Zeinidar Auliyaun N.

Zeinidar Auliyaun N.

Ria Fitriani

Sevin Ramahwati

Zeinidar Auliyaun N.

Ria Fitriani

Zeinidar

Ayu Priyan

Auliyaun N. Sevin Ramahwati

Ria Fitriani

Zeinidar

Ayu Priyan

N rul Istiqomah

Ria Fitriani

Auliyaun N. Sevin Ramahwati

Dimas Hadi Prayog N rul Istiqomah

Ria Fitriani
Ayu Priyan

Auliyaun N. Sevin Ramahwati

Zeinidar

HIGH RISK !!

Prevalensi Diarrhea
Prevalensi Diare

The infant mortality rate in Indonesia from 2003 to 2012 has decreased very slowly or stagnant, that is from the birth of 1,000 babies, about 32 babies died. This condition may occur due to lack of coverage of exclusive breastfeeding. only about 15% of infants who received breast milk intake.

Based on data of Riskesdas 2010

The same thing occurs in infants, which is about 46 of the 1,000 infants died. The biggest cause of death of infants and toddlers is diarrhea. Exclusive breastfeeding is the minimum intake is a major cause diarrhea in infants.

While deaths in infants are more affected because immediate treatment of diarrheal diseases. The data says that only about 35% of infants who received treatment in the form of oral rehydration salts (Riskesdas, 2010).

2.1.2

SMALL INTESTINE Jejenum (8 feet) and ileum (12 feet) continue degenerative process. Surface area increased by plica circulares (circular folds) carrying villi, cells of villi cary microvilli. Each villus has a capillary and a lacteal (lymphatic capillary).

Jejenum terminates at cecum. Cecum is small sac like evagination, important in some animals as a repository for bacteria/other organism able to digest cellulose Anus In anatomy, anus or bottom hole is an opening from rectum to the outside of body. Opening and closing of anus is arranged by sphincter muscle.

Large Intestine

The rectum is the final straight organ of the large intestine, terminating in the anus. The human rectum is about 12 cm long. The rectum intestinum acts as a temporary storage facility for feces. As the rectal walls expand due to the materials filling it from within, stretch receptors from the nervous system located in the rectal walls stimulate the desire to defecate

Rectum

Accessory Digestive Organs

Salivary glands Liver and Gallbladder Pancreas

DEFINISI

Gastrointeritis is an inflammation of the stomach and intestines that may be accompanied by vomiting and diarrhea. It can affect any part of the GI tract. Diarrhea is a common problem in children, accounting for 13% of hospitalizations in children less than 5 years of age

Van Niel, Feudtner, Garrison& Christakis, 2002)

It may be an acute problem, caused by viral, bacterial, or parasitic infections, or a cronic problem . Rotavirus is the leading caused of gastroenteritis in children

(Hsu et al., 2005)

KLASIFIKASI
Four types of diarrhea are recognize (Limbos,2005) Osmotic diarrhea results when osmotically active particles in the intestine draw excess fluid into the stool, this condition occurs with dumping syndrome, lactase deficiency, overfeeding, and malabsorption syndromes

Acute diarrhea can caused :

1 viruses

Secretory diarrhea occurs because there is active secretion of water and electrolyte from mucosal crypt cells in the small intestine into the bowel lumen.
Motility disorders cause diarrhea but not malabsorption. Bile salt and pancreatic enzyme deficiency can cause diarrhea by deletion or inhibition of the normal absorption process Inflammatory processes, such as bacterial invasion, celiac sprue, or surgical procedures can change the anatomy and functional ability

2 bacteria 3
parasites

E T I O L O G Y

E. Coli
Shigella Giardi a lambli a Norwal k virus Entamoeba histolytica Balantidi um coli

Salmonella

Corona virus

Rotavirus

Viral causes of acute diarrhea include :

1. Rotavirus affect children 4 to 24 months old, cause half of all cases of acute gastroenteritis, occur mostly in the cooler months, and can cause significant dehydration. 2. Adenoviruses are the second most common type of viral diarrhea. This illness does not generally include the high fever or respiratory symptoms associated with nonenteric adenovirusdehydration.

Bacterial diarhea, which is much less common, can be cused by:

1. Campylobacter jejuni is gram-negative rod found mostly in raw or undercooked poultry or meat

Salmonella is a gram-negative rod found in contaminated, improperly cooked poultry, eggs, dairy product, and sausage 3.Shigella is gram-negative rod found in contaminated food and water. Human are the host and reservoir, and the organism is spread by the fecal-oral routemeat

2.

3. Noroviruses cause most of the diarrhea in industrialized countries (Dennehy, 2005). Fifty percent of food-borne outbreaks of diarrhea caused by noroviruses.
4. Invasion of the GI tract by pathogens result in increased intestinal secretion as a result of enterotoxins, cytotoxic mediators, or decreased intestinal absorption secondary to intestinal damage or inflammation. The most serious and immediate physiologic disturbances associated with severe diarrheal disease are: (1) dehydration, (2) acid-base imbalance with acidosis, and (3) shock that occurs when dehydration progresses to the point that circulatory status is seriously impaired.

3. Enteroadherent and enterotoxigenic strains of E.coli usually cause mild travelers diarrhea.

4.

Enterohemorrhagic E.coli (O157:H7) can be associated with a mild, self-limited diarrhea that causes bloody stool and abdominal cramping, 5. Yesrinia enterocolitica is a gram-negative rod found in contaminated food (e.g., uncooked pork and unpasturized milk) and water.

6. C. Difficiles is a gram-positive anaerobic bacillius. Asymtomatic carriers of C. Defficile who take antibiotic (ussually ampicilin,clindamycin, and cephalosporis) experience increased

PATOFISIOLOGI
Invasion of the GI tract by pathogens increased intestinal secretion as a result of enterotoxins, cytotoxic mediators decreased intestinal absorption secondary to intestinal damage or inflammation. Enteric pathogens attach to the mucosal calls

systemic diarrhea

the pathogenesis of the diarrhea depends on whether the organism remains attached to the cell surface

penetrates to mucosa

noninvasive, toxinproducing, noninflammatory type diarrhea

resulting in a secretory toxin

form a cuplike pedestal on which the bacteria rest

RISK
Ketersediaan air bersih tidak memadai

FACTORS

Not washing hand

Sanitasi buruk

Makanan tidak higienis

Kebersihan lingkungan buruk

Tidak memberikan ASI eksklusif

CLINIC MANIFEST
Etiology 1. Emotional stress (anxiety, fatigue) Bowel Manifestation 1. Incrased motility

2. ntestinal infection (bacteria [E. Coli, Salmonella, Shigella], Viral 2. Inflammation in mucosa; increased mucus secretion in colon [Human Rotavirus, enteric adenovirus], fungal overgrowth) 3. Food sensivity (Gluten, Cows milk)

3. Decreased digestion of food

4. Food intolerance (lactose, introduction of new food, overfeeding)

4. Incrased motility; increased mucus secretion in colon

5. Medication (iron, antibiotics)

5. Irritation and suprainfection

6. Colon disease (colitics, necrotizing enterocolitis, enterocolitis

6. Inflammation and ulceration of intestinal walls; reduces absorption of fluid; increased intestinal motility

7. Surgical alterations ( short bowel syndrome)

7. Reduces size of colon; decreased absorption surface

WOC (lihat di makalah)

Acute diarrhea can cause :

KOMPLIKASI
cardiovascular colaps

metabolic asidosis
Rotavirus has been linked to bacteremia in children with recurrent fever or new onset of fever in children who had know fever associated with the initial diarrhea illness (lowenthal et all, 2006)

Dehydration

possible death

MANAJEMEN DIARRHEA PEDIATRIC

The following steps are taken :

1. Restore and maintain hydration. Oral rehydration with an oral electrolyte solution should be attempted. Appropriate rehydration solutions include pedialyte and invalyte. It is in appropriate to use fliud juices, kool aid, sprots drinks, or soda. Resume early refeeding because contens of the bowel stimulate the growth. 2. Enterocyte and help to facilitate mucosal repair following injury. The resumption of a regular diet once rehydretion has been accomplished or continouing with a regular diet despite
the diarrhea has been shown to shorten the duration of the disease.

3. Administer parenteral hydration if necessary for the following: a. Impaired circulation and possible shock b. Weigh less than 4 to 5 kg or a child younger than 3 months old c. Intractable diarrhea, lethargy anatomic anomalies d. Failure to gain weigh or continued weigh loss despite oral fluid 4.Prescribe medication as indicated 5. Anti diarrheals are not generally recommended because the offending organism must be excreted. Most over the counter products intended for diarrhea now contain salicylates, and there is cocern for reye sindrom. If diarrhea persist beyond the initial infection, cautious use of those agents without salicylates in older children is acceptable.

6. Lactobacillus given early in a viral diarrheal illness or antibiotic associated diarrhea can shorten the duration of the diarrhea and lessen the number of stooles per day (banks, 2004; Szajewska et all, 2006) 7. Dioctahedral smectite, an adsorbend clay, has been found to protect the intestinal mucosa by absorbin viruses, bacterial, and bacterial toksin with few site effect. (Szajewska et all, 2006; Yen & Lai, 2006) .

PREVENTION
Preventive measures include the following :

1. Good hand washing by the child and care providers. Liquid soap ang paper towels are recommended at day care center.

2. Good sanitation and appropriate removal of soiled clothing and deepers. Diapering area should be cleaned after changing each baby at day care center. 3. Avoid unnecessary antibiotics usage. 4. Avoiding contamined soures; meat should be properly cooked. 5. With shigella, culture all symptomatic contacs and treat those with positive stool cultures.

CASE STUDY A mother brings her 8-month-old infant, Mary, to the primary care clinic. The mother reports that Mary has had a cold for about 2 days, and this morning she began to vomit and has had diarrhea for the past 8 hours. The mother states that Mary is still breastfeeding, but that she is not taking as much fluid as usual, and she is having three times as many stools as usual (the stools are watery in consistency). When the nurse practitioner examines Mary, she notes that her temperatures is 380 C (100.40 F) her pulse and blood pressure are in the normal range, her mucous membranes are moist, and she has tears when she cries. The nurse practitioner also note that Marys weight has decreased from what it was when she was seen in the clinic 2 weeks ago for her well-child visit.

Identity:
Name Age Sex : Mary : 8 months : Female

Assessment: Subjective data: cold for about 2 days not taking as much fluid as usual the stools are watery in consistency vomit and has had diarrhea for the past 8 hours Objective data: The temperature is 380 C had diarrhea for the past 8 hours Pulse and blood pressure is normal Mucous membranes are moist Has tears when she cry Lossing weight

Clinical findings
History . the following should be included: 1. Pattern of diarrhea : when diarrhea began ,nube of stools,frequency, and quality of stools. 2. Signs and symptoms associated wit infectious diarrhea: bloody stool ,abdominal pain , vomiting , or fever. 3. Number of wet diapers in the past 24 hours and approximate time of last void. 4. Dietary record , changes in a diet that might correlate with increased stooling. Family members with similiar illnes or others GI diseases. 5. Day care or schol illnes patterns and contacts. 6. Travel history. 7. Most recent weight and previous growth pattern.

Physical Examination .
Assess the following : Complete physical examminations including vital sign ,assessment of behaviour ,and evaluation of anterior fontanelle , if it is still open. Assesment of dehydration . Steiner and colleagues (2004) ,found that CRT ,skin turgor, tacypnea ,when consideret together, were the most helpful in the determination of dehydration. Normal CRT is less than 2 seconds. Research has shown that a CRT of 2 to 2.9 seconds corresponds to a 50-to 90-ml/kg loss, 3 to 3.5 seconds corresponds to a 90to 110-ml/kg loss, 3.5 to 3.9 corresponds to a 110- to 120-ml/kg loss, and more tahan 4 seconds corresponds to a 150-ml/kg loss (Findberg, 2002).

Diagnostic Studies. Most diarrheal ilness does not require any lab testing. The following are ordered as indicated:
Stool examination (Color, consistency, blood, mucus, pus, odor, volume). Stool pH, clinitest, and heme test. Stool cultures should be considered for bloody or prolonged diarrhea ,suspected food postioning,or recent travel aboard(Banks,2004) Specific laboratory findings . Rotavirus is diagnosed using enzyms immunosasy and later agglutination for group A rotavirus antigen in the stool ,electron microscopy, and reverse transcriptase PCR ( Dennehy,2005). Adenoviruses are diagnoses by antigen detection by immunoassay. Noroviruses are diagnosed via reverse transcriptase. Campylobacter is diagnosed by stool culture. E.Coli O157:H7 is diagnosed using MacConkey agar with sorbitol. The following are criteria to culture stool for C.Difficile : -Test patients who are older than 1 year. C.Defficile is commonly found in asymtomatic children less than 1 year old. -Severe diarrhea lasting at least 2 days. -The presence of other GI symtoms (cramping,abdominal pain). If intravenous fluids are necessary, serum bicarbonate will help establish the severity of the dehydration. Other serum electrolytes and glucose may help to evaluated complicated diarrhea (banks , 2004

Diferrential diagnosis
Numerous causes, including infection (bacterial or viral) , medication ingestion , parasitic infestation ,anatomic abnormalities,dietary intolerances and appendicities , may be responsible for accute diarrhea .

Collaborative Care
Diagnosis is based on the history, physical examination and laboratory findings . athrough history may help identify the cause. Ask parents about recent exposure to illnesses, use of antibiotics, travel, food and formula preparation, food sensitives or allergies, and whether the child attends childcare. Physical examination provides to guide the severity of dehydration . the stool can be examinate for the presence of ova, parasites infectious organism, viruses, fat and undigested sugars. Laboratory evaluation of serum and urine helps identify electrolyte imbalances and other deficiencies.

Diagnostic Evaluation
Evaluation of the child with acute gastroenteritis begins with a careful history that seeks to discover the possible cause of diarrhea, to assess the severity of symptoms and the risk of complication, and to elicit information about current symptoms indicating other treatable illnesses that could be causing the diarrhea. The history should include question about recent travel, exposure to untreated drinking or washing water sources, contact with animals or birds, daycare center attendance, recent treatment with antibiotics, or recent diet changes. History question should also explore the presence or absence of other symptoms such as fever and vomiting, frequency and character of stools, urinary output, dietary habits, and recent food intake.