PROBLEM 3- GASTROINTESTINAL SYSTEM Made by:

PLENARY (TUE, 6 SEPT 2016) Group 11-GIT System

GROUP 11- GASTROINTESTINAL SYSTEM
•Tutor : dr. Sari
•Leader : Agustina Cynthia Cesari Supit (405140066)
•Secretary : Ivany Lestari Goutama (405140070)
•Writer : David William (405140205)
•Members :
1. Arianto Salim (405140012) 6. Siti Suryani (405140141)
2. Nailah Ramlah (405140069) 7. Katherine Chia (405140145)
3. Chyntia Winata (405140079) 8. Egie Madgani Ainul Kamil (405140153)
4. Kent Harlendo (405140091) 9. Callista Harlim (405140249)
5. Richard Anderson (405140131)
 PROBLEM 3
A 12-year-old girl presented to emergency room with one-day history of bloody,
mucousy diarrhea. This can happen as much as five times a day. She also complains of
abdominal cramp, nausea, vomiting, fever, feeling irritable, and decrease in appetite
for the past two days. Her mother said that she likes to eat street foods and half-
boiled egg. The pipes watering to their house were under renovation. On examination,
patient looked lethargic. Temperature 39⁰C. Pulse 100bpm. Oral mucosa was dry with
coated tounge. Inspection of abdomen showed a distended abdomen.
Her brother, a 7-month-old boy, experienced frequent watery diarrhea since he
started drink formula milk a month ago, without vomiting or fever.
What can you learn from the problem?

3
 STEP 1. UNFAMILIAR TERMS
1. Lethargic = keadaan yang capek, lesu
2. Coated tounge= lidah berselaput
3. Distended abdomen = buncit

4
 STEP 2. FORMULATE PROBLEMS
a) Anak perempuan: diare berlendir & berdarah
 kram abdomen, mual, muntah, demam, penurunan nafsu makan (2
hari yang lalu)
 pemeriksaan disik= letargi, febris, HR= 100 bpm (N), coated
tounge, distended abdomen
b) Anak laki-laki: diare cair, tanpa muntah & demam  setelah minum
susu formula (1 bulan yang lalu)

5
 STEP 2. FORMULATE PROBLEMS
1. Apa hubungan makan telur setengah matang dan jajan sembarangan
dengan keluhan anak tersebut?
2. Apa yang menyebabkan lidah berselaput?
3. Apa hubungan pipa yang sedang direnovasi dengan gejala anak
tersebut?
4. Apa yang menyebabkan diare berlendir dan berdarah?
5. Apa yang menyebabkan distensi abdomen pada hasil pemeriksaan?
6. Kenapa diare disertai demam dan muntah?
7. Apa perbedaan diare berlendir dan berdarah dengan diare cair?
8. Apa bahaya diare cair dan diare berlendir berdarah bila dibiarkan?
9. Apa hubungan susu formula dengan diare cair?
6
 STEP 3. BRAINSTORMING
1. Jajan sembarangan  kurang higienitas, telur setengah matang  bakterinya tidak mati.
2. Terjadinya kolonisasi bakteri & jamur.
3. Kurangnya higienitas dan kualitas air karena terkontaminasi: bakteri ( E.coli 0157:H7, Shigella);
parasit lain (amoeba, STH: Ascaris lumbricoides, Trichuris trichiura, Strongyloides stercoralis, Oxyuris
vermicularis, Ancylostoma duodenale, Necator americanus).
4. Diare berdarah  adanya luka terbuka; diare berlendir mukosa usus terkikis  sel goblet
rusak=> etiologi :Shigella, Amoeba; diare cair  air tidak terabsorpsi, tubuh mendeteksi ancaman
infeksi sehingga berupaya mengeluarkan cairan.
5. Perforasi akibat infeksi abdomen dikarenakan luka terbuka pada mukosa dibiarkan sehingga usus
menipis permukaannya  distensi abdomen.
6. TNF-α  hipotalamus (pusat pengatur suhu tubuh) demam (akibat inflamasi yang disebabkan
infeksi parasit, virus, bakteri, dan jamur)
7. sama dengan no. 4.
8. Diare cair jika dibiarkan dapat menyebabkan cairan tubuh yang dikeluarkan  dehidrasi; diare
berlendir dan berdarah bila dibiarkan  anemia.
9. Intoleransi laktosa, infeksi V.cholerae, infeksi Rotavirus
7
STEP 4. MIND-MAPPING
Pencegahan + KIE

Pemeriksaan Tatalaksana Farmako

Komplikasi & Non-Farmako
& prognosis
Infeksi
Etiologi
Tanda & gejala Diare Non-infeksi

Klasifikasi patofisiologi
Mekanisme
defekasi

8
 STEP 5. LEARNING OBJECTIVES
1. Explain Anatomy of Lower GIT
2. Explain Histology of Lower GIT
3. Explain Biochemistry of Lower GIT
4. Explain Physiology of Lower GIT
5. Explain the definition and classification of diarrhea
6. Explain the etiology of diarrhea
7. Explain the pathophysiology of diarrhea
8. Explain the sign and symptoms of diarrhea
9. Explain the physical and supporting examination for diarrhea
10.Explain the pharmacological and non-pharmacological treatment for diarrhea
(+ PRESCRIPTION)
11.Explain the prevention and education for diarrhea
12.Explain the complication and prognosis of diarrhea
9
LO 1. ANATOMY OF LOWER GIT

10
Source: Moore KL. Clinically oriented anatomy. 5th Ed. 2005. pg 386-399
SMALL INTESTINE

11
Source: Moore KL. Clinically oriented anatomy. 5th Ed. 2005. pg 386-399
ARTERIAL SUPPLY AND MESENTERIES OF INTESTINES

Source: Moore KL. Clinically oriented anatomy. 5th Ed. 2005. pg 386-399

12
LARGE INTESTINE

Source: Moore KL. Clinically oriented anatomy. 5th Ed. 2005. pg 386-399 13
CECUM & APPENDIX
Cecum

-. Has no mesentery
-. Lies in the iliac fossa inferior
-. If distended with feces or gas  palpable
-. Ileocolic artery

Appendix

-. Position: retrocecal
-. Has short triangular mesentery 
mesoappendix
-. Appendicular artery

Source: Moore KL. Clinically oriented anatomy. 5th Ed. 2005. pg 386-399
ARTERIAL SUPPLY TO THE INTESTINES

Source: Moore KL. Clinically oriented anatomy. 5th Ed. 2005. pg 386-399 15
 LO 2. HISTOLOGY OF LOWER GIT
ABSORPTIVE SURFACE OF SMALL INTESTINE

17
Source: Mescher AL. Juncqueira’s Basic histology text & atlas. 13th Ed. pg.462-482
PANETH CELL
• located in the basal portion of the
intestinal crypts below the stem cells
• are exocrine cells with large,
eosinophilic secretory granules in their
apical cytoplasm
• produce two chemicals that thwart bacteria:
1. lysozyme, the bacterial-lysing enzyme
also found in saliva; and
2. defensins, small proteins with
antimicrobial powers

18
Source: Mescher AL. Juncqueira’s Basic histology text & atlas. 13th Ed. pg.462-482
 GOBLET CELLS
• produce glycoprotein mucins that are
hydrated and cross-linked to form mucus,
whose main function is to protect and
lubricate the lining of the intestine.

19
Source: Mescher AL. Juncqueira’s Basic histology text & atlas. 13th Ed. pg.462-482
 Jejunum
Jejunum •This is very similar to the duodenum
except Brunner’s glands are absent
•Extensive villi are present as are
the crypts of crypts of Lieberkuhn
•The pilcae cicularis are permanent
folds in the intestinal mucosa
•There are 2 layers of smooth
muscle: longitudinal and circular
•Mucosa consists of simple columnar
epithelium with goblet cells.

Source: Mescher AL. Juncqueira’s Basic histology text & atlas. 13th Ed. pg.462-482
Ileum
Ileum

•This is very similar to the duodenum except Brunner’s glands are absent
•The villi are present as are the crypts of Lieberkuhn
•The 2 layers of smooth muscle (TM) and the submocusa (SM)
•Contains lymphatic nodules called Peyer’s patches that are found in the
mucosa
Source: Mescher AL. Juncqueira’s Basic histology text & atlas. 13th Ed. pg.462-482
Source: Mescher AL. Juncqueira’s Basic histology text & atlas. 13th Ed. pg.462-482
WALL OF THE LARGE INTESTINE

23
Source: Mescher AL. Juncqueira’s Basic histology text & atlas. 13th Ed. pg.462-482
Colon
Colon

Source: Mescher AL. Juncqueira’s Basic histology text & atlas. 13th Ed. pg.462-482
Appendix
Appendix

•Epithelium lining, with goblet cells and underlying submucosa and

smooth muscle
•It also contains lymphatic nodules and other diffuse lymphatic tissue.

Source: Mescher AL. Juncqueira’s Basic histology text & atlas. 13th Ed. pg.462-482
The distal end of the GI tract is the anal canal, 3-4 cm long.
At the rectoanal junction the simple columnar mucosal lining of the
rectum is replaced by stratified squamous epithelium

Stratified squamous epithelium

Simple columnar epithelium

Source: Mescher AL. Juncqueira’s Basic histology text & atlas. 13th Ed. pg.462-482
LO 4. BIOCHEMISTRY OF UPPER GIT
Food is passed down the esophagus into the stomach
by muscular contractions= peristalsis.
The small intestine: duodenum, jejunum, and ileum.
The large intestine: caecum, colon, and rectum, where
faeces are finally passed through the anus.
Two major absorption processes:
1. Absorption of dietary water, minerals, and digestion
products, required for the maintainance of body
structure and function occurs mainly in the jejunum.
2. Conservation of water, minerals, and cofactors secreted
during thedigestive processes maintain body fluid or
physiological homeostasis.

The major function of large intestine= absorption of

fluid and salts, and the storage of faeces until
voiding.
27
Source: Ahmed N.Clinical Biochemistry.2011: pg.481-491
LO 3. BIOCHEMISTRY OF LOWER GIT

Source: Sherwood, 7th Edition

 29
Source: Ahmed N.Clinical Biochemistry.2011: pg.481-491
CARBOHYDRATE DIGESTION

Source: Sherwood, 7th Edition

CARBOHYDRATE ABSORPTION

Source: Sherwood, 7th Edition

PROTEIN DIGESTION

Source: Sherwood, 7th Edition

PROTEIN ABSORPTION

Source: Sherwood, 7th Edition

BILE SALTS

Source: Sherwood, 7th Edition

FAT DIGESTION & ABSORPTION

Source: Sherwood, 7th Edition

LO 4. PHYSIOLOGY OF LOWER GIT

Source. Pearson Education. 2006 36

SMALL INTESTINE: SEGMENTATION

37
Source: Sherwood L. Human physiology: From cells to systems. 8th Ed. 2013: pg.581-606
SPHINCTER

38
Source: Sherwood L. Human physiology: From cells to systems. 8th Ed. 2013: pg.581-606
 Absorption

39
Source: Sherwood L. Human physiology: From cells to systems. 8th Ed. 2013: pg.581-606
LARGE INTESTINE: COLON
• Receives ± 500 ml of chyme from
the small intestine each day.
•  feces
• Haustral contractions  slowly
shuffle the contents in a back-and-
forth mixing movement largely
controlled by locally mediated
reflexes involving the intrinsic
plexuses.

40
Source: Sherwood L. Human physiology: From cells to systems. 8th Ed. 2013: pg.581-606
DEFECATION REFLEX
• The gastroileal reflex moves the remaining
smallintestine contents into the large intestine,
• the gastrocolic reflex pushes the colonic contents
into the rectum, triggering the defecation reflex.
• Feces are eleminated by the defecation reflex.

Source: Pearson Education. 2013 41

LO 5. DIARRHEA
•Diarrhea is the reversal of the normal net absorptive
status of water and electrolyte absorption to
secretion.
•The augmented water content in the stools:
• above the normal value of approximately 10 mL/kg/d in the
infant and young child,
• or 200 g/d in the teenager and adult

•is due to an imbalance in the physiology of the small

and large intestinal processes involved in the
absorption of ions, organic substrates, and thus water.
Source: Pearson Education. 2013
 FUNCTIONAL DIARRHEA FOR ADULTS
Diagnostic criterion*
 Loose (mushy) or watery stools without pain occurring in at least 75% of stools

* Criterion fulfilled for the last 3 months with symptom onset at least
6 months prior to diagnosis

Based on Rome III: Diagnostic Criteria for FGID

43
 FUNCTIONAL DIARRHEA: INFANT/ TODDLER
Diagnostic criteria must include all of the following:
1. Daily painless, recurrent passage of three or more large, unformed stools
2. Symptoms that last more than 4 weeks
3. Onset of symptoms that begins between 6 and 36 months of age
4. Passage of stools that occurs during waking hours
5. There is no failure-to-thrive if caloric intake is adequate

Based on Rome III: Diagnostic Criteria for FGID

44
 LO 5. CLASSIFICATION OF DIARRHEA
Diarrhea

Duration Etiology Mechanism

Acute Subacute/ Chronic

Persistent Infection Non- Osmotic Secretory Exudative Abnormal
(< 2 weeks) (2-4 weeks) (> 2 weeks) infection motility
 CLASSIFICATION OF DIARRHEA BASED ON DURATION
ACUTE DIARRHEA CHRONIC DIARRHEA
• <2 weeks • >4 weeks
• 90% of cases of acute diarrhea are • most of the causes of chronic diarrhea are
caused by infectious agents noninfectious
• 10% or so are caused by medications,toxic • The classification by pathophysiologic
ingestions,ischemia, and other conditions mechanism
• often accompanied by vomiting, fever, and
abdominal pain
LO 6. Etiology of Diarrhea
Viruses : Enterovirus, Adenovirus, Rotavirus
Enteral Infection Bacteria : Vibrio sp., E. coli, Shigella sp.,
Salmonella sp., Campylobacter sp.,
Yersinia sp., Aeromonas sp.
Infection Protozoa : G. Lamblia, E. Histolitica,
Isospora belli
Parasites Helminth : Ascaris sp., Trichuris sp.,
Oxyyuris sp., Strongyloides sp.
Etiology of Fungal : Candida albicans
diarrhea
Parenteral Infections : Acute otitis media, Tonsilofaringitis,
Bronkopneumonia, Morbilli
Malabsorption : Carbohydrate, Lipid, Protein
Food : out-of-date, poisonous
Allergic
Immunodeficiency
Phsycology : afraid, worried
LO 7. PATHOPHYSIOLOGY MECHANISM OF DIARRHEA
LO 7. PATOPHYSIOLOGY MECHANISM BASED ON ETIOLOGY OF DIARRHEA :
INFECTION AND NON-INFECTION
PATHOGENESIS OF INFECTIOUS DIARRHEA
INFECTIOUS DIARRHEA:
THE PRIMARY PATHOGENIC MECHANISM
Depending on how they interact with human host:

1. Changing delicate balance of water and electrolytes in the small bowel,

noninflamatory process, usually produce enterotoxin

2. Causing cell destruction or a marked inflammatory response following invasion of

host cell, usually produce cytotoxin

3. Penetrating the intestinal mucose, with subsequent spread and multiplication in

lyphatic/RES/blood stream  systemic infection
INFECTIOUS DIARRHEA:
VIRAL & BACTERIAL INFECTION
•Viruses injure the absorptive surface of mature villous cells,resulting
in decreased fluid absorption and dissacharidase deficiency.

•Bacteria produce intestinal injury by directly invading the

mucosa,damaging the villous surface or releasing toxin.
PATHOGENIC MECHANISM OF ENTERIC INFECTIONS:
MAJOR SYMPTOMS
PATHOGENIC MECHANISM OF ENTERIC INFECTIONS:
TOXIN PRODUCTION & ATTACHMENT WITHIN/ CLOSE TO MUCOSAL CELLS/ ADHERENCE
TOXIN PRODUCTION
1. ENTEROTOXIN OF V. CHOLERAE
2. CYTOTOXIN
Disrupt the structure of epithelial cell  lost of secretion and
absorptive function  inflammation response  PMN and other
inflammation cell

Usually occur in colon

Common type : EHEC, Shigella sp., Clostridium Difficile

ENTEROHEMORRHAGIC ESCHERICHIA COLI (EHEC)
 PATHOGENESIS
Systemic vascular
produce toxin (like Spread to the blood Renal, colon, small
endothelial cell damage
shiga)( stream intestine, and lungs
to various organ

TTP&HUS

*)thrombotic thrombocytopenic purpura (TTP)

*)hemolytic uremic syndrome (HUS)
 SHIGELLA SP.
 Apoptosis  death cell
release IL-1 & IL-8 
 Damage colonic mucose
 resulting in
 Mucous, bloody diarrhea
CLOSTRIDIUM DIFFICILE
Causing PMC (pseudomembran colitis) or antibiotic-associated colitis

Etiology : antibiotic/antimetabolit theraphy, usually broad spectrum antibiotcs such

as ampicillin, clindamycin, or cephalosphorine

Enterotoxin : toxin A and B causing necrosis of wall intestine

Decreased of
Theraphy Begin to multipication Toxin production
floranormal
3. NEUROTOXIN
Pathogen Pathogenesis Found in Result

Staph. aureus Most common food borne, Meat or diary product Vomitting and diarrhea
grow in warm condition,
onset 2-6 hr

Baillus aureus Produce 2 type of toxin Cooked meat, poultry, Vomitting and diarrhea
vegetables, and dessert

Clostridium Perfringens Usually mild, self limiting Meats and gravies Diarrhea
after 24 hrs of diarrhea

c. Botulinum Prevent neurotransmitter In adults :Canned-tomato Falccid paralysis

achon cholinergic nerve and cream-based food
junction, can infect infant In infant : honey and corn
<9 mo syru before 9 mo
ATTACHMENT WITHIN OR CLOSE TO
MUCOSAL CELLS/ ADHERENCES
BACTERIAL INFECTION
VIRAL INFECTION
ADENOVIRUS
Adenoviruses may be associated with acute gastroenteritis, especially in
children <2 yrsof age.
Illness usually occurs during summer.
Diagnosed by: stool viral culture.

NORWALK-VIRUS
 Usually cause epidemics in school-aged children or
adults.
 Infection usually comes from contaminated wateror food.
 Clinical manifestations: (usually last several days)
 Cramping abdominal pain
 vomiting,and low-grade fever
 Diagnosed by: stool viral culture.
VIRAL INFECTION
ROTAVIRUS
Most common cause of viral gastroenteritis.
Usually occurs between 3 months and 3yrs of age. Although most
common during wintermonths, it may occur year round.
Clinical manifestations:
Diarrhea
Fever and vomiting.
Blood is not usually found in stools
Usually lasts for few days and up to 1 wk.

Detection of rotavirus antigen in stoolby enzyme immunoassay is

diagnostic.
HELMINTHS CAUSING DIARRHEA
ENTAMOEBA HISTOLYTICA
Trichuris Life Cicle
GIARDIA LAMBLIA
ASCARIS LUMBRICOIDES
 LO 8. SIGNS AND SYMPTOMS OF DIARRHEA

SOURCE: BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING

SOURCE: BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING
COATED TOUNGE
A white film on the tongue can be caused by an
overgrowth of naturally occurring yeast, a condition
known as oral thrush.
 "Science Journal of Clinical Medicine" notes that the
most common cause of oral thrush is Candida albicans.
One characteristic of thrush is that the white coating
can be easily rubbed off the tongue, typically
revealing a reddened area that may bleed.
 Taking antibiotics or inhaled steroids increases the
risk for oral thrush.
DEHYDRATION
 78
Source: NMSU Campus Health
DEHYDRATION IN PAEDIATRIC

SOURCE: MAYOCLINIC.ORG 79
 Typhoid Fever
Definition and epidemiology
• Typhoid fever is a life-threatening illness caused
by the bacteriumSalmonella Typhi.
• In the United States, it is estimated that
approximately 5,700 cases occur annually. Most
cases (up to 75%) are acquired while traveling
internationally. Typhoid fever is still common in
the developing world, where it affects about
21.5 million persons each year.
http://www.cdc.gov/nczved/divisions/dfbmd/diseases/typhoid_fever/
etiology
• Salmonella is part of the family of
Enterobacteriaceae
• It comprises two species, Salmonella
bongori and Salmonella enterica,
• Common :Salmonella Typhi lives only in
humans
• Typhoid carriers
• Fecal-oral transmission route
 Pathophysiology Typhoid Fever

enteric fever/typhoid fever occurs by ingestion multiply in the lumen small intestine
penetrate the small intestine mucosa  From the submucosa, invading bacteria are taken
up by macrophages,and the organisms travel to mesenteric lymph nodes bloodstream via
the thoracic duct (primary bacteraemia) liver – gallbladder(cholecystitis) & spleen
(secondary bacteraemia)

Manson's Tropical Infectious Diseases 23rd Ed

 Typhoid Fever
Sign and symptoms
Early illness
• fever as high as 103° to 104° F (39° to 40° C)
• also feel weak
• headache
• loss of appetite.
• Headache
• Muscle aches
• Sweating
• Dry cough
• weight loss
• Abdominal pain
• Diarrhea or constipation
• Extremely swollen abdomen
•
In some cases,
• patients have a rash of flat
• rose-colored spots. http://www.mayoclinic.org/diseases-conditions/typhoid-
fever/basics/definition/con-20028553
 Typhoid Fever
Diagnosis and tests
• Blood and Bone Marrow Culture
– blood cultures are usually positive in about
60–80% of cases
– Bone marrow culture of about 80–90%
• Faecal and Urine Cultures
– With modern techniques, faecal cultures are
often positive even during the first week,
– Urine cultures are positive less often.
Manson's Tropical Infectious Diseases 23rd Ed
• Serology
– Widal test measures antibodies against flagellar (H)
and somatic (O) antigens of the causative organism.
– In acute infection, O antibody appears first, rising
progressively, later falling and often disappearing
within a few months.
– H antibody appears a little later but persists for longer
raised  identify the type of enteric fever.
• Newer Diagnostic Methods
• detect IgM or IgG antibodies Typhidot and Tubex
 Typhoid Fever
Treatments
• Emergence of Multi-resistant Typhoid • Management of Chronic Carriers
Fever • Ciprofloxacin (750 mg twice daily) and
– Ciprofloxacin and Other Fluoroquinolone norfloxacin (400 mg twice daily)
Drugs.
• amoxicillin or co-trimoxazole
– Third-generation
Cephalosporins(Cefotaxime, ceftriaxone and
cefoperazone)
– Azithromycin.
– Chloramphenicol, Ampicillin, Amoxicillin and
Cotrimoxazole.
– Corticosteroid Therapy (High-dose
dexamethasone)

Manson's Tropical Infectious Diseases 23rd Ed

 Risk factor
– Work in or travel to areas where typhoid
fever is endemic
– Work as a clinical microbiologist handling
Salmonella typhi bacteria
– Have close contact with someone who is
infected or has recently been infected with
typhoid fever
– Drink water contaminated by sewage that
contains S. typhi

http://www.nejm.org/doi/full/10.1056/NEJMra020201

http://www.mayoclinic.org/diseases-conditions/typhoid-fever/basics/definition/con-20028553
 Typhoid Fever

• Prevention
– Vaccines
– Wash your hands
– Avoid drinking untreated water.
– Avoid raw fruits and vegetables.
– Choose hot foods.
• Prevent infecting others
– Avoid handling food.
– Wash your hands often.
– Take your antibiotics

http://idai.or.id/public-articles/klinik/imunisasi/melengkapi-
mengejar-imunisasi-bagian-i.html

http://www.mayoclinic.org/diseases-conditions/typhoid-fever/basics/definition/con-20028553
 Typhoid Fever
Prognosis
• Early antibiotic therapy has transformed
a previously lifethreatening illness of
several weeks’ duration with a mortality
rate approaching 20% into a short-
lasting febrile illness with negligible
mortality.
• The high mortality rates which continue
to be reported from some endemic
countries are undoubtedly related to
delayed diagnosis and/or inappropriate
treatment.

Manson's Tropical Infectious Diseases 23rd Ed

LO 9. EXAMINATIONS FOR DIARRHEA
ANAMNESIS/HISTORY EXAM OF DIARRHEA
PHYSICAL EXAMINATION OF DEHYDRATION FOR PAEDIATRICS

http://www.aafp.org/afp/2009/1001/p692.html
 CHARACTERISTIC OF STOOL EXAMINATION

SOURCE: BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING

 CHARACTERISTIC OF STOOL EXAMINATION

SOURCE: BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING

ACUTE DIARRHEA ALGORITHM
CHRONIC DIARRHEA ALGORITHM
CHRONIC DIARRHEA ALGORITHM
LO 10.PHARMACOLOGIC & NON-PHARMACOLOGIC
TREATMENT FOR DIARRHEA
ANTIBIOTIC THERAPY FOR
ENTERIC FEVER IN ADULTS

Harrison’s principles of internal

medicine. 19th ed. Pg.1052
TYPHOID FEVER WITHOUT COMPLICATION
SEVERE TYPHOID FEVER TREATMENT
 Body Fluid requirements
TBW Calculation: Intake and Output
• TBW = Total Body Water • Dietary Reference Intakes: adequate intakes (AIs) for
• BW= Body Weight water
• TBW = 60%/ BW (=45-75% / BW) – Adult males (>19 years): 3.7 liters (L)/day
– Adult females (>19 years): 2.7 L/day
• Intracellular fluid (ICF) = 2/3 TBW (40%)
• Extracellular fluid (ECF) =
– Plasma = 5%
• Body Fluid needs (based on weight (kg))
– Interstitial = 15% – For 0 - 10 kg = weight (kg) x 100 mL/kg/day
– Transcelluler = 1-3% – For 10-20 kg = 1000 mL + [weight (kg) x 50 ml/kg/day]
– For > 20 kg = 1500 mL + [weight (kg) x 20 ml/kg/day]
• Ratio of ICF : ECF
– Adult = 2:1
– Children = 3:2
– Infants = 1:1
• TBW :
1. Adult = 45-75%/ BW
a) Men = 60%
b) Women = 55%
2. Infant and Child = 75%

Source: Eckstein L, Adams K, eds. Pocket Resource for Nutrition Assessment. Chicago, IL: Dietetics in Health Care Communities Dietetic Practice 105
Group, Academy of Nutrition and Dietetics; 2013.
 NON- PHARMACOLOGIC TREATMENT
Oral Rehydration
Administration of 1-2 L dextrose 5% in 0.5 isotonic
sodium chloride solution with 50 mEq NaHCO3 and
10-20 mEq KCl over 30-45 minutes may be necessary
in patients who are severely dehydrated.
Rehydrate patients until mental status and signs of
perfusion and pulse are normal
For pediatric patients, administer 20 mL/kg of
isotonic sodium chloride solution initially for
resuscitation; Repeat as necessary and add KCl as
indicated
PAY ATTENTION TO SOME NUTRITION THAT CAUSES DIARRHEA
LO 11. PREVENTION FOR DIARRHEA
Preventing viral diarrhea
 Wash frequently.
 Use hand sanitizer when washing isn't possible.

Preventing diarrhea from contaminated food

 Serve food right away or refrigerate it after it has been cooked or reheated.
 Wash work surfaces frequently to avoid spreading germs from one food item to another.
 Use the refrigerator to thaw frozen items.

Preventing traveler's diarrhea

 Watch what you eat. Eat hot, well-cooked foods.
 Watch what you drink.
 Drink bottled water, soda, beer or wine served in its original container.
 Avoid tap water and ice cubes.
 Use bottled water even for brushing your teeth. Keep your mouth closed while you shower.
 Remember that alcohol and caffeine can aggravate diarrhea and dehydration.
 Ask your doctor about using antibiotics.
 Check for travel warnings.

SOURCE: HARRISON'S 18TH

 LO 11. EDUCATE FOR DIARRHEA
Wash your hands

Avoid drinking untreated water

Avoid raw fruits and vegetables

Choose hot foods

http://www.mayoclinic.org/diseases-conditions/typhoid-fever/basics/prevention/con-20028553
LO 12. COMPLICATIONS FOR DIARRHEA
Loss of water and electrolytes  Dehydration, hypokalemia,
metabolic acidosis, seizures, metabolic alkalosis
Impaired blood circulation  hypovolemic shock
Hypoglycemia  Disturbance nutrition, protein energy
malnutrition
Weight loss
Disturbance of renal function worsened diarrhea lead to
kidney failure
Death
LO 12. PROGNOSIS FOR DIARRHEA
 CONCLUSION
We assume that the first patient (12-year-old girl) may have gastroenteritis as the main
reason of the symptoms acquired, such as abdominal cramp, nausea, vomiting, fever, feeling
irritable, and decrease in appetite for the past two days, also with one-day history of bloody,
mucousy diarrhea five times a day; while her brother ( 7-month-old boy), may have
intolerance to lactosa due to the change consumption type of milk that causes the osmotic
pathogenic mechanism resulted in the watery diarrhea.
 MEDICAL PRESCRIPTION
R/ Ciprofloxacin 500 mg tab No. XIV
∫ 2 dd 1 p.c.
_______________________________§
R/ Paracetamol 500 mg tab No. XXI
∫ 3 dd 1 p.r.n. Panas >38⁰C
_______________________________§
Name : Patient X
Age : Adult (>18 y.o)
Diagnosis : Typhoid Fever

For children:
Contraindication to < 18 y.o.
PCT dosage=10 mg/kgBW/x
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http://www.mayoclinic.org/diseases-conditions/typhoid-fever/basics/prevention/con-20028553