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7/31/2019 Case Report Gastroenteritis
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Case report : Gastroenteritis
PRESENTED BY
ADE IRMA 070100054
SRI WAHYUNI 070100076
SUPERVISOR : Prof. dr. Atan Baas Sinuhaji, Sp.A(K)
PEDIATRIC DEPARTEMENT
HAJI ADAM MALIK GENERAL HOSPITAL2011
1
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Definition Gastroenteritis
Diarrhoea is the passage of unusually loose or
watery stools, usually at least three times in a
24 hour period. However, it is the consistency
of the stools rather than the number that is
most important. Frequent passing of formed
stools is not diarrhoea (WHO, 2005).
2
WHO. The Treatment of Diarrhoea: a Manual for Physicians and Other Senior Health
Workers 2005.
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Epidemiology
3Farthing et al. Acute Diarrhea. World Gastroenterology Organisation, 2008;
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Inverse association between coverage rates of oral rehydration
solution (ORS) use and rates of mortality from diarrhoea in
various countries.
4Farthing et al. Acute Diarrhea. World Gastroenterology Organisation, 2008;
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Etiology
Causes of diarrhoea with acute onset includethe following:
Infections
Drug-induced
Food allergies or intolerances
Disorders of digestive/absorptive processes
Chemotherapy or radiation-induced enteritis
Vitamin deficienciesGuandalini S. Diarrhea. Available from: http://emedicine.medscape.com/article/928598-followup[Accesed 23
February 2011].
5
http://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followup7/31/2019 Case Report Gastroenteritis
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Infectious causes of acute diarrhoea in
developed countries
Viruses
Rotavirus - 25-40% ofcases
Norovirus - 10-20% of
cases Calicivirus - 1-20% of
cases
Astrovirus - 4-9% ofcases
Enteric-type adenovirus -2-4% of cases
Bacteria
Campylobacter jejuni - 6-8% of cases
Salmonella - 3-7% of
cases E Coli - 3-5% of cases
Shigella - 0-3% of cases
Y enterocolitica - 1-2% ofcases
C difficile - 0-2% of cases
Vibrio parahaemolyticus -
0-1% of cases V cholerae - Unknown
Aeromonas hydrophila -0-2% of cases
Parasites
Cryptosporidium - 1-3% of cases
G lamblia - 1-3% ofcases
6Guandalini S. Diarrhea. Available from: http://emedicine.medscape.com/article/928598-followup [Accesed 23 February 2011].
http://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followup7/31/2019 Case Report Gastroenteritis
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Classification
which lasts several hours or days: the main danger is dehydration;weight loss also occurs if feeding is not continued;
Acute watery diarrhoea (including cholera)
Bloody and mucous present. The main dangers are damage of theintestinal mucosa, sepsis and malnutrition
Acute bloody diarrhoea (Dysentry )
which lasts 14 days or longer
Persistent Diarrhoea
Main dangers are severe systemic infection, dehydration, heart failureand vitamin and mineral deficiency
Diarrhoea with severe malnutrition (marasmus orkwashiorkor):
7
WHO. The Treatment of Diarrhoea: a Manual for Physicians and Other Senior Health Workers.2005.
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Feces from humans or animals containing pathogenic microbes
or their toxins
food fluids fingers
Ingestion of organism and/ or toxin
Organisms multiply and toxinproduced but infection remain in GI
tract
Organism invade or toxins absorbed
dissemination
Symptoms ofsystemic
infection ex.
Fever etc.
DIARE
Pathogenesis of diarrhoea 8
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Pathophysiology
9
Silbernagl S and Lang F. Color Atlas of Pathophysiology. New York: Thieme, 2009;
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10https://reader009.{domain}/reader009/html5/0426/5ae1c46babdad/5ae1c472cad85.png
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Diagnosis
History : askpresence of blood in the
stool; duration of diarrhea; number of
watery stools per day; number ofepisodes of vomiting etc.
Physical examination: look and feel
Take temperature
11
WHO. The Treatment of Diarrhoea: a Manual for Physicians and Other Senior Health Workers
2005.
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Look and Feel
12WHO. The Treatment of Diarrhoea: a Manual for Physicians and Other
Senior Health Workers 2005.
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Laboratory
Completeblood count
Electrolyte Anal swabCulture
stool
Immuno
assay
13
Guandalini S. Diarrhea. Available from: http://emedicine.medscape.com/article/928598-followup [Accesed 23
February 2011].
http://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followup7/31/2019 Case Report Gastroenteritis
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Differential Diagnose
Appendicitis
Intussuception
Crohn disease
Irritable bowel syndrome
14
Guandalini S. Diarrhea. Available from: http://emedicine.medscape.com/article/928598-followup [Accesed 23 February 2011].
http://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followuphttp://emedicine.medscape.com/article/928598-followup7/31/2019 Case Report Gastroenteritis
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Treatment
ORS, iv infusionZn
Nutrition
Vitamin A
Antibiotic
Probiotic
15WHO. The Treatment of Diarrhoea: a Manual for Physicians and Other Senior HealthWorkers.2005.
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16
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17
Ionic composition of intravenous infusion solutions
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Prevention
Water, sanitation, and hygiene:
Safe food:
Cooking eliminates most pathogens from foods
Exclusive breastfeeding for infants
Weaning foods are vehicles of enteric infection.
Micronutrient supplementation: the effectiveness
of this depends on the childs overall immunologic
and nutritional state; further research is needed.
vaccines
18Farthing et al. Acute Diarrhea. World Gastroenterology Organisation, 2008;
CASE REPORT
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CASE REPORT
19
7-months-old girl
(BW: 7kg & BH: 70cm)
February 13th 2011
diarrhea
Since 3 days ago
The frequency is 10times in a day
The volume glass
every time diarrheaIn feces the water ismore than the dregs
Mucus (+)
Blood (+)
Vomitiing
The frequency is 3times in a day
The volume 20 ccfor each time
vomiting
the contents ofvomite is that what
she ate and drank
Fever
Since since oneweek ago
high temperature
Fever lowered with
antipyretic
Seizure (-)
shiver (-)
recurrent fever (+)since birth
Wormsinfection
Weight loss (+)
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20
Patient was born spontaneously
aided by a midwife
cried immediately at birth
Cyanosis (-)
History of birth
fever (-), hypertension (-), diabetes mellitus(-),drugs(-)
used the herbal medicine while two monthspregnancy (used for abortion)
Patient is the fifth child
mother age is 32 years old
History ofmaternal
conditions
0-2 months : Breast feed and cow milk 2 monthsnow : breast feed, cow milk and
porridgeAte history
BCG (+), Polio (three times), Hepatitis B (two
times), DPT (two times).
History of
immunization
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PHYSICAL EXAMINATION
Generalized Status:
Body weight : 7 kg
Body height : 70 cm
BW/ BH : 82,3% (mild malnutrition)
Sensorium : Compos Mentis Body Temperature: 38,2 oC
Anemic (-)
Icteric (-)
Cyanotic (-)
Oedem (-)
Dyspnoe (-)
21
Light reflexes (+/+)
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22
Light reflexes (+/+)
Isochoric pupiloric,
pale on inferior palpebrals conjunctival (-/-)
sunken eyes (+)
Examination of the ear, mouth and nose cannotbe found any abnormalities.
Head
Lymph node enlargement (-)Neck symmetrical fusiform.
Heart rate was 132 bpm, regular, murmur (-)
Respiratory rate 40 tpm regular, ronchi (-)
Chest Soft and tenderness,
peristaltic was increased
the liver and spleen was unpalpable,
turgor slow to return.Abdominal
Pulse was 132 bpm, regular, pressure andvolume were normal
acral was warm.
Blood pressure was 90/60 mmHg
Extremities
Female. No abnormalitiesUrogenital
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Working Diangnosis
Gastroenteritis with mild-moderate
dehydration.
23
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Management
IVFD RL 75cc/kgBB/4hours 130 cc 130
gtt/i micro
Paracetamol 3 x 100 mg (pulv)
Breast feed + porridge diet of 700 ccal with 96
gram of protein
24
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Investigation Plan
Complete Blood Count
Electrolit
Ad random glucoseRenal function test
Liver function test
25
L b t i Fi di (D b 13th 2010) f P t l Cli i
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Laboratorium Findings (December 13th 2010) from Patology Clinic
Adam Malik General Hospital
26
Test
Result Normal Value
Hemoglobin (Hb)
Erytrocyes (RBC)
Leucocytes (WBC)
Hematocrit
Thrombocyte (PLT)
MCV
MCH
MCHC
RDW
Complete Blood Count
10.50 g%
4.82 x 106/mm3
11.00 x 103/ mm3
33.20 %
456 x 103/ mm3
68.80 fL
21.80 pg
31.70 g%
15.70 %
11.1-14.4
3.71-4.25
6.0-17.5
35-41
217-497
82-100
24-30
28-32
14.9-18.7
Neutrophil
Lymphocyte
Monocyte
Eosinophil
Basophil
Cell Count
37.80 %
47.10 %
12.90 %
0.12 %
2.040 %
37-80
20-40
2-8
1-6
0-1
Sodium
Potassium
Chloride
Ad random glucose
Electrolit
133
3,4
90
Carbohydrate metabolism
104.00 mg\dl
135-155
3.6-5.5
96-106
< 200
Follow Up Date 14/2/2011
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Follow Up Date 14/2/2011
27
S : Diarrhea (+), the frequency is 7 times in a day, in feces the water is more than the
dregs
O: Consciousness: Compos Mentis T: 37.7oC, BW: 7kg, BH: 70cm, BW/ BH: 82,3%
Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior palpebralsconjunctiva (-/-), Ears and Nose: no, Mouth: dry mouth (+)
Neck : Lymph node enlargement (-)
Chest : Symmetrical fusiformic, retraction (-),
HR: 126 bpm, regular, murmur (-)
RR: 38 tpm, regular, ronchi(-).
Abdomen : Soft and terderness, normal peristaltic. No liver and spleen enlargement.
Extremities : Pulse 126 bpm, regular, Pressure/Volume: adequate, warm acral
BP: 90/60 mmHg
Urogenital : Female, no abnormalitites
A: Gastroenteritis without dehydration.
P : IVFD D5% NaCl 0.225%: 30 gtt/i microParacetamol 3 x100 mg (pulv)
porridge 700 ccal with 14 gram of protein
Follow Up Date 15/2/2011
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Follow Up Date 15/2/2011
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S : Diarrhea (+), the frequency is 3 times in a day, the volume 20 cc everytime
diarrhea , in feces the water is more than the dregs
O: Consciousness: Compos Mentis T: 36.8oC, BW: 8kg, BH: 70cm, BW/ BH: 94.12%
Head : Eyes: Light reflexes(+/+), isochoric pupil, pale inferior palpebrals
conjunctiva (-/-), Ears, Nose, Mouth: no abnormalities
Neck : Lymph node enlargement (-)
Chest : Symmetrical fusiformic, retraction (-),
HR: 140 bpm, regular, murmur (-)
RR: 4 tpm, regular, ronchi(-).
Abdomen : Soft and terderness, normal peristaltic. No liver and spleen enlargement.Extremities : Pulse 140 bpm, regular, Pressure/Volume: adequate, warm acral,
BP: 90/60 mmHg
Urogenital : Female, no abnormalitites
A: Gastroenteritis without dehydration.
P : IVFD D5% NaCl 0.225%: 30 gtt/i microParacetamol 3 x100 mg (pulv)
Zink 1x20 mg
porridge 700 ccal with 14 gram of protein
Follow Up Date 16/2/2011
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Follow Up Date 16/2/2011
29
S : Diarrhea (+), the frequency is 4 times in a day, the volume 20 cc everytime
diarrhea , in feces the water is more than the dregs
O: Consciousness: Compos Mentis T: 37.4oC, BW: 8kg, BH: 70cm, BW/ BH: 94.12%
Head : Eyes: Light reflexes(+/+), isochoric pupil, pale inferior palpebrals
conjunctiva (-/-), sunken eyes (-), Ears and Nose: no abnormalities,
Mouth: dry mouth (+)
Neck : Lymph node enlargement (-)
Chest : Symmetrical fusiformic, retraction (-),
HR: 132 bpm, regular, murmur (-)
RR: 52 tpm, regular, ronchi(-).Abdomen : Soft and terderness, normal peristaltic. No liver and spleen enlargement.
Turgor fast return (+)
Extremities : Pulse 132 bpm, regular, Pressure/Volume: adequate, warm acral,
BP: 100/60 mmHg
Urogenital : Female, no abnormalititesA: Gastroenteritis without dehydration.
P : IVFD D5% NaCl 0.225%: 30 gtt/i micro
Paracetamol 3 x100 mg (pulv)
Zink 1x20 mg
porridge 700 ccal with 14 gram of protein
Oralit 50-100 cc/each time diarrhea
Follow Up Date 17/2/2011
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Follow Up Date 17/2/2011
30
S : Diarrhea (+), the frequency is 4 times in a day, in feces the water and dregs were the
same, mucus (+), blood (-).
O: Consciousness: Compos Mentis T: 38oC, BW: 8kg, BH: 70cm, BW/ BH: 94.12%
Head : Eyes: Light reflexes(+/+), isochoric pupil, pale inferior palpebrals
conjunctiva (-/-), sunken eyes (-), tears (+). Ears, Nose, and Mouth: no
abnormalities
Neck : Lymph node enlargement (-)
Chest : Symmetrical fusiformic, retraction (-),
HR: 152 bpm, regular, murmur (-)
RR: 40 tpm, regular, ronchi (-).Abdomen : Soft and terderness, normal peristaltic. No liver and spleen enlargement.
Turgor fast return (+)
Extremities : Pulse 152 bpm, regular, Pressure/Volume: adequate, warm acral,
BP: 100/60 mmHg
Urogenital : Female, no abnormalititesA: Gastroenteritis without dehydration.
P : IVFD D5% NaCl 0.225%: 30 gtt/i micro
Paracetamol 3 x100 mg (pulv)
Zink 1x20 mg
porridge 700 ccal with 14 gram of protein
Oralit 50-100 cc/each time diarrhea
Laboratorium Findings (December 17th 2010) from Patology Clinic
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Laboratorium Findings (December 17 2010) from Patology Clinic
Adam Malik General Hospital
31
Test
Result Normal Value
Hemoglobin (Hb)
Erytrocyes (RBC)
Leucocytes (WBC)
Hematocrit
Thrombocyte (PLT)MCV
MCH
MCHC
RDW
Complete Blood Count8.80 g%
3.97 x 106/mm3
9.21 x 103/ mm3
26.30 %
404 x 103
/ mm3
56.20 fL
22.20 pg
33.50 g%
17.40 %
11.1-14.4
3.71-4.25
6.0-17.5
35-41
217-49782-100
24-30
28-32
14.9-18.7
Neutrophil
Lymphocyte
Monocyte
Eosinophil
Basophil
Cell Count23.80 %
53.50 %
20.20 %
1.80 %
0.700 %
37-80
20-40
2-8
1-6
0-1
Electrolit
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Sodium
Potassium
Chloride
Ad random glucose
Total bilirubin
Direct bilirubin
ALP
SGOT
SGPT
Ureum
Creatinine
Uric acid
ColorConsistency
Blood
Mucus
Worm egg
Amoeba
Red blood cells
White blood cells
137
2.0
108
Carbohydrate metabolism
86.80 mg\dl
Liver function test
0.23 mg/dl
0.09 mg/dl
83 U/L
24 U/L
10 U/L
Renal function test
8.00 mg/dl
0.23 mg/dl
1.7 mg/dl
Anal swab
YellowWatery
Negative
Negative
Negative
Negative
0-1
0-1
135-155
3.6-5.5
96-106
< 200
< 1
0-0.2
< 462
< 32
< 31
< 50
0.17-0.42
< 5.7
Negative
Negative
Negative
Negative
Di i
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Discussion
33
Theory Case
Diarrhea is the passage of unusuallyloose or watery stools, usually at least
three times in a 24 hour period.
However, it is the consistency of the
stools rather than the number that is
most important
the patient was admitted with chiefcomplain diarrhea and the frequency is
10 times in a day with the water is
more than the dregs.
Acute diarrhea is thus defined as an
episode that has an acute onset and lasts
no longer than 14 days
the patient has acute diarrhea because
he has diarrhea for 7 days
A child with diarrhea should be assessedfor dehydration. In some dehydration,
we must look at the condition (restless,
irritable), sunken eyes, thirsty and
eagerly to drink, and feel the skin pinch
that goes back slowly
the patient was restless, has sunkeneyes, thirsty and eagerly to drink.
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Theory Case
Replacement of fluid and electrolytes
is the most important to treat diarrhea.
This patient, general supportive care
should include IVFD RL
75cc/kgBB/4hours
The children usual diet should be
continued during diarrhea and
increased afterwards. Food should
never be withheld and the child's
usual foods should not be diluted.
Breastfeeding should always be
continued.
The patient continued to has
breastfeeding addition with porridge
diet of 700 ccal with 96 gram of
protein
By giving zinc as soon as diarrhea
starts, the duration and severity of the
episode as well as the risk of
dehydration will be reduced
On February 15th 2011, the patient got
zinc for the first time.
34
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Summary
It has been reported that a case of a 7-months-old
girl diagnosed as gastroenteritis with mild-
moderate dehydration. The diagnosis was
established based on history taking, clinical
manifestation, and laboratory finding. Thetreatment of this patient are IVFD D5% NaCl
0.225%, Paracetamol, Zink, Oralit, and diet
(porridge) 700 ccal with 14 gram of protein. The
patient has been recovered after get medicationfor 4 days in Adam Malik General Hospital and
was controlled at Adam Malik General Hospital
gastroentererology polyclinic.35
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