CASE REPORT

ACUTE DIARRHEA WITH MILD

TO MODERATE DEHYDRATION

Runi Arumndari (11-004)

Supervisor: dr. Alfred Siahaan, Sp.A

INTRODUCTION
Introduction
Acute diarrhea is a condition in infants or children when
the frequency of defecation happens to be more than
3x/day with a change in consistency, with or without
mucus and blood, that lasts less than a week.
6 million of children In the world dies every year because
of diarrhea.
In Indonesia, diarrhea is still the most cause of death in
children.
Introduction
Thus, managing diarrhea in children as early as possible is
very important.
While having a diarrhea, a child is also losing much fluids
and electrolytes, so that it is very important to evaluate
the signs of dehydration and do a rehydration soon
afterwards.
The purpose of this case report is to recall the broad
principles of managing diarrhea in children.
CASE REPORT
 A 3 year and 9 month-old boy came to the hospital with a
watery stool that happened 18 hours ago. It appeared
4 times a day, yellow-colored, watery, had some dregs,
and had no blood or mucous. It didnt squirt. It also didnt
have a bad specific odor, such as stinky, fishy smell, or
sour. The volume for each time he defecated was about a
quarter of a glass of aqua. He didnt feel pain when he
defecated.
He also complains that a day ago he threw up every time
he drank or ate something. The vomit consist of water and
food he had just eaten. There was no blood in the vomit.
 He had already brought to a clinic and was given
Gastrusit and domperidone but he felt nothing changed.
His mother said that hes very thirsty, and that he was fussy.
He had just urinated about an hour ago, its yellow in
color, and it was less than 1/5 of a glass of water. He once
had a fever for 37.7C at about 4 hours ago. He felt a pain
in the stomach. He didnt feel any hard to breathe, a
bloated stomach, and didnt have any flu or cough. He
didnt have any allergic. He had not felt anything like this
before. He often forgot to wash his hands before he eat
something.
 From the physical examination, the patient looked moderate ill (was in full
consciousness, looked fussy, didnt have any hard to breathe). The
temperature was 38C (axilla), pulse rate 96x/min, respiratory rate 24x/min.
His weight and height respectively is 16 kg and 104 cm, thus his nutritional
status based on WHO chart is in good nutrition. His eyes were sunken, had
no tears, and his mouth was dry. There was a tenderness on the
epigastrium, hipokondrika sinistra et dextra regions. The skin pinch went
back slowly. The laboratory test showed hemoglobin 11.6 g/dl, leukosit
13.000 /ul, trombosit 305.000 /ul, hematokrit 35.3%, dan GDS 82 mg/dl
He was then hospitalized with an acute diarrhea at cause viral infection
with mild to moderate dehydration. He was given intravenous RL 1120 cc
for 2.5 hours for rehydration and continued by KAEN 3B 15 drops per min
(makro), L-Bio 2x1 sach (PO), Paracetamol syrup 4x7.5ml (PO),
domperidone 3x5ml (PO), zinc syrup 1x20mg (PO), and 150cc oralit for
every time he defecate.
Day 1
After 24 hours of hospitalization, the patient still got fever for
38.3C. He defecated 5 times, yellow-colored stools with dregs,
for about a quarter of a glass of water. He still threw up every
time he drink or eat something. He still felt pain in the stomach.
From the physical examination, there was still a tenderness on
the epigastrium and hipokondrika sinistra regions, and also an
increase in bowel sounds for 10x/min. He took a complete
feces test that showed that the feces is colored yellow, flabby,
mucous (+), no blood, no E.coli and E.histolytica, no cyst, no
helminth, fat (+), leukocyte 0-1/LPB, and eritrocyte 3-5/LPB.
He was given some additional medicines, metronidazole
3x180mg (IV) and Ranitidine 15mg (IV).
Day 2
After 48 hours of hospitalization, the patient has already
got no fever, but he still had watery stools for 5x, its yellow
and with some dregs. He still got vomiting sometimes, not
as often as the day before. The pain in his stomach has
also decrease in quality. There is nothing abnormal found
in the physical examination, and the therapy is still the
same as before.
Day 3
After 72 hours of hospitalization, the patients stools is not
as watery as before. Its flabby with some dregs and its
yellow in color. Hes had defecation for 2 times. He has
already got no vomiting. There is nothing abnormal found
from the physical examination. The therapy is still the same
as before.
Day 4
After 96 hours of hospitalization, the patient has only
defecated once, its flabby, yellow-brown colored with
dregs. There is nothing abnormal found in the physical
examination. The patient is still got the same medicines as
before.
Day 5
The patient is allowed to go home on the 5th day of
hospitalization because he has been free from the fever
for 3 days, the stools is not watery and the frequency of
defecation is already less than 3 times a day.
DISCUSSION
 A child is said to have an acute diarrhea if the frequency
of defecation is more than 3 times per day, with a change
in consistency, with or without mucous or blood, that lasts
for less than a week.
Its transmission is through fecal-oral way, through foods or
drinks that are contaminated with the enteropathogens,
or having a contact with stuffs that are contaminated with
a patients stools.
 Diagnosing a diarrhea in children needs to also look for
the signs of dehydration, and then decide whether its a
diarrhea without dehydration, with mild to moderate
dehydration, or even severe dehydration.
The classification of dehydration
according to who*
Parameters NO DEHYDRATION MILD/MODERATE SEVERE
DEHYDRATION DEHYDRATION
Appearance Well, alert Restless, irritable Lethargic, or
unconscious; floppy

Eyes Normal sunken Very sunken

Thirst Drinks normally, not Thirsty, drinks eagerly Drinks poorly or not
thirsty able to drink
Skin pinch Goes back quickly (< Goes back slowly (1 Goes back very
1 second) second) slowly ( 2 seconds)

*Is diagnosed if found 2 or more signs.

The five pillars in managing diarrhea
1.Rehydration
2.10 days zinc administration
3.Continue giving breastmilk and food
4.Selective antibiotics
5.Education
Acute diarrhea with no
dehydration (plan therapy a)
Administering additional fluid at home:
10ml/kg,
Or,
50-100ml for children <1y.o
100-200ml for children aged 1-5y.o
200-300ml for children aged 5-12y.o

For children <2y.o, additional fluid must be

administered using a spoon, with 1 spoon for every
1-2 minutes.

If the child happens to be vomiting, stop giving it for

10 minutes, then continue giving 1 spoon for every
2-3 minutes.

Keep doing this until the child stops having diarrhea.

Acute diarrhea with mild/moderate
dehydration (plan therapy b)
Hospitalization
Identified Unidentifie If there are some
weights d weights things that make
Rehydrate orally within the first 3 the oralit
Rehydrate orally with 75ml/kg
hours with: couldnt be
oralit within the first 3 hours
300ml oralit for children <1y.o given orally, we
600ml oralit for children aged 1- could administer
5y.o it through a
1200ml oralit for children >5y.o nasogastric tube
After the first 3 hours with the same
amount of
Evaluate the patients general state. volume and with
Re-classify the hydration status 20ml/kg/hour
No Severe
rate.
Mild/moderate
dehydratio dehydratio
dehydration
n n

Plan therapy A Plan therapy B Plan therapy C

Acute diarrhea with severe
dehydration (plan therapy c)
1. Give 100ml/kg intravenous fluid (Lactated Ringers) with the procedure explained on the table belo
If the child is able to drink, give oralit orally while IV fluid is being prepared.
AGE THE FIRST 30 ML/KG FOR: THE SECOND 70 ML/KG FOR:
<12 m.o 1 hour 5 hours
12m.o 5y.o 30 minutes 2.5 hours

Give 5ml/kg/hour oralit orally during the administration of IV fluid once the child wants to drink;
it usually takes 3-4 hours for babies and 1-2 hours for children.

2. Evaluate the childs general state and hydration state every hour. If it doesnt get better, speed
up the IV drops rate.

3. After 6 hours for babies and 3 hours for children, re-evaluate the hydration status and re-classify it.
For the next step, choose the right plan therapy based on the new hydration status.
Additional therapy
Giving some additional medicines such as anti-emetic is
sometimes needed if the patient have a persistent emesis.
Ondansetron is the anti-emetic chosen to give for a child
with diarrhea and persistent emesis.
The use of probiotics is also useful in restoring beneficial
intestinal flora and enhance host protective immunity.
CASE ANALYSIS
 The patient is diagnosed with an acute diarrhea et causa viral
infection based on the examination, which is the frequency of
defecation is more than 3 times a day, without mucous or
blood and lasts for less than a week. This patient has this
criteria, and it happened since 18 hours before he came to
the hospital.
Based on the examination, the signs of mild/moderate
dehydration were all found: the patient looked very thirsty and
irritable, the eyes are sunken and the skin pinch went back
slowly.
Based on the theory, a child with mild/moderate dehydration
is needed to be given oralit for 75ml/kgBB for 3 hours. But, since
this patient has persistent vomiting, as an alternate, he was
given an intravenous RL for 70ml/kgBB for 2.5 hours. 70x16 =
1120ml for 2.5 hours.
 Zinc is administered for 10 days in a row, with children
under 6 month-old be given 10mg, and those who are
above 6 month-old be given 20mg. This patient is 3 year
and 9 month-old, so he was given 20mg zinc, which is fit
the theory.
 Antibiotic is only given to those who have bloody stools or
those who have cholera, and those who have severe
infection from other organs. This patient had no such
features. Thus, based on the theory, this patient should not
be given metronidazole.
Although there is a fat found in his stool, it is not an
indication for a children to be given metronidazole. Based
on the theory, there must be a cyst or parasite of
Entamoeba histolytica or Giardia lamblia in the stool.
This patient also has no enough features of E.histolytica or
Giardia lamblia infection.
 In this case, the patient is also given domperidone as an
anti-emetic. This isnt suitable with the theory saying that
Ondansetron is an effective and less-toxic anti-emetic.
The conclusion is, in making the diagnosis for this patient,
the health-care had already done it according to the
theory, although the given therapy was not fully theory-
based.