Download - 2. Diare Dan Dehidrasi
Diarrhea & Dehydration
Prof. Dr. M. Juffrie, SpAK, Ph.D
Quantum of ProblemGreat public health problem in developing
countries II killer disease
High Morbidity & Mortality. 70% deaths due to dehydration.
ORS brought revolution : Greatest invention of century.
5 Millions - 1.5 millions deaths/ annum now. Main focus on Prolonged/ Persistent diarrhea/CD.
Physiological Definition of Diarrhea
Loss of fluid and electrolytes via stools is net result of imbalance between secretory and absorptive processes in small & large intestine. Electrolytes have a critical role in the regulation of water absorption and secretion across the intestine.Watery stools, more than 3 time a day (24 hours) (WHO, 2007)
Walker Smith 2004
Normal Villi
What is not Diarrhea ?
• Stools of an infant– Breast fed– Artificially fed
• Exaggerated gastrocolic reflex• Irritable bowel syndrome (IBS)• Spurious / factitious diarrhea
Age specific incidence for diarrhoea episode per Child per year from 2 reviews of prospective studies in developing areas,1980 - 2000
0
1
2
3
4
5
0-5m 6-11m 1 year 2 years 3 years 4 years
1980-19901990-2000
Number of episodes/person/year
Kosek et al. Bulletin of the WHO 2003; 81:197-204.
2-5 episodes/year
Types of Diarrhea(a) Depending upon duration.
Acute diarrhea 3 - 7 days Prolonged or Indeterminate 8 - 14 days
Persistent diarrhea > 14 days (b) Depending upon characteristics of stools. Watery diarrhea --- Secretory & Osmotic
Bloody diarrhea --- Blood & Mucus (Dysentery)(c) Severity of diarrhea
Diarrhea with severe malnutrition Diarrhea with HIV infection
Diarrhea with the other immune deficient states.
Pathogenesis
• Absorption disorder• Secretory disorder• Osmotic disorder
Overview ofGI Processes
Food
Secretion
Digestion
Absorption
Blood Vessels
Motility
Na+
Cl -
1. Active2. Change H+3. Change Cl-4. Glucose
EnterocytecAMP
Osmotic
1
2
3
Common Causes of Acute Common Causes of Acute DiarrhoeaDiarrhoea
• Infection – highly contagiousViral gastroenteritis (“stomach flu”)
Rotavirus
Usually cause explosive, watery diarrhoea
Typically last only 48-72hrs
Usually no blood and pus in stool
Bacterial enterocolitis Sign of inflammation – blood or pus in
stool, fever
E. Coli bacteria•Contaminated food or
water•Usually affect small kids
Bacterial enterocolitis Sign of inflammation – blood or pus in
stool, fever
Salmonella enteritidis bact
•In contaminated raw or undercooked chicken and
eggs
Bacterial enterocolitis Sign of inflammation – blood or pus in
stool, fever
Shigella bacteria Campylobacter
bacteria
Cryptosporidium• in contaminated
water – can survive chlorination
Parasites
Giardia lamblia• in contaminated
water •Usually not associated
with inflammation
Common Causes of Acute Common Causes of Acute Diarrhoea – cont.Diarrhoea – cont.
• Food PoisoningBrief illness cause by toxins produced by
bacteriaCause abdominal pain, vomittingCause SI secrete high amnt of water –
diarrhoeaSome bacteria produce toxins in food
before intake or in intestine after food is eaten
Symptoms usually appear within sev. hours
• Food Poisoning
Staphylococcus aureus• Produces toxins in food before it is eaten•Usually food contaminated left unrefrigerated overnight
• Food Poisoning
Clostridium perfringens• Multiplies in food•Produces toxins in SI after contaminated food is eaten
Common Causes of Acute Common Causes of Acute Diarrhoea – cont.Diarrhoea – cont.• Traveller’s Diarrhoea• Drugs / medications
DIARE
Diare akut keluarnya BAB 1x/ lebih yg berbentuk cair dlm 1 hari/ lebih & berlangsung < 14 hari (Cohen MB)
Diare episode keluarnya tinja cair sebanyak 3x/ lebih, atau lebih dari 1x keluarnya tinja cair yg berlendir atau berdarah dalam 1 hari (Shahid NS)
Faktor2 yang mempengaruhi kejadian diare: Lingkungan kebersihan lingkungan & perorangan Gizi pemberian makanan Kependudukan insiden diare pd daerah kota yg padat/
kumuh lebih Pendidikan pengetahuan ibu Perilaku masyarakat kebiasaan2 Sosial ekonomi
ETIOLOGI DIARE
1. Faktor infeksia. Infeksi enteral infeksi pada GIT (penyebab utama)
Bakteri : Vibrio cholerae, Salmonella spp, E. coli dllVirus : Rotavirus (40-60%), Coronavirus, Calcivirus dllParasit: Cacing (Ascaris, Oxyuris,dll), Protozoa (Entamoba histolica,Giardia Lambia, dll) Jamur (Candida Albicans)
b. Infeksi parenteral infeksi di luar GIT (OMA, BP, Ensefalitis,dll)
2. Faktor malabsorbsi : KH, Lemak, P3. Faktor makanan : basi/ beracun, alergi4. Faktor psikologis : takut dan cemas
PATOFISIOLOGI
VIRUS masuk enterosit (sel epitel usus halus) infeksi & kerusakan fili usus halus
Enterosit rusak diganti oleh enterosit baru (kuboid/ sel epitel gepeng yg blm matang) fungsi blm baikFili usus atropi tdk dpt mengabsorbsi makanan & cairan dgn baik
Tek Koloid Osmotik motilitas DIARE
BAKTERI NON INFASIF (Vibrio cholerae, E. coli patogen) masuk lambung duodenum berkembang biak mengeluarkan enzim mucinase (mencairkan lap lendir) bakteri masuk ke membran mengeluarkan subunit A & B mengeluarkan (cAMP) merangsang sekresi cairan usus, menghambat absobsi tampa menimbulkan kerusakan sel epitel tersebut volume usus dinding usus teregang DIARE
BAKTERI INFASIF (Salmonella spp, Shigella spp, E. coli infasif, Champylobacter) prinsip perjalanan hampir sama, tetapi bakteri ini dapat menginvasi sel mukosa usus halus reaksi sistemik (demam, kram perut) dan dapat sampai terdapat darah
Toksin Shigella masuk ke serabut saraf otak kejang
BERDASARKAN PATOFISIOLOGIDiare osmotik : diare akibat adanya bahan yang tidak dapat diabsorbsi oleh lumen usus hiperosmoler hiperperistalsisDiare sekretorik : terjadi akibat stimulasi primer dari enterotoksin atau oleh neoplasmaDiare akibat gangguan motilitas usus : gangguan pada kontrol otonomik
Treatment of Acute Diarrhea
• Oral Rehydration Therapy• Dietary therapy• Zinc therapy• Antimicrobials • Education
Oral Rehydration Therapy (ORT)
Oral Rehydration Solution (ORS)
WHO - ORS = Physiological Basis
Other Fluids & Liquid Diets
Home Available FluidsRecommended• Salt sugar solution• Lemon water(Sikanjabi)• Rice water / Kanjee• Soups • Dal water• Lassi• Coconut water• Plain water
Not recommended• Simple sugar solution• Glucose solution• Carbonated soft
drinks• Fruit juices-tinned or
fresh• Fluids for athletes• Gelatin desserts• Tea/Coffee
Composition of WHO High & Low Osmolality ORS
------------------------------------------------------------------------------------------------------------------------------------Ingredients / L High Osmolality Low Osmolality Components / Litre_________
Sodium Chloride 3.5 2.6 Na 90 75Sodium Citrate 2.9 2.9 Citrate 1010
or Sodium Carbonate 2.5 2.5 H CO3 30 30
Potassium Chloride 1.5 1.5 K 2020Glucose 20 13.5 Glucose 111 75
Osmolality 311 245-------------------------------------------------------------------------------------------------------------------------------------
Limitations of WHO High Osm-ORS Does not lower volume, frequency and duration of
diarrhea Induces vomiting due to taste, acceptability poor
Enhances volume, purge rate & duration of diarrhea due to high osmolality
More chances of dehydration – Dehydrating fluid So more oftenly IV fluids required
Hypernatremia Good to correct deficit fluids but not good for
maintenance therapy
Need of Low Osm-ORS
• Does lower volume, frequency & duration • Equally effective in cholera, toxin related & RV
diarrhea : Deficit & maintenance therapy• No need of IV fluids• Good for all ages infancy to adulthood• Asymptomatic hyponatremia.
Role of Diet in Acute Diarrhea Dietary therapy
• Key role in treatment of diarrhea• Gained great importance in recent years.• Early refeeding during or after rehydration
mandatory• Delayed feeding even by one day-slow recovery• Fasting deterimental for outcome
Advantages of Dietary Therapy
• Maintains nutrition, helps in absorption• Faster recovery• Take care of infection and avoids malnutrition• Prevents prolongation of diarrhea• Corrects malnutrition in mal-nourished
children.• Extra diet in convalescence / on recovery
What are the Diets to be Continued or Given ?
• Age appropriate diets• Breast feeding : Aseptic paint.• Artificially fed – milk• Whatever child taking earlier• Rice, khichri, pulses/ curd/yogurt• Small frequent aliquots – Spoon & Katori
Foods to be Avoided
• Fat rich• Fruits and fruit juices• Junk foods• Spicy foods• Carbonated fluids• Sugar & glucose rich foods
Diarrhea
ORSContinue breast
feeding
Cereal supplementsMalnutrition(Marasmus)
Mucosal injury(Malabsorption)
“TREAT THE DIARRHEA WITH REGULAR DIET”
PD
Role of Zinc in Acute Diarrhea
Acute as well as persistent diarrheaTremendous loss in stools.Absorption of Zinc intact
Deficiency during diarrhea results into lowering of Cell division & maturation.Tissue growth & repair.Maturation of enterocytes.Brush border enzymes.Water & electrolyte absorption. Immune functions.
Zinc Supplementation in AD
Responsible for > 200 enzymes in body. Improves the immune function & absorption. Supplementation in AD and PD helpful in 20-30%
reduction in diarrhea. 42% lower rate of treatment failure or death.
Dosageso Infants 10mg daily x 2 weeks.o Older children 20mg daily x 2 weeks.o Persistent diarrhea x 4 weeks
Acta Pediatr 2001Am J Clin Nutr 2000
ASCODD 2001
Antimicrobial Therapy in AD
No proof that antibiotics effective in reducing the duration of diarrhea
Cochrane review of 12 trials – no advantage rather adverse effects more in acute watery diarrhea.
Why Antibiotics are not Required in AD?
Lack of knowledge of sensitivity of drug
against causative agent Risk of development of resistant bacteria Risk of adverse reactions (AAD) Cost of treatment
Indications for Antimicrobials ----------------------------------------------------------------------------------------------------Micro
- organisms Drugs----------------------------------------------------------------------------------------------------
Bacteria - Shigella Nalidixic acid, Norfloxaclin Ciprofloxacin
Ofloxacin, Cefotaxime, Ceftriaxone- Salmonella typhi Ciprofloxacin, Ofloxacin
- Vibrio cholera Cotrimoxazole, Tetracycline,Ciprofloxacin, - Compylobacter jejuni Nalidixic acid, Norfloxacin, Furazolidine
- EPEC (PD) Furazolidine, Norfloxacin, Cotrimoxazole Protozoa
- Giardia lamblia } Mitronidazole, - Entameba histolytica } Tinidazole, Nitazoxanide, Furazolidine
-Cryptosporidium parvum Pramomycin, Nitazoxanide----------------------------------------------------------------------------------------------------
Other Special Indications of Antibiotics. Severity of symptoms Host related risk factors
* Severely sick child * Neonatal age* Septicemia * Malnutrition* Neurological involvement * HIV Infection
* Septic shock State * Other immune deficiency* Invasive diarrhea
Socio- environmental indications* Cholera
* Nosocomial infection* At risk contacts.
* Epidemics
Probiotics
• Duration of acute diarrhea decreases by one day in meta-analysis
• Saccharomyces boulardii : Strong benefit in AAD • Shown in meta-analysis of seven studies
Aliment Pharmacol Ther 2002
Diet in Indeterminate Diarrhea(8-14 days)
• Breast feeds continue • Diet A : Low lactose diet• Diet B : Lactose free diet, if no response to
Diet A.• Diet C : Monosaccharide based diet if no
response to Diet B.
Dietary Algorithm for Treatment Of PD Stabilize
Success Start Diet A
Treatment failure (Screen for infections)
Start Diet B
Discharge Success Failure (Screen for infection) Appropriate Discharge Diet Cdiet 7-14 days
Diet A after 10 days Success Failure
After 7-14 days Gradually Parenteralnormal diet Diet B then nutrition
Diet A & normal Bull WHO 1996
Traditional Practices to be Avoided
• Antimotility & antispasmodic drugs• Stool binding agents• Enzyme preparations & steroids• Antimicrobial agents in combination• Bottle feeding• IV fluids to every case • Starvation-Nothing like bowel rest• These will hamper natural clearance, lower
immunity, promote growth of unusual organisms & PEM
Practices to be Adopted
• Breast feeding: Aseptic paint for GIT
• Cereal supplementation
• Spoon & katori/ directly from pot
• Judicious use of antimicrobials
• Proper hygiene & sanitation
• Rotavirus vaccine
When to refer to higher center
• Duration of diarrhea more than 7 days• Fast deteriorating condition • No response to usual therapy• Associated complications• Severely malnourished child• HIV positive
… to conclude
Low Osm-ORS.. quite effective
Zinc therapy ..important component
Treat diarrhea with regular diet
Limited use of antibiotics : Dysentery
DEHYDRATION
OBJECTIVES
At the end of this lecture you will able to know the followings:
*What is dehydration?*What are the causes of dehydration?*The clinical manifestaions of dehydration.*The investigations required.*Management of dehydration.
Fluid and electrolytes requirementsWater: : Constitutes about 70% of infant's body weight as
compared to 60% in adults.
Most of the water is found within the cells of the body (intracellular space). The rest is found in the extracellular space, which consists of the blood vessels (intravascular space) and the spaces between cells (interstitial space).
Total body water = intracellular space + intravascular space + interstitial space
DEHYDRATION
Average daily requirement of water (ml/kg): -First year: 130 – 150. -2 to 4 years: 100 – 130. -4 to 10 years: 70 – 100.-10 to 18 years: 50- 70.
Dietary Reference Intakes (DRI) of electrolytes:Sodium (mg/day): 120 in the 1st 6months, 200 in the age 7-12 months, 225 in the age 1-3 years, and 300 from 4-8 years of age.
Potassium (mg/day): 500 in the 1st 6 months, 700 from7-12 months, 1000 from1-3 years, and 1400 from 4-8 years of age.
What is dehydration? Dehydration occurs when the amount of water leaving the body is
greater than the amount being taken in. We lose water routinely when:• We breathe and humidified air leaves the body;• We sweat to cool the body; and, • We urinate or have a bowel movement to get rid the body waste
products. Hyponatremia ; Is a condition in which the body's stores of sodium are too low, and
this condition can result from drinking extreme amounts of water. Hyponatremia can lead to confusion, lethargy, agitation, seizures,
and in extreme cases, even death. Early symptoms are nonspecific may include disorientation, nausea,
or muscle cramps. The symptoms of hyponatremia may also mimic those of dehydration, so athletes experiencing these symptoms drinking more water that result in further worsening the condition.
CONSERVATION OF BODY WATER• In a normal day, a person has to drink a significant amount of water
to replace the routine losses. • If intravascular water is lost, the body can compensate by shifting
water from cells into the blood vessels, but this is a very short-term solution. Signs and symptoms of dehydration will occur quickly if the water is not replenished.
• The thirst mechanism signals the body to drink water when the body is dry. As well, hormones like anti-diuretic hormone (ADH) work within the kidney to limit the amount of water lost in the urine.
• The electrolytes in our body include sodium, potassium, chloride, calcium and phosphate, but sodium is the substance of most concern when replacing fluids lost through exercising.
Hypernatremic dehydration• Dehydration,characterized by increased concentrations of sodium
and chloride in the extracellular fluid, it results from diarrhea in infants.
• The occurance of the hypernatremia and hyperchloremia lies in the relatively greater expenditure of water than electrolyte via skin, lungs, stool and urine. The water deficit in these infants is primarily intracellular.
• The majority of infants with this type of dehydration show varying
degrees of depression of central nervous system varying from
lethargy to coma. Convulsions are frequently observed.
• Dilute solutions of electrolyte are indicated in rehydration. Rapid adjustment, however, appears to accentuate the CNS disturbance. Rehydration is best carried out slowly over a 2- to 3-day period.
What causes dehydration? • Diarrhea: is the most common reason for loss of excess water.
Worldwide, more than four million children die each year because of dehydration from diarrhea. -Vomiting: can also be a cause of fluid loss .
• Sweat: The body can lose significant amounts of water when it tries to cool itself by sweating whatever the cause of hotness of the body such as intense exercising in a hot environment, or presence of fever .
• Diabetes: In people with diabetes, elevated blood sugar levels cause sugar to spill into the urine and water then follows. For this reason, frequent urination and excessive thirst are among the symptoms of diabetes.
• Chronic renal failure: dehydration occurs due to polyuria.• Burns: dehydration occur because water moves into the damaged skin.
Other inflammatory diseases of the skin are also associated with fluid loss.
• Inability to drink fluids: The inability to drink adequately is the other potential cause of dehydration.
Clinical picture:Examination. - Body weight. - Temperature.- Signs of
dehydration. - Systemic examination.General manifestations:- Dry skin and mucous membrane.- Decrease all body secretions (urine, sweats,
tears, saliva) - Depressed fontanel, sunken eyes, thirst,
irritability, lately hypotension, acidosis and coma.
DEGREES OF DEHYDRATION:Degree of dehydration Plan A:
No dehydrationPlan B: Some dehydration
Plan C: Severe dehydration
General condition Calm, alert Restless irritable
Lethargic, unconscious
Eye manifestation Normal Sunken Sunken
Ability to drink Normal Thirsty, eager to drink
Poor
Skin pinch Goes back quickly
Slowly Very slowly
IMCI MANAGEMENT: Integrated management of childhood illness ( WHO)
* Plan A: Give fluid and food to treat diarrhea at home • If child is 2 years or older and there is Cholera in your area, give
antibiotic for cholera.• Advise mother when to return immediately• Follow-up in 5 days if not improving.* Plan B: Give fluid and food for some dehydration.• If child has also a severe classification:• Refer URGENTLY to hospital with mother giving frequent sips of
ORS on the way• Advise the mother to continue breast-feeding• If child is 2 years or older and there is Cholera in your area, give
antibiotic for cholera.• Advise mother when to return immediately• Follow-up in 5 days if not improving.
IMCI MANAGEMENT: Integrated management of childhood illness ( WHO)
* Plan C: - Give fluids for severe dehydration or If child has also another severe classification:
• Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way
• Advise the mother to continue breast-feeding• If child is 2 years or older and there is Cholera in your area,
give antibiotic for cholera.• 100 cc/kg/bw: 30 cc/kg in first ½ hour, 70 cc/kg in second
21/2 hour for child > 1 year; and in first 1 hour and 5 hours further for child < 1 year (WHO 2007)
MANAGEMENT OF DEHYDRATION-Replace Phase 1: Acute Resuscitation :
– Give Lactated Ringer OR Normal Saline at 10-20 ml/kg IV over 30-60 minutes.
– May repeat bolus until circulation stable -Calculate 24 hour maintenance requirements
– Formula: • First 10 kg: (100 cc/kg/24 hours) • Second 10 kg: (50 cc/kg/24 hours) • Remainder: (20 cc/kg/24 hours)
Example: 35 Kilogram Child • Daily: 1000 cc + 500 cc + 300 cc = 1800 cc/day
-Calculate Deficit:– Mild Dehydration: (40 ml/kg) – Moderate Dehydration: (80 ml/kg) – Severe Dehydration: (120 ml/kg)
MANAGEMENT Continue ----------Calculate remaining deficit:
– Substract fluid resuscitation given in Phase 1 -Calculate Replacement over 24 hours:
– First 8 hours: 50% Deficit + Maintenance – Next 16 hours: 50% Deficit + Maintenance
• Determine Serum Sodium Concentration – Hypertonic Dehydration (Serum Sodium > 150) – Isotonic Dehydration – Hypotonic Dehydration (Serum Sodium < 130)
• Add Potassium to Intravenous Fluids after patient voids urine – Potassium source
• Potassium Chloride • Potassium Acetate for Metabolic Acidosis
– Potassium dosing • Weight <10 kilograms: 10 meq KCl /liter glucose • Weight >10 Kilograms: 20 meq KCl /liter glucose