GASTROENTERITIS

PRESENTER : GESSY ADET LUSIANA SITORUS (060100403)

SESYLIA CLARISSA (060100148)

SUPERVISOR : Prof Dr H. Sjabaroeddin, Sp.A(K)

1.INTRODUCTION
1.1 DEFENETION
Gastroenteritis is a clinical syndrome caused by various viral, bacterial, and
parasitic enteropathogens. The primary gastroenteritis manifestation is diarrhea, but it
may be accompanied by nausea, vomiting, and abdominal pain. A universal defenition
of diarrhea does not exist, although patient seem to have no difficulty defining their
own situation. Although most defenitions centre of the frequency, consitency, and
water content of stools, we prefers defining diarrhea as stools that take the shape of
their container. The severity of illness may vary from mild and inconvenient to severe
and life threatening. Appropriate management requires extensive history and
assessment and appropriate, general supportive treatment that is often etiology
specific. Diarrhea associated with nausea and vomiting is referred to as
gastroenteritis. Because the disease severity depends on the degree of fluid loss,
accurately assessing dehydration status remaince a crucial step in preventing
mortality.2

1.2 EPIDEMIOLOGY

Diarrhea is one of the most common reasons patients seek medical care. In the
developed world, it is the most common reason for missing work, while in the
developing world, it is a leading cause of death. In developing countries, diarrhea is a
seasonal scourge usually worsened by natural phenomena. An estimated 100 million
cases of acute diarrhea occur every year in the United States. Of these patients, 90%
do not seek medical attention, and 1-2% require admission. Diarrheal diseases can
quickly reach epidemic proportions, rapidly overwhelming public health systems in

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even the most advanced societies. In developing countries, gastroenteritis is cause of
death of 1,8 million children each year or 19% cause of the children death. The most
common cause of gastroenteritis in developing countries is rotavirus that consist of
60% cases in under 2 years old children. More than one billion cases were reported
case there were not any less 4 million death reported in whole world. Inspite of little
change of gastroenteritis prevalence in children for the last 4 decade, the mortality has
rapidly decrease, from 4,6 million cases in 1980, 3 million cases in1970 to 2,5 million
cases in 1990. This dereasing was succeded the international supporting to use oralit
as the option of therapy for the acute diarrhea, with the episodic diarrhea proportion
was cured by oralit has increase from 15% in 1984 to 40% in 1993.2

1.3 ETIOLOGY

Flow in the gastrointestinal tract is steady state involving massive fluid

secretion into and absorbtion from the gastroinstestinal lumen, but in gastroenteritis
there are imbalance between absorbtion and secretion. Each process is controlled by
both extrinsic and intrinsic factors. Subtle abberations in input and output at any
several levels can result in diarrhea with or without nutrient malabsorption. Thus, an
excessive osmotic load, increased secretion, or dismished fluid resorption may result
in diarrhea. An excessive osmotic load in gastrointestinal tract may come about in
three different ways: by direct oral ingestion of excessive osmoles; by ingestion of a
substrate that may be converted into excessive osmoles; and as an enzyme deficiency
in the setting of a particular diet. Secretion is increased by either blood-borne or
intraluminal secretagogues. This include endogenous endocrine products, exotoxins
due to direct ingestion, or gastointestinal luminal substances that stimulate secretion.
Absorption of fluid, electrolytes, and nutrients can be dismished by many factors,
including the toxic effects of alcohol; mucosal damage from infectious agents;
prokinetic agents that speed up gastointestinal motility, at last, inflammatory and
other disorders resulting in loss of mucus, blood, or protein from the gastrointestinal
tract may be manifested as diarrhea.2

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Table 1.1 Mechanisms of diarrhea and major specific causes5

1.4 Pathophysology

Adequate fluid balance in humans depends on the secretion and reabsorption of

fluid and electrolytes in the intestinal tract; diarrhea occurs when intestinal fluid
output overwhelms the absorptive capacity of the gastrointestinal tract. The 2 primary
mechanisms responsible for acute gastroenteritis are:

1. Damage to the villous brush border of the intestine, causing malabsorption

of the intestinal contents and leading to an osmotic diarrhea
2. The release of toxins that bind to specific enterocyte receptors and cause
the release of chloride ions into the intestinal lumen, leading to secretory
diarrhea. Microorganism may produce toxins that facilitate infection.
Enterotoxins are generated by bacteria that act directly on secretory
mechanism and produce typical, copius watery diarrhea. No mocusal

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 infetion occurs. The small intestines are primarily affected, and elevation
of the adenosine monophosphate (AMP) levels is the common mechanism.
Cytotoxin production by bacteria results in mucosal cell destraction that
leads to bloody stools with inflamatory cells. A resulting decressed
absorptive abbility occurs.1,2

1.5 Clinical Manifestation

a. History

The history and phisycal examination severe 2 vital function :

 Differentiating gastroenteritis from other causes of vomiting and diarrhea in

children.
 Estimating the degree of dehydration.

Table 1.2 Clinical Finding Dehydration4

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Symptom/Sign Mild Dehydration Moderate Dehydration Severe Dehydration

Level of Alert Lethargic Obtunded

consciousness

Capillary refill* 2 s 2-4 s >4 s, cool limbs

Mucous Normal Dry Parched, cracked

membranes

Tears Normal Decreased Absent

Heart rate Slightly increased Increased Very increased

Respiratory Normal Increased Increased and

rate/pattern* hyperpnea

Blood pressure Normal Normal, but orthostasis Decreased

Pulse Normal Thready Faint or impalpable

Skin turgor* Normal Slow Tenting

Fontanel Normal Depressed Sunken

Eyes Normal Sunken Very sunken

Urine output Decreased Oliguria Oliguria/anuria

In some cases, the history and physical examination can also aid in determining
the type of pathogen responsible for gastroenteritis, though only rarely will this affect
menagement.

 Diarrhea : duration of diarrhea, the frequency and amount of stools, the time
since last episode of diarrhea, and the quality stools. Frequent, watery stools
are more consistent with viral gastroenteritis, whereas stools with blood or
mucus are indicative of a bacterial pathogen. Similary, a long duration of
diarrhea (14 day) is more consistent with a parasitic or noninfectious cause of
diarrhea.
 Vomiting : duration of vomiting, the amount and qualityof vomitus, and time

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 since the last episode of vomiting. Vomiting a symptom common to a host
illness, implies proximal bowel involvement, especially with performed
neurotoxin, as elaborated by S aureus and B aureus.
Vomiting is leading symptom of intestinal obstruction, usually coulped with
distention; however, ditention may not significant if the obstructing lesion is
very proximal. Vomiting without diarrhea must always prompt a search for
noninfection causes and cannot be reffered to as gastroenteritis.

 Pain : The location and character of pain may be indicative of the area of
infection because colonic involvement is usually associated with tenesmus and
pain in either of the lower quadrants or the lower back, whereas jejunoileal
infection may result in periumbilical pain. Cramps may be caused by an
electrolyte imbalance.

 Stools : Ask about frequency, nature (amount, color, watery, semisolid, odor),
and presence of blood and/or mucus. Large volumes of stool are usually
associated with enteric infection, whereas colonic infection results in many
small stools. The presence of blood indicates colonic ulceration (bacterial
infection, inflammatory disease, ischemia). White bulky feces that float (high
fat content) are due to a small bowel pathology that leads to malabsorption.
Copious (rice water) diarrhea is a hallmark of cholera.

 Extraintestinal : A history of other nonintestinal illnesses that can lead to

diarrhea may be obtained. Vomiting and/or diarrhea may be a manifestation of
that illness or a result of its treatment. Obtaining a history of recent surgery or
radiation, food or drug allergies, and endocrine or gastrointestinal disorders is

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 extremely important. The patient should always be questioned regarding prior
episodes.
Malaria, Whipple disease, irritable bowel, incomplete bowel obstruction,
inflammatory disease, nutritional disease, and carcinoid and malabsorption
syndromes can result in diarrhea.
Drugs such as colchicine, quinidine, antimicrobials, cancer chemotherapeutic
agents, and magnesium-containing antacids frequently cause diarrhea.
 Dehydration : Orthostasis, lightheadedness, diminished urine formation, and a
change in mentation herald marked dehydration and electrolyte loss, requiring
aggressive treatment. These symptoms are particularly important in elderly
patients, a group that is most at risk from diarrhea.
 Epidemiology factors

b. Physical
A thorough physical examination is essential to assess the general state of
hydration and nutrition and to exclude extraintestinal causes of diarrhea. Often, the
cause of diarrhea cannot be determined based on the physical findings present, which
may be scarce.
 The most important element of the physical examination is the assessment of
the patient's hydration status. Additionally, signs of bacteremia or sepsis
should be sought. Patients with chronic diarrhea may need an evaluation
of their nutritional status.

Table 1.3 Estimated Fluid Deficit4

Severity
Infants (weight <10 kg) Children (weight >10 kg)

Mild dehydration 5% or 50 mL/kg 3% or 30 mL/kg

Moderate 10% or 100 mL/kg 6% or 60 mL/kg

dehydration

Severe dehydration 15% or 150 mL/kg 9% or 90 mL/kg

 A rectal examination should be performed, involving checking for blood and

mucus. Rectal examination may reveal abscesses, fistulae, and fissures, which

7
 may indicate inflammatory bowel disease. A partially obstructing tumor or a
fecal impaction may be discovered as a cause of diarrhea. Finally, the stool
can be examined for the presence of blood and pus.
 Hydration and nutritional status
Diminish skin turgor, weight loss, resting hypotension and tachycardia, dry
mucus membranes, decreased frecuency of urination, changes in mental
status, and orthostasis can be used to gauge dehydration. In children, the
absence of tears, poor capillary refill, sunken eyes, depressed frontanelles,
increased axillary skin folds, and dry diapers all may reflect a dehydrated
state. Muscle wasting and sign of neural dysfunction dueto nutritional
depletion may be obbserved in patient with chronic diarrhea.
 Abdominal examination
A careful abdominal examination is necessary to exclude causes of diarrhea
that may require surgical intervention, such as pelvic abscesses close to the
rectosigmoid that are causing tenesmus.
The examiner should look for signs of an acute abdomen, listening for bowel
sounds, determining the location of any tenderness, and palpating for masses
or organomegaly. Appendicitis in children may manifest as diarrhea.2

1.6 Treatment

A. Prehospital Care

Children with acute gastroenteritis rarely require intravenous acces. In those

presenting with circulatory collapse due to severe dehydration or sepsis, intravenous
access should be obtained and followed by an immediate 20mL/kg bolus of normal
saline.

B. Emergency Departement Care

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 The American Academy of Pediatrics, the European Society of Pediatric
Gastroenterology and Nutrition (ESPGAN), and the World Health Organization all
recommend oral rehydration solution (ORS) as the treatment of choice for children
with mild-to-moderate gastroenteritis in both developed and developing countries,
based on the results of dozens of randomized, controlled trials and several large meta-
analyses.

One large meta-analysis of 16 trials including 1545 children with mild-to-

moderate dehydration found that, compared with intravenous rehydration, children
treated with ORS had a significant reduction in length of hospital stay and fewer
adverse events, including seizures and death.16 The overall rate of ORS failure
(percentage of children eventually requiring intravenous hydration) in studies
comparing ORS to intravenous hydration was about 4%.

Initial care in the emergency department should focus on correction of

dehydration. The type and amount of fluid given should reflect the degree of
dehydration in the child.

C. Dehydration Treatment

 Minimal or no dehydration

No immediate treatment is required. If the child breastfed, the mother should

be encouraged to breastfed more frequently than usual and for longer at each
feed. If the child is not exclusively breastfed, then oral maintenance fluids
(including clean water, soup, rice water, yogurt drink, or other culturally
appropriate fluid) should be given at a rate of approximately 500 mL/day for
children younger than 2 years, 1000 mL/day for children aged 2-10 years, and
2000 mL/day for children older than 10 years. In addition, ongoing fluid losses
should be replaced with 10 mL/kg body weight of additional ORS for each
loose stool and 2 mL/kg body weight of additional ORS for each episode of
emesis (both for breastfed and nonbreastfed children).

 Mild to moderate dehydration

Children should be given 50-100 mL/kg of ORS over a 2- to 4-hour period to

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 replace their estimated fluid deficit, with additional ORS given to replace
ongoing losses (10 mL/kg body weight for each stool and 2 mL/kg body
weight for each episode of emesis). After the initial rehydration phase, patients
may be transitioned to maintenance fluids as described above. ORS should be
given slowly by the caregiver or parent using a teaspoon, syringe, or medicine
dropper at a rate of 5 mL every 1-2 minutes. If tolerated by the patient, the rate
of ORS delivery can be increased slowly over time. For patients who do not
tolerate ORS by mouth, nasogastric (NG) feeding is a safe and effective
alternative. Multiple clinical trials have found NG rehydration to be as
efficacious as intravenous rehydration, but more cost-effective and with fewer
adverse events. Patients should be reassessed frequently by the clinician to
ensure adequacy of oral intake and resolution of the various signs and
symptoms of dehydration.

 Severe dehydration
Severe dehydration constitutes a medical emergency requiring immediate
resuscitation with intravenous fluids. Intravenous access should be obtained,
and patients should be administered a bolus of 20-30 mL/kg lactated Ringer's
(LR) or normal saline (NS). If pulse, perfusion, and/or mental status do not
improve, a second bolus should be administered. After this, the patient should
be given an infusion of 70 mL/kg LR or NS over 5 hours (children <12
months) or 2.5 hours (older children). If no peripheral veins are available, an
intraosseous line should be placed. Serum electrolytes, bicarbonate,
urea/creatinine, and glucose levels should be sent.
Once resuscitation is complete and mental status returns to normal,
rehydration should continue with ORS as described above, as it has been
shown to decrease the rate of hyponatremia and hypernatremia when
compared with intravenous rehydration.

D. Feeding and nutrition

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 In general, children with gastroenteritis should be returned to a normal diet as
rapidly as possible. Early feeding reduces illness duration and improves nutritional
outcome. Breastfed infants should continue breastfeeding throughout the rehydration
and maintenance phases of acute gastroenteritis. Formula fed infants should restart
feeding at full strength as soon as the rehydration phase is complete (ideally in 2-4 h).
Weaned children should restart their normal fluids and solids as soon as the
rehydration phase is complete. Fatty foods and foods high in simple sugars should be
avoided. For most infants, clinical trials have found no benefit of lactose-free
formulas over lactose-containing formulas. Similarly, highly specific diets, such as
the BRAT (bananas, rice, applesauce, and toast) diet, have not been shown to improve
outcomes and may provide suboptimal nutrition for the patient.

E. Medication

The goals of pharmacotherapy are to reduce morbidity, to prevent

complications, and for prophylaxis. Antidiarrheal (kaolin-pectin) and antimotility
agents (loperamide) are contraindicated in the treatment of acute gastroenteritis in
children because of their lack of benefit and increased risk of side effects, including
ileus, drowsiness, and nausea. Probiotics are live microbial feeding supplements
commonly used in the treatment and prevention of acute diarrhea. Possible
mechanisms of action include synthesis of antimicrobial substances, competition with
pathogens for nutrients, modification of toxins, and stimulation of nonspecific
immune responses to pathogens. Two large systematic reviews have found probiotics
(especially Lactobacillus GG) to be effective in reducing the duration of diarrhea in
children presenting with acute gastroenteritis. Because probiotic preparations vary
widely, estimating the effectiveness of any single preparation is difficult. One meta-
analysis, including 18 published studies, all conducted in developing countries, found
zinc supplementation to be effective in reducing the duration and severity of diarrhea
in children with acute gastroenteritis. The WHO recommends zinc supplementation
(10-20 mg/d for 10-14 d) for all children younger than 5 years with acute
gastroenteritis, though little data exist to support this recommendation for children in
developed countries.

 Vaccine

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 Rotavirus vaccine is indicated to prevent rotavirus gastroenteritis , a major
cause of severe diarrhea in infants
Adult
Not indicated
Pediatric
<6 weeks: Not established.
RotaTeq6-12 weeks: 2 mL PO as a single dose, followed by 2 additional doses
at 4- to 10-week intervals; do not administer after age 32 week.
Rotarix6 weeks: 1 mL PO as a single dose; administer a second dose after an
interval of at least 4 week and before age 24 week.
 Antimicrobials
Metronidazole (Flagyl)
Recommended as the treatment of choice for mild-to-moderate cases of C
difficile colitis. Provides effective therapy, with reported response rates from
95-100%. In vitro activity is bactericidal and dose dependent. Standard dosing
has been shown to promote fecal concentrations capable of a 99.99%
reduction of C difficile. Metronidazole IV may be administered to those
patients who cannot tolerate PO medications because of its potential to
accumulate in the inflamed colon. IV route is not as effective as PO.

Nitazoxanide (Alinia)
Inhibits growth of C parvum sporozoites and oocysts and G lamblia
trophozoites. Elicits antiprotozoal activity by interference with the pyruvate:
ferredoxin oxidoreductase (PFOR) enzyme-dependent electron transfer
reaction, which is essential to anaerobic energy metabolism. Available as an
oral suspension (20 mg/ml).

Tetracycline (Sumycin)
Treats gram-positive and gram-negative organisms as well as mycoplasmal,
chlamydial, and rickettsial infections. Inhibits bacterial protein synthesis by
binding with 30S and possibly 50S ribosomal subunit.Treatment of choice for
cholera. Not recommended for children younger than 8 years.

Doxycycline (Bio-Tab, Doryx, Doxy)

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 Broad spectrum, synthetically derived bacteriostatic antibiotic in the
tetracycline class. Almost completely absorbed, concentrates in bile, and is
excreted in urine and feces as a biologically active metabolite in high
concentrations.Inhibits protein synthesis and, thus, bacterial growth by binding
to 30S and possibly 50S ribosomal subunits of susceptible bacteria. May block
dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent
protein synthesis to arrest.Treatment of choice for cholera. Not recommended
for children younger than 8 years.

Antiemetics

One large, prospective, randomized, double-blind trial compared a single dose

of an orally disintegrating ondansetron tablet to placebo in children presenting
to an emergency department with acute gastroenteritis.31 The study found that
children treated with ondansetron were less likely to vomit, had greater oral
intake, were less likely to require IV rehydration, and had a reduced length of
stay in the emergency department compared to children treated with placebo.
Several smaller studies have also shown ondansetron to be similarly effective
in children.

Further Outpatient Care

 Parents should be instructed to continue providing maintenance ORS fluids at

home as needed. Breastfeeding and formula feeding should be continued for
infants, and children should be encouraged to return to a regular diet as rapidly
as possible.
 Parents should be instructed to look for the various signs of dehydration
outlined above, such as change in mental status, decreased urine output,
sunken eyes, absence of tears, dry mucous membranes, and slow return of
abdominal skin pinch.
 Parents should seek medical attention if dehydration returns, oral intake is
inadequate, or if their child develops worsening abdominal pain, fever >101°F,
or prolonged diarrhea lasting longer than 14 days.1

Patient Education

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  Patients should be educated on the importance and proper methods of oral
rehydration and early appropriate feeding.
 All patients, especially the parents of infants and young children, must be
extensively educated about the signs and symptoms of dehydration.
 Patients with food-borne exposures should be educated on deterrence.
 Immunocompromised patients and individuals with liver disease should be
educated not to consume raw shellfish, especially oysters.
 Travelers to underdeveloped areas should be made aware of proper avoidance
measures, appropriate treatment, and current endemic illnesses.
 For excellent patient education resources, visit eMedicine's Esophagus,
Stomach, and Intestine Center. Also, see eMedicine's patient education
articles, Gastroenteritis, Abdominal Pain in Adults, Diarrhea, and Vomiting
and Nausea.

1.7 Prognosis

In most cases, gastroenteritis is a self-limited condition with an excellent

prognosis. Symptoms of gastroenteritis usually subside within 3 to 5 days. Failure to
improve within 2 weeks should bring the diagnosis into question. The duration of
traveler’s diarrhea caused by E. coli or Shigella infection can be significantly
shortened with antibiotic therapy.
Although infectious gastroenteritis is usually acute (rapid onset with a short
duration), certain parasites such as Giardia can cause chronic diarrhea. For more
severe or prolonged cases, the prognosis depends on the organism causing the
gastroenteritis and the effectiveness of treatment. Recovery can be delayed by an
extensive infection, unusual reactions to medicines, or infection from bacteria that
produce a more powerful toxin. Without replacement, extreme loss of body fluid and
electrolytes can lead to shock, coma, or death.
The prognosis for prolonged (more than 2 weeks) noninfectious gastroenteritis
depends upon accurate identification and treatment of the underlying cause and ranges
from good (food intolerances, allergies, medication side effects) to fair or poor (heavy
metal toxicity, cytomegalovirus infection in HIV-compromised individuals).6

II.Objective
The aim of this paper is to report a case of gastroenteritis in a 10 months old boy.

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III. Case
GK, male, 10 months old, 7,3 kgs, 70 cm was admitted to the infection unit of Haji
Adam Malik General Hospital on 12th August 2010 at 21.05 pm with the chief
complaint of watery stool this past 5 days. This condition was happen in 5 times daily,
volume ± half of aqua cup with water > waste, mucous (-), blood (-).

Vomiting was found since this 5 days, frequention > 5 times daily, volume ¼ cup,
consist of food and drink.

Patient was having fever since 5 days ago, with the temperature going up and down
and reduced by the consumtion of antipyretic drug. Coughing and influenza was not
found.

History of immunization was unclear, morbili (-)

History of feeding: 0-4 months : exclusive mother breast feeding, 4 month till now:
ASI/PASI + milk porridge

Mixturation was normal, the last mixturation was in emergency room.

PHYSICAL EXAMINATION
Body weight : 7,3 kgs
Body length : 70 cm
BW / BL : 104% (normoweight)
Body temperature : 38.8°C
Level of consciousness : GCS 15 (E4V5M6)
Anemic (-), icteric (-), cyanosis (-), oedema (-),
dypsnoe (-)
Head : Eye : light reflexes (+/+), isochoric pupil, eyelids
pale (-/-),oedema in palpebra superior and inferior
(+/+) Sunken eyes (+)
Ears : within normal limit

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 Nose : within normal limit
Mouth : dry lips (+)
Neck : Lymph node enlargement (-)
Chest : Symmetric fusiformic, no retraction
HR: 130 bpm, regular, no murmur
RR: 32 rpm, regular, no rales
Abdominal : Soepel, peristaltic (+) increase, liver and spleen: not
palpable, skin turgor return slowly.
Extremities : Pulse: 130 tpm, regular, adequate pressure/volume, BP:
90/60 mmHg
Working diagnosis : Gastroenteritis with mild-moderate dehydration
Management : - IVFD RL 75 cc/kg BW in 4 hours (135 gtt/minute micro)
- Zinc 1x 10 mgs
- Lacto B 2x1
- Paracetamol 3x 100 mgs (when needed)
- Porridge diet 730 kkal with 15 grs protein

LABORATORY FINDINGS (12th August 2010)

Full Blood Count Hb 12,6 g%

RBC 5.49 x 10.3/mm3

Ht 36,5%

WBC 20,16 x 10.3/mm3

Plt 510 x 10.3/mm3

Electrolyte Serum Natrium (Na) 134 mEq/L

Kalium (K) 2,7 mEq/L

Cloride (Cl) 109 mEq/L

Carbohydrate metaboism Blood Glucose 145.00 mg/dl

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Follow Up August 13th 2010 at 01.00 pm

S: watery stool 3 times, volume ± ¼ cup, water > waste

O: Sens: Compos Mentis, Temp: 37.8°C, BB: 7,4 kg, PB: 70 cm, BB/TB: 83%.
Head : Sunken fontanel (+), Eyes: sunken eyes (+),isochoric pupil,
pale palpebra inferior (-/-),
oedema palpebra superior/inferior (-/-)
Ear/ Nose: within normal limit
Mouth: dry lips (+)
Neck: lymph node enlargement (-)
Chest : Symmetrically fusiformed, retraction (-)
HR = 110 bpm, regular, murmur (-)
RR = 32 tpm, regular, ronchi (-)
Abdomen : Soepel, increased peristaltic. H/L: unpalpable
Extremities : BP: 100/60 mmHg
Pulse : 110 bmp, regular, adequate pressure/volume

A: Gastroenteritis with mild-moderate dehydration

P: - IVFD RL 75 cc/ kgs BW in 4 hours (135 gtt/minutes- micro)

Follow Up August 13th 2010 at 05.00 pm (after rehydration)

S: defecation (+) once, soft consistency, water=waste

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Follow Up August 13th 2010 at 05.00 pm (after rehydration)

O: Sens: Compos Mentis, Temp: 37°C, BB: 7,3 kg, PB: 70 cm, BB/TB: 83%.
Head : Sunken fontanel (-), Eyes: sunken eyes(-) isochoric pupil, pale palpebra
Inferior (-/-)
oedema palpebra superior/inferior (-/-)
Ear/ Nose: within normal limit
Mouth: dry lips (-)
Neck: lymph node enlargement (-)
Chest : Symmetrically fusiformed, retraction (-)
HR = 110 bpm, regular, murmur (-)
RR = 32 tpm, regular, ronchi (-)
Abdomen : Soepel, normal peristaltic. H/L: unpalpable
Extremities : BP: 100/60 mmHg
Pulse : 110 bmp, regular, adequate pressure/volume

A: Gastroenteritis without dehydration

P: - IVFD D5% NaCl 0,225% 35 gtt/minutes

Follow Up August 13th 2010

S: watery stool (-)

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 Follow Up August 13th 2010

O: Sens: Compos Mentis, Temp: 37,7° C, BB: 7,3 kg, PB: 70 cm, BB/TB: 83%,
Head : Sunken fontanel (-), Eyes: sunken eyes (-), isochoric pupil, pale
Palpebra inferior (-/-)
oedema palpebra superior/inferior (-/-)
Ear/ Nose: within normal limit
Mouth: wet lips mucosa
Neck: lymph nodes enlargement (-)
Chest : Symmetrically fusiformed, retraction (-)
HR = 105 bpm, regular, murmur (-)
RR = 28 tpm, regular, ronchi (-)
Abdomen : Soepel, normal peristaltic. H/L: unpalpable
Extremities : BP: 100/70 mmHg
Pulse : 110 bmp, regular, adequate pressure/volume

A : Gastroenteritis without dehydration

P: - IVFD D5% NaCl 0,225% + KCl 10 mEq 30 gtt/i-micro

- Zinc 1x 10 mg
- Lacto B 2x 1 sachet
- Paracetamol 3x 100 mg (when needed)
- porridge diet wit 730 kkal + 15 gr protein

Patient was discharged as outpatient on August 13th 2010.

IV. Discussion

GK, male, 10 months old, 7,3 kgs, 70 cm was admitted to the infection unit of
Haji Adam Malik General Hospital on 12th August 2010 at 21.05 pm with the chief
complaint of watery stool this past 5 days. This condition was happen in 5 times daily,
volume ± half of aqua cup with water > waste, mucous (-), blood (-).Vomiting was
found since this 5 days, frequention > 5 times daily, volume ¼ cup, consist of food
and drink.

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 Gastroenteritis is a clinical syndrome caused by various viral, bacterial, and
parasitic enteropathogens. The primary gastroenteritis manifestation is diarrhea, but it
may be accompanied by nausea, vomiting, and abdominal pain. Diarrhea associated
with nausea and vomiting is referred to as gastroenteritis. The most common cause of
gastroenteritis in developing countries is rotavirus that consist of 60% cases in under
2 years old children.2

The history and phisycal examination severe 2 vital function : differentiating

gaastroenteritis from other causes of vomitting and diarrhea in children, and
estimating the degree of dehydration.

Symptom/Sign Mild Dehydration Moderate Dehydration Severe Dehydration

consciousness Alert Lethargic Obtunded
Capillary refill* 2s 2-4 s >4 s, cool limbs
Mucous Normal Dry Parched, cracked
membranes
Tears Normal Decreased Absent
Heart rate Slightly increased Increased Very increased
Respiratory Normal Increased Increased and hyperpnea
rate/pattern*
Blood pressure Normal Normal, but orthostasis Decreased
Pulse Normal Thready Faint or impalpable
Skin turgor* Normal Slow Tenting
Fontanel Normal Depressed Sunken
Eyes Normal Sunken Very sunken
Urine output Decreased Oliguria Oliguria/anuria

In this patient we can find that this patient was in alert condition. But this
patient have a dry mucous membranes such as on his lips. The skin turgor in this
patient is return slowly. And we can see that this patient have the depressed fontanel
and sunken eyes. The last mixturation in this patient was in emergency room. So, we
can conclude this patient was in mild-moderate dehydration condition.

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 Children with acute gastroenteritis rarely require intravenous acces. In those
pressenting with circulatory collapse due to severe dehydration or sepsis, intravenous
access should be obtained and followed by an immediate 20mL/kg bolus of normal
saline. Initial care in the emergency department should focus on correction of
dehydration. The type and amount of fluid given should reflect the degree of
dehydration in the child. Children should be given 50-100 mL/kg of ORS over a 2- to
4-hour period to replace their estimated fluid deficit, with additional ORS given to
replace ongoing losses (10 mL/kg body weight for each stool and 2 mL/kg body
weight for each episode of emesis). After the initial rehydration phase, patients may
be transitioned to maintenance fluids as described above. ORS should be given slowly
by the caregiver or parent using a tea spoon, syringe, or medicine dropper at a rate of
5 mL every 1-2 minutes. If tolerated by the patient, the rate of ORS delivery can be
increased slowly over time. For patients who do not tolerate ORS by mouth,
nasogastric (NG) feeding is a safe and effective alternative. Multiple clinical trials
have found NG rehydration to be as efficacious as intravenous rehydration, but more
cost-effective and with fewer adverse events. Patients should be reassesed frequently
by the clinician to unsure adequacy of oral intake and resolution of the various signs
and symptoms of dehydration.

The goals of pharmacotherapy are to reduce morbidity, to prevent

complications, and for prophylaxis. Probiotics are live microbial feeding supplements
commonly used in the treatment and prevention of acute diarrhea. Possible
mechanisms of action include synthesis of antimicrobial substances, competition with
pathogens for nutrients, modification of toxins, and stimulation of nonspecific
immune responses to pathogens. Two large systematic reviews have found probiotics
(especially Lactobacillus GG) to be effective in reducing the duration of diarrhea in
children presenting with acute gastroenteritis. The WHO recommends zinc
supplementation (10-20 mg/d for 10-14 d) for all children younger than 5 years with
acute gastroenteritis, though little data exist to support this recommendation for
children in developed countries.

V. Summary

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 It has been reported an 9 months old boy with his chief complaint of watery
stool this past 5 days. He has been diagnosed with gastroenteritis with mild-moderate
dehydration based on the history taking, physical examination and laboratory results.

REFRENCE

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1. Diskin, A. Gastroenteritis – Treatment and Medication [Internet]. 2009
[Updated 2009 October 22]. eMedicine Gastroentestinal. Available from:
http://emedicine.medscape.com/article/775277-treatment.

2. Diskin, A. Gastroenteritis – Overview [Internet]. 2009 [Updated 2009

October 22]. eMedicine Gastroentestinal. Available from:
http://emedicine.medscape.com/article/775277-overview

3. Levine, A. Gastroenteritis – Overview [Internet]. 2010 [Updated 2010

April7]. eMedicine Specialist Pediatrics. Available from:
http://emedicine.medscape.com/article/801948-overview.

4. Luang, LH. Dehydration – Overview [Internet]. 2009 [Updated 2009

November 29]. eMedicine Specialties Pediatrics. Available from:
http://emedicine.medscape.com/article/906999-overview.

5. Mcphee SJ, Linaggapa VR, Ganong WF. Pathophysiology of Disease An

Introduction to Clinical Medicine. 2nd ed. California: Lingappa VR; 1997.
Chapter 13. Diarrhea; p311-13.

6. Wedro. Gastroenteritis – Prognosis [Internet]. 2010 [Updated 2010 27

August ]. Medical Disabillity Advisor – Gastroenteritis. Available from:
http://emedicine.medscape.com/article/801948-overview.

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