ACUTE DIARRHEA

DR. Dr. A. A. Gede Budhitresna, Sp.PD, FINASIM

Lecture Block Gastroenterology Faculty of Medicine Warmadewa University 2011

Acute Diarrhea
Acute diarrhea is a disease characterized by changes in the character and frequency of stool. It can be defined as the passage of a greater number of stools of decreased form from the normal lasting less than 14 days. Generally associated with other signs or symptoms including 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 fecal urgency. (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.

Patofisiologi
Diare Osmotik: bahan makanan yang tidak dapat diabsorpsi sehingga terjadi hiperosmolaritas Diare Sekretorik: terjadi gangguan transpor elektroklit baik absorpsi yang berkurang atau sekresi yang meningkat melalui dinding usus Diare Eksudatif: akibat inflamasi menimbulkan kerusakan 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

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, obatobatan dan toksisn, sindroma usus iritabel, alergi makanan, defisiensi laktosa

Diagnosis
History Physical examination Diagnostic: Stool examination (mucus, blood, leukocytes, stool cluture), Blood examination (ureum, creatinine, blood gas analyse), colonoscopy/sigmoidoscopy

Diagnosis
Complete blood count can be obtained to look for anemia, hemoconcentration, or an abnormal white blood cell count. (4) Measurements of serum electrolyte concentrations and blood urea nitrogen and serum creatinine levels can be used to determine the extent of fluid and electrolyte depletion and its effect on renal function. (4)
(4) Sleisenger and Fordtrans Gastrointestinal and Liver Disease. 8th edition. 2006. Feldman, Mark MD. Volume II. p169.

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.

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

Acute Diarrhea
Initial rehydration
The most common risk with diarrheal illnesses is dehydration. The critical initial treatment must include rehydration, which can be accomplished with an oral glucose or starch-containing electrolyte solution in the vast majority of cases. Although many patients with mild diarrhea can prevent dehydration by ingesting extra fluids (such as clear juices and soups), more severe diarrhea, postural lightheadedness, and reduced urination signify the need for more rehydration fluids. (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.

Dehydration
Mild (3-5%)
Normal or increased pulse Decreased urine output Thirsty Normal physical exam

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

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

Physical Examinations

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

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/hari
Dalam satu jam pertama berikan 50% defisit cairan, kemudian 3 jam berikutnya diberikan sisa defisit, selanjutnya diberikan sesuai kehilangan cairan melalui feses

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

(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

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 a reduction 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].

Dont Forget It

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 supporting data are limited. (3) Clear liquids are not recommended as a substitute for oral rehydration solutions (ORS) or regular diets in the prevention or therapy of dehydration. (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 5 years. Cincinnati (OH): Cincinnati Childrens Hospital Medical Center; 2006 May. 15 p. [50 references].

Acute Diarrhea
Oral Feeding Following Rehydration > It is recommended that giving the patients usual diet be started at the earliest opportunity after an adequate degree of rehydration is achieved. (5) On-going IV or NG Fluids following Rehydration > It is recommended that maintenance IV fluids or NG ORS be given:
when unable to replace the estimated fluid deficit and keep up with the on-going losses using oral feedings alone, and/or to severely 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 months through 5 years. Cincinnati (OH): Cincinnati Childrens Hospital Medical Center; 2006 May. 15 p. [50 references].

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

Acute Diarrhea
When to admit?
Unstable Severely dehydrated Bloody diarrhea Persistent Vomiting No improvement after initial hydration or symptoms exacerbate/ overall condition gets worse
(6) World Gastroenterology Organisation (WGO). WGO practice guideline: acute diarrhea. Munich, Germany: World Gastroenterology Organisation (WGO); 2008 Mar.

(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

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.

Immunocompromised patients
If 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.

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)

Patient Education
Many diarrheal diseases can be prevented by following simple rules of personal hygiene and safe food preparation. Hand-washing with soap is an effective step in preventing spread of illness and should be emphasized for caregivers of persons with diarrheal illnesses. As noted above, human feces must always be considered potentially hazardous, whether or not diarrhea or potential pathogens have been identified. (3)
(3) Practice Guidelines for the Management of Infectious Diarrhea. Infectious diseases Society of America. Clinical Infectious Diseases 2001; 32:33150.

Patient Education
Consequently, microbial studies should not be needed to justify careful attention to hygiene. Select populations may require additional education about food safety, and health care providers can play an important role in providing this information. (3)
(3) Practice Guidelines for the Management of Infectious Diarrhea. Infectious diseases Society of America. Clinical Infectious Diseases 2001; 32:33150.

APPROACH TO A PATIENT WITH CHRONIC DIARRHEA

CLASSIFICATION
Acute diarrhea Chronic diarrhea
4 weeks cut off point

CAUSES
Chronic Fatty Diarrhea malabsorption syndromes Chronic Inflammatory Diarrhea Chronic Watery Diarrhea
Secretory Diarrhea Osmotic Diarrhea Drug-Induced Diarrhea

Infectiuos diarrhea Functional diarrhea :Irritable Bowl Disease

Infectious Diarrhea Endocrine diarrhea Functional Diarrhea (diagnosis of exclusion)

Irritable Bowel Syndrome

HISTORY

AGE
Young patients
Inflammatory Bowel Disease Tuberculosis Functional bowel disorder (Irritable bowel) Colon Cancer Diverticulitis

Older patients

DIARRHEA PATTERN
Diarrhea alternates with Constipation
Colon Cancer Functional bowel disorder (Irritable bowel)

Intermittent Diarrhea

Diverticulitis Malabsorption Functional bowl disorders

Inflammatory Bowl Disease

Persistent Diarrhea

SMALL BOWEL/LARGE BOWEL

Small intestine or proximal colon involved
Large stool Diarrhea Abdominal cramping persists after Defecation

Distal colon involved

Small stool Diarrhea Abdominal cramping relieved by Defecation

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 Inflammatory Bowel Disease

WEIGHT LOSS
Despite normal appetite
Hyperthyroidism Malabsorption

Associated with fever

Inflammatory Bowel Disease

Weight loss prior to Diarrhea onset

Pancreatic Cancer Tuberculosis Diabetes Mellitus Hyperthyroidism Malabsorption

STOOL CHARACTERISTICS
Water: Chronic Watery Diarrhea Blood, pus or mucus: Chronic Inflammatory Diarrhea Foul, bulky, greasy stools: Chronic Fatty Diarrhea

MEDICATION AND DIETARY INTAKE

Drug induced diarrhea Food borne illness waterborne illness High fructose corn syrup Excessive sorbitol or mannitol Excessive coffee or other caffeine

TRAVEL
Travelers diarrhea Infectious diarrhea

ASSOCIATED SYMPTOMS
Abdominal pain Alternating constipation Tenesmus Unintentional wt. loss Fever

PHYSICAL EXAMINATION

GPE
General appearance and mental status Vital signs Body weight Orthostasis- volume depletion,autonomic dysfunction

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, laxative abuse, malignancy)

SKIN LESIONS
dermatitis herpetiformis (celiac disease) erythema nodosum and pyoderma gangrenosum (IBD) hyperpigmentation (Addison's disease) flushing (carcinoid syndrome) migratory necrotizing erythema (glucagonoma).

ABDOMINAL EXAMINATION
Surgical scars abdominal tenderness Masses Hepatosplenomegaly Borborygmus on auscultation
malabsorption bacterial overgrowth obstruction, or rapid intestinal transit.

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.

INVESTIGATIONS

Always Remember

BLOOD TESTS
CBC TSH Serum electrolytes Serum albumin

STOOL EVALUATION
Stool pH (<6 in carbohydrate malabsorption ) Fecal electrolytes (Fecal sodium and osmolar gap)
Differentiates chronic watery diarrhea category

Fecal occult blood test

Fecal leukocytes

Fecal fat (abnormal if >14 grams/24 hours) Stool ova and parasites (2-3 samples) Giardia lamblia antigen
Indicated for diarrhea >7 days and >10 stools/day

Clostridium difficle toxin

Indicated if recent antibiotics or hospitalizatio

Consider testing stools for laxative abuse

ENDOSCOPY
PROCTOSIGMOIDOSCOPY

TREATMENT

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

SPECIFIC THERAPIES
Clonidine
Diabetic diarrhea moderate and severe diarrhea-predominant IBS

Somatostatin
refractory diarrhea
AIDS, post chemotherapy, and hormone secreting tumors.

Antimikrobial- empirik fluroquinolon

Think About

Any questions?