/ kg for 5 hours
- 12 months - 5 years first administration 30 ml / kg for 30 minutes,
followed by 70 mg / kg for 2 and half hours.
• Antibiotics are not routinely given. Antiemetics, antidiarrics and
antimotility are not used. Review every 1 hour, if not improved,
accelerated. Fluids with dextrose should not be used for initial
rehydration as they may aggravate. If the child can take ORS orally
when the intravenous fluids are prepared, give 5ml / kg immediately.
• Review after 6 hours (infant) or 3 hours (child) for hydration status and
select plan A, B, C for next. If intravenous access can not be fast, think
of giving ORS with NGT. The child is conscious and there is no ileus,
20 ml / kg / hr. If required, intraosseous access may be performed in
children under 6 years of age.

Other Management4

• Antibiotics

 Used for certain indications of specific bacterial infections or protozoa,

cholera, Shigella, Giardia. In patients with severe and persistent diarrhea,
with other diseases such as heart failure, lung disease, and AIDS.
 Cholera - tetracycline 12.5 mg / kgBW / day divided into 3 doses.

30
  Shigella dysentery - cefixime 8 mg / kgBW / day divided into 5
doses.
 Amoebiasis - Metronidazole 30-40 mg / kgBW / day divided in 7-10
doses.
 Giardiasis - Metronidazole 30-40mg / kgBW / day divided into 10
doses
• Adsorbents (kaolin, pectin, activated charcoal)
o Just little change in stool consistency, but does not reduce fluid
loss and salt.
• Antimotility (diphenoxylate, opium tincture or loperamide)
o Slows down the elimination of diarrheal organisms and may
prolong the disease.
• Probiotics
o Some strains of probiotics (lactic acid bacteria or mycetes) are
found to be effective as adjuvants in dealing with children with
acute diarrhea. Data from well-designed randomized controlled
trials show statistically significant gains in shortening sickness.
Currently probiotic strains (most Lactobacillus GG and
Saccharomyces boulardii) are widely used in the management of
acute liquid diarrhea in infants and children in developing
countries.
• Zinc
o In children aged 2 bualn and above, zinc tablets are given for 10
days with doses ½ tablets (10) / day for those <6 months old, and 1
tablet (20 mg) / day for those> 6 months.

2.3.SEIZURE

Seizures are signs and / or symptoms that occur transiently due to

abnormal activity or the presence of synchronicity in neurons in the brain.
International Classification of Epileptic Seizures (ICES) divides epileptic
seizures into 2 categories: focal (partial) and generalized. In focal seizures
abnormal activity occurs only in one of the brain hemispheres, while the

31
 generalized type occurs in both hemispheres. Approximately 30% of patients
with first seizures will develop epilepsy later; the risk of occurrence of about
20% in patients with neurologic examination results, EEG, and normal
neuroimaging.2

Febrile seizures are a special category. While acute symptomatic seizure

occurs in acute disturbances that disrupt the excitability of the brain such as
electrolyte imbalance or meningitis. Most children with this type of seizure
have a good prognosis, but sometimes in seizures involving major structures
of the brain, inflammation, or metabolic disorders of the brain, such as
meningitis, encephalitis, acute stroke, or brain tumors, the prognosis depends
on the underlying cause. Unprovoked seizure is not an acute symptomatic
seizure. Remote symptomatic seizure is a seizure caused by previous brain
damage such as an old stroke. Seizure disorder is a common term used to
describe one of several disorders, including epilepsy, febrile seizures, and
seizures caused by infection, metabolic disorders, or other causes (eg,
hypocalcemia, meningitis).2

Relationship Disruption of fluid and electrolyte balance with the occurrence

of seizures.8

Water and electrolytes are constantly moving through blood vessels and
cell membranes, to maintain balance. The homeostatic fluids and electrolytes are
regulated by the interactions of the kidneys, skin, lungs, adrenal glands, and brain.
The presence of malfunction in one of these organs can cause a disturbance of
fluid or electrolyte balance. Severe persistent diarrhea or vomiting with poor fluid
intake can lead to excessive depletion of water in the body or dehydration.

Other causes of dehydration include excessive sweating, polyuria, diabetes

mellitus, and diabetes insipidus. In infants and children dehydration often occurs
along with electrolyte imbalances. Excessive fluid loss while many salts in the
body cause hypertonic dehydration. Excessive salt loss will lead to a hypotonic
state. Both conditions can disrupt brain development. In hypertonic dehydration,
cell leak occurs so that venous thrombosis can occur. Rapid correction in

32
hypertonic state may cause cerebral edema. In hypotonics, water moves into the
brain set, allowing cerebral edema with intracellular swelling.

The clinical manifestations of dehydration depend on the rate of change of

fluid and electrolytes, including the degree of hypo or hypernatremia. Lethargy
and confusion occur in the acute isotonic dehydration state. If the condition lasts
long, hypotension can occur and will cause cerebral ischemia to the point of coma.
At a change in mental status, hypotonic dehydration may be accompanied by
seizures. In acute hypertonic conditions may appear iritabel, increased muscle
tone, hyperrefleks, seizures, and changes in mental status. Rapid and excessive
rehydration and sodium reduction in these conditions can cause brain
intraparenchymal hemorrhage with coma, multifocal abnormalities on
examination, and seizures.

A history of vomiting and / or diarrhea, and inadequate fluid intake, along

with poor skin turgor, dry mucosa, sunken eyes, and lack of tear production make
the diagnosis of dehydration easier. However, the invention will be difficult to see
if there is a hypertonic dehydration state, since the relative extracellular fluid
volume is maintained.

Intravenous fluid replacement is the primary treatment. Faster fluid and

electrolyte replacement initiation is needed to maintain and restore cardiovascular,
kidney, and organ perfusion function. Subsequently, fluid and electrolyte
replacement is done slowly to replace the deficiency to the maximum and to
maintain adequate fluid volume.

Specific parameters for fluid and electrolyte replacement should be on a

case-by-case basis, looking at age, neurological and cardiovascular status,
electrolyte balance degrees, and other factors. Supervision of electrolytes and
kidney function is important to determine further therapy. If severe acidosis
occurs, bicarbonate administration may be performed. in the dehydration of
hypernatremia, hypotonic fluids may be used as fluid replacement therapy, but it
is important to gradually decrease the level of sodium for 72 hours, to minimize
the occurrence of complications that may occur with over-correction. In a state of
rapid correction, of particular concern is the occurrence of cerebral edema with

33
the potential for encephalopathy and even herniation. Seizures usually respond to
correction of dehydration and electrolyte imbalances and no anticonvulsants are
required. The final outcome generally varies although severe cerebral edema or
intraparenchymal bleeding has occurred.

Table 3. Clinical Symptoms Differences in Dehydration

Gejala Dehidrasi Hipotonik Isotonik Hipertonik

Rasa haus - + +
Berat badan turun sekali turun turun
Turgor kulit buruk turun tidak jelas
Mukosa Basah kering kering sekali
SSP Apatis koma iritabel, kejang,
refleks meningkat
Sirkulasi sangat buruk buruk relatif baik
Nadi sangat lemah cepat-lemah cepat-keras
Tekanan darah sangat rendah rendah rendah

Electrolyte Imbalance 9

Hyponatremia (Na <135 mEq / L)

a. Hypertonic hyperatremia (POsm> 295)

Etiology:
- hyperglycemia, co. DKA
- mannitol, glycerol
b. Isotonic Pseudohyponatremia (POsm 280-295)
Etiology
- hyperproteinemia
- hyperlipidemia
c. Hypotonic hyponatremia (POsm <280)
1) Hypovolaemic (decreased total Na total and water)
Etiology:

34
 - Renal losses: diuretic excess, osmotic diuresis, obstructive uropathy,
adrenal insufficiency, Fanconi syndrome, pseudohypoaldosteronism,
Bartter's syndrome, interstitial nephritis
- GI losses: vomiting, diarrhea, fistulas, post-op tubes, gastrocystoplasty
- Sweat, heat stroke
- Third space: effusion, ascites, burns, muscle trauma, pancreatitis,
peritonitis
2) Euvolemic (+ total Na total and total water increase in body)
Etiology:
- water intoxication
- excess ADH
- glucocorticoid deficiency
- hypothyroidism
- osmotate reset: CVA, TB infection, malnutrition
- Hypervolemics (increase of total Na in body and water)
- Etiology:
- edema: GJK, cirrhosis, nephrotic syndrome, too much free water
especially in neonates
- kidney failure (acute, chronic)

Clinical Manifestations

Apathy, agitation, anorexia, nausea, vomiting, diarrhea, weakness, mental

status changes, coma, hypotension, seizures.

Treatment

- Management depends on the underlying cause.

- In euvolemic and hypervolemic treated with fluid restriction, whereas in
hypovolemic need restriction of Na.
- In hypovolemic correction of shock with fluid replacement using normal
saline.
- Symptomatic Hyponatremia
a. In acute Na decrease <120 mEq / L there is often a seizure or
coma

35
 b. Symptoms can usually be resolved by increasing Na 3 mEq / L
c. Na required = (Na target - Na at time) x 0.6 x BB
 3% NaCl = 513 mEq / L (0.5 mEq / cc) is given for 1-2
hours (can be given fast for 15 minutes)
- The correction of Na should not be faster than 0.5 mEq / L / hr.
- Monitor Na every 4 hours until stable.
- Overcome the underlying etiology.

* POsm = 2Na + (glucose / 18) + (BUN / 2.8); will be similar to measured

osmolality in the absence of alcohols, mannitol, glycerol, or sorbitol

Hypokalemia (K + <3.5 mEq / L)

Etiology

1. Less intake: vomiting, starvation, malnutrition, kwashiorkor, anorexia nervosa

2. GI losses: chronic diarrhea, fistulas, excessive laxative use, colostomy,
nasogastric drainage, ureterosigmoidostomy
3. Renal losses: tubular diseases, Cushing's syndrome, hypomagnesemia,
hyperaldosterone, drugs (aminoglycosides, amphotericin, ticarcillin, NSAIDs,
diuretics), nephritis, licorice ingestion, Fanconi syndrome, distal RTA, toluene
sniffing, Bartter syndrome, Gitelman syndrome, Liddle's syndrome
4. Skin losses: fibrosis cysts, burns
5. Redistribution: metabolic alkalosis, insulin, ß2 agonists (especially albuterol),
hypothermia
6. Respiratory alkalosis

Clinical Manifestations

a) Weak, paralysis, hyporeflex, ileus

b) Atrial and ventricular premature contractions, ST depression, flattened T
wave, U wave, prolonged q-u interval
c) Digitalis toxicity

36
Treatment

1. Overcome the underlying abnormalities.

2. Oral administration is recommended: 1-3 mEq / kg / day, correction takes 5-
7 days
3. If K <2.5 is given intravenously 0.5 mEq / kg for 1 hour
4. Delivery rate of 0.25-0.5 mEq / kg / hr and IVF concentration <40 mEq / L
is a safe limit.

37
 REFERENCE

1. World Health Organization. Diarrhoea Disease Fact Sheet. Available at

http://www.who.int/mediacentre/factsheets/fs330/en/index.html#. Geneva,
2009.
2. Kliegman RM, Behrman RE, Stanton BMD, Geme JS, Schor N. Nelson
textbook of pediatrics. Edisi 19. Saunders. 2011.
3. Guandilini S, Frye RE, Tamer MA. Diarrhea. Available at URL
http://emedicine.medscape.com/article/928598-overview. Accessed Januari 14
2012.
4. Departemen Ilmu Kesehatan Anak RSCM. Panduan Pelayanan Medis RSCM.
2008.
5. Abba K, Sinfield R, Hart CA, Garner P. Pathogens associated with persistent
diarrhoea in children in low and middle income countries: systematic review.
BMC Infectious Disease. 2009.
6. Walker WA, Kleinman RE, Sanderson IR, Sherman PM, Shneider BL.
Pediatric gastrointestinal disease. Edisi 4. 2004.
7. WHO. Pocket book of hospital care for children. Guidelines for the
management of common illnesses with limited resources. 2005.
8. Flink, Michael and Trauner, DA. Toxic and metabolic encephalopathies. In:
Ronald B. David; Clinical Pediatric Neurology. 3rd edition. New York: Demos
Medical, 2009. p119.
9. Kirsch, Erica A.Pediatric Emergency Manual. Texas: Department of Pediatrics
San Antonio Uniformed Services HEC Pediatric Residency. 2000.

38