Diarrhea is Loosely Defined as Passage of Abnormally Liquid or Unformed Stools at an Increased...
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Transcript of Diarrhea is Loosely Defined as Passage of Abnormally Liquid or Unformed Stools at an Increased...
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Diarrhea is loosely defined as passage of abnormally liquid or unformed stools at an
increased frequency. For adults on a typical Western diet, stool weight >200 g/d can
generally be considered diarrheal.Diarrhea may be further defined as acute if 2
wee!s, persistent if 2"# wee!s, and chronic if ># wee!s in duration.$wo common
conditions, usually associated with the passage of stool totaling 200 g/d, must bedistinguished from diarrhea, as diagnostic and therapeutic algorithms differ.
Diare longgar didefinisi!an sebagai bagian dari abnormal cairan atau berbentu!
bang!u di pening!atan fre!uensi. %ntu! orang dewasa pada !has &arat diet, berat
feses> 200 g / d secara umum dapat dianggap diare.Diare dapat lebih didefinisi!an
sebagai a!ut 'i!a 2 minggu, terus(menerus 'i!a 2(# minggu, dan !ronis 'i!a> #
minggu dalam durasi.Dua !ondisi umum, biasanya berhubungan dengan berlalunya
tin'a total 200 g / d, harus dibeda!an dari diare, diagnostic dan algoritma terapi
berbeda
)*%$+ D)--+)
ore than 01 of cases of acute diarrhea are caused by infectious agents these
cases are often accompanied by 3omiting, fe3er, and abdominal pain. $he
remaining 401 or so are caused by medications,to5ic ingestions, ischemia, and
other conditions.nfectious )gents ost infectious diarrheas are acquired by fecal(
oral transmission or, more commonly, 3ia ingestion of food or water contaminated
with pathogens from human or animal feces. n the immunocompetent person, theresident fecal microflora, containing >600 ta5onomically distinct species, are rarely
the source of diarrhea and may actually play a role in suppressing the growth of
ingested pathogens.Disturbances of flora by antibiotics can lead to diarrhea by
reducing the digesti3e function or by allowing the o3ergrowth of pathogens, such as
*lostridium difficile 7*hap. 4289. )cute infection or in'ury occurs when the ingested
agent o3erwhelms the host:s mucosal immune and nonimmune 7gastric acid,
digesti3e en;ymes, mucus secretion, peristalsis, and suppressi3e resident flora9
defenses. +stablished clinical associations.with specific enteropathogens may offer
diagnostic clues.n the %nited
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lebih disebab!an oleh obat(obatan, ingestions beracun, is!emia, dan !ondisi
lainnya. )gen infe!si diare ebanya!an infe!si diperoleh oleh fecal(oral transmisi
atau, lebih umum, melalui !onsumsi ma!anan atau air yang ter!ontaminasi dengan
patogen dari !otoran manusia atau hewan. Dalam imuno!ompeten yang orang,
mi!roflora tin'a pendudu!, mengandung> 600 ta!sonomi spesies yang berbeda, 'arang sumber diare dan mung!in sebenarnya berperan dalam mene!an
pertumbuhan patogen ditelan. @angguan flora dengan antibioti! dapat
menyebab!an diare dengan mengurangi fungsi pencernaan atau dengan
memung!in!an pertumbuhan berlebih dari patogen, seperti *lostridium difficile
7&ab. 4289. nfe!si a!ut atau cedera ter'adi !eti!a agen tertelan menguasai mu!osa
host !e!ebalan tubuh dan nonimmune 7asam lambung, en;im pencernaan, se!resi
lendir, peristalti!, dan Flora pendudu! pene!an9 pertahanan. )sosiasi !linis
Didiri!an dengan enteropatogen tertentu mung!in menawar!an petun'u! diagnosti!.
Di )meri!a #E h without
impro3ement, recent antibiotic use, new community outbrea!s, associated se3ere
abdominal pain in patients >60 years, and elderly 7G0 years9 or
immunocompromised patients. n some cases of moderately se3ere febrile diarrhea
associated with fecal leu!ocytes 7or increased fecal le3els of the leu!ocyte proteins9
or with gross blood, a diagnostic e3aluation might be a3oided in fa3or of anempirical antibiotic trial 7see below9. $he cornerstone of diagnosis in those
suspected of se3ere acute infectious diarrhea is microbiologic analysis of the stool.
Wor!up includes cultures for bacterial and 3iral pathogens, direct inspection for o3a
and parasites, and immunoassays for certain bacterial to5ins 7*. difficile9, 3iral
antigens 7rota3irus9, and proto;oal antigens 7@iardia, +. histolytica9. olecular
diagnosis of pathogens in stool can be made by identification of unique DC)
sequences and e3ol3ing microarray technologies could lead to a more rapid,
sensiti3e, specific, and cost(effecti3e diagnostic approach in the future. Aersistent
diarrhea is commonly due to @iardia 7*hap. 2029, but additional causati3e
organisms that should be considered include *. difficile 7especially if antibiotics had
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been administered9, +. histolytica, *ryptosporidium, *ampylobacter, and others. f
stool studies are unre3ealing, then fle5ible sigmoidoscopy with biopsies and upper
endoscopy with duodenal aspirates and biopsies may be indicated. &rainerd
diarrhea is an increasingly recogni;ed entity characteri;ed by an abrupt(onset
diarrhea that persists for at least # wee!s, but may last 4"8 years, and is thought tobe of infectious origin. t may be associated with subtle inflammation of the distal
small intestine or pro5imal colon. 60 tahun, dan
lansia 7G0 tahun9 atau immunocompromised pasien. Dalam beberapa !asus diare
demam dari cu!up parah ter!ait dengan leu!osit fecal 7atau pening!atan !adar
!otoran dari protein leu!osit9 atau dengan darah !otor, e3aluasi diagnosti! mung!in
dihindari mendu!ung percobaan antibioti! empiris 7lihat di bawah9. ?andasandiagnosis mere!a yang dicurigai a!ut diare menular adalah analisis mi!robiologis
dari tin'a. &e!er'a termasu! budaya untu! patogen ba!teri dan 3irus, inspe!si
langsung untu! telur dan parasit, dan immunoassay untu! ba!teri tertentu racun 7*.
difficile9, antigen 3irus 7rota3irus9, dan antigen proto;oa 7@iardia, +. histolytica9.
Diagnosis mole!uler patogen dalam tin'a dapat dila!u!an dengan identifi!asi urutan
DC) yang uni! dan ber!embang microarray te!nologi dapat menyebab!an lebih
cepat, sensitif, spesifi!, dan Aende!atan diagnosti! hemat biaya di masa depan.
Diare persisten umumnya disebab!an @iardia 7&ab. 2029, tetapi organisme
penyebab tambahan yang harus dipertimbang!an termasu! *. difficile 7terutama
'i!a antibioti! telah diberi!an9, +. histolytica, *ryptosporidium, *ampylobacter, danlain(lain. Hi!a penelitian tin'a yang unre3ealing, sigmoidos!opi !emudian fle!sibel
dengan biopsi dan endos!opi atas dengan aspirasi duodenum dan biopsi dapat
diindi!asi!an. &rainerd diare adalah entitas sema!in dia!ui ditandai dengan diare
mendada!(onset yang berlangsung selama setida!nya # minggu, namun dapat
berlangsung 4(8 tahun, dan dianggap berasal dari infe!si. ni mung!in ter!ait
dengan peradangan halus distal usus !ecil atau usus pro!simal. Aemeri!saan
stru!tural dengan sigmoidos!opi, !olonos!opi, atau perut *$ scan 7atau
pende!atan pencitraan lainnya9 mung!in tepat pada pasien dengan diare persisten
uncharacteri;ed untu! mengecuali!an &D, atau sebagai pende!atan awal pada
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pasien yang dicurigai diare a!ut menular seperti mung!in disebab!an oleh is!emi!
!olitis, di3erticulitis, atau obstru!si parsial usus.
)cute diarrhea is defined as the abrupt onset of 8 or more loose stools per day. $he
augmented water content in the stools 7abo3e the normal 3alue of appro5imately 40
m?/!g/d in the infant and young child, or 200 g/d in the teenager and adult9 is due to
an imbalance in the physiology of the small and large intestinal processes in3ol3ed
in the absorption of ions, organic substrates, and thus water. ) common disorder in
its acute form, diarrhea has many causes and may be mild to se3ere.
*hildhood acute diarrhea is usually caused by infection of the small and/or large
intestine howe3er, numerous disorders may result in diarrhea, including a
malabsorption syndrome and 3arious enteropathies. )cute(onset diarrhea is usually
self(limited howe3er, an acute infection can ha3e a protracted course. &y far, themost common complication of acute diarrhea is dehydration.
)lthough the term Iacute gastroenteritisI is commonly used synonymously with
Iacute diarrhea,I the former term is a misnomer. $he term gastroenteritis implies
inflammation of both the stomach and the small intestine, whereas, in reality, gastric
in3ol3ement is rarely if e3er seen in acute diarrhea 7including diarrhea with an
infectious origin9 in addition, enteritis is also not consistently present. +5amples of
infectious acute diarrhea syndromes that do not cause enteritis include Jibrio
cholerae" induced diarrhea and
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state of acti3e secretion. $he most common cause of acute(onset secretory
diarrhea is a bacterial infection of the gut.
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watery diarrhea secondary to small bowel hypersecretion occurs with ingestion of
preformed bacterial to5ins, enteroto5in(producing bacteria,and enteroadherent
pathogens. Diarrhea associated with mar!ed 3omiting and minimal or no fe3er may
occur abruptly within a few hours after ingestion of the former two types 3omiting is
usually less, and abdominal cramping or bloating is greater fe3er is higher with thelatter. *ytoto5in( producing and in3asi3e microorganisms all cause high fe3er and
abdominal pain. n3asi3e bacteria and +ntamoeba histolytica often cause bloody
diarrhea 7referred to as dysentery9. Qersinia in3ades the terminal ileal and pro5imal
colon mucosa and may cause especially se3ere abdominal pain with tenderness
mimic!ing acute appendicitis. Finally, infectious diarrhea may be associated with
systemic manifestations. -eiter:s syndrome 7arthritis, urethritis, and con'uncti3itis9
may accompany or follow infections by
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demam dapat ter'adi tiba(tiba dalam beberapa 'am setelah !onsumsi dari mantan
dua 'enis muntah biasanya !urang, dan !ram perut atau !embung adalah lebih
besar demam lebih tinggi dengan yang !edua. *ytoto5in( memprodu!si dan
mi!roorganisme in3asi3e semua menyebab!an demam tinggi dan perut rasa sa!it.
&a!teri in3asif dan +ntamoeba histolytica sering menyebab!an diare berdarah7disebut sebagai disentri9. Qersinia menyerang terminal ileum dan !olon pro!simal
mu!osa dan mung!in menyebab!an sa!it perut sangat parah dengan !elembutan
meniru apendisitis a!ut. )!hirnya, diare infe!si mung!in ter!ait dengan manifestasi
sistemi!. -eiter
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agents such as loperamide can be useful ad'uncts to control symptoms. # wee!s warrants e3aluation to e5clude serious underlying
pathology. n contrast to acute diarrhea, most of the causes of chronic diarrhea are
noninfectious. $he classification of chronic diarrhea by pathophysiologic mechanism
facilitates a rational approach to management, though many diseases cause
diarrhea by more than one mechanism 7$able #0(89.
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penyebab utama !ematian. Aasien mendalam dehidrasi, terutama bayi dan orang
tua, membutuh!an J rehidrasi. Dalam nonfebrile cu!up parah dan diare tida!
berdarah, )ntimotility dan agen antise!resi seperti loperamide dapat tambahan
yang berguna untu! mengendali!an ge'ala. )gen tersebut harus dihindari dengan
disentri demam, yang dapat diperburu! atau ber!epan'angan oleh mere!a. bismuthsubsalicylate dapat mengurangi ge'ala muntah dan diare, tetapi tida! boleh
diguna!an untu! mengobati pasien immunocompromised atau mere!a dengan
gangguan gin'al !arena dari risi!o bismuth ensefalopati. &i'a!sana penggunaan
antibioti! yang tepat dalam !asus yang dipilih a!ut diare dan dapat mengurangi
!eparahan dan durasi 7@br. #0(29. banya! do!ter mengobati pasien sedang sampai
berat dengan demam disentri empiris tanpa e3aluasi diagnosti! mengguna!an
!uinolon, misalnya ciproflo5acin 7600 mg bid selama 8(6 d9. Aengobatan empiris
'uga dapat dianggap !arena dicurigai giardiasis dengan metronida;ole 7260 mg qid
selama G d9. sele!si antibioti! dan re'imen dosis sebali!nya ditentu!an oleh spesifi!
patogen, pola geografis perlawanan, dan !ondisi yang ditemu!an 7&ab. 422, 4#8,
dan 4#R(4629. *a!upan antibioti! diindi!asi!an apa!ah atau tida! organisme
penyebab ditemu!an pada pasien yang immunocompromised, memili!i !atup
'antung me!anis atau cang!o! 3as!ular baru(baru ini, atau sudah berusia lan'ut.
)ntibioti! profila!sis diindi!asi!an untu! pasien tertentu bepergian !e negara(
negara berisi!o tinggi di antaranya !emung!inan atau !eseriusan diare diperoleh
a!an sangat tinggi, termasu! mere!a yang immunocompromise, &D,
hemochromatosis, atau achlorhydria lambung. Aenggunaan trimetoprim /
sulfametho5a;ole, ciproflo5acin, atau rifa5imin dapat mengurangi diare ba!teri
dalam wisatawan tersebut dengan 01, mes!ipun rifa5imin mung!in tida! coco!untu! in3asi3e penya!it. )!hirnya, do!ter harus waspada untu! mengidentifi!asi
apa!ah wabah diare Aenya!it ini ter'adi dan mengingat!an otoritas !esehatan
masyara!at segera. al ini dapat mengurangi u!uran utama dari pendudu! yang
ter!ena bencana.
D)-+ -BC<
Diare berlangsung> # minggu waran e3aluasi untu! mengecuali!an serius yang
mendasari patologi. &erbeda dengan diare a!ut, sebagian besar penyebab diare
!ronis yang tida! menular. lasifi!asi diare !ronis dengan me!anisme patofisiologis
memfasilitasi pende!atan rasional untu! mana'emen, mes!ipun banya! penya!it
menyebab!an diare lebih dari satu e!anisme 7$abel #0(89. Aenyebab diare
se!retori se!retori! disebab!an oleh ter'adinya penurunan cairan dan transportasi
ele!trolit di mu!osa enterocolonic. mere!a adalah ditandai secara !linis oleh berair,
ber3olume besar output fecal yang biasanya tanpa rasa sa!it dan bertahan dengan
puasa. arena tida! ada malab(diserap ;at terlarut, tin'a osmolalitas dicatat oleh
endogen yang normal ele!trolit tanpa !esen'angan osmoti! tin'a.
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Diarrhea
Diarrhea results from rapid mo3ement of fecal matter through the large intestine.
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refle5 passing from the rectum to the conus medullaris of the spinal cord and then
bac! to the descending colon, sigmoid, rectum, and anus. When the spinal cord is
in'ured somewhere between the conus medullaris and the brain, the 3oluntary
portion of the defecation act is bloc!ed while the basic cord refle5 for defecation is
still intact. Ce3ertheless, loss of the 3oluntary aid to defecationTthat is, loss of theincreased abdominal pressure and rela5ation of the 3oluntary anal sphincterToften
ma!es defecation a difficult process in the person with this type of upper cord in'ury.
&ut, because the cord defecation refle5 can still occur, a small enema to e5cite
action of this cord refle5, usually gi3en in the morning shortly after a meal, can often
cause adequate defecation. n this way, people with spinal cord in'uries that do not
destroy the conus medullaris of the spinal cord can usually control their bowel
mo3ements each day.
diare
asil diare dari gera!an cepat tin'a melalui usus besar. &eberapa penyebab diare
dengan ge'ala sisa fisiologis penting adalah sebagai beri!ut.
Enteritis. +nteritis berarti peradangan biasanya disebab!an bai! oleh 3irus atau
ba!teri dalam saluran usus. Di diare infe!si biasa, infe!si yang paling luas dalam
usus besar dan u'ung distal ileum. Di mana(mana infe!si hadir, mu!osa men'adi
luas 'eng!el, dan la'u se!resi men'adi sangat diting!at!an.
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yang sangat menggairah!an !edua 749 motilitas dan 729 !elebihan se!resi lendir di
distal colon.$hese dua efe! ditambah!an bersama(sama dapat menyebab!an diare
ditandai.
Ulcerative colitis. olitis ulserati3a adalah penya!it di mana daerah luas dindingusus besar men'adi meradang dan ulserasi. otilitas usus ulserasi sering begitu
besar sehingga gera!an massa ter'adi hampir sepan'ang hari bu!an untu! biasa 40
sampai 80 menit. Huga, se!resi usus besar adalah sangat enhanced.)s )!ibatnya,
diare pasien telah diulang buang air besar. Aenyebab !olitis ulserati3a tida!
di!etahui. beberapa do!ter percaya bahwa itu hasil dari alergi atau !e!ebalan efe!
merusa!, tetapi 'uga bisa ter'adi a!ibat !ronis infe!si ba!teri belum dipahami.
)papun sebab, ada !ecenderungan turun(temurun yang !uat untu! !erentanan
untu! !olitis ulserati3a.
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duodenum pro3ides an especially strong stimulus for 3omiting. $he sensory signals
that initiate 3omiting originate mainly from the pharyn5, esophagus, stomach, and
upper portions of the small intestines. )nd the ner3e impulses are transmitted, as
shown in Figure RR"2, 7Ceutral connections of the U3omiting center.V $his so(called
3omiting center includes multiple sensory, motor, and control nuclei mainly in themedullary and pontile reticular formation but also e5tending into the spinal cord.9
tiple distributed nuclei in the brain stem that all together are called the U3omiting
center.V From here, motor impulses that cause the actual 3omiting are transmitted
from the 3omiting center by way of the 6th, Gth, th, 40th, and 42th cranial ner3es to
the upper gastrointestinal tract, through 3agal and sympathetic ner3es to the lower
tract, and through spinal ner3es to the diaphragm and abdominal muscles.
Antiperistalsis, the Prelude to Vomiting. n the early stages of e5cessi3egastrointestinal irritation or o3erdistention, antiperistalsis begins to occur often many
minutes before 3omiting appears. )ntiperistalsis means peristalsis up the digesti3e
tract rather than downward. $his may begin as far down in the intestinal tract as the
ileum, and the antiperistaltic wa3e tra3els bac!ward up the intestine at a rate of 2 to
8 cm/sec this process can actually push a large share of the lower small intestine
contents all the way bac! to the duodenum and stomach within 8 to 6 minutes.$hen,
as these upper portions of the gastrointestinal tract, especially the duodenum,
become o3erly distended, this distention becomes the e5citing factor that initiates
the actual 3omiting act. )t the onset of 3omiting, strong intrinsic contractions occur
in both the duodenum and the stomach, along with partial rela5ation of theesophageal(stomach sphincter, thus allowing 3omitus to begin mo3ing from the
stomach into the esophagus. From here, a specific 3omiting act in3ol3ing the
abdominal muscles ta!es o3er and e5pels the 3omitus to the e5terior, as e5plained
in the ne5t paragraph.
Vomiting Act. Bnce the 3omiting center has been sufficiently stimulated and the
3omiting act instituted, the first effects are 749 a deep breath, 729 raising of the hyoid
bone and laryn5 to pull the upper esophageal sphincter open, 789 closing of the
glottis to pre3ent 3omitus flow into the lungs, and 7#9 lifting of the soft palate to close
the posterior nares. Ce5t comes a strong downward contraction of the diaphragmalong with simultaneous contraction of all the abdominal wall muscles.$his
squee;es the stomach between the diaphragm and the abdominal muscles, building
the intragastric pressure to a high le3el. Finally, the lower esophageal sphincter
rela5es completely, allowing e5pulsion of the gastric contents upward through the
esophagus. $hus, the 3omiting act results from a squee;ing action of the muscles of
the abdomen associated with simultaneous contraction of the stomach wall and
opening of the esophageal sphincters so that the gastric contents can be e5pelled.
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UChemoreceptor Trigger one! in the "rain #edulla for $nitiation
of Vomiting %y Drugs or %y #otion &ickness. )side from the 3omiting initiated by
irritati3e stimuli in the gastrointestinal tract itself, 3omiting can also be caused by
ner3ous signals arising in areas of the brain.$his is particularly true for a small arealocated bilaterally on the floor of the fourth 3entricle called the chemoreceptor
trigger ;one for 3omiting. +lectrical stimulation of this area can initiate 3omiting but,
more important, administration of certain drugs, including apomorphine, morphine,
and some digitalis deri3ati3es, can directly stimulate this chemoreceptor trigger
;one and initiate 3omiting. Destruction of this area bloc!s this type of 3omiting but
does not bloc! 3omiting resulting from irritati3e stimuli in the gastrointestinal tract
itself. )lso, it is well !nown that rapidly changing direction or rhythm of motion of the
body can cause certain people to 3omit. $he mechanism for this is the following=
$he motion stimulates receptors in the 3estibular labyrinth of the inner ear, and from
here impulses are transmitted mainly by way of the brain stem 3estibular nuclei intothe cerebellum, then to the chemoreceptor trigger ;one, and finally to the 3omiting
center to cause 3omiting.
'ausea
+3eryone has e5perienced the sensation of nausea and !nows that it is often a
prodrome of 3omiting. Causea is the conscious recognition of subconscious
e5citation in an area of the medulla closely associated with or part of the 3omiting
center, and it can be caused by 749 irritati3e impulses coming from the
gastrointestinal tract, 729 impulses that originate in the lower brain associated withmotion sic!ness, or 789 impulses from the cerebral corte5 to initiate
3omiting.Jomiting occasionally occurs without the prodromal sensation of nausea,
indicating that only certain portions of the 3omiting center are associated with the
sensation of nausea.
@angguan %mum
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tetapi 'uga memperluas !e sumsum tulang bela!ang.9 tiple inti didistribusi!an di
batang ota! bahwa semua bersama(sama disebut Imuntah pusat.I Dari sini, impuls
motor yang menyebab!an muntah sebenarnya ditransmisi!an dari pusat muntah
dengan cara(6, !e(G, , 40, dan 42 saraf !ranial !e saluran cerna bagian atas
saluran, melalui saraf 3agal dan simpati! untu! saluran yang lebih rendah, danmelalui saraf tulang bela!ang !e diafragma dan otot perut.
Antiperistalsis, Prelude to #untah. Aada tahap awal iritasi gastrointestinal yang
berlebihan atau o3erdistensi, antiperistalsis mulai sering ter'adi banya! menit
sebelum muntah muncul. )ntiperistalsis berarti peristaltic up saluran pencernaan
daripada !e bawah. ni mung!in mulai se'auh turun di saluran usus sebagai ileum,
dan gelombang antiperistaltic per'alanan mundur up usus pada ting!at 2 sampai 8
cm / deti! proses ini benar(benar dapat mendorong bagian besar dari usus !ecil
yang lebih rendah si semua per'alanan !embali !e duodenum dan perut dalam
wa!tu 8 sampai 6 minutes.$hen, !arena ini atas bagian dari saluran pencernaan,terutama duodenum, men'adi terlalu buncit, distensi ini men'adi fa!tor menari! yang
memulai actual muntah tinda!an. Aada awal muntah, !ontra!si intrinsi! yang !uat
ter'adi bai! di duodenum dan lambung, bersama dengan rela!sasi sebagian dari
esofagus(lambung sfingter, sehingga memung!in!an muntahan untu! mulai
bergera! dari perut !e !erong!ongan. Dari sini, tertentu muntah tinda!an yang
melibat!an otot(otot perut membutuh!an atas dan mengusir para muntahan !e luar,
seperti yang di'elas!an dalam paragraf beri!utnya.
#untah Undang(Undang.
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langsung merangsang !emoreseptor ini memicu ;ona dan memulai muntah.
Aenghancuran ini blo! daerah 'enis ini muntah tetapi tida! memblo!ir muntah a!ibat
rangsangan iritasi pada saluran pencernaan itu sendiri.
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8/9/2019 Diarrhea is Loosely Defined as Passage of Abnormally Liquid or Unformed Stools at an Increased Frequency
18/20
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8/9/2019 Diarrhea is Loosely Defined as Passage of Abnormally Liquid or Unformed Stools at an Increased Frequency
19/20
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8/9/2019 Diarrhea is Loosely Defined as Passage of Abnormally Liquid or Unformed Stools at an Increased Frequency
20/20