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TABLE OF CONTENTS

Table of contents .............................................................................................. 1


BAB 1 Introduction .......................................................................................... 2
BAB 2 Gastroenteritis ...................................................................................... 4
2.1. Definition...................................................................................... .. 4
2.2. Epidemiology.................................................................................. 4
2.3. Etiology .......................................................................................... 4
2.4. Pathogenesis. .................................................................................. 6
2.5. Diagnosis and clinical features. ...................................................... 7
2.6. Risk Factors. ................................................................................... 9
2.7. Treatments ...................................................................................... 11
2.8. Differential Diagnosis ...................................................................... 21
2.9. Complications .................................................................................. 22
2.10. Preventiom ..................................................................................... 23
2.10.1. Rotavirus Vaccine ................................................................... 23

BAB 3 Case Report .......................................................................................... 25

BAB 4 Discussion and Summary..................................................................... 32

References ........................................................................................................ 35

1
INTRODUCTION

Gastroenteritis is a common infection of the bowel that can cause diarrhoea


(runny faeces or poo), vomiting, or both. Gastroenteritis normally settles quickly
without treatment. Vomiting may last a day or two. Diarrhoea usually lasts two to
three days but can last up to 10 days.1
Gastroenteritis can cause dehydration. Babies under six months of age are
most at risk. The most common cause of gastro is a virus, which tends to spread
very easily. Less common causes of gastro include bacteria or food poisoning.
Most causes of gastro are not helped by antibiotics.1
Gastrointestinal tract and is characterized by diarrhea or vomiting. It is a
common childhood disease. Children in developing countries are particular at risk
of both morbidity and mortality. Worldwide, gastroenteritis affects 3 to 5 billion
children each year, and accounts for 1.5 to 2.5 million deaths per year or 12% of
all deaths among children less than 5 years of age.2
Diarrheal disease remains a global health problem especially in developing
countries. The magnitude of the problem is evident from the high morbidity and
mortality due to diarrhea. WHO estimates that 4 billion cases occurred in the
world in 2000 and 2.2 million of them died, most of children under 5 years. In
Indonesia, diarrhea is still one major public health problem. This is due to a high
rate of cause a lot of pain and death, especially in infants and toddlers, as well as
frequent cause of outbreaks.2
In developed countries, such as the United States, acute gastroenteritis
seldom causes deaths, however, it still accounts for 300 deaths per year.
Moreover, it puts a heavy burden on the health care system. Acute gastroenteritis
causes 1.5 million visits to primary care providers each year and 220,000 hospital
admissions for children under the age of 5 years; that is 10% of all the hospital
admissions of children in the United State. 3
In general, developing countries have a higher rate of hospital admissions
as compared to developed countries. In the United States, the admission rate is 9
per 1000, per annum, for children younger than 5 years old. When compared to

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the United Kingdom and Australia, the admission rates are around 12 to 15 per
1000 per annum. However, the rate increases dramatically to 26 per 1000 per
annum in China. This may be due to the facts that children in developed Countries
have a better nutrition status and better primary care.4
Diarrhea is one of the health problems in Indonesia and according
Household Health Survey 1986 turns diarrheal disease in 8 Indonesia's major.
Diarrhea morbidity reaches 200 to 400 events per 1000 population of the year.
Most (70% - 80%) of patients are children under five and 1% -2% of patients will
fall into dehydration and or will die. Recorded 300.000-500.000 toddler who died
from diarrhea.5
The difference can also be explained by the fact that, the incidence of
acute gastroenteritis is significantly higher in developing countries than the
industrialized countries.6

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GASTROENTERITIS

2.1. DEFINITION
Gastroenteritis is an infection of the gut (intestines). The severity can
range from a mild tummy upset for a day or two with some mild diarrhoea, to
severe diarrhoea and vomiting for several days or longer. Many viruses, bacteria
and other microbes (germs) can cause gastroenteritis. Viruses are easily spread
from one person to another by close contact.
This is often because of the virus being present on people's hands after
they have been to the toilet. Surfaces or objects touched by the infected person
can also allow transmission of the virus. The virus can also be passed on if the
infected person prepares food. Outbreaks of a virus causing gastroenteritis in
many people can occur - for example, in schools, hospitals or nursing homes.
Food poisoning (eating food infected with microbes) causes some cases of
gastroenteritis.

2.2. EPIDEMIOLOGY
According to the Ministry of Health (2003), the incidence of diarrhea in
Indonesia in 2000 was 301 of 1000 population for all age groups and 1.5
episode each year for the toddler age group. Cause Specific Death Rate (CSDR)
diarrhea toddler age group is about 4 of 1000 infants.5
Incidence of diarrhea in boys almost the same with girls.
The disease is transmitted through the fecal-oral food and drink contaminated. In
developing countries, the high incidence of diarrheal disease is a combination of a
source of contaminated water, lack of protein and calories that cause a decline in
the immune system.7

2.3. ETIOLOGY
Viruses are the most important etiology and are responsible for
approximately 70% of the episodes of acute gastroenteritis in children.10 There

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are over 20 different types of viruses that have been identified as etiological
agents.8
Worldwide, rotavirus is still the most common virus causing this disease
and accounts for some 30% to 72% of all the hospitalizations and 4% to 24% of
acute gastroenteritis at the community level. Virtually all children have been
infected with rotavirus by the age of 3 years. Rotavirus infection is seasonal in
temperate climates, peaking in late winter, although it occurs throughout the year
in the tropics. The peak age for infection ranges from 6 months to 2 years.9
Other common viruses causing gastroenteritis include calicivirus,
adenovirus and astrovirus. Globally these viruses are responsible for diarrhea
episodes in hospitalized children, with detection rates varying from 3.2%29.3%,
1%31%, and 1.8%16%, respectively. Rates of virus infection are similar in both
developed and less developed countries.9
Bacterial infection accounts for 10% to 20% of all the acute
gastroenteritis. The most common bacterial causes are, Salmonella species,
Campylobacter species, Shigella species and Yersina species. Vibrio cholerae
remains a major cause of diarrhea, especially after a disaster where sanitation is
compromised. Giardia lamblia is the most common protozoal infection that
causes gastroenteritis, although it tends to be associated with more persistent
diarrhea. Other protozoa include Cryptosporidium species and Entamoeba
histolytica.9
However, less developed countries have a higher rate of parasites and
Escherichia coli infection which are both relatively uncommon in the
industrialized countries. This indicates that improvement in sanitation will not
decrease the disease prevalence of viral infection but can help in prevention of
parasites and bacterial infections.9

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Gastroenteritis clinical picture based on etiology:
Symptom Rotavirus Shigella Salmonell EIEG EIGG kolera
a
Fever ++ ++ ++ - ++
nausea/vomi Often Rarely Often - - often
t
abdominal tenesmus Cramp Kolik - Cramp cramp
pain
Headache - + + - - -
Duration of 5-7 hours > 7 hours 3-7 hours 2-3 hours Variation 3 hours
illness s
Feces
Volume moderete Little Little many Little Many
Fequency 5-10x/hr > 10x/hr Many many Many Continu
e
Consistency liquid Mushy Mushy liquid Mushy Liquid
Mucus seldom Often + + + +
Blood - Often Sometime - + -
s
Color yellow, red, green Greenish colorless red, green washing
green rice
Odour - +/- Foul + - Fishy
Leukosit - + + - + -
Other anoreksia Seizures +/- sepsis +/- meteorismus Infeksi -

2.4. PATHOGENESIS
The most common cause of diarrhea in children are caused by rotavirus.
This virus causes 40-60% of cases of diarrhea in infants and children. After
exposure to a particular agent, the virus enters the body along with food and
drinks. Then the virus it will be up to the epithelial cells of the small intestine and

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will cause infection and damage the epithelial cells. Epithelial cells are damaged
will be replaced by new enterocytes shaped cells cuboidal or flattened epithelial
cells are immature cells that function is still not good. This causes the small
intestine villi will atrophy and can not absorbed water and food. Fluids and food
will be collected earlier in the small intestine and will increase the osmotic
pressure of the gut. This causes a lot of fluid drawn into the lumen of the intestine
and will cause intestinal hiperperistaltik. Fluids and food are not absorbed before
will be driven out through the anus and there was diarrhea.10

2.5. DIAGNOSIS & CLINICAL FEATURES

History

The objectives of the history and physical examination are to assess whether the
child is dehydrated and to determine the etiology of the acute gastroenteritis, if
possible. The history should include the following:

how often the child is urinating and having bowel movements, whether vomiting
is interfering with the child's ability to keep down fluids and solid food, the
duration of illness, the nature of the stools (e.g., whether blood or mucus is
present), the type of emesis (e.g., whether bile is present), the presence of fever,
the child's mental status, any accompanying medical conditions, recent exposure
to a potentially untreated or compromised water supply (e.g., travel), availability
of a caregiver to provide oral rehydration therapy, and whether oral rehydration
therapy has been attempted with any success.12 Specific questions should be asked
to rule out other potential illnesses that can cause diarrhea. Caregivers can be
interviewed by telephone about the child's symptoms.

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Physical Examination

Red Flags in a Child with Diarrhea Warranting Urgent Physician Evaluation

- Caregiver report of decreased tearing, sunken eyes, decreased urine


output, or dry mucous membranes
- Fever
100.4F (38C) in infants younger than three months
102.2F (39C) in children three to 36 months of age
- Frequent and substantial episodes of diarrhea
- History of premature birth, chronic medical conditions, or an
accompanying illness
- Mental status changes (e.g., apathy, lethargy, irritability)
- Persistent vomiting
- Poor response to oral rehydration therapy or inability of the caregiver
to give adequate therapy
- Visible blood in the stool
- Young age (younger than six months) or low body weight (less than 17
lb, 10 oz [8 kg]) 3

It is important to assess hydration in gastroenteritis as hydration status


determines the immediate management of this condition. The infant or child with
profuse watery diarrhoea and frequent vomiting is most at risk. Clinicians often
overestimate the extent of dehydration. Clinical signs are usually not present until
a child has lost at least 5% of his or her body weight. Documented recent weight
lost is a good indicator of the degree of dehydration, but this information is rarely
available. The best clinical indicators of more than 5% dehydration are prolonged
capillary refill, abnormal skin turgor, and absent tears.13

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The degree of dehydration (WHO 2005)
No sign of dehydration Some dehydration Severe
Condition Well Restless /irritable Lethargic/coma
Eyes Normal Sunken Sunken
Thirsty Normal, not thirsty Thirsty Drinks poorly
Skin Turgor Fast Slowly Very slowly (> 2)
NB: 1. Reading from right to left
2. Considered severe or some dehydration if 2 or more the sign are
present

Laboratory Testing

Serum electrolyte measurement is usually unnecessary in children with mild to


moderate dehydration. Urine specific gravity and blood urea nitrogen
measurements have poor sensitivities and specificities for diagnosing dehydration
in children.14 Laboratory values may be helpful in evaluating severe dehydration,
for which intravenous fluids and electrolyte supplementation (especially
potassium, bicarbonate, and sodium) are needed. Although it is not necessary to
routinely obtain stool cultures and send stool for ova and parasite testing, they
should be collected in cases of persistent diarrhea (at least 14 days) or if an
outbreak of a diarrheal disease needs to be diagnosed (e.g., rotavirus infection).12

2.6. RISK FACTORS


1. Nutritional status
Weight and duration of diarrhea was strongly influenced by nutritional status and
diarrhea suffered by children with severe malnutrition when compared with good
nutritional status of children as children with malnutrition status and stool output
more fluid so that the child will suffer severe dehydration. Infants and toddlers
who are malnourished, most of which died because of diarrhea. This can be
caused by dehydration and malnutrition.7
2. Socioeconomic Factors

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Socioeconomic factors also have a direct influence on the factors that cause
diarrhea. Most children who suffer from diarrhea easily come from large families
with low purchasing power, poor housing conditions, do not have clean water
supplies that meet the requirements of health, low education parents and attitudes
and habits that are not beneficial. Therefore, education and economic
improvement was instrumental in the prevention and control of diarrhea.7

3. Education Factors
The high morbidity and mortality ( morbidity and mortality ) due to diarrhea in
Indonesia caused by factor inadequate environmental health, nutritional status,
demography, education, socio-economic circumstances and behavior that directly
or indirectly affect the state of the diarrheal disease.11

4. Toddler Age Factor


Most of diarrhea occur in children under the age of 2 years. The results of further
analysis of IDHS (1995 ) found that toddlers aged 12-24 months had 2.23 times
the risk of diarrhea than children aged 25-59 months.11

5. Breastfeeding
Exclusive breastfeeding is breastfeeding newborns up to age 6 months, without
any additional food given. states that the increased incidence of diarrhea during
the first child to recognize food additives and is gradually increasing.18 Full
breastfeeding would provide protection diarrhea 4 times than breastfed infants
with milk bottles. Babies with a milk bottle most discussions will have a greater
risk of diarrhea and even 30 times more than fully breastfed infants.5

6. Household Toilet Factors


The risk of diarrhea was greater in families who do not have household toilet
facilities and provision of public toilets can reduce the risk of the incidence of
diarrhea. In connection with the personal hygiene of the people who supported the

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habitual situation polluting the surrounding environment and especially in areas
where water is a problem and bowel habits are not healthy.11

7. Factors Water Source


The source of water is the water used to get. The raw water is treated before it is
used once, but some are directly used by the public. Raw water quality generally
depends on where the water source is obtained .There are several sources of water
such as: rainwater, groundwater ( dug wells, pumping wells ), surface water (
rivers, lakes ) and springs. If the water quality of the water source has been
qualified in accordance with health regulations, can be directly used, but if it does
not meet the requirements, must go through the water treatment process first.
Based on data from demographic and health survey 1997, a group of children
under five years whose families use the facilities dug wells have 1.2 times the risk
of diarrhea compared with children whose families use the well pump source.11

2.7. TREATMENT

Flow Chart for the Management of Suspected Gastroenteritis

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* Details about IV rehydration and oral rehydration therapy below.

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Oral Rehydration Therapy (ORT)

This is the treatment of choice for dehydration from gastroenteritis. It is safer and
more effective than IV therapy for all degrees of dehydration except shock.

ORT uses Oral Rehydration Solution, which takes advantage of glucose / sodium
co-transport mechanisms in the small bowel.

[Electrolyte] (mmol/l)

Preparation Na+ K+ Chloride Citrate Glucose (%)

Gastrolyte 60 20 60 10 1.8

Pedialyte 45 20 35 30 2.5

Certain principles must be remembered:

ORT is intensive. It depends on a lot of input from the child's caregiver, or


the use of a nasogastric tube.
Pedialyte is the ORS of choice
The treatment of gastroenteritis with ORS occurs in two phases:
rehydration and maintenance. Except in hypernatraemia, ORT aims for
full rehydration within 4 (or at most 12) hours of admission.
The schedule suggested here for the rehydration phase is a standard rate of
replacement for all dehydrated children who are not shocked. The final
volume given is determined by clinical assessment of when the child is
rehydrated.
During the rehydration phase, fluid is given at a rate of 5 ml per minute,
by teaspoon or syringe. The small volumes decrease the risk of vomiting.
The rate (1 teaspoon / minute) is easy to calculate and administer for a
parent sitting at the bedside. 25 ml every 5 minutes can also be used.

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This rate of replacement is already maximal, and is not supplemented for
ongoing losses. If the child's ongoing losses exceed an intake at this rate,
the child will require nasogastric or intravenous fluids. This rate will
rehydrate a moderately dehydrated 1 year old in 2 to 4 hours and a 2 year
old in 3 to 5 hours (estimating diarrhoea at 0 -10 ml per kg per hour).
An alternative rate is 25 ml / kg /hr, in small aliquots frequently
There must be frequent review (at least 2 hourly) in the rehydration phase.
Vomiting is not a contra-indication. Most children with gastroenteritis who
vomit, will still absorb a significant percentage of any fluid given by
mouth or NG. 18

Nasogastric Tube

Delivery of ORS by constant infusion through a NG tube is very effective. If the


clear diagnosis is gastroenteritis, choose NG infusion in preference to IV fluids in
the child who is refusing ORS, has intractable vomiting or profuse diarrhoea, or
where there is no caregiver able to give ORS by mouth. The principles are the
same: to rehydrate fully within 4 hours in the iso-osmolar child, and more slowly
in the moderately hypernatraemic child.

Rate for constant infusion is 25 ml/kg/hr Pedialyte.


Reduce rate to 15 ml/kg/hr in moderate hypernatraemia.
Medical review at least every 2 hours is mandatory during rehydration.

When the child is rehydrated, remove the NG tube. If there is doubt about the
child's ability to drink to keep up with ongoing losses, then it can be left in until
this is clarified.18

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Intravenous Rehydration in Osmolar or Hypo-Osmolar Dehydration

Most children with gastroenteritis do not need IV therapy. Indications for an IV


are:

Shock
If oral fluids might be unsafe (decreased consciousness, ileus, surgical
abdomen)
Severe hyperosmolality ([Na+] > 170, osmolality > 350)
The failure of oral or NG rehydration due to intractable vomiting (rare)

After correcting shock, the speed of IV rehydration varies with osmolality. If the
osmolality is < 350, the child has been fully resuscitated, is fully conscious and
able to drink, and has no evidence of paralytic ileus change to oral or NG fluids.

Calculation of Osmolality The serum osmolality can be measured directly, but is


easy to calculate:

Serum osmolality (mOsm / l) = (2x[Na+]) + (2x[K+]) + [Urea] + [Glucose]

Definition Serum Osmolality Serum [Na+]

Hypo-osmolar < 280 < 130

Iso-osmolar 280 - 319 130 150

Hyperosmolar (Moderate) 320 - 350 > 150

Hyperosmolar (Severe) > 350 > 170

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Calculation of Maintenance Fluids (requirement per 24 hours)

Age < 1 month 120 ml / kg / day

Age > 1 month as below

Weight Hourly maintenance fluid requirements

< 10 kg 4 ml/kg/hr

10 - 20 kg 40 ml/hr + 2 ml/hr for every kg over 10

> 20 kg 60 ml/hr + 1 ml/hr for every kg over 20

Iso-osmolar Dehydration ([Na+] 130 - 150 mmol/l, osmolality 280 - 319)

Use 0.45% NaCl and 2.5% Dextrose. Replace the rest of the deficit + maintenance
over 24 hours. Give 1/2 the deficit in the first 8 hours, and the other 1/2 over 16
hours.

Hypo-osmolar Dehydration ([Na+] < 130 mmol/l , Osmolality < 280)

Replace the water deficit as for iso-osmolar dehydration. If [Na+] is < 120, admit
to PICU. A slow infusion of 3% NaCl (517 mmol/l Na+, @ 0.5 mmol/ml) at 1.2
ml/kg/hr (0.6 mmol/kg/hr) will raise [Na+] by 1 mmol/hr. Once [Na+] is 120, if
necessary replace the remaining Na+ deficit over 24 hrs by adding extra Na+ to
the IV fluids.

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Note: the total Na+ deficit (mmol) = [135 - serum [Na+](mmol/l)] x 0.6 x weight
(kg)

Acidosis
Acidosis may be due to bicarbonate loss or tissue hypoxia. If the latter, it usually
corrects itself as hypovolaemia is corrected. If severe acidosis persists (arterial pH
<7.1) always reconsider the diagnosis and consider adding bicarbonate to the IV
fluids in consultation with senior colleagues.18

Potassium
If the child passes urine, and is not hyperkalaemic, add 10 mmol KCl to 500 ml
IV fluid. If there is acidosis or profuse diarrhoea, more KCl than this may be
needed.
Note: correction of the acidosis may cause a rapid fall in the serum [K+].

Calcium
If the serum [Ca++] is low, add 10 ml Calcium Gluconate / 500 ml IV fluid.
Do not add Calcium Gluconate to a solution containing bicarbonate.18

Ongoing Losses While on Intravenous Rehydration

Ideally, weigh the stools and replace every 1 gm of stool with 1 ml of fluid.
Alternatively, approximate ongoing losses by giving 10 ml/kg per loose stool, and
2 ml/kg per vomit. In the child with profuse losses, calculate the fluid balance
hourly.

If the child cannot drink, measure ongoing losses hourly and replace ml for ml by
IV infusion over the following hour. Or, estimate ongoing losses and add the
estimate to the IV infusion rate. If you do this, review the child often and adjust
the infusion rate as losses change. If the child can drink, estimate ongoing losses
as above, and replace them orally in frequent small aliquots. There is no substitute
for frequent clinical re-assessment. Weigh the child daily, and if in doubt, 12 or
even 8 hourly.18

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Management of Hypernatraemia or Hyperosmolality

This is defined as a serum Na > 150 mmol / l, or a serum osmolality > 320 mOsm
/ l. Note that a child with a high urea or glucose may be hyper-osmolar in the
presence of a normal serum [Na+].

In the hyper-osmolar child, rapid correction of osmolality may cause cerebral


oedema, convulsions and permanent brain damage. Severe hyperosmolar
dehydration should be managed very cautiously with IV rehydration. Moderate
hyperosmolar dehydration can be managed with IV rehydration, or with cautious
modified ORT(see below).18

Intravenous Rehydration of Hyperosmolar Dehydration

Moderate hyperosmolar dehydration: [Na+] > 150 osmolality 320

Severe hyperosmolar dehydration: [Na+] > 170 osmolality 350

Admit children with severe hyperosmolar dehydration to PICU.

In order to reduce the risk of cerebral oedema and brain damage during
intravenous rehydration in hyperosmolality, aim to lower the serum [Na+] slowly
at a rate of 10 - 15 mEq in 24 hours, and the osmolality by no more than 0.5 - 1
mmol/hr.

In moderate hyperosmolar dehydration, after initial resuscitation, replace the


remaining deficit plus maintenance slowly at a uniform rate over 48 hours, using
0.45% NaCl and 2.5% Dextrose.

In severe hyperosmolar dehydration, after initial resuscitation, aim to replace the


remainder of the deficit and maintenance over a period of 72 - 96 hours.

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Never give a total IV volume of more than 200 ml/kg/day - usually give 100 -150
ml/kg/day. Calculate the osmolality at least 4 hourly, and measure it at least 12
hourly. If it is falling too quickly, reduce the rate of infusion by 20% and reassess
in 4 hours.18

Acidosis, Potassium and Calcium as per sections in 'Intravenous Rehydration'


above. Ongoing Losses While on Intravenous Re-hydration as per sections in
'Intravenous Rehydration' above. Changing From IV Re-hydration to Oral Re-
hydration when the osmolality has fallen below 350 and the serum [Na+] has
fallen below 170, change to ORT (provided the child has been fully resuscitated,
is fully conscious and able to drink, and has no evidence of paralytic ileus or a
surgical abdomen).

Oral Re-hydration In The Presence of Moderate Hypernatraemia


Moderately hypernatraemic children can be safely rehydrated orally, giving fluids
at a maximum rate of 15 ml/kg/hr. Rehydralyte (a rehydration fluid with a higher
[Na+] content) is no longer available in Starship so pedialyte should be used,
being cautious not to allow a rapid drop in osmolality or serum [Na+].

The rate of rehydration is about half that used in iso-osmolar dehydration. It is


based on the assumption that most hypernatraemic children are severely
dehydrated ("10%" or more), and allows for ongoing losses. If ongoing losses
exceed this rate of replacement, the child may need nasogastric or intravenous
rehydration. Electrolytes must be checked 4 hourly, and the rate of replacement
slowed if the serum [Na+] is falling at a rate faster than 1 mmol/hour.

Oral Maintenance Therapy

During the intensive acute rehydration phase of ORT ongoing losses are
included in the standard rate of fluid replacement. After the acute phase, give both
maintenance fluids and extra Pedialyte to replace the fluid in every loose stool, or
the child will slip back into dehydration.

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In children who are very unwell or have profuse losses, measure and replace stool
loss as for children on IV therapy. In rehydrated children whose losses are not
unusually profuse, advise parents to give both maintenance fluids and roughly 10
ml/kg for a diarrhoeal stool. As with ORT itself, this volume should be given in
small aliquots rather than as a single large bolus. 18

Children who are not dehydrated often refuse Pedialyte. The following
table analyses some of the alternative fluids often given by parents. Note that
undiluted juice or fizzy drink contains 5 - 15% sugar, and must be diluted to bring
the sugar content down to 2% or less. In most cases, this means a dilution of 1
part juice to 5 (or more) parts water to avoid the risk of osmotic diarrhoea. If the
parents have the container of juice or fizzy drink with them, you may be able to
work out the dilution needed from the information on the packet. 18

[HCO3-
Fluid [Na+] [K+] Glucose (g/l) Osmolality
]

50 - 150 including
Cola 2 0.1 13 550
fructose

50 - 150 including
Ginger ale 3 1 4 540
fructose

Apple juice 3 20 0 100 - 150 700

Chicken
250 5 0 0 450
broth

Tea 0 0 0 0 5

Lucozade 13 0.5 185 695

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Feeding

Children with diarrhoea who are fed throughout the illness lose less weight and
recover more quickly. During the acute phase (2 - 4 hours) of oral rehydration, it
is reasonable to give oral rehydration fluids only, unless the child indicates a
strong desire for milk or food as well. After this brief period however, feeding
should be re-introduced. In the hypernatraemic child, milk may need to be
introduced gradually to avoid a sudden fall in serum [Na+].

Breast-feeding should never be discontinued. Formula can be given at standard


strength. Solids can be given if the child is interested in them. 18

Lactose Malabsorption

This is not common. It is a clinical diagnosis based on symptoms of carbohydrate


malabsorption (profuse stooling on lactose challenge and re-challenge), together
with a positive stool fluid Clinitest for reducing substances. Anything more than a
trace is positive (i.e. + % or more). A positive test is clinically irrelevant if not
accompanied by diarrhoea. The test is meaningless in breastfed babies. If lactose
intolerance is confirmed, a lactose-free formula will need to be used until the
intestine has recovered. This is usually no more than 4 - 8 weeks.

2.8. DIFFERENTIAL DIAGNOSIS


Always keep in mind the possibility that the diagnosis of gastroenteritis
could be incorrect. Gastroenteritis consists of the triad of vomiting, diarrhoea and
fever. Be cautious of evaluating the child with vomiting alone. The following list
is not exclusive. Consider also14
1. Acute appendicitis
2. Strangulated hernia
3. Intussusception or other causes ofbowel obstruction
4. Urinary tract infection
5. Meningitis and other types of sepsis
6. Any cause of raised intracranial pressure

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2.9. COMPLICATIONS
Complications can include the following:
Dehydration and salt (electrolyte) imbalance in the body. This is the
most common complication. It occurs if the water and salts that are lost in
your child's stools, or when they vomit, are not replaced by them drinking
enough fluids. If your child drinks well, then it is unlikely to occur, or is
only likely to be mild and will soon recover as your child drinks.
Reactive complications. Rarely, other parts of your child's body can
'react' to an infection that occurs in their gut. This can cause symptoms
such as arthritis (joint inflammation), skin inflammation and eye
inflammation (either conjunctivitis or uveitis). Reactive complications are
uncommon if you have a virus causing gastroenteritis.
Spread of infection to other parts of your child's body such as their bones,
joints, or the meninges that surround their brain and spinal cord. This is
rare. If it does occur, it is more likely if gastroenteritis is caused by
Salmonella infection.
Persistent diarrhoea syndromes may rarely develop.
Irritable bowel syndrome is sometimes triggered by about of
gastroenteritis.
Lactose intolerance can sometimes occur for a while after gastroenteritis.
It is known as 'secondary' or 'acquired' lactose intolerance. Your child's gut
lining can be damaged by the episode of gastroenteritis. This leads to lack
of an enzyme (chemical) called lactase that is needed to help the body
digest a sugar called lactose that is in milk. Lactose intolerance leads to
bloating, abdominal pain, wind and watery stools after drinking milk. The
condition gets better when the infection is over and the gut lining heals.
Haemolytic uraemic syndrome is a rare complication. It is usually
associated with gastroenteritis caused by a certain type of E.coli
infection, E. coli O157. It is a serious condition where there is anaemia, a

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low platelet count in the blood and kidney failure. If recognised and
treated, most children recover well.
Malnutrition may follow some gut infections. This is mainly a risk for
children in developing countries.
Severe vomiting can lead to aspiration and tear in the esophagus.10

2.10. PREVENTION
Among the steps that can be performed by the toddler 's mother, the
most important is to maintain good hygiene individuals. This can be done by
implementing healthy behavior, ie washing hands with soap after children and
dispose of feces after defecation and before preparing food to children. Mothers
should also train their children from the beginning again on hand washing
behavior, especially before eating and after playing. It can prevent the
transmission of germs that can cause diarrhea.15
In addition, the toddler 's mother also should practice breastfeeding to
their children from birth so that the first 4-6 months of life. Breast milk contains
antibodies that are useful to keep the baby 's immune system that is not
susceptible to infection. Breast milk is also rich in substances that are optimal for
the growth of children. Breastfeeding during diarrhea also can reduce the severity
of diarrhea.17
Based on numerous studies, the affordability of the utilization of clean
water is essential to reduce the risk of diarrhea. Therefore, people should make
sure the water used in the house is really clean and does not have to qualify the
color, smell and taste before it is used for everyday purposes.17

2.10.1. ROTAVIRUS VACCINE

The rotavirus vaccine is an oral, live vaccine. The Centers for Disease
Control and Prevention's Advisory Committee on Immunization Practices
recommends routine vaccination at two, four, and six months of age.15 There are
specific guidelines for premature infants and infants who have missed the initial

23
doses. Contraindications to the vaccine in infants are hypersensitivity to the
vaccine, gastrointestinal tract congenital malformation, and severe combined
immunodeficiency. The live virus is shed in the stool of 25 percent of infants who
receive the vaccine and could be transmitted to an unvaccinated contact. 16

24
CASE REPORT

Name : JZ
Age : 3 month
Sex : Male
Date of Admission : November, 10th 2014

Chief Complaint : Vomit and Diarrhea

History :
- An 3 month old male is brougt to the emergency departement with a chief
complaint of diarrhea and vomitting for 1 weeks.
- Her mother describes stools as liquid and foul smelling, with no mucous, slime or
blood.
- Vomiting after every feeding, even water.
- She has about 5-6 episodes of diarrhea and 4 episodes of vomiting perday.
- Her mother reports that he is not feeding well and his activity level is decreased
he seems weak and tired. He has a decreased number of wet diapers.
- Fever is common its intermittent with febrifuge
- On examination, the patient appeared subfebrile. The temperature was 37,6 C.
- Cough is common for 1 weeks
- The patient has been suffered nausea and vomit, 4 times a day, water contained.
- History of anorexia (+), history of weight loss (-).
- History of previous illness :-
- History of previous medications : paracetamol
-
Pregnant History
She was 25 year old in her first pregnacy.
There is no history of fever, hypertension, diabetic mellitus, and consumed herbal
medicine.

25
Birth History
The patient is the first kid
Spontaneous; attended by midwives; BW 2900 gram; BL 48 cm, cyanotic (-).

Immunization History
The imunization never given

Feeding History
From birth to 1,5 months : Breast milk only
From 1,5 months to 3 months : Breast milk and formula milk (SGM)

History of Growth and Development


-

History of Family Disease


There is no relative with thyphoid fever or dengue fever.

Physical Examination
Generalized status
Body weight: 5000 kg, Body length: 63 cm
Body weight according to age WHO 2006 : >-3 z-score <-2
Body length accorning to age WHO 2006 : >-2 z-score <0
Body weight according to body length WHO 2006 : z-score = -3
Interpetation : Undernutrition

Presens status
Consciousness: Alert, Body temperature: 37.2 oC.
Anemic (-); Icteric (-); Cyanosis (-); Edema (-). Dyspnea (-).

26
Localized status
Head :
Fontanel concave (-) No deformities. Black hair, normal.
Right Eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-). Icteric
sclera (-). Light reflex (+), sunken eyes (+)Mucosa lips dry (+)
Left eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-). Icteric
sclera (-). Light reflex (+), Sunken eyes (+)
Ear, nose and mouth were within normal limit.

Neck :
Lymph node enlargement (-).

Thorax:
Symmetrical fusiformis. Chest retraction (-) epigastrial, intercostals, suprasternal.
HR: 140 bpm, regular, murmur (-). RR: 50x/i, reguler, rales (-/-).

Abdomen:
Soepel, peristaltik (+), skin turgor slowly , H/L ttb

Extremities:
Pulse 140x/i, regular, adequate pressure and volume, warm, CRT < 3.

Urogenital:
Male ; within normal limit.

Laboratory Findings (September,10th 2014):


Parameters Value Normal Value
Complete Blood Count
Hemoglobin 12,50 gr% 10,7-17,1 gr%
Hematocrite 22,80 % 38-52 %

27
Erithrocyte 2,98 x 106 /mm3 3.75 4,95 x 106 /mm3
Leucocyte 29,37 x 103 /mm3 6.0 17.5x 103 /mm3
MCV 77,00 fl 93 115 fl
MCH 26,20 pg 29 35 pg
MCHC 34,20 gr% 28 34 gr%
RDW 13,50 % 14.9 18.7 %
Morphology count
Neutrofil 72,70 37-80
Limfosit 19,70 20-40
Monosit 7,40 2-8
Eosinofil 0,10 1-6
Basofil 0,100 0-1
Neutrofil absolute 21,36 1,9-5,4
Limfosit absolute 5,80 3,7-10,7
Monosit absolute 2,16 0,3-0,8
Eosinofil absolute 0,02 0,2-0,5
Basofil absolute 0,03 0-0,1
Carbohydrate Metabolism
Blood Glucose ad random 229,00 mg/Dl < 200
Electrolyte
Sodium 154 mEq/L 135-155
Potassium 2,4 mEq/L 3,6-5,5
Chloride 115 mEq/L 96-106

Differential Diagnosis:
- Gastroenteritis with severe dehidration

Working Diagnosis:
- Gastroenteritis with severe dehidration

28
Management:
- IVFD RL initral 30cc/kgbb/jam ->150cc/jam selanjutnya 90cc/kgbb/jam selama 5
jam ->450cc
- Zinc 1 x 10mg
- Paracetamol syr 3 x 60 mg (if needed)
- Diet ASI ad libitium
Diagnostic Planning:
- Feces
- Blood : Elektrolit

FOLLOW UP

November, 10th 2014


S Diarrhea (+) vomiting (+)
O Sens: CM, Temp: 37,1oC. Anemic (-). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-)
Body weight: 5000 gr, Body length: 63 cm.
Head No deformities. Black hair, normal.
Eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-). Icteric
sclera (-). Light reflex (+). Sunken eyes (+) Mucosa lips dry (+)
Neck Lymph node enlargement (-)
Thorax Simetris fusiformis. Retraction (-) HR: 120 bpm, reguler; murmur (-).
RR: 40x/i, regular, rales (-)
Abdomen Soepel. Normoperistaltic. Rapid turgor. Hepar and splen unpalpable (-)
Pulse 140 x/i, regular, adequate p/v, warm, CRT < 3.
Extremities
Genital Male,within normal limit.
A- Gastroenteritis with severe dehidration
P Management:
- IVFD RL initral 30cc/kgbb/jam->150cc/jam/i mikro (Rehidration 75cc/kgBB dalam 4
jam)

29
- Zinc1 x 10mg
- Paracetamol syr 3 x 60 mg (if needed)
- Diet ASI ad libitum
Diagnostic Planning:
- Complete blood count serial
- Feces
September11th 2014
S Diarrhea (+) Vomit (-)
O Sens: CM, Temp: 37oC. Anemic (-). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-)
Body weight: 5500 gr, Body length: 63 cm.
Head No deformities. Black hair, normal.
Eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-). Icteric
sclera (-). Light reflex (+). Sunken eyes (-). Mucosa lips dry (+)
Neck Lymph node enlargement (-).
Thorax Simetris fusiformis. Retraction (-). HR: 135 bpm, reguler; murmur (-).
RR: 48 x/i, regular, rales (-/-)
Abdomen Soepel. Normoperistaltic. Rapid turgor. Hepar and splen unpalpable (-).
Extremities Pulse 135 x/i, regular, adequate p/v, warm, CRT < 3.
Genital Male; within normal limit.
A- Gastroenteritis with mild to moderete dehidration
P Management:
- IVFD RL (Rehidration 75 cc/kg BB dalam 3 jam)
- Zine 1 x 10mg
- Paracetamol syr 3 x 60 mg (if needed)
- Diet ASI ad libitum
Diagnostic Planning:
- Feces
- KGD&AGDA
- Electolit post rehidration
-

30
September 12th 2014
S Vomit (-), Diarrhea (-)
O Sens: CM, Temp: 37,1oC. Anemic (-). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-)
Body weight: 6000 gr, Body length: 63 cm.
Head No deformities. Black hair, normal.
Eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-). Icteric
sclera (-). Light reflex (+)Sunken eyes (-). Mucosa lips dry (+).
Neck Lymph node enlargement (-).
Thorax Simetris fusiformis. Retraction (-) epigastrial; intercostals, suprasternal.
HR: 132 bpm, reguler; murmur (-).
RR: 40 x/i, regular, rales (-)
Abdomen Soepel. Normoperistaltic. Rapid turgor. Hepar and splen unpalpable (-).
Extremities Pulse 132 x/i, regular, adequate p/v, warm, CRT < 3.
Genital Male; within normal limit.
A- Gastroenteritis post rehidration
P Management:
- IVFD RL 25gtt/i (mikro)
- Zine 1 x 10mg
- Inj. Gentamycin 30mg/24h/iv
- Paracetamol syr 3 x 60 mg (if needed)
Diet ASI/PASI ad libitum
Diagnostic Planning: -

31
Discussion and Summary

Discussion
Based on the literature, diarrhea occur in children under the age of 2 years
old and babies under six months old are most at risk. In this case we found the
concurrence between the literature and the patient age is 3 month old.
The others symptom on this patient were an 3 month old male is brougt to
the emergency departement with a chief complaint of diarrhea and vomitting for 1
weeks. Her mother describes stools as liquid and foul smelling, with no mucous,
slime or blood. Vomiting after every feeding, even water. She has about 5-6
episodes of diarrhea and 4 episodes of vomiting perday. Her mother reports that
he is not feeding well and her activity level is decreased she seems weak and tired.
She has a decreased number of wet diapers. In the theory of diarrhea, Early signs
of diarrheal disease are infants and children become restless
and whiny, body temperature is usually increased, decreased appetite or no, then
arise diarrhea. Feces will be liquid and may be accompanied by mucus or blood.
Stool color may eventually turn into greenish because mixed with bile. Anus and
surrounding area scratched by frequent defecation and fecal increasingly acidic as
a result the number of lactic acid derived darl lactose can not be absorbed by the
intestine during diarrhea. Symptoms of vomiting may occur before or after the
diarrhea and stomach can also be caused by inflamed or due to disturbances of
acid-base balance and electrolyte.
Based on the literature, if the patient has lost a lot of fluids and
electrolytes, then the symptoms dehydration began to appear. Weight loss,
decreased skin turgor, eyes and large fontanel sunken, lips and mucous
membranes of the mouth and the skin looks dry. In this case we found weight
loss, decreased skin turgor, sunken eyes, lips mucous looks dry.
Risk factor diarrhea, nutritional status diarrhea patient suffered by
children with severe malnutrition when compared with good nutritional status of
children as children with malnutrition status and stool output more fluid so. In this
case we found nutritional status patien in the undernutrition.

32
Full breastfeeding would provide protection diarrhea 4 times than breastfed
infants with milk bottles . Babies with a milk bottle most discussions will have a
greater risk of diarrhea and even 30 times more than fully breastfed infants. In this
case we found, patient feeding history from birth to 1,5 months: Breast milk only,
from 1,5 months to 3months: Breast milk and formula milk (SGM).
The management of gastroenetritis divided based on the degree of
dehydration. In this patients we give treatment based on the degree of dehydration
is some dehydration; Oralit 75 mL/kg BW/3-4 hours, Indikasi Ringers Lactate /
Ringers Acetate, Evaluation :Diarrhea continues (+), then repeat.

Summary

This conclusion of this paper is a boy, 3 month old, diagnosed with Gastroenteritis
with mild to severe dehidration . The patient received :
- IVFD RL 70cc/kgbb selama 5 jam->350cc->70cc/jam
- Zink 1 x 10mg
- Paracetamol syr 3 x 60 mg
- Diet ASI ad libitum
The patient should keep hygiene and always wash hand before and after eat
something. Also the patient need to be careful when buying food or drink from
street vendors.

33
REFERENCES

1. Victorian, 2010 Gastroenteritis In Children. Emergency department factsheets,


Melbourne.

2. Harianto, 2004. Penyuluhan Penggunaan Oralit untuk Menanggulangi Diare di


Masyarakat. Departemen Farmasi Universitas Indonesia, Jakarta.

3. King CK, Glass R, Bresee JS, Duggan C. MaSnaging acute gastroenteritis among
children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm
Rep. 2003;52(RR-16):116.

4. Glass RI, Kilgore PE, Holman RC, et al. The epidemiology of rotavirus diarrhea
in the United States: surveillance and estimates of disease burden. J Infect Dis.
1996;174(Suppl 1):S5S11.

5. Depkes RI, 2000. Buku Pedoman Pelaksanaan Program Pemberantasan Penyakit


Diare, Ditjen PPM & PLP, Jakarta. (2)

6. By-Payne J, Elliott E. Gastroenteritis in children. Clin Evid. 2004;12:443454

7. Suharyono, 1986. Diare Akut. Dalam: Simatupang M., 2004. Analisis Faktor-
Faktor Yang Berhubungan Dengan Kejadian Diare Pada Balita Di Kota Sibolga
Tahun 2003. Program Pascasarjana, Medan: Universitas Sumatera Utara. (13)

8. Wilhelmi I, Roman E, Sanchez-Fauquier A. Viruses causing gastroenteritis. Clin


Microbiol Infect. 2003;9(4):247262. (14)

34
9. Jakab F, Peterfai J, Meleg E, Banyai K, Mitchell DK, Szucs G. Comparison of
clinical characteristics between astrovirus and rotavirus infections diagnosed in
1997 to 2002 in Hungary. Acta Paediatr. 2005;94(6):667671. (16)

10. Kliegman R.M., Marcdante K.J., and Behrman R.E., 2006. Nelson Essentials of
Pediatric. 5th ed. Philadelphia: Elsevier Saunders.

11. Simatupang M., 2004. Analisis Faktor-Faktor Yang Berhubungan Dengan


Kejadian Diare Pada Balita Di Kota Sibolga Tahun 2003. Program
Pascasarjana, Medan: Universitas Sumatera Utara.

12. Acute Gastroenteritis Guideline Team. Cincinnati Children's Hospital Medical


Center. Evidence-based care guideline for prevention and management of acute
gastroenteritis in children age 2 months to 18 years. December 21, 2011.
http://www.cincinnatichildrens.org/service/j/anderson-center/evidence-based-
care/gastroenteritis/. Accessed January 20, 2012

13. American Medical Association, Centers for Disease Control and Prevention,
Center for Food Safety and Applied Nutrition, Food and Drug Administration,
Food Safety and Inspection Service, U.S. Department of Agriculture. Diagnosis
and management of foodborne illnesses: a primer for physicians. MMWR Recomm
Rep. 2001;50(RR-2):169.

14. NSW Goverment health, 2013.Children and Infan With Gastroenteritis: Acute
Menegement, Sydney.

15. Reid SR, Bonadio WA. Outpatient rapid intravenous rehydration to correct
dehydration and resolve vomiting in children with acute gastroenteritis. Ann
Emerg Med. 1996;28(3):318323.

35
16. Rotarix [package insert]. Research Triangle Park, N.C.: GlaxoSmith-Kline; 2011.
http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm09
3830.htm. Accessed July 12, 2011.

17. Patel MM, Lpez-Collada VR, Bulhes MM, et al. Intussusception risk and
health benefits of rotavirus vaccination in Mexico and Brazil. N Engl J Med.
2011;364(24):22832292.

18. Dr. Gavin,raewyn. Starship Childrens Health Clinical Guideline. 2006.


http://www.adhb.govt.nz/starshipclinicalguidelines/_Documents/Gastroenteritis.p
df. Accesed June,2006.

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