CHAPTER I

INTRODUCTION

1.1 Background
Digestive System are the eleventh block in the 4th semester competency-based
curriculum in medical faculty of Muhammadiyah Palembang University . Learning
in this block is very important to learn in medical faculty of Muhammadiyah
Palembang University.
On this occasion, a case study tutorial of scenario A which presents cases that
related to the digestive system. Diwan, a 2 years old, is brought by his mother to
Puskesmas with chief complaints of fluid defecating since 4 days ago. Frequency of
defecation are 3-4 times a day, consistency of feces more liquid than pulp, as much as
1/4 cup, yellowish color, no blood and mucus in the feces. He had experienced fever.
He also sufferes nausea and vomitting with frequency 1-2 times a day, as much as 1/4
cup, contain what his consumed, and not expulsion. He began letahrgic but still want
to drink. Last urinate was 4 hours ago.

1.2 Purpose
The purpose of this case study tutorial report are:
1. As a group task report which is a competency-based curriculum learning system
in the medical facultyof Muhammadiyah Palembang.
2. Can solve cases given in a scenario by group analysis and learning methods
3. The purpose of the tutorial learning method is reached

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 CHAPTER II
DISCUSSION

2.1 Tutorial Data

Tutor : dr. Putri Rizki Amalia Badri
Moderator : Rama Muhammad Tri Arachman
Desk Secretary : Fildzah Sharfina
Bord Secretary : Syarifah Hayati
Time : Sunday, March 19th 2018
Wednesday, March 21st 2018
Time 13.00 – 15.30 p.m .

The Rule of Tutorial 1. Deactivate the phone or condition the phone in

silence.
2. Raise your hand when going to argument.
3. Get permission when going out of the room.
4. It is prohibited to bring food or eat in the room
during the discussion process is in progress.

2.2 Scenario A
Diwan, a 2 years old, is brought by his mother to Puskesmas with chief complaints of
fluid defecating since 4 days ago. Frequency of defecation are 3-4 times a day,
consistency of feces more liquid than pulp, as much as 1/4 cup, yellowish color, no
blood and mucus in the feces. He had experienced fever. He also sufferes nausea and
vomitting with frequency 1-2 times a day, as much as 1/4 cup, contain what his
consumed, and not expulsion. He began letahrgic but still want to drink. Last urinate
was 4 hours ago.
Physical Examination:
General Condition : moderate illness, weight 11 kg, height 84 cm
Vital signs : compos mentis, PR 140 times per minute, regular; RR 32 times
per minute; Temp 36.4 C
Spesific Condition:

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Head : closed forehead, sunken eyes, no tears, wet mouth mucous.
Thorax : symmetrical, retraction (-)
Cor : SI-SII normal, no heart noisy
Lung : vesicular, wheezing (-), ronki (-)
Abdomen : flat, increased bowel sounds, liver and lien are not palpable,
decreases turgor pressure
Extremities : palms and soles are warm
Laboratory Examination:
Hb 12.6 gr/dl, WBC 6000/mm, differential count 0/1/2/45/48/4
Routine examination of the feces:
Macroscopic : more liquid than pulp, blood (-), pus (-), mucous (-), yellowish
color
Leukocyte feces : 1-2/hpf, erythrocytes: 0,1/hpf, bacteria (-), hyfa (-)

2.3 Terms of Clarification

Clarification
Fluid Defecation Condition when a feces product from that
people is more watery than a normal
condition (Dorland, 2015).
Hyfa The structure of the fungi shape liked a
tube that is form the growth of the spores
or conidia (Dorland, 2015).
Sunken eyes The sign of dehydration level.
Bowel sounds Abdominal sounds are meet by the
movement of the intestines (Dorland,
2015).
Mucous Free mucous from the mucosa membrane
(Dorland, 2015).
Feces Last product of digestive process after
through a digestive system (Dorland,
2015).
Turgor pressure The resiliency of the skin caused by the
outward pressure of the cells and
interstitial fluid (Dorland, 2015).
Vomitting Forced expulsion of gastric content
through the mouth (Dorland, 2015).
Lethargic Decreased level of consciousness,
characterized by feeling sleepy and
apatis (Dorland, 2015).

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 2.4 Problem Identification
1. Diwan, a 2 years old, is brought by his mother to Puskesmas with chief
complaints of fluid defecating since 4 days ago. Frequency of defecation are 3-4
times a day, consistency of feces more liquid than pulp, as much as 1/4 cup,
yellowish color, no blood and mucus in the feces.
2. He had experienced fever. He also sufferes nausea and vomitting with frequency
1-2 times a day, as much as 1/4 cup, contain what his consumed, and not
expulsion.
3. He began letahrgic but still want to drink. Last urinate was 4 hours ago.
4. Physical Examination:
General Condition : moderate illness, weight 11 kg, height 84 cm
Vital signs : compos mentis, PR 140 times per minute, regular; RR 32 times
per minute; Temp 36.4 C
Spesific Condition:
Head : closed forehead, sunken eyes, no tears, wet mouth mucous.
Thorax : symmetrical, retraction (-)
Cor : SI-SII normal, no heart noisy
Lung : vesicular, wheezing (-), ronki (-)
Abdomen : flat, increased bowel sounds, liver and lien are not palpable,
decreases turgor pressure
Extremities : palms and soles are warm
5. Laboratory Examination:
Hb 12.6 gr/dl, WBC 6000/mm, differential count 0/1/2/45/48/4
Routine examination of the feces:
Macroscopic : more liquid than pulp, blood (-), pus (-), mucous (-), yellowish
color
Leukocyte feces : 1-2/hpf, erythrocytes: 0,1/hpf, bacteria (-), hyfa (-)

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 2.5 Problem Analysis
1. Diwan, a 2 years old, is brought by his mother to Puskesmas with chief
complaints of fluid defecating since 4 days ago. Frequency of defecation are 3-4
times a day, consistency of feces more liquid than pulp, as much as 1/4 cup,
yellowish color, no blood and mucus in the feces.
a. How’s the anatomy, physiology, and histology of digestive system?
Answer:
Anatomy:

Oral Cavity

The mucosal layer of the mouth is composed of stratified squamous epithelial cells.
These cells slough off during normal food chewing and are easily replaced. The
mouth functions to break down food into smaller parts. The main structures of the
mouth include: Tongue ,Salivary ,Teeth ,Pharynx.

Esophagus
The esophagus is the “food tube” that allows the passage of the food bolus from the
mouth to the stomach. It plays no part in the digestive process. The esophagus only
produces mucus, which acts to: Facilitates the passage of food, lubricate and
protect the esophagus

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Gaster

The uppermost regions of the stomach are the cardiac region and the fundus, which
lead into the body of the stomach. The antrum is the lower segment of the stomach,
leading into the most distal part of the stomach, known as the pylorus. At the base
of the pylorus is the pyloric sphincter, which allows the passage of chyme into the
small intestine.

Gastric Blood Supply & Innervation

Blood supply to the stomach is via the celiac plexus. The celiac plexus is composed
of: The right and left gastric artery, Gastroduodenal artery, Splenic artery
Innervation to stomach includes: Intrinsic innervation: This occurs via the
mesenteric (Auerbach’s) plexus and the sub‐mucosal (Meissner’s) plexus.
Intrinsic innervation influences muscle tone, contractions, speed, excitation, and

6
secretions of the stomach. Extrinsic innervation: This occurs via the
parasympathetic and sympathetic nerves.

Small Intestine

The small intestine extends from the pylorus to the ileocecal valve. The small
intestine is composed of the duodenum, jejunum, and ileum. The ligament of Treitz
divides the duodenum from the jejunum. Upper gastrointestinal bleeding
occurs above this ligament and lower gastrointestinal bleeding occurs below this
ligament.
The primary function of the small intestine is the absorption of vitamins and
nutrients, including electrolytes, iron,carbohydrates, proteins, and fats. Most
digestion of nutrients happens here.The small intestine also absorbs approximately
8,000 milliliters (mL) of water per day (Barron, 2010). Three thousand milliliters
of digestive enzymes are secreted in the small intestine daily.

Intestinal Blood Supply & Innervation

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Blood supply to the small intestine is derived from: The celiac artery, The superior
mesenteric artery Innervation of the small intestine is the same as for the stomach
(Krumhardt & Alcamo, 2010).

Large Intestine

8
The large intestine extends from the terminal ileum at the ileocecal valve to the
rectum. At the terminal ileum, the large intestine becomes the ascending colon, the
transverse colon, and then the descending colon. Following the descending
colon is the sigmoid colon and the rectum (Scanlon, 2011).

Bile & Bile Pigments

Bile has three major components: Water, Bile salts, Bile pigments.

9
Gallbladder

The gallbladder is a pear‐shaped, sac‐like organ attached to the liver that serves as
a storage facility for bile. It can hold and concentrate approximately 50 mL of bile.
The cystic duct connects the gallbladder to the common bile duct, which terminates
at the Sphincter of Oddi in the duodenum of the small intestine.

Liver

The liver is a very large organ located in the upper right abdomen. There are right,
left, and caudate lobes of the liver. Each of these lobes is further sub‐divided into
eight segments. These segments can be resected during surgery if diseased or
traumatized.

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Pancreas

The pancreas is both an endocrine and exocrine gland.

Blood Supply & Innervation of the Pancreas

Blood supply to the pancreas occurs via the hepatic and cystic artery.
The pancreas is innervated by the splanchnic nerve and right branch of the vagus
nerve. Vagal (parasympathetic) stimulation results in the secretion of pancreatic
enzymes. These secretions travel through the main pancreatic exocrine duct, the
Duct of Wirsung. This duct terminates next to the common bile duct at the
Sphincter of Oddi (Scanlon, 2011).

Biliary Ducts

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While not organs themselves, the ducts of the biliary tract are very important in the
proper functioning of the gastrointestinal system and body as a whole. In the liver,
bile is collected in the bile calculi, which eventually become the left and right
hepatic ducts, which exit theliver as the common hepatic duct.

Rectum

Arterial supply and venous drainage of the rectum

The principal artery supplying the rectum is the superior rectal artery (the name
given to the inferior mesenteric artery at the point where the latter crosses the
pelvic brim to enter the pelvic cavity).

Arterial supply and venous drainage of the anal canal

The arterial supply of the external and internal anal sphincters as well as the
mucosa over the lower half of the anal canal is derived from the right and left
inferior rectal arteries.

Physiology:

Mouth, pharynx, and esophagus

- The ingestion process on volunteer. The tongue press a bolus to palatum durum
and palatum molle
- Tongue push the bolus into pharynx
- Ingestion center inhibit respiratory center
- Uvula is elevation to avoid the food enter to nasal canal
- Epiglotis is close

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- The contraction of pharynx push a bolus through sfingter faringoesofageal
- Peristaltic push a bolus on esophagus to through sfingter gastroesofageal
- Bolus enter to gaster

Gaster

- Peristaltic contraction start from fundus and push to sfingter pilorus

- The contraction is increased when arrive in antrum
- That contraction push kimus
- Kimus enter to duodenum (not all of kimus)
- When the sfingter pilorus has closed, the kimus back to antrum again

Secretion of pancreas and bile

- Produce proteolitic enzym

- Pancreas amilase
- Pancreas lipase

Intestine tenue

1. Motility
a. Segmentation
A process that kimus in intestine tenue are mix and push by smooth muscle
triggered by a specific cell that has depolaritation. This segmentation is 12 x/min

b. MMC “Migrating motility complex”

It happens between meals times. It has a function to remove the leftovers of food. It
regulated by motilin hormon

2. Secretion
Everyday exocrine glans produce sukus enterikus (instestive juice) 1,5 L into
lumen. Mucous of secretion has a function for protect our lumen and supply H2O
for enzymatic process. The enzym has processed in brush border.
3. Digestion

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A process that transform a carbohydrate to monosaccharides and polysaccharides,
protein become amino aciid, and fat become triglycerides.
4. Absorption
a. Carbohydrate
It absorb by transform become disacaride, maltose, sucrose, lactose, and even
polysacharides form.
b. Protein
It has change become amino acid and peptide
c. Lipid
It has change become triglyseride
d. Vitamin

Intestine crassum

Consist of caecum, apendix, colon, and rectum. Normal colon receive 500 mL of
kimus from intestine tenue per day because the process absoprtion 90% is finish in
intestine temue. The thing that transport from intestine tenue to colon is residue
(selulose). Colon supply H2O and natrium to make solid mass (feses. The main
function of intestine crassum is save the feses before defecation. Process to puss a
feses is 3-4 x/day after ear, the process is increase from the motility when
ascendent and transversum are contractiob to push the feses until rectum (mass
motion). The outing feses by dfecation reflex stimulate sfingter anus internus to
relax (smooth muscle) and rectum, and colon sigmoid is contraction. When the
sfingter anus externus is also relax that can make a defecation process (Sherwood,
2015).

Hystology:

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 The intestinal wall consists of four layers similar to those in most
gastrointestinal tracts: mucosa, submucosa, muscularis, and serosa. The mucosa
consists of a layer of epithelium, lamina propria, and mucosal muscularis. The
epithelial lining of the small intestinal mucosa consists of simple columnar
epithelium containing many cell types. Epithelial absorptive cells digest and absorb
nutrients in the small bowel. In the epithelium there are also goblet cells, which
secrete mucus. The intestinal mucosa contains many gaps lined by glandular
epithelium. The cells that line the gap form the intestinal gland, or the lieberkuhn
crypts, and secrete intestinal sap. The intestinal glands also contain paneth cells and
enteroendocrine cells. Paneth cells secrete lysozyme. There are 3 types of
neuroendocrine cells in the small intestine of S cells, CCK cells, and K cells, each
secreting secretory hormone, kolisistekinin or CCK, and glucose-dependent
insulinotropic peptide, or GIP.
Lamina propria of the small intestine mucosa contains isolar connective
tissue and many mucosal lymphoid tissue (MALT). The duodenal submarine
contains the duodenal gland, also called Brunner's gland which secretes the alkaline
mucus to help neutralize the stomach acid in the kimus. The intestinal muscularis
consists of two layers of smooth muscle. The outer layer containing longitudinal
fibers, a deeper layered layer containing circular fibers.

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 The small intestine has a microvilli, ie the protrusion of the apical
membrane (free) absorptive cells. Each microvilus is a membrane-cylindrical
cylindrical bulge with a length of 1 micrometer containing a beam of 20-30 actin
filaments. When viewed with a light microscope, the microvilli is too small to be
seen alone. Microvillas form a faint line, called the brush border, which extends
into the lumen of the small intestine (Tortora, 2016).

b. How’s the structure and composition of a normal feces?

Answer:

 It is identified basically that the human excrements is composed of 3/4 of

water and 1/4 of solid substance (composed for bacteria deceased – 30%, fat
– 10 to 20%, inorganic substance – 10 to 20%, proteins – 2 to 3%, remaining
portions not digested –30%).

 Brown color caused by the sterkobilin and urobilin from bille.

 Feces smell caused by bacteria product like indol, sacratol, merkaptan and
hydrogen sulfide (Guyton, 2008).

fecal composition normally consists of water by 75%, the rest is the material -
solid material consisting of 30% of bacteria die, fat (10% -20%), inorganic
materials (10-20%), protein (2-3% ), and dietary fiber that is not digested, and
elements - elements of digestive juices, such as bile pigment and cells - the cells
apart (Rochsitasari, 2011).

c. What is the relation between age and gender with this case?
Answer:

Cases of diarrhea is usually the most on children age 0 -5 years because in

that age the immune system is weak, so susceptible virus infected, usually in

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children 0-5 years diarrhea most caused by virus , nothing relation between gender,
man or women are same (Marchdante, 2014).

Risk of diarrhea in high children, about 70 - 80% of cases of

diarrhea. Death most often occurs in children younger than 5
years old. In the case of children aged 10 years are still vulnerable
to infection. Because at the age of 10 years is still active to play,
so easily infected with bacteria or viruses both from the
environment and food. Gender: The incidence of diarrhea in boys
is almost the same as that of a female child (Widoyono, 2008).

d. What is the etiology of fluid defecating?

Answer:

According to the cause (2002) Soegijanto fluid defecations:

1. The indirect cause of: Nutritional Status, Environment, Clean and healthy
lifestyles, Social economy

2. The direct cause: Infection with bacteria, viruses, and parasites, Malabsorbsi,
Allergies, Chemicals poisoning or poisoning by toxins produced by the remains
miniscule, fish, fruits, and vegetables. Liquid diarrhea can be caused from food or
drink contaminated by enteropatogen, or direct contact with sufferers of diarrhea or
items that have been contaminated with the stool or diarrhea sufferers indirectly
through flies. 

Risk factors that can increase the transmission of enteropatogen namely: Do not
give a full Breast Milk for the first month of life 4-6 baby, Inadequacy of providing
clean water, Contamination by fecal matter, The lack of sanitary (sanitary facility),
Environmental Hygiene and bad personal, The preparation and storage of food
hygienic easy-way of weaning is not a good.

Risk factors that increase tendency in liquid diarrhea (diarrhea):

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➢ Poor nutrition

➢ Imunodeficiency

➢ The reduced stomach acidity

➢ The intestinal motility Decreased

➢ Menderit measles in last 4 weeks

➢ Factor genetic

Rotavirus in Indonesia throughout the year and increased throughout the dry
season. Bacteria tend to increase the rainy season (Juffrie, 2012).

Diarrhea-Causing Factors

1. Infection/enteropatogen

-Bacteria: e. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Yersinia

enterocolitica, Staphylococcus aureus

-Viruses: adenovirus, rotavirus, astrovirus, coronavirus, cytomegalovirus

-Parasites: Entamoeba histolytica Balantidium coli, Trichuris trichiura,

Crytosporidium parvum,.

2. Noninfeksius: Difficulty eating, abnormalities anatomik, malabsorbsi,

endokrinopati, toksigenik food (heavy metals, fungus, etc.), Neoplasm, Milk
Allergy, Immune deficiency (Behrman, 2012).

e. How’s the physiology of defecation?

Answer:

the process of defecation begins with mass movement pushing the contents of
the colon of the distal colon, where the material is stored until the occurrence of
defecation. three or four times a day, generally after meals, there is a noticeable

18
 increase in motility when large segments of ascending and transverse colon are
contracted simultaneously, pushing the 1/3 to 3/4 colon lengths in seconds

when the mass movement in the colon pushes the stool into the rectum, the
stretching that occurs in the rectum, triggering the reflexes of defecation. this
reflex causes the internal anal sfringter to dilate and the rectum and sigmoid
colon contract stronger. if the external anal sphincter is also weakened there is
defecation (Sherwood, 2015).

f. What is the meaning of fluid defecating since 4 days ago?

Answer:

its meaning is experiencing acute diarrhea, because Diarrhea is defined as

defecation with unformed stools or liquid with frequency more than 3 times in 24
hours. When the diarrhea lasts less than 2 weeks, it is referred to as acute
diarrhea. If diarrhea lasts 2 weeks or more, it is classified as chronic diarrhea.
Feces can be with or without mucus, blood, or pus. Companion symptoms may
include nausea, vomiting, abdominal pain, heartburn, tenesmus, fever, and signs
of dehydration (Amin, 2015).

g. What is the meaning of frequency of defecation are 3-4 times a day,

consistency of feces more liquid than pulp, as much as ¼ cup, yellowish color,
no blood and mucus in the feces?
Answer:

Four days ago to the clinics and suffered of fluid defecation with frequency 3-
4/day, the consistency of water more than pulp, the amount of approximately
1/4 glasses of fluid defecation shows the acute diarrhea.

Because diarrhea (defecation) with the stool-shaped half-liquid or liquid (half

solid), the content of feces more than usual over 200 g/200 ml/24 hours. The
frequencies of fluid defecation more than 3 times.

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 There is no blood and mucus in the stool of dysentery, diarrhea due to not
show the infection shigella (Sudoyo, 2009).

h. How is the classification of diarrhea?

Answer:

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.

It is classified as:

Acute diarrhea, which is a common cause of death in developing countries. This

type is usually caused by infections and the duration is 14 days or less.

Chronic diarrhea. It may be caused by infection, allergy, or could be a sign of a

serious disorder, such as IBD (inflammatory bowel disease), or Crohn’s disease.
The duration is more than 14 days.

Types of diarrhea:

Secretory diarrhea

Either the gut is secreting more fluids than usual, or it cannot absorb fluids
properly. In such cases structural damage is minimal. This is most commonly
caused by a cholera toxin - a protein secreted by the bacterium Vibrio cholera.

Osmotic diarrhea

Too much water is drawn into the bowels. This may be the result ofceliac
disease, pancreatic disease, or laxatives. Too much magnesium, vitamin C,

20
 undigested lactose, or undigested fructose can also trigger osmotic diarrhea
(Guandalini, 2017).

i. What is the normal frequency of defecation?

Answer:

Normal frequency of defecating on child up to 5 years - Adult is 1 -2 times a day

but defecation frequency on baby under 6 month more often (more than 3 time a
day) because some anzyme and digestive system is not functioning optimally
(Guyton, 2014).

j. What is the type of feces?

Answer:

 Type 1 These stools have small round shapes like nuts, very hard, and very
difficult to remove. Usually this is a form of stool sufferers of chronic
constipation.

 Type 2 These stools have sausage-shaped features, the surfaces are prominent
and non-flat, and look like they will split into pieces. Usually this type of stool
can clog the toilet, can cause hemorrhoids, and is a stool sufferers of chronic
close constipation.

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 Type 3 These stools have sausage-shaped features, with uneven surfaces, and
few cracks. Feces like this are stools with mild constipation.

 Type 4 These stools have features such as sausages or snakes. This stool is a
form of stool sufferers of early symptoms of constipation.

 Type 5 These stools have shaped features such as soft spots, smooth surfaces,
and are fairly easy to remove. This is a stool of a person whose intestines are
healthy.

 Type 6 These stools have very smooth surface characteristics, are easy to melt,
and are usually very easy to remove. Usually this is a form of stool with diarrhea.

 Types 7 The stools have a very liquid feature (already resembling water) and do
not see any solid parts. This is a stool of people with chronic diarrhea.

(Candy, 2005).

2. He had experienced fever. He also sufferes nausea and vomitting with frequency
1-2 times a day, as much as 1/4 cup, contain what his consumed, and not
expulsion.
a. What is the meaning of he had experienced fever?
Answer:
the meaning of he had experienced fever is he has infection that cause diarrhea.
b. What is the meaning of he also sufferes nausea and vomiting with frequency
1-2 times a day, as much as ¼ cup, contain what his consumed, and not
expulsion?
Answer:
the meaning of he also sufferes nausea and vomiting with frequency 1-2 times a
day, as much as ¼ cup, contain what his consumed, and not expulsion is he has
infection that cause diarrhea.

c. What is the type of vomit?

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 Answer:
1. Based on the type
 Projectile vomit, caused by increased intracranial pressure
 Non-projectile vomit, caused by infection of the dygestive system
2. Based on the characteristic
 Dark red/black vomit, caused by gastric ulcer
 Reddish vomit, caused by esopaghus injury
 Green/yellowish vomit, indicated medical emergency

d. What is the relation between nausea and vomiting with chief complaint?
Answer:
It means that, the complaints are caused by rotavirus infection. The infection of
rotavirus by oral, comes to our digestive tract (proximal) and thats why our body
compensate with nausea and vomitting. And also, the rotavirus release NS4
(toxin) which is, can stimulate our CNS (the vagus nerves) to stimulate vomitting.

e. What is the patophyshiology of fever, nausea and vomiting?

Answer:
Fever

viral infection through oral transmission / fecal -> virus enters

through the upper gastrointestinal tract -> virus infects the eptel
layer in the intestinal tenue -> immune response -> inflammatory
mediator expenditure -> endothelial stimulation of the
hypothalamus -> arachidonic acid -> prostaglandin -> fever.

Nausea and Vomitting

The virus infects the epithelial layer in the small intestine -> the
virus enters and multiplies in the mature enterocytes at the end
of the proximal small bowel -> spreads distally within the
incubation period 48 hours -> impairs enterocytes in intestinal villi

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 -> replaced by new enterocytes, immune cuboid form -> atrophy
villus -> absorption of fluid and food disturbed -> liquids and
unabsorbed food causes the lumen in the full intestinum ->
intestinal stretching -> sensory receptors in the intestinal tunes
transmit sensory signals of nausea to center of vomiting in the
medulla oblongata through the afferent nerve vagal and the
sympathetic nerve -> the stimulation of the vomiting center ->
the medulla oblongata transmits the motor signal as feedback of
the sensory signal through the cranial nerves V, VII, IX, X and XII
to the tractus digestvus, the vagus and nerve sympathetic to the
lower dizzy tract and the spinal nerve to the diaphragm and
abdominal muscles -> the occurrence of antiperistaltic in the inte
stinum tenue, relaxation of sphincter pylorus and cardiacal
sphincter and closing the tracheal area to prevent vomiting from
entering the respiratory tract. this antiperistaltic movement with
contraction of the diaphragm and abdominal muscles ->
diaphragm contractions press down to the stomach → contraction
of the abdominal muscles pressing the abdominal cavity →
abdomen moving upward → hysteric stomach → gastric contents
pushed upwards through sphincters → closed glottis, uvula lifted
→ food out through mouth → food vomit pushed into the
esophagus, cavum oris -> vomiting.

( Sherwood, 2015).

3. He began letahrgic but still want to drink. Last urinate was 4 hours ago.
a. What is the meaning of began lethargic but still want to drink and last urinate
was 4 hours ago?
Answer:

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 It means that Diwan is moderately dehydrated which, according to WHO signs of
dehydration, are: regular drink is not thirsty: without dehydration, thirst to drink a
lot: moderate dehydration, lazy drinking / not drinking: heavy dehydration ( WHO,
UNICEF, 2006 )

b. How’s the level of dehidration?

Answer:
There are three possible classifications of dehydration:
If two or more of the following signs are present, classify the child as having severe dehydration:
Without dehidration Mild – moderate Severe
dehidration
Loss of body fluid Loss of body fluid Loss of body fluid 5 - Loss of body fluid
3% of weight 9% of weight more than 9% of
weight
Puls rate Normal Decreassed Bradikardi, not
palpable
turgor Normal Slightly decreassed Decreassed ( not
( back in 2 second) back in to second)
Urine production normal oliguria Anuria and heavy
oliguria
Tears + decreassed -

1. Lethargic or unconscious
2. Sunken eyes
3. Not able to drink or drinking poorly
4. Skin pinch goes back very slowly (longer than 2 second)
If two or more of these signs are present, classify the child as having mild to
moderate dehydration:
1. Restless, irritable
2. Sunken eyes
3. Drink eagerly, thirsty
4. Skin pinch goes back slowly (less than 2 seconds but longer than nornal).

(Marcdante, 2014).

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4. Examination:
General Condition : moderate illness, weight 11 kg, height 84 cm
Vital signs : compos mentis, PR 140 times per minute, regular; RR 32 times
per minute; Temp 36.4 C
Spesific Condition:
Head : closed forehead, sunken eyes, no tears, wet mouth mucous.
Thorax : symmetrical, retraction (-)
Cor : SI-SII normal, no heart noisy
Lung : vesicular, wheezing (-), ronki (-)
Abdomen : flat, increased bowel sounds, liver and lien are not palpable,
decreases turgor pressure
Extremities : palms and soles are warm

a. How’s the interpretation of physical examination?

Answer:
General condition
- moderate illness (abnormal)
- Temp 36,5 C: normotermia

Specific condition
HEAD
- Closed forehead: abnormal
- Sunken eyes: abnormal

ABDOMEN
- Increased bowel sounds: abnormal
- Decrease turgor pressure: abnormal

EXTREMITIES
- Palms and soles are warm: abnormal

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 b. How’s the abnormal mechanisms of physical examination?
Answer:

Closed forehead, sunken eyes, no tears& decreasses turgor pressure

The presence of vomiting and fluid dust → decreased body fluid → fluid balance
disturbances → occurring osmosis (CIS → CES) → fluid moves out of cell over
time shrink → body compensation: reduce fluid in loose connective tissue and soft
tissue → signs of dehydration: sunken eyes, decreasses turgor pressure
Fever

viral infection through oral transmission / fecal -> virus enters

through the upper gastrointestinal tract -> virus infects the eptel
layer in the intestinal tenue -> immune response -> inflammatory
mediator expenditure -> endothelial stimulation of the
hypothalamus -> arachidonic acid -> prostaglandin -> fever

Increased bowel sounds

Infection Microorganisms (Virus) through oral transmission / fecal → virus

entering the digestive tract → virus infects the epithelium in the small intestine →
viruses enter and multiply in mature enterocytes at the end of the intestinal villi →
damage tthe enterocytes in the intestinal vilus → absorption function inadekuat →
interference absorption (not absorbing well) → increased osmotic pressure
intestinal cavity → shift of water and electrolyte into the intestinal cavity →
intestinal contents become excessive → stimulate the intestine to remove it →
intestinal hiperperistaltik

5. Laboratory Examination:
Hb 12.6 gr/dl, WBC 6000/mm, differential count 0/1/2/45/48/4
Routine examination of the feces:
Macroscopic : more liquid than pulp, blood (-), pus (-), mucous (-), yellowish
color
Leukocyte feces : 1-2/hpf, erythrocytes: 0,1/hpf, bacteria (-), hyfa (-)

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 a. How’s the interpretation of laboratory examination?
Answer:

Normal range Interpretation

b.

Laboratory examination
Hb 12,6 g/dl Child : 11-16 gr/dl Normal
Child below 3yo :
9-15 gr/dl
WBC 6.000/mm3 5000-18.000 Normal
3
sel/mm
Differential Count 0/1/2/45/48/4  Basofil: 0-1 % Increased
 Eusinofil: 1-3 % lymphocyte
 Neutrofil batang: s
2-6 %
 Neutrofil
segmen: 50–70
%
 Limfosit: 20-40
%
Monosit : 2-8 %
Routine examination of the
feces
Macroscopic More liquid than pulp Diarrhea
Blood (-)
Pus (-)
Mucous (-)
Yellowish color
Leukocyte feces 1-2/hpf Normal
Erythrocytes 0-1/hpf Normal
Bacteria (-) Normal
Hyfa (-) Normal

How’s the abnormal mechanisms of laboratory examination?

Answer:

Differential Count (Lymphocyte Increase)

Occurred due to infection, viral infection can cause immune system activation, in
the acute phase of PMN which will work to eradicate the virus.

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 Feces more fluid than pulps:

Viral infections acquired through oral fecal transmission (via respiration, food)
which is contaminated, does not wash hands) will cause the virus to infect the
lining epithelium in the small intestine, then the virus enters and multiplies itself in
the enterocytes matur at the end of the proximal small bowel villi. The virus will
spread to distal ileum and colon and damage the enterocytes in the intestinal villi,
so that will be replaced by new enterocytes, kuboid form immature, atrophy villus.
This causes the absorption of fluid and food disturbed so liquids and foods that are
not absorbed / digested. Then there will be increased pressure colloid osmotic
intestine, resulting in more and more hyperperistaltic and intestinal fluid, so that
the absorption decreases, secretion increases, and occurs defecate liquid (more
fluid than dregs).

6. How to diagnose?
Answer:

Anamnesis :

- Fluid defecation since 4 days ago

- Frequency of defection are 3-4 times a day, consistency of feces more liquid than
pulp, as much as ¼ cup, yellowish colour.
- He had experienced fever
- He also sufferes nausea and vomiting with frequency 1-2 times a day, as much as
¼ cup, contain what is comsumed, and not expulsion.
- He began lethrgic but still want to drink
- Last urinate was 4 hours ago.

Physical Examination :

- General condition : Moderate illness

Specific condition :

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 - Head : closed forehead, sunken eyes, no tears.
- Abdomen : Increased bowel sound, decreases turgor pressure

Laboratory :

- Differenrential count 0/1/2/45/48/4

Routine examination of the feces :

- Macroscopic : more liquid that pulp

7. Differential diagnosis?
Answer:

Rotavirus shigella cholera

Nausea, vomitting (+) Often (+) sudden (+) Often

Fever + + -
Defecation frequency More then 10 times a Often continous
day
Consistension of fluid soft fluid
feces
Blood in feces - + -
Colour Yellowish - green Red - green White seems like rice
water

8. Supporting examination?
Answer:

1. Examination of urea and creatinine, to check for fluid volume and body mineral
deficiency

2. Enzyme linked immunosorbent assay (ELISA), to detect giardiasis.

3. X ray abdomen

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 (Simadibrata, 2014).

9. Working diagnosis?
Answer:

Acute diarrhea with mild to moderate dehydration et causa rotavirus infection.

10. Treatment?
Answer:
Promotive
a. Advise maintaining cleanliness of the environment and personal hygiene
ranging from washing hands, throwing garbage, cooking, washing household
appliances with clean water especially pacifiers and consuming water cooked
until cooked.
b. Explain to parents to understand signs of dehydration such as fussiness, thirst,
sunken eyes, crying out tears, dry lips. If the child has diarrhea with recurrent
vomiting, the child is thirsty should be immediately taken to the nearest hospital
or clinic (important if after returning from RSDK child ill again).
Preventive
a. prevent diarrhea due to rotavirus infection, can be given rotavirus vaccine per-
oral (by mouth).
b. breast milk exclusive
c. Food supplement that is clean and nutritious after the baby 6 month years old
d. Wash hands

Curative
According to the Ministry of Health RI (2011), the principle of diarrhea
management in toddlers is LINTAS DIARE (Five Steps to Resolve Diarrhea),
supported by Indonesian Pediatric Association with the recommendation of WHO.
Rehydration is not the only way to treat diarrhea but improve bowel conditions and
speed healing / stopping diarrhea and preventing children from malnutrition due to
diarrhea is also a way to treat diarrhea. The LINTAS DIARE program is:
1.Rehydration using low osmolality Oralite

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 Give immediately if the child is diarrhea, to prevent and overcome
dehydration. Viral-induced diarrhea does not cause severe electrolyte deficiency
in dysentery. Therefore diarrhea experts develop new oralit formulas with lower
osmolarity levels, the osmolarity of new solutions closer to plasma osmolarity,
thus less risk of hypernatremia.
New oralitans with low osmolarity also decreased intravenous
supplementation requirements and were able to reduce fecal contents by up to
20% and reduce vomiting by up to 30%. The new oralit has been recommended
by WHO and UNICEF for acute diarrhea in children.
• For children <2 years of age: 50-100 ml each time chapter
• For children aged 2 or more: 100-200 ml each time chapter
 (Guarino, 2001 and Hans S, 2001).
In patients with mild-to-moderate dehydration diarrhea should be treated to health
advised and promptly given oral rehydration therapy with ORS. The amount of
ORS is given the first 3 hours 75 cc / kg BW. So, in this case. Must be given 825
cc for about 3-4 hours. If the patient is still thirsty and still want to drink should be
given again. Preferably when the volume above the eyelid becomes swollen,
giving oralit should be stopped temporarily and given a drink of water. (Juffrie,
2012)

2.Zinc is given for 10 days in a row

Zinc reduces the duration and severity of diarrhea. Zinc can also restore the
child's appetite. Zinc includes micronutrients that are absolutely necessary to
maintain optimal life. Zinc plays a role for cell growth and division, antioxidants,
sexual development, cellular immunity, dark adaptation, tasting and appetite.
Zinc also plays a role in the immune system and is a potential mediator
pertahnan body against infection (Altaf Waseef MD, 2001).
The use of zinc in the treatment of acute diarrhea is based on its affects on
immune function or on the structure and function of the gastrointestinal tract and
to the process of repairing the gastrointestinal epithelium during diarrhea. Giving
zinc to diarrhea can increase water absorbs and electrolytes by the small

32
 intestine, increase immune response and accelerate clearance of pathogens from
the intestine.
• Children <6 months: 10 mg (half tablet) per day
• Child> 6 months: 20 mg (1 tablet) per day
Zinc is given 10-14 days in a row even though the child has recovered from
diarrhea. For babies, zinc tablets can be dissolved with boiled water, breast milk,
or ORS. For older children, zinc can be chewed or dissolved in boiled water or
oralit (Altaf Waseef MD, 2001).

3.Continue breastfeeding and Food

Breast milk and food continue to be passed on to the child's age with the
same menu at a healthy child's time to prevent weight loss and nutrient
replacement lost. In bloody diarrhea the appetite will decrease. Improved
appetite indicates a healing phase.

4.Selective Antibiotics
There’s no need. Because in this case, diarrhea caused by virus.

5.Advice to parents

Rehabilitative
Advice to parents

11. Complication?
Answer: Hipovolemik syok

12. Prognosis?
Answer:
Dubia ad Bonam

13. KDU?

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 Answer: 4A

14. NNI?
Answer:

O people, eat what is halal from what is on the earth, and do not follow the steps
of shaitan; for verily the shaitan is a real enemy to you. Indeed, Shaitan only tells
you to do evil and wickedly, and to tell God what you do not know (QS: Al
Baqarah: 168-169).

From Abu sa’iddan, Abu Hurayrah, They heard the RassulAllah S.A.W says : “ No
believer is struck by a calmamity of pain, wich is not healed, tired, painful and
anxieties are overthrown but his sins are forgiven” (HR Muslim: 2573)
Content : from the hadith can be taken the lesson that every disaster is a reeporoach
from Allah SWT for the sins we have committed and calamity to introspection our
self for be better, to be rahmatanlilalamin.

2.6 Conclusion
Diwan, a 2 years old, complaints of fluid defecating since 4 days ago because of acute
diarrhea with mild-moderate dehydration et causa rotavirus infection.

2.7 Concept

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 Rotavirus Infection by oral

Virus entering the digestive

tract (proximal)

Nausea and Vomitting

The rotavirus moves into distal

location (intestine) and infects the
intestine

Diarrhea

Signs of dehydration: closed forehead,

sunken eyes, decreased turgor
pressure

35