Case Presentation

Presented by:
Mentari Indah Sari
Erniyanti Puspita Sari
Advisor:
Dr. Achirul Bakri, SpA(K)

Department of Pediatric
Dr. Mohammad Hoesin General Hospital
Sriwijaya University Faculty of Medicine
2016

I. INTRODUCTION

- Diarrhoea remains one of the major causes of morbidity

and mortality of children in developing countries .
- Most of acute diarrhea caused by infection. Many of the
impacts that occur due to infection of the gastrointestinal
tract including toxin that can cause impaired secretion and
reabsorption of fluid and electrolyte due to dehydration,
electrolyte balance disorders and acid-base balance
disorder. The invasion and destruction of epithelial cells ,
penetrate into the lamina propria and damage the microvilli
may constitute a maldigest and malabsorption .
- To carry out the treatment of diarrhea in a comprehensive ,
efficient and effective way, it must be done rationally. The
use of oral rehydration solutions are generally effective in
correcting dehydration. Intravenous fluid administration is
needed if there is a failure because of the high frequency of
diarrhea, uncontrollable vomiting and oral input to
disruption due to infection. Some ways of prevention by
vaccination and the use of probiotics has been widely
disclosed and treatment with specific antibiotics and
antiparasitic.

II. PATIENT STATUS

IDENTIFICATION
Name
: AN
Age / Birth date
: 11 months/ March, 15th 2015
Sex
: Female
Weight
: 7 kg
Height
: 69 cm
Religion
: Islam
Address
: Perum Azhar Blok G No 05
Kenten Laut Tl.
Kelapa RT 38 RW 03 Kab. Banyuasin
Palembang
Admission
: March, 11th 2016

ANAMNESIS

(Alloanamnesis: patients mother, 11 March 2015,

16.00)
Chief Complain
: Watery stool
Secondary Complain : Vomit and fever

History

There was no previous illness with similar symptoms

There was no alergic history of milk, food, and drugs

History in familial illness with the same complaint

in the family denied

Birth
Histor
y
Pregnant duration
Parturition
Helped by
Date
Birth weight
Birth length
Birth condition

:
:
:
:
:
:

: Aterm
Spontaneous
Midwife
March, 15th 2016
2800 gram
48 cm
spontaneous crying

Diet

Feeding History
Breast milk
: 0-6 months
Formula milk
: 6 months- present
Rice porridge
: 6-8 months
Stewed rice
: 8 months-present
Rice
:+
Beef
:+
Tempe and tofu
:+
Vegetables
: 10 months presents
Fruits
: 10 months presents
Feeding historys quality were enough.

Growth
developme
nt
Lying down on stomach : 3 months
Sitting
: 6 months
Standing
: 10 months
Walking
:11 months
Talking (mama papa) : 9 months
Reacted to person
: 5 months
Social smiling
: 1-2 months
Motoric development, socializing, and intelligence
development within normal limits

Immunization
Basic Immunization

1 Bln

3 bln

9 bln

BCG

DPT 1

DPT 2

DPT 3

HEPATITIS B

HEPATITIS

HEPATITIS

1
Hib 1

B2
Hib 2

B3
Hib 3

POLIO 1

POLIO 2

POLIO 3

Measles

Conclusion: Basic immunization complete

Physical Examination
(11 March 2016)
General condition: mild illness
Consciousness
: Compos Mentis
Edema (- /-), sianosis (-/-),
dyspnue (-/-), anemia
(-/-),
icteric (- /-),
dismorfic (-/-)
Temp
: 37 OC
Respiration
: 26 x/menit
Type

Pulse
Quality
Regularity

: Abdominothoracal

: 118 x/ menit
: Enough
: Reguler

Weight
Length
Nutritio
n State

: 7 Kg
: 69 cm

Weight/Age
Length/Age
Weight/Length

: 0 SD -2 SD
: 0 SD -2 SD
: -1 SD -2 SD

Conclusion : Normoweight

Specific Examination
Shape

Head

: Normocephaly, symmetrical,
dysmorphic (-)
: Black, straight, not easily

Hair
pulled off
Eyes
: Sunken eyes (+/+), tears (+),
pupils:
round, isocoric, 3mm,
light reflexes
+/+, pale
conjunctiva (-), icteric sclera (-)
Nose
: Secretion (-), nasal flaring (-).
Ears
: Secretion (-).
Mouth
: Dry oral mucosa and lips
(+),cyanosis (-)
Throat
: Hyperemic pharynx (-), Tonsil
T1-T1
Neck
: Lymph node enlargement (-)

Pulmo

I
: Static/dynamic: symmetrical, retraction
-/P
: Stem fremitus left = right
P
: Sonorous in both hemithorax
A
: Normal vesicular sound, rhonchi (-),
wheezing (-).

Heart

I
P
P
A
sound

: Ictus cordis not visible

: No palpable thrill
: Normal heart line
: HR 118 bpm, regular rhythm, heart
I-II
normal, additional sounds (-)

Abdome
n

I
A
P
skin
P

: Stomach raised
: Increased bowel sound (8 x/min)
: Supple, liver and spleen not palpable,
turgor decreased (<2), tenderness (-)
: Tympanic, shifting dullness (-)

Inguinal
eritema perianal
Extremity
(-)
Genitalia

: Large lymphnode (-),

(-), prolaps ani (-)

: cold acral (-), cyanosis (-), edema

: Normal.

Neurologic examination is normal

Acute diarrhoea e.c susp. Viral infection with mild moderate

dehydration + Failure of oral rehydration
Acute diarrhoea e.c susp. Bacterial infection with mild moderate
dehydration + Failure of oral rehydration

Acute diarrhoea e.c susp. Rotavirus with mild moderate dehydration

+ profuse vomiting

Therapy
Additional Examination
Laboratory of Blood analysis and electrolit
Laboratory of Faeces analysis

Therapy ( Supportive SimptomaticCausative)

Non Pharmacologist
Inform patients condition
Educate oralit usage

Therapy
Pharmacologist
IVFD RL 75 cc/kg/4 hr 525 cc/4 hr, then KAEN
3A gtt 7x/m macro
Oralit 100 cc if vomit or watery stool occurs
Zinc 1 x 20 mg po

Evaluating
Vital sign
Post rehidration clinical appearance

Prognosis
Bonam

Bonam

FOLLOW
UP

Blood analysis ( Emergency Unit 11-03-2016 on 15:46)

Hb : 11,8 g/dl (11,1-14,4 g/dl )
Ht : 35 vol% (35-41 vol%)
Eritrosit : 4,66 x10 mm3/jam (3,71-4,25 x10 mm3/jam)
Leukosit : 9.800/mm3 (6.000-17.500 /mm3)
Trombosit
: 290.000/mm3 (217.000-497.000/mm3)
Hitung jenis
: 0/1/39/48/12 (0-1/1-6/50-70/20-40/2-8
mm3)
LED
: 16mm/jam (<20 mm/jam)

Tanggal
Keterangan
12-3- S : Keluhan : BAB cair (+) 3x, cair >
2016 ampas, darah (-), lendir (-), muntah (+)
tiap habis makan, isi apa yang
dimakan banyaknya gelas
belimbing, demam (-).
O : Sense : CM; N : 108x/menit RR :
24x/menit T : 37,1oC
Kulit
: turgor normal
Kepala
: UUB cekung (-), mata
cekung (-),
air mata +/+, mukosa
bibir kering (-)
Thoraks
: simetris, retraksi (-)
Pulmo
: vesikuler (+) normal,
ronkhi (-),
wheezing (-)
Cor
: HR = 108x/menit, BJ I
dan II
normal, murmur (-),
gallop (-)
Abdomen Abdomen
: datar,
lemas, BU (+) meningkat, hepar/lien
tidak teraba, cubitan kulit perut
kembali cepat
Ekstremitas
: akral dingin
tidak ada, CRT <3
Hasil pemeriksaan feses rutin:
Warna: hijau kekuningan
Konsistensi: Lembek
Amoeba: negatif
Eritrosit: Negatif
Leukosit: 1-2/lp
Bakteri: negatif
Jamur: Negatif
Telur cacing: negatif
Sisa makanan (karbohidrat, protein,
lemak): negatif
Darah samar: negatif

13-32016

S : Keluhan : BAB cair (+) 2x, darah (-),

lendir (-), muntah (-)
O : Sense : CM
N : 98x/menit RR : 24x/menit T : 36,7oC
Kulit
: turgor normal
Kepala
: UUB cekung (-), mata
cekung (-), air
mata +/+, mukosa bibir
kering (-)
Thoraks : simetris, retraksi (-)
Pulmo
: vesikuler (+) normal, ronkhi
(-), wheezing (-)
Cor
: HR = 98x/menit, BJ I dan
II normal,
murmur (-), gallop (-)
Abdomen
: datar, lemas, BU (+)
normal,
hepar/lien tidak teraba,
cubitan kulit
perut kembali cepat
Ekstremitas
: akral dingin tidak
ada, CRT<3
A : Diare akut e.c susp. infeksi virus
dengan dehidrasi ringan sedang
(terehidrasi)
P : - IVFD KAEN 3A gtt 7x/m makro
- zinc 20 mg 1x1 tab
- oralit 100cc tiap BAB cair atau
muntah

14-3-2016

S : Keluhan : BAB cair (-) dan muntah (-)

O : Sense : CM; N : 98x/menit RR : 24x/menit T : 36,7oC
Kulit
: turgor normal
Kepala : UUB cekung (-), mata cekung (-), air mata +/+,
mukosa bibir kering (-)
Thoraks : simetris, retraksi (-)
Pulmo : vesikuler (+) normal, ronkhi (-), wheezing (-)
Cor
: HR = 98x/menit, BJ I dan II normal, murmur (-),
gallop (-)
Abdomen : datar, lemas, BU (+) normal, hepar/lien tidak
teraba, cubitan kulit perutkembali cepat
Ekstremitas : akral dingin tidak ada, CRT<3
A : Diare akut e.c susp. infeksi virus dengan dehidrasi ringan
sedang (terehidrasi)
P : - IVFD KAEN 3A gtt 7x/m makro
- zinc 20 mg 1x1 tab
- oralit 100cc tiap BAB cair atau muntah
- Rencana pulang

III. LITERATURE REVIEW

27

Diarrhea
Diarrhea: defecation with
liquid/semisolid feces (more water
content) for >200 grams or >200
ml/24h
WHO definition: watery defecation
>3x/d, with or without mucus or blood
in feces
Acute diarrhea: less than a week, <
4 episodes/month
28

Epidemiology
Mostly in the first 2 years of life
Highest incidence: age 6-11 months
Decline in maternal antibody and childs
low active immunity
Introduction of food possibly
contaminated
Direct contact with fecal material
(animal/human) when child starts
crawling
29

Asymptomatic Infection
Proportion increases after the age of 2
formation of active immunity
During this phase, fecal material contains
infectious pathogens (viral, bacteria, protozoal
cysts)
Role: spread of enteropathogens esp. with low
hygiene and moving one place to another
Seasonal Factor
Tropical areas (eg. Indonesia):
Rotaviral: year-round, increases in dry
season
Bacterial diarrhea: increases in rainy season
30

Risk Factors
No exclusive breastfeeding in the first 4-6
months of life
Inadequate supply of clean water
Fecal material contamination
Lack of sanitation facility
Poor personal and environmental hygiene
Poor food preparation and storage hygiene
Improper weaning
Host factors: malnutrition, immunodeficiency,
decreased gastric acidity, decreased intestinal
motility, morbilli in past 4 weeks, genetic
factor
31

Etiology
Infectious diarrhea types: non-inflammatory and
inflammatory
Non-inflammatory: bacterial enterotoxin production,
villi surface destruction by viral, attachment by
parasites, attachment and/or translocation of
bacteria
Inflammatory: direct bacterial invasion, cytotoxin
production

Non-infectious diarrhea:
Food allergies
Neoplasms
Anatomical defects (microvilli atrophy, malrotation,
Hirschsprung)
Malabsorptions
Food poisoning
Immune deficiency
32

Common Etiology

33

Spread of Infection
Fecal-oral : 4 F = finger, flies, fluid,
field
Food/water contamination by
enteropathogens
Hand contact with patient/contaminated
belongings
Indirectly: through flies

34

Pathophysiology
Osmotic diarrhea:
Material not absorbed (Mg, glucose, sucrose,
lactose, maltose) in colon different osmolarity
between intestinal lumen and blood water
flows into lumen water collection exceeds
colons absorption capacity diarrhea

Secretory diarrhea:
Stimulation by enterotoxin Na+ absorption by
villi disrupted Cl secretion increases water
and electrolyte are passed out as watery stool

Motility disturbances
Inflammation of the colon and small
intestine
35

Clinical Manifestations
GI symptoms: diarrhea, abdominal cramps,
vomiting
Electrolyte and water loss: dehydration,
metabolic acidosis, hypokalemia
Related extraintestinal infection:
vulvovaginitis, urinary tract infection,
endocarditis, osteomyelitis, meningitis,
pneumonia, hepatitis, peritonitis, septic
trombophlebitis
Fever (may be due to inflammatory process
or dehydration)
36

Rotaviral

Shigella

Salmonella

ETEC

EIEC

Cholera

Incubation

17-72 hrs

24-48 hrs

6-72 hrs

6-72 hrs

6-72 hrs

48-72 hrs

Fever

++

++

++

Nausea/vomiting

Often

Seldom

Often

Often

Abdominal pain

Tenesmus

Tenesmus,

Tenesmus, colic

Tenesmus,

Cramp

cramp

cramp

Headache

Duration

5-7 days

>7 days

3-7 days

2-3 days

Varies

3 days

Volume

Medium

Few

Few

A lot

Few

A lot

Frequency

5-10x/d

>10x/d

Often

Often

Often

Continuous

Consistency

Watery

Watery

Semisolid

Watery

Semisolid

Watery

Blood

Sometimes

Smell

Rotten

Foul

Fishy

Color

Yellow-

Red-

Greenish

No change

Red-

Rice water

greenish

greenish

Anorexia

Convulsion Sepsis +
+

Feces:

WBC
Others

greenish
+

Meteorismus

Systemic
infection +

37

Diagnosis
Anamnesis:
Duration, volume of feces
Fecal consistency, color, smell, presence/absence
of mucus and blood
If vomiting is present: volume and frequency
Urination (normal? Decreased? Has not passed
urine in 6-8 hours?)
Food and drinks given during diarrhea
Fever, other accompanying diseases (cough, runny
nose, otitis media, measles)
Medication, oralit administration, administered
drugs
Immunization history
38

 Physical Examination
Body weight, vital signs
Signs of dehydration
Kussmaul respiration: metabolic acidosis
Weak or absent bowel sounds:
hypokalemia
Extremity: CRT (related to dehydration)

39

MMWR Dehydration
Classification

40

WHO Dehydration
Classification

41

Laboratory Investigations
Complete lab workup generally not required
unless unknown underlying cause or other
conditions (sepsis, severe dehydration)
Sometimes needed:
Blood: Complete blood count, serum
electrolyte, blood gases analysis, glucose,
culture, resistance test
Urine: urinalysis, culture, resistance test
Feces: macroscopic (consistency, color,
presence of blood/mucus, smell, froth) and
microscopic (leukocyte, staining)
42

Management
Principles (pillars): rehydration,
nutritional support, medication as
indicated, parent education
Treatment plans: according to WHO
dehydration classification
Plan A: no dehydration
Plan B: some dehydration
Plan C: severe dehydration
43

44

45

46

Zinc Supplementation
WHO/UNICEF:
6 months old: 10 mg/day for 10-14 days
>6 months old: 20 mg/day for 10-14 days

Feeding
Children with diarrhea must still be fed
Breastfed babies: as often as possible; on
demand
Babies, not breastfed: milk at least every 3
hours
Children 4 months old with soft/solid foods:
continue feeding in small but frequent servings
(6x/more)
47

Medications
Antibiotics: generally not required in acute
diarrhea (most are due to Rotaviral self-limited)
If caused by bacteria: according to causative
Causative Agent
Antibiotic of Choice
Alternative
agent
V. cholerae
Shigella

Tetracycline 12,5 mg/kg

Erythromycin 12,5 mg/kg

4x/d for 3 days

4x/d for 3 days

Ciprofloxacin 15 mg/kg

Pivmecillinam 20 mg/kg

2x /d for 3 days

4x/d for 3 days

Ceftriaxone 50-100 mg/kg
1x/d IM for 2-5 days

Amoebiasis

Metronidazole 10 mg/kg
3x/d for 5 days (10 days in severe
cases)

Giardiasis

Metronidazole 5mg/kg
3x /d for 5 days

48

Medications
Antidiarrhea: often used but has no
practical benefit not indicated to
treat acute diarrhea in children
Probiotics and Prebiotics promotes
balance of intestinal microflora

49

Complications
Electrolyte Imbalances:
Hypernatremia
Hyponatremia
Hypokalemia

Fever
Edema/Overhydration
Metabolic Acidosis
Paralytic Ileus
Convulsions
50

Prevention

Proper breastfeeding
Proper preparations and storage of food
Use of sufficient clean water
Makes habit of handwashing with soap after
defecation and before eating
Use of hygienic and clean lavatory by all family
members
Proper stool disposal
Host immunity-related:
Breastfeeding until age 2
Increasing nutritional value of foods and adequate
feeding improves nutritional status
Immunization (morbilli, rotaviral)
51

Prognosis
Most (90%) resolve in <7 days
A few (5%) continue but resolve in
<14 days
5% become persistent diarrhea

52

IV. CASE ANALYSIS

53

Anamnesis
Watery stool
defecation >10x/day
without blood or
mucus and volume:
cup each
defecation and last
for <14 days (1 day)
Mild fever
Often vomitting 4x
cup each vomit

Acute diarrhea
Viral Infection

54

Physical Examination

55

56

Rotaviral

Shigella

Salmonella

ETEC

EIEC

Cholera

Incubation

17-72 hrs

24-48 hrs

6-72 hrs

6-72 hrs

6-72 hrs

48-72 hrs

Fever

++

++

++

Nausea/vomiting

Often

Seldom

Often

Often

Abdominal pain

Tenesmus

Tenesmus,

Tenesmus, colic

Tenesmus,

Cramp

cramp

cramp

Headache

Duration

5-7 days

>7 days

3-7 days

2-3 days

Varies

3 days

Volume

Medium

Few

Few

A lot

Few

A lot

Frequency

5-10x/d

>10x/d

Often

Often

Often

Continuous

Consistency

Watery

Watery

Semisolid

Watery

Semisolid

Watery

Blood

Sometimes

Smell

Rotten

Foul

Fishy

Color

Yellow-

Red-

Greenish

No change

Red-

Rice water

greenish

greenish

Anorexia

Convulsion Sepsis +
+

Feces:

WBC
Others

greenish
+

Meteorismus

Systemic
infection +

57

Management
Rehydration: according to Plan B
Oralit 75cc/kgBW/4hrs rehydrated
oralit 10-20cc/kgBW
Failed oral rehydration attempt:
IVFD Lactated Ringers 75cc/kgBB/4 hrs

Antibiotics: not administered

Zinc supplementation

58

Prognosis
Quo ad vitam et functionam: dubia ad
bonam
Viral infection e.g Rotaviral diarrhea:
self-limited
90% cases resolve in <7 days with
optimal management

59

Thank
you