case report gastroenteritis

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.



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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-followup


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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-followup


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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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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-followup


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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-followup


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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


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.

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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

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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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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



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28

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




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




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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%


conjunctiva (-/-), sunken eyes (-), Ears and Nose: no abnormalities,

Mouth: dry mouth (+)




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


Oralit 50-100 cc/each time diarrhea



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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%


conjunctiva (-/-), sunken eyes (-), tears (+). Ears, Nose, and Mouth: no

abnormalities




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


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

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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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32

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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case report gastroenteritis

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