By: Varla Septrinidya Gharatri

DEFINITION
Diarrhea is a disease
characterized by increased frequency
of defecation more than usual (> 3
times / day) accompanied by a change in stool
consistency (a liquid), with /without
blood and / or mucus
diarrhea that continues for
2 weeks or more to lose weight or not
gain weight during the diarrhea chronic diarrhea
AKUT < 2
MINGGU
KRONIK > 2
MINGGU
DIARE
TRAVELERS
DIARRHEA
EPIDEMIOLOGY
3 main causes to the health center
In Indonesia is estimated to be found with
diarrhea about 60 million events each year, most (70-
80%) of these patients are children under 5 years

ETIOLOGY
Viral infections
Cause most cases of diarrhea and are typically associated with mild-to-moderate
symptoms with frequent, watery bowel movements, abdominal cramps, and a low-
grade fever.
Rotavirus (infants), norovirus (adults & schoolage children), adenovirus (all age groups)
Bacterial infections
Occurs from contaminated food or drinks (food poisoning).
Cause severe symptoms: vomiting, fever, and severe abdominal cramps or abdominal pain.
Bowel movements occur frequently and may be watery.
In serious cases, the stool may contain mucus, pus, or blood.
Campylobacter, salmonellae, and shigella organisms are the most common causes of
bacterial diarrhea. Less common causes are Escherichia coli (commonly called E
coli) Yersinia, and listeria.
Use of antibiotics can lead to an overgrowth of Clostridium difficile (C diff) bacteria in the
intestines.
Parasites
Cause infection of the digestive system by the use of contaminated water.
Common parasitic causes of diarrhea include Giardia lamblia, Entamoeba histolytica,
and Cryptosporidium.
ETIOLOGY
Intestinal disorders/ disease
Inflammatory bowel disease, irritable bowel
syndrome (IBS), diverticulitis, microscopic colitis,
and celiac disease can cause diarrhea.
Reaction to certain medications
Common medications include antibiotics, blood
pressure medications, cancer drugs, and antacids
(especially ones containing magnesium).
Intolerance to foods
Artificial sweeteners and lactose (the sugar found in
milk) can cause diarrhea.

AKUT < 2
MINGGU
BERKEMBANGBIAK
SALURAN CERNA
MIKROORGANISME
MEMBENTUK TOKSIN
RANGSANG MUKOSA USUS
HIPERPERISTALTIK
SEKRESI CAIRAN
USUS
SETELAH BERHASIL
LEWATI ASAM
LAMBUNG
PATHOGENES
Entry of microorganisms into the gastrointestinal tract
Proliferation
of microorganisms after successfully passing the
stomach acid
Toxin formation by microorganisms
The stimulation of the intestinal mucosa that lead
to hyperperistalsis and intestinal fluid
secretion resulting in diarrhea
SYMPTOMS
Watery, liquid stools
Abdominal cramps
Fever
Dehydration
Adults may be very thirsty and have a dry mouth.
The skin of older people may appear to be loose. The
elderly may also become very sleepy or have behavioral
changes and confusion when dehydrated.
Dehydrated infants and children may have sunken eyes,
dry mouths, and urinate less frequently than usual. They
may appear very sleepy or may refuse to eat or drink.

MANIFESTASI KLINIK DIARE
Cengeng
Gelisah
T
Nafsu makan atau tidak ada
Muntah
BB
Bayi ubun-ubun besar cekung
Tonus & turgor kulit
Selaput lendir mulut & bibir terlihat kering
Diarrhea that occurs without damage to the intestinal
mucosa and is caused by bacterial
toxins (especially E. coli), usually have
symptoms completely liquid stool, no blood,
abdominal pain (especially
the umbilicus), bloating, nausea, and vomiting.
If vomiting is very striking, usually caused by a
virus or S. aureus (food poisoning)
If diarrhea with mixed blood, mucus, and fever
damage to the intestinal
mucosa invasion caused like Shigella, Salmonella, or
amebiasis. The affected area is the colon
DIAGNOSE
Medical history & physical examination
Stool culture
Blood tests
Fasting tests
Sigmoidoscopy / Colonoscopy
X-rays/ CT-scans
DIAGNOSIS DIARE
Anamnesa
Lamanya sakit diare (sudah berapa jam, hari ?)
Frekuensi (berapa x/hari?)
Banyaknya/volumenya (berapa banyak setiap
defekasi)
Warnanya (biasa, kuning berlendir, berdarah,
seperti air cucian beras, dsb)
Baunya (amis, asam, busuk)
DIAGNOSIS DIARE
Pemeriksaan laboratorium
Pemeriksaan tinja
Makroskopik & mikroskpoik
Biakan kuman
Tes resistensi terhadap berbagai antibiotik
pH & kadar gula ada intoleransi laktosa
Pemeriksaan darah
Darah lengkap
Kadar ureum ggg faal ginjal
Pemeriksaan elektrolit
Intubasi duodenal diare kronik kuman penyebab
SELF-CARE
Adults
Drink plenty of fluids to avoid dehydration.
Avoid greasy or fatty foods.
BRAT (banana, rice, applesauce, and toast) diet
Avoid alcoholic beverages and spicy foods
Children
Pedialyte may be more appealing than water
Stay at home and avoid school and day-care until these
symptoms go away
BRAT diet
SYMPTOMATIC TREATMENT
Antidiarrheal drug
Adsorbent
Stimulans
Antiemetics
Antipiretika
TREATMENT
Antibiotic
Loperamide (Imodium)
Bismuth subsalicylate (Pepto-Bismol, Kaopectate,
etc.)
Pedialyte, Rehydralyte, Naturalyte Solution.
PENATALAKSANAAN ANTIFUNGAL
PEMBEDA
ANTIFUNGAL UNTUK INFEKSI SISTEMIK
AMFOTERISIN B FLUSITOSIN KASPOFUNGIN TERBINAFIN
DESKRIPSI Hasil fermentasi Streptomyces nodosus;
terefektif untuk mikosis sistemik berat
Merupakan jamur sintetik asal dari fluorinasi
pirimidin
Merupakan kelas baru
ekinokandin
Suatu derivat alilamin
sintetik
CARA KERJA Berikatan kuat dengan ergosterol (membran
sel jamur) bocor bahan2 intrasel keluar
& kerusakan permanen
+ sitosin deaminase (dalam sel jamur) & dalam
sitoplasma gabung dengan RNA 5
fluorourasil & fosforilasi # sintesis DNA
Hambat sintesis beta
(1,3)-D-glukan
komponen esensial
dinding sel jamur
Pengaruhi biosintesis
ergosterol dinsing sel
jamur melalui
hemabtan enzim
skualen epoksidase
INDIKASI Untuk koksidiodomikosis,
parakoksidioidomikosis, aspergilosis,
kromoblastomikosis, kandidiosis,
histoplasmosis, kriptokokosis sistemik,
leismaniasis mukokutan
Efektif pada maduromikosis &
mukormikosis
Obat terpilih blastomikosis selain
hidroksistilbamidin
Tetesan topikal efektif u/ korneal &
keratitis mikotik
Endoftalmitis intraorbital
Pasien + amfoterisin B HARUS
dirawat di RS
Kurang toksik daripada amfoterisin B;
cepat resisten
Pakai tunggal Cryptococcus
neoformans, beberapa spesies Candida &
oleh infeksi kromoblastomikosis
+ amfoterisin B meningitis oleh
Cryptococcus & kombinasi obat terpilih
u/ kromoblastomikosis
Kandidiasi invasif
(kandidemia
pasien
neutropenia/non)
Kandidiasis
esofagus
Kandidiasi
orofaring
Aspergilosis invasif
yang sudah
refrakter terhadap
antijamur lain
Dermatofitosis
(onkomikosis)
Kandidiasis
kutaneus &
tinea versikolor
+ imidazol
atau triazol
EFEK
SAMPING &
KONTRAINDI
KASI
kulit panas, keringatan, sakit kepala,
demam, mengigil, lesu, anoreksia,
nyeri otot, kejang, flebitis (terjadi +
heparin 1000 unit dalam infus), &
fungsi ginjal INFUS
50% demam & mengigil awal IV
+ flusitosin efek toksik pada ginjal
Anemia normositik normokrom
jangka panjang
Anemia, leukopenia, trombositopenia
pasien kelainan hematologik yang sedang
dapat pengobatan radiasi, obat penekan
fungsi sumsum tulang , dan punya
riwayat dengan obat tsb.
Mual, muntah, diare, dan enterokolotis
hebat
5% enzim SGOT & SPGT
Sakit kepala, kebingungan, pusing,
mengantuk dan halusinasi
# wanita hamil (walau belum terbukti)
Demam,mual,
muntah, flushing,
pruritus (lepasnya
histamin)
#
+siklosporin+takro
limus darah
Keamanan pada
wanita hamil &
anak < 18 tahun
belum
diketahui
Gangguan GIT
Sakit kepala
Hepatotoksisitas
, netropenai
berat, sindrome
Steven Johnson,
nekrolisis
epidermal
toksik jarang
# ibu menyusui
PEMBEDA
ANTIFUNGAL UNTUK INFEKSI SISTEMIK
GOLONGAN IMIDAZOL & TRIAZOL
KETOKONAZOL ITRAKONAZOL FLUKONAZOL VORIKONAZOL
DESKRIPSI Turunan imidazol sintetik dengan struktur
mirip mikonazol & klotrimazol
Triazol sintetik Suatu fluorinated bis-triazol
dengan khasiat farmakologi
baru
Triazol yang sama dengan
flukonazol tapi punya
aktivitas dan spektrum yang
luas
CARA KERJA Pengaruhi permeabilitas membran sel
sampai ubah biosintesis lipid (sterol, sel
jamur) dengan inhibisi enzim P450
sitokrom fungi
Pengaruhi permeabilitas
membran sel sampai ubah
biosintesis lipid (sterol, sel
jamur) dengan inhibisi
enzim P450 sitokrom fungi
Pengaruhi permeabilitas
membran sel sampai ubah
biosintesis lipid (sterol, sel
jamur) dengan inhibisi
enzim P450 sitokrom fungi
Pengaruhi permeabilitas
membran sel sampai ubah
biosintesis lipid (sterol, sel
jamur) dengan inhibisi
enzim P450 sitokrom fungi
INDIKASI Histoplasmosis paru, tulang, sendi
dan jaringan lemak
Parakoksidioidomikosis, beberapa
bentuk koksidioidomikosis,
dermatomikosis, dan kandidiasis
(mukokutan, vaginal, & oral)
#meningitis kriptokokus
Efektif kriptokokus nonmeningeal
Hasil memuaskan :
Blastomikosis,
histoplasmosis,
koksidioidomikosis,
sariawan mulut &
tenggorokan serta
tinea versikolor
Aspergilosis di luar
SSP
Cegah relaps
meningitis akibat
Cryptococus pada
pasien AIDS setelah
pengobatan dengan
amfoterisin B
Kandidiasis pada
mulut dan
tenggorokan pada
pasien AIDS
Aspergilosis sistemik
dan infeksi jamur
berat ( Scedosporium
apiospermun dan
Fusarium sp.)
Candida sp,
kriptococus dan
dermatofit
Infeksi kandida yang
resisten flukonazol
EFEK
SAMPING &
KONTRAINDIK
ASI
Mual, muntah tersering
Sakit kepala, vertigo, nyeri
epigastrik, fotofobia, pruritus,
parestesia, gusi berdarah, erupsi
kulit, dan trombositopenia jarang
Ginekomastia (pria) & haid ireguler
(wanita 10%)
# wanita hamil & wanita menyusui
15% mual, muntah
Kemerahan, pruritus,
lesu, pusing, edema
kaki, parestesia, dan
kehilang libido
pernah dilaporkan
Gangguan GIT
terbanyak
Pasien AIDS : urtikaria,
eosinofilia, sindrom
Steven-Johnson,
gangguan fungsi hati
tersembunyi, dan
trombositopenia
Gangguan penglihatan
(kabur atau fotofobia
30%)
Reaksi fotosensitivitas
& kenaikan kadar
transaminase serum
(sementara)
# wania hamil
Rash 6%
KOMPLIKASI DIARE
KOMPLIKASI PALING SERING
1. Dehidrasi
2. Gangguan keseimbangan
asam basa (asidosis
metabolik)
3. Hipoglikemia
4. Gangguan gizi
5. Gangguan sirkulasi
COMPLICATIONS
Hypernatremia
Hyponatremia
Fever
Edema
Acidosis
Hypocalemi
Paralytic ileus
Convulsions
Lactose intolerance
Glucose malabsorption
Vomit
Renal failure
PREVENTION
Pemberian ASI
Memperbaiki makanan sampihan
Menggunakan air bersih
Mencuci tangan
Menggunakan jamban keluarga
Cara membuang tinja yang baik dan benar
Pemberian imunisasi campak
HUBUNGAN IMUNISASI CAMPAK
DENGAN DIARE
Pada balita, 1-7% kejadian diare berhubungan dengan
campak, dan diare yang terjadi pada campak
umumnya lebih berat dan lebih lama karena adanya
kelainan epitel usus
Diperkirakan imunisasi campak yang mencakup 45-
90% bayi berumur 9-11 bulan dapat mencegah 40-60%
kasus campak, 0,6-3,8% kejadian diare dan 6-25%
kematian karena diare pada balita.
PREVENTION
Washing hand
Food should be cooked to the recommended
temperatures.
Fruits and vegetables consumed raw should be
thoroughly rinsed in clean water.
Unpasteurized (raw) milk may be contaminated with
bacteria and should always be avoided.
Use caution when traveling, especially to foreign
countries. Do not eat foods from street vendors.

ETIOLOGY
In general can be grouped into
4 categories pathogenesis:
Osmotic diarrhea
Caused by intestinal intraluminal osmolality is higher than in
serum
This happens to lactose
intolerance, laxative medications (lactulose, magnesium sulfa
te),drugs (antacids)
Secretory diarrhea
Occurrence of excessive intestinal secretion and
reduced absorption of the liquid cause diarrhea
Generally caused by endocrine tumors, malabsorption of
bile salts.
Motility disorders
This is due to rapid intestinal transit or the occurrence of stasis that
causes excessive growth of bacteria intraluminal.
Cause by IBS
Inflammatory diarrhea
Caused by inflammatory factors such as IBD
Malabsorption
Generally caused by small
bowel disease, partial bowel resection, lymphatic obstruction,
pancreatic enzyme deficiency, and bacterial overgrowth
Chronic infection
Such as G. lamblia, E. histolytica, intestinal nematodes, or
immunocompromized
DIAGNOSIS DIARE
Derajat dehidrasi
Ringan : BB 2,5-5 %
Sedang : BB 5-10 %
Berat : BB > 10 %
MTBS
Mild/ moderate dehydration Severe dehydration
There are two or more of the following
signs:
1. restlessness, irritability / anger
2. Sunken eyes
3. Thirsty
4. Slow skin pinch test
There are two or more of the following
signs:
1. Lethargy
2. Sunken eyes
3. Cannot drink
4. Very slow skin pinch test
TREATMENT
Rehydration
Breast feeding
Do not use antidiarrheal drugs
antibiotic is given only in cases
of cholera and dysentery caused by shigella, whereas
metronidazole is given in cases of giardiasis and amebiasis
Effective guidance for mothers and caregivers about:
How to care for a sick child at home
Signs that can be used as a guide to bring the child back
to seek treatment and get better medical supervision
An effective method for preventing diarrhea


DIETETIC TREATMENT
O-ralit
B-reast feeding
E-arly feeding
S-imultaneously with
E-ducation

CARA PEMBERIAN MAKANAN
Bayi dengan ASI
ASI dilanjutkan bersama-sama dengan oralit, selang-seling. Pada
bayi berumur > 4 bulan dilanjutkan dengan fase readaptasi, sedikit
demi sedikir makanan diberikan kembali seperti sebelum sakit
Bayi dengan susu formula
Diberikan oralit, selang-seling dengan susu formula. Jika bayi telah
mendapat makanan tambahan, makanan tambahan untuk
sementara dihentikan, diberikan sedikit demi sedikit mulai hari ke
3
Anak-anak berumur lebih dari 1 tahun
Dengan gizi jelek, realimentasi sama dengan bayi
Dengan gizi baik, realimentasi diberikan sbb:
Hari 1: oralit + bubur tanpa sayur + pisang
Hari 2: bubur dengan sayur
Hari 3: makanan biasa
PENATALAKSANAAN DIARE
PREVENTION OF DEHYDRATION
Explain to mothers how to treat diarrhea at home
Give your child more fluids than usual to prevent dehydration
Continue feeding
Bring your child to a healthworker if:
Defecate several times
Very thirsty
Eyes become sunken
Fever
Do not eat
Do not grow well
Bloody stool
Show the mother how to mix and give ORS
Explain to the mother of seven effective interventions to
prevent diarrhea
HOW TO MIX AND GIVE ORS
umur < 2 tahun: 50-100 ml (1/4 - 1/2 gelas) setiap
buang air besar
umur 2-5 tahun: 100-200 ml (1/2 - 1 gelas) setiap bab
anak-anak yang lebih besar: minum sebanyak
mungkin
bila anak muntah, tunggu 10 menit kemudian
pemberian oralit diteruskan tetapi lebih lambat: 1
sendok makan setiap 2-3 menit
berikan kepada ibu oralit untuk 2 hari
TREATMENT OF SEVERE
DEHYDRATION
Mulai dari sini
Apakah anda dapat
memberikan cairan
intravena?
ya
1. Berikan cairan intravena
2. Setelah 1-3 jam periksa kembali dan
pilih rencana pengobatan yang cocok
tidak
Apakah penderita
dapat minum?
ya
1. Mulai berikan larutan oralit sesuai
rencana B
2. Rujuklah untuk mendapatkan
pengobatan intravena
tidak
Apakah anda terlatih
memasang sonde
lambung?
ya
1. Mulailah rehidrasi dengan
mempergunakan sonde lambung
2. Jika pengobatan intravena dapat
dilakukan dekat anda bertugas
rujuklah
Segera dirujuk untuk
pengobatan intravena
tidak
Dosis pemberian cairan intravena:
1 jam pertama: 30 ml/ kg BB
2 jam berikutnya: 40 ml/ kg BB
Dosis pemberian cairan per sonde
lambung:
20 ml/ kg BB/ jam
instructions intravenous rehydration tre
atment in patients
with severe dehydration
Kelompok umur Jenis cairan/ cara
pemberian
Jumlah cairan
per kg BB
Waktu
pemberian
Bayi < 12 bulan RL intravena 30 ml 1 jam
Dilanjutkan dengan
RL intravena 40 ml 2 jam berikutnya
Dilanjutkan dengan (bila sudah memungkinkan)
Oralit per oral atau
per sonde
40 ml 3 jam berikutnya
Anak lebih besar RL intravena 100 ml 3 jam (pasien
dengan renjatan
berikan secepat
mungkin sampai
nadi teraba cukup
kuat)
DAFTAR PUSTAKA
Robert M Kliegman, Hal B Jenson, Richard E Behrman,
Bonita F Stanton. Nelson Textbook of Pediatrics. Edisi
18. Amerika Serikat: Saunder Elsevier, 2007.
Sudaryat Suraatmaja, editor. Kapita Selekta
Gastroenterologi Anak. Jakarta: Sagung Seto, 2007.
L Katthleen Mahan, Sylvia Escott-Stump. Krauses Food
& Nutrition Therapy. Edisi 12. Kanada: Saunders
Elvesier, 2008.
Arthur C Guyton, John E Hall. Buku Ajar Fisiologi
Kedokteran. Edisi 11. Jakarta: EGC, 2007.