GASTROENTERITIS

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GASTROENTERITIS
An infection or inflammation of the digestive tract, particularly the stomach and intestines It is frequently referred to as the stomach or intestinal flu
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CAUSES
Viruses such as caliciviruses, rotaviruses, astroviruses and adenoviruses.

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CAUSES
Bacteria such as the Campylobacter bacterium

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CAUSES
Parasites such as Entamoeba histolytica, Giardia lamblia and Cryptosporidium

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CAUSES
Bacterial toxins poisonous byproducts caused by bacteria can contaminate food -Some strains of staphylococcal bacteria produce toxins that can cause gastroenteritis

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 Epidemiology Food borne botulism Commercial sterilization Toxin destroyed by heating foods
Wound botulism deep crushing wounds Infant botulism Inhalation or ingestion of spores Commonly associated with honey or juices

CAUSES
Chemicals lead poisoning, for example, can trigger gastroenteritis

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CAUSES
Drugs certain drugs, such as antibiotics, can cause gastroenteritis in susceptible people and can irritate the digestive tract
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INFECTIOUS GASTROENTERITIS
Escherichia coli infection

this is a common problem for travelers to countries with poor sanitation. Infection is caused by drinking contaminated water or eating contaminated raw fruits and vegetables.

Campylobacter infection the bacteria are found in animal feces. Infection is caused by, for example, consuming contaminated food or water, eating undercooked meat (especially chicken), and not washing your hands after handling infected animals.

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INFECTIOUS GASTROENTERITIS
Cryptosporidium infection parasites are found in the bowels of humans and animals. Infection is caused by, for example, swimming in a contaminated pool and accidentally swallowing water, or through contact with infected animals. An infected person may spread the parasites to food or surfaces if they dont wash their hands after going to the toilet.. Giardiasis parasite infection of the bowel. Infection is caused by, for example, drinking contaminated water, handling infected animals or changing the nappy of an infected baby and not washing your hands afterwards.

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INFECTIOUS GASTROENTERITIS
Salmonellosis Shigellosis Bacteria are found in bacteria are found in animal feces. Infection is feces. An infected caused by eating person may spread contaminated food or the bacteria to food or handling infected animals. surfaces if they dont An infected person may wash their hands after also spread the bacteria to other people or surfaces by going to the toilet. not washing their hands properly.
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Cholera
Causative agent: Vibrio cholerae High infectious dose
Bacteria sensitive to stomach acid Adheres to small intestine and multiply Bacteria dont enter cells

INFECTIOUS GASTROENTERITIS
Viral Gastroenteritis

viruses are found in human feces. Infection is caused by person-to-person contact such as touching contaminated hands, feces or vomit, or by drinking contaminated water or food.
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Viral Gastroenteritis
Common causative agents:
Rotaviruses and Noroviruses Both naked RNA viruses

Star-like Noroviruses

Wheel -like Rotaviruses

 Epidemology Infect intestinal cells causing cell death Typically self-limiting Norovirus epidemics cause 90% of cases Rotaviruses responsible for 50% infant cases of serious diarrhea 600,000 worldwide annual fatalities Oral vaccine available

 Cholera toxin
Potent exotoxin Causes intestinal cells to rapidly pump out electrolytes Passive osmotic H2O loss follows Metabolic acidosis Shock

 Heavy loss of fluid

rice-water stool Up to 20L of fluids lost per day

May discharge 1 million bacteria per ml of feces

Untreated cases potentially fatal

Fluid/electrolyte replacement Tetracycline reduces toxin production

Shigellosis
Causative Agent: Shigella sp.
S. dysenteriae, S. flexneri, S. boydii, S. sonnei

Low infecting dose

Bacteria not sensitive to stomach acid Characterized by fever and dysentery

Infects cells of large intestine and initiates intense inflammatory response Dead cells slough off Produces areas covered with pus and blood

 All species produce enterotoxin and type III secretion systems S. dysenteriae produces powerful endotoxin
shiga-toxin

Ciprofloxacin, rifampin or azithromycin may reduce duration and infectivity

Salmonellosis and Typhoid Fever

Causative agent: Salmonella enterica
2000 strains (serotypes) Typhimurium and Enteritidis commonly cause Salmonellosis Typhi and Paratyphi cause Typhoid Fever

 Common intestinal flora of many animals Contaminated animal products are reservoir
Reptiles, eggs and undercooked poultry

Virulent strains tolerate stomach acid and pass to intestines Toxin induces phagocytosis in intestinal cells Pathogen reproduces inside phagosome killing host cell Bacteria (Typhi) may pass through intestinal cells into bloodstream

 Typhoid fever is an enteric fever

Macrophages carry bacteria to liver, spleen, bone marrow and gallbladder Treated with ciprofloxacin or ampicillin Surgical removal of gallbladder

High risk groups

Young age groups Immune deficient individuals Measles Malnutrition Travel to endemic areas Lack of breast feeding Exposure to unsanitary conditions Attendance to child care centers Poor maternal education

SYMPTOMS
Loss of Appetite Bloating

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SYMPTOMS
Nausea and Vomiting Diarrhea

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SYMPTOMS
Abdominal Pain and Cramps Body Aches
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SYMPTOMS
Bloody stools (in some cases) Pus in the stools (in some cases)

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SYMPTOMS
Lethargy These symptoms are sometimes also accompanied by Fever and Weakness
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COMPLICATION
The greatest danger presented by gastroenteritis is dehydration. The loss of fluids through diarrhea and vomiting can upset the body's electrolyte balance, leading to potentially life-threatening problems such as heart beat abnormalities (arrhythmia) The risk of dehydration increases as symptoms are prolonged. Dehydration should be suspected if a dry mouth, increased or excessive thirst, or scanty urination is experienced created by: Elizabeth Margaretha

COMPLICATION
If symptoms do not resolve within a week, an infection or disorder more serious than gastroenteritis may be involved. Symptoms of great concern include a high fever (102 F [38.9 C] or above), blood or mucus in the diarrhea, blood in the vomit, and severe abdominal pain or swelling. These symptoms require prompt medical attention.
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DIAGNOSIS
The symptoms of gastroenteritis are usually enough to identify the illness It is important to establish the cause, as different types of gastroenteritis respond to different treatments. Diagnostic methods may include: - Medical history - Physical examination General appearance Hydration Status Mild Moderate severe Systemic Examination Extraintestinal manifestations - Blood tests - Stool tests

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General approach
Clinical assessment:Historical points :
Diarrhea :
duration & severity Stool consistency Mucous & blood

Associated symptoms :
GI Fever Neurological Symptoms Others

Risk factors Social & family History

Dehydration
No dehydration Condition Eyes Thirst Well, alert Normal Drinks normally, not thirsty Goes back quickly Plan A < 5% of body wt or < 50 ml/kg body wt Some dehydration Severe dehydration Restless, irritable Lethargic or unconscious Sunken Thirsty, drinks eagerly Sunken Drinks poorly, or not able to drink

Skin pinch Treatment Fluid deficit

Goes back slowly Goes back very slowly Plan B Plan C

5-10% of body wt > 10% of body wt or 50-100 ml/kg of or > 100 ml/kg of body wt body wt

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TREATMENT
Treatment depends on the cause but may include: Plenty of fluids and Right Diet Oral rehydration drinks, available from your chemist Admission to hospital and intravenous fluid replacement, in severe cases
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TREATMENT
Antibiotics, if bacteria are the cause Drugs to kill the parasites, if parasites are the cause Avoiding anti-vomiting or antidiarrhea drugs unless prescribed or recommended by your doctor, because these medications will keep the infection inside your body
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Specific therapy
Anti-microbial therapy :
Indications are organism-dependant. Salmonella : Infants< 3months, typhoid fever, bacteremia , disseminated disease with local suppuration. Shigella : all cases Vibrio cholera : all cases Aeromonas: dysentery like, prolonged diarrhea. C. difficile: moderate to severe disease. E.coli.

Anti diarrheal agents

Antibiotics / drugs :
Shigelosis (WHO) : Kotrimoksazol (trimetoprim dan sulfametoksazol) Alternatif : Ampisilin, Cefixime, Ceftriaxone, Asam nalidiksat. Amoeba : metronidazole Salmonella : ciprofloxacin, ampisillin, cloramfenicol, ceftriaxon Alternatif : fluoroquinolon, cephalosporine Cholera : trimethoprim, sulfametoxazole, tetrasiklin Campylobacter : gentamisin, furazolidone, doxicycline dan cloramfenicol. Viral : antiviral ex acyclovir
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BACTERIAL FOOD INTOXICATION Treatment Antitoxin Gastric washing and surgical removal of tissues Artificial respiration may be required Anti-microbials given to kill bacteria in infant and wound botulism
Prevention Proper sterilization and sealing of canned food No honey or unpasteurized juices for infants!!

PREVENTION
General suggestions on how to reduce the risk of gastroenteritis include:

Wash hands thoroughly with soap and water after going to the toilet or changing nappies, after smoking, after using a handkerchief or tissue, or after handling animals Wash your hands thoroughly with soap and water before preparing food or eating
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PREVENTION
Use disposable paper towels to dry your hands rather than cloth towels, since the bacteria can survive for some time on objects Keep cold food cold (below 5C) and hot foot hot (above 60C) to discourage the growth of bacteria Make sure foods are thoroughly cooked
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PREVENTION
Clean the toilet and bathroom regularly, especially the toilet seat, door handles and taps When travelling overseas to countries where sanitation is suspect, only drink bottled water. Dont forget to brush your teeth in bottled water too. Avoid food buffets, uncooked foods or peeled fruits and vegetables, and ice in drinks
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PROGNOSIS
Gastroenteritis is usually resolved within 2 to 3 days and there are no long-term effects. If dehydration occurs, recovery is extended by a few days

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DISEASE PROCESS
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CLINICAL FEATURES OF GASTROENTERITIS

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THANK YOU!!!
By: Elizabeth Margaretha coass IPD. Periode 1 juli 7 sept 2013.

DIARE

PENDAHULUAN
Diare adalah BAB cair atau setengah cair, kandungan air tinja > normal (> 200 gr, > 200 cc/24 jam). Atau: BAB encer > 3x sehari Diare akut: < 15 hari Diare infektif: penyebabnya infeksi, sebaliknya disebut diare non infektif Diare organik: penyebabnya kelainan anatomik, bakteriologik, hormonal atau toksikologik; sebaliknya disebut diare fungsional

KLASIFIKASI
1. 2. 3. 4. 5. LAMA DAN WAKTU DIARE: AKUT KRONIK MEKANISME PATOFISIOLOGIK: OSMOTIK - SEKRETORIK BERAT - RINGAN INFEKTIF NON INFEKTIF ORGANIK - FUNGSIONAL

ETIOLOGI
A. INFEKSI 1. ENTERAL 2. PARENTERAL MAKANAN IMUNODEFISIENSI: hipogamaglobulinemia, penyakit granulomatosa kronik, def IgA dll TERAPI OBAT: antibiotik, kemoterapi, antasid TINDAKAN TERTENTU: gastrektomi, radiasi LAIN-LAIN: sindroma Zollinger Ellison, neuropati autonomik

B. C.

D.

E.
F.

ETIOLOGI DIARE AKUT DI RS.PERSAHABATAN JAKARTA

ETIOLOGI E.coli Vibrio cholerae Ogawa Aeromonas sp Shigella flexneri FREKUENSI 38,29% 18,29% 14,29% 6,29%

Salmonella sp Entamoeba histolytica

Ascaris lumbricoides Rotavirus Candida sp Vibrio NAG Trichuris trichiura Plesiomonas shigelloides Ancylostoma duodenalis Blastocystis hominis

5,71% 5,14%
3,43% 2,86% 1,71% 1,14% 1,14% 0,57% 0,57% 0,57%

INFEKSI
1. ENTERAL Bakteri: Shigella, Salmonella, E coli Virus: rotavirus, adenovirus, CMV, HIV Parasit (protozoa): E histolytica, G lamblia Worm: A lumbricoides, T trichiura Fungus: candida, monilia 2. PARENTERAL: OMA, pneumonia, E.coli 3. Travelers diarrhea: E coli, G lamblia, Shigella, E histolytica

MAKANAN
Intoksikasi makanan: makanan beracun atau mengandung logam berat, makanan mengandung bakteri/toksin: C perfringens, S aureus dll Alergi makanan: susu sapi, makanan tertentu Malabsorbsi/maldigesti: Karbohidrat: monosakarida (laktosa), disakarida (sakarosa) Protein: asam amino tertentu, celiac spure Lemak: rantai panjang trigliserida

KELOMPOK RESIKO TINGGI

1. 2. 3. Baru bepergian/melancong Makanan atau keadaan makan yang tidak biasa Homoseksual, pekerja seks, pengguna obat intravena, risiko infeksi HIV Baru saja menggunakan obat antimikroba pada institusi: institusi kejiwaan/mental, rumah perawatan, rumah sakit

4.

PATOFISIOLOGI
Diare dapat disebabkan 1/ lebih keadaan berikut:

1. 2. 3. 4.
5.

6. 7.
8.

Diare Osmotik: osmotik isi lumen usus Diare Sekretorik: sekresi cairan usus Malabsorbsi (asam empedu dan lemak): gangguan pembentukan micelle empedu Defek sistem pertukaran anion/transport elektrolit aktif di enterosit gangguan absorbsi Na+ dan air Motilitas dan waktu transit usus abnormal Gangguan permeabilitas usus Inflamasi dinding usus: diare inflamatorik Infeksi dinding usus: diare infeksi

PATOGENESIS DIARE INFEKSI

1. DIARE ENTEROTOKSIGENIK: karena bakteri non invasif seperti: V cholerae Eltor, ETEC (Enterotoxigenic E coli), C perfringens. Toksin pada mukosa sekresi aktif anion klorida diikuti oleh air, ion bikarbonat, kation natrium dan kalium

2.

DIARE ENTEROVASIF: EIEC (Enteroinvasif E coli), Salmonella, Shigella, Yersinia. Kerusakan dinding usus nekrosis dan ulserasi diare sekretorik eksudatif, tinja dapat bercampur lendir- darah Umumnya patogen usus halus tidak invasif, sebaliknya patogen ileokolon mengarah ke invasif

 DIARE ENTEROTOKSIGENIK: (Non invasif )

Toksin pada mukosa sekresi aktif anion klorida diikuti oleh air, ion bikarbonat, kation natrium dan kalium KLINIS: TANPA DEMAM, TANPA DARAH tinja air banyak, tidak ada leukosit di tinja, sering disertai nausea, sering pada diare turis (85%),

 Patogen: bakteri non invasif seperti ETEC (penyebab tersering diare turis), G lamblia, rotavirus, V cholera, jamur kolera: tinja seperti cucian beras, disertai muntah Sebab lain: bahan toksik pada makanan (logam berat misalnya preservatif kaleng, nitrit, pestisida, histamin pada ikan) Diagnosis: pemeriksaan tinja: tidak ada leukosit di tinja

 DIARE ENTEROVASIF: EIEC (Enteroinvasif E coli), Salmonella, Shigella, Yersinia. Kerusakan dinding usus nekrosis dan ulserasi diare sekretorik eksudatif, tinja dapat bercampur lendir- darah

KLINIS ADA DEMAM DAN TINJA BERDARAH

Disebabkan oleh mo invasif, sering di kolon, diare berdarah, sering tapi volume sedikit, sering diawali diare air

 Shigela spp, Campylobacter jejuni, Salmonella spp, Kultur tinja untuk Salmonella, Shigella, Campylobacter, Yersinia Diferensiasi klinik sulit, terutama membedakan dengan penyakit usus inflamatorik idiopatik non infeksi Banyak leukosit di tinja (patogen infasif)

DEHIDRASI
DERAJAT DEHIDRASI DITENTUKAN BERDASARKAN : 1. KEADAAN KLINIS 1. Dehidrasi ringan: kehilangan cairan 2-5% BB. Turgor kurang, suara serak, (vox choleroca), belum presyok 2. Dehidrasi sedang: kehilangan cairan 5-8% BB. Turgor buruk, suara serak, presyok/syok: nadi cepat, napas cepat dalam 3. Dehidrasi berat: kehilangan cairan 8-10% BB. Tanda dehidrasi sedang ditambah kesadaran menurun, otot kaku, sianosis 2. BERDASARKAN BERAT JENIS PLASMA 3. BERDASARKAN PENGUKURAN (CVP) Central Venous Pressure (CVP < +4 CM H20)

DIAGNOSIS
ANAMNESIS: jenis diare PEMERIKSAAN FISIK: bunyi usus, distensi abdomen, nyeri tekan PEMERIKSAAN PENUNJANG Lab: darah tepi, elektrolit, ureum kreatinin, pemeriksaan tinja, pemeriksaan giardiasis ELISA, serologi amuba Foto abdomen Rektoskopi/sigmoidoskopi: atas indikasi (diare berdarah)

PENATALAKSANAAN
1. 2. REHIDRASI: oral, NGT, IV DIET
Tidak puasa Minuman yang tidak mengandung gas Hindari kafein dan alkohol (motilitas) Makanan yang mudah dicerna Hindari susu sapi karena def laktase transien pada diare Antimotilitas: loperamid Pengeras tinja: atapulgite (4x2 tab/hari)

3. OBAT ANTI DIARE

4.

OBAT ANTIMIKROBA. Pengobatan empirik tidak dianjurkan pada kasus ringan, virus, atau bakteri non invasif

REHIDRASI
JUMLAH CAIRAN:
1. 1. BJ PLASMA METODE PIERCE

PEMBERIAN CAIRAN:
1. Tahap 1 : Rehidrasi inisial (2jam) sebanyak total kebutuhan cairan
2. Tahap 2 (1 jam) tergantung

2.

Ringan: 5% BB (kg)
kehilangan

Sedang: 8% BB (kg) Berat: 10% BB (kg)

cairan dalam tahap 1 3. Tahap 3 berdasarkan kehilangan cairan melalui tinja berikutnya dan IWL

METODE DALDIYONO

JENIS CAIRAN:
Oral: oralit, diberikan bila skor <3 dan tidak ada syok IV: cairan Ringer Laktat, NaCl 0,9%, dll

BJ PLASMA
Klasifikasi berdasarkan BJ Plasma: 1. Berat : BJ 1,032-1,040 2. Sedang : BJ 1,028 1,032 3. Ringan : BJ 1,025 1,028 Rumus kebutuhan cairan:

BJ PLASMA 1,025

x Berat Badan x 4

ml
0,001

METODE DALDIYONO
KEBUTUHAN CAIRAN SKOR ________

x 10% x Kg BB x 1

liter

15

SKOR DEHIDRASI
Klinis
Rasa haus/muntah
TD sistolik 6090 mmHg

Skor
1
1

Klinis
Vox cholerica

Skor
2

Facies cholerica 2

TD sistolik < 60 mmHg

Frekuensi nadi > 120/mnt

2
1

Turgor kulit menurun

Washer womans hand

1
1

Kesadaran apati 1
Somnolen, sopor, koma Frek napas > 30/mnt 2 1

Ekstremitas dingin
Sianosis Usia 50-60 tahun Usia > 60 tahun

1
2 1 2

OBAT ANTIMIKROBA
PENYEBAB Shigelosis S (para) typhi Campylobacter TERAPI Siprofloksasin 2 x 500 mg 3 hari Siprofloksasin 2 x 500 mg 10 hari, Amoksisilin 4x750 mg 14 hari Eritromisin 4x250mg 5 hari

Disentri ameba
V cholerae Giardia lamblia

Tinidazol 1 x 2 gram 3 hari

Siprofloksasin 1 x 1 gram Tinidazol 1 x 2 gram

Schistosoma
Strongiloides Isospora belli

Praziquantel 1 x 40 mg/kgBB
Albendazol 1 x 400 mg 3 hari Kotrimoksazol 3 x 960mg 14 hari

ALGORITME TATALAKSANA
Anamneses
Lama, Epidemiologi, Bepergian, Makanan, air
PEMERIKSAAN FISIK

Karakteristi k Tinja, air, berdarah

Nyeri abdomen Kolitia akut Penyakit

usus/ inflamasi

Penyakit lain, Obat-obatan

Umum, Keseimbanga n Cairan, suhu, nutrisi

Abdomen Nyeri tekan distensi

Pemeriksaa n Rektal, Fecal occult Blood test

PEMERIKSAAN AWAL Toksik Penyakit berjalan terus Darah di tinja Dehidrasi

Nontoksik Lama penyakit Sebentar Tidak berdarah Tidak nyeri tekan

Terapi simtomatik Cairan rehidrasi oral Obat antidiare

TIDAK RESPON
Replesi cairan / elektrolit

RESPON

Evaluasi laboratorium
Pemeriksaan darah tepi lengkap Hemokonsentrasi Diferensial leukosit

Kimia darah Elektrolit Ureum Kreatinin Serologi ameba

Pemeriksaan tinja Pem telur & parasit Antigen Giardia Toksin clostridium difficile

Leukosit tinja Positif Negatif Sigmoidoskopi atau Kolonoskopi dengan Biopsi Terapi antibiotik empirik Terapi spesifik

Kultur tinja

THANK YOU!!!
By: Elizabeth Margaretha coass IPD. Periode 1 juli 7 sept 2013.