PERSISTENT DIARRHEACHRONIC DIARRHEA

Moderator Presented by Dr. Sumit Das Dr. Fahad Muhamed Shareef A TAss. Prof. PG in Pediatrics

Dept. of Pediatrics

• Diarrhea

– 3 times in 24 hours

– Consistency important over frequency

• Acute Diarrhea

• Persistent Diarrhea

• Chronic Diarrhea

TERMS & DEFINITIONS

PERSISTENT DIARRHEA

• Starts as acute, lasts at least 14 days with

the exclusion of chronic or recurrent

diarrheal conditions

– Celiac disease Tropical Sprue

– Biochemical Congenital

– Metabolic

?WHY

• 10% of total diarrhea

• 35% of diarrheal deaths

• For every 100 children, 7 suffers

• PD in Malnutrition – 20%

• 60% < 6 months

• 90% < 1 year

RISK FACTORS & CAUSES• Repeated enteric infections

• Malabsorption of CHO & fats

• Malnutrition

• Very young age

• Recent introduction of animal milk

• Irrational usage of antibiotics

• Lack of breast feeding/ bottle feeding

• Improper therapy of ADD

• Protein dietary intolerance

PATHOGENESIS“PSIMI”

Mucosal injury d/t invasive pathogens

Malabsorption of macro & mircronutrients

Prolongation of mucosal injury & delayed intestinal repair

mechanisms (ineff. villous repair)

Sequential infection with multiple pathogens

Increased absorption of foreign proteins

Malnutrition

PRESENTATION

• Several loose stools

• Dehydration absent

• If present, inc stool output

dec oral intake

• Features of PEM

Clinical Evaluation• History & Physical Examn.

• Should be excluded from Chronic

diarrhoea

• To R/o associated systemic infections

– CBC

– URE & C/S

– CXR

• Stool microscopy

• Stool pH & reducing substance

• Nutritional management is the cornerstone

– Dietary management

– Supplemental vitamins & minerals

• Two third cases – OPD

• Assess dehydration

• Hospitalization necessary or not

• Avoid unnecessary antibiotics

TREATMENT

When to hospitalize?

• Age < 4 mon & not breast fed

• Dehydration

• Severe malnutrition

– W/L < 70%

– W/A < 60%

– Pedal edema

• Systemic infection

Dietary Management

< 6 months

• Encourage exclusive breast feeding

• Reestablish breast feeding

• Replace animal milks with curds or lactose

free formula

• Cooked rice may be mixed if necessary

>6 months

• Continue Breast feeding

• Mixed diet

• Initiate DIET A

• DIET B

• DIET C

Milk cereal mixtures v/s

milk free diet• Highly palatable

• Provide good quality protein

• Some micronutrients

• Faster weight gain

• No significant increase in stool output

• No increasing risk of dehydration

Principles

• Total elimination of milk not necessary

• Limit intake to 2g/kg/day lactose (50-60

ml)

• Start feeding asap

• 6-7 feeds per day

• Start with 110kcal/kg and inc to 150kcal/kg

over 2 weeks

• If enteral intake diff, start NG feed

DIET A reduced lactose diet (65-70%)Ingredients Measures Wt/Vol

Milk 1/3 katori 50ml

Sugar 1.5 tsp 7g

Oil 1 tsp 4.5g

Puffed rice powder 2 tsp 6.0g

Water 2/3 katori 100ml

Calories/100g 85 kcal

Proteins/100g 2.0g

How to prepare

DIET Blactose free with reduced starch(15-20%)

Ingredients Measures Wt/Vol

Egg white 3 tsp Half egg white

Puffed rice powder 3 tsp 9.0g

Glucose 1.5 tsp 7g

Oil 1.5 tsp 7g

Water 3/4 katori 120ml

Calories/100g 90 kcal

Proteins/100g 2.4g

How to prepare

DIET CMonosaccharide based

Ingredients Measures Wt/Vol

Egg white 3 tsp Half egg white

Or Chicken puree 5 tsp 15 g

Glucose 1.5 tsp 7 g

Oil 1.5 tsp 7 g

Water 1 katori 150ml

Calories/100g 67 kcal

Proteins/100g 3 g

How to prepare

Supplementation

• 2 x RDA of multivitamins and minerals for

2-4 weeks

• At least Vit A (single dose) & Zinc 10-

20mg (2 weeks)

• In severe malnutrition,

– 50% Mg sulfate 0.2ml/kg/dose twice a day for

3 days

– Potassium 5-6meq/kg/day

Monitoring response

• Dec in no. of diarrheal stools

– <= 2 liquid stools/day for 2 consec. Days

• Adeq. Food intake

• Weight gain

Most children lose wt in the initial 1-2 days

and then show a steady gain

When to change diet• Marked increase in stool freq (10/day)

• Return of signs of dehydration

• Failure to establish wt gain by day 7

after discharge little milk after 10 days

No signs of lactose intolerance

Milk qty increased and normal diet ovr a

week

PARENTERAL NUTRITION

• PD with oral intolerance after 10 days

• Severe forms of IBD+ resistant colitis

• Severe NEC

COMPLICATIONS

PARTIAL PARENTERAL NUTRITION

• Isolyte P - 250ml 25%D – 150ml

• A.A – 100ml NaHCO3 – 20ml

• KCl – 5ml MVI – 2ml

• 50-60 ml/kg/d

Antimicrobial Therapy

• Gross blood in stools

• Asso systemic infection

• Severe malnutrition

• Screen for UTI and treat

• Group B Salmonella isolated in stool

PREVENTION

• Improving nutritional status

• Prevention and rational treatment of acute

diarrhea

• Promote exclusive breast feeding

• Ensure safe complemetary feeding

practices

• Zinc supplementaton

• Avoid irrational & unnecessary use of

antibiotics

• Continued feeding during diarrhea

CHRONIC DIARRHEA

• Diarrhea for >= 14 days with exclusion of

persistent diarrhea.

• Infections

• Malabsorption

• Metabolic

• Miscellaneous

INFECTIONS• Tuberculosis

• Eosinophilic gastroenteritis

• IBD

• NEC

• Henoch Scholein

MALABSORPTION

• Pancreatic diseases

• Liver diseases

• Intestinal diseases

INTESTNAL MALABSORPTION

• CELIAC DISEASE (TVA)

• GIARDIASIS

• BACTERIAL OVERGROWTH

• MALNUTRITION PVA

• TROPICAL SPRUE

• ABETALIPOPROTEINEMIA

• LYMPHANGIECTASIA

• ENZYME DEF.

Miscellaneous

• TODDLER’S DIARRHEA

• CHRONIC NON SPECIFIC DIARRHEA

• IRRITABLE BOWEL SYNDROME

• AUTOIMMUNE ENTEROPATHY

• MOTILITY DOSORDERS

• ENDOCRINE

• NEOPLASTIC DISORDERS

• MANCHAUSEN BY PROXY

Clinical evaluation• Onset

– At birth chloride diarrhea, microvillous inclusion dis.

– 6 mon autoimmune enteropathy

– Infant Hirschsprung’s dis

– Abrupt Infections

– Gradual Rest

• Weight loss : Malabsorption,neoplasm

• Dietary history

– Lactose intolerance, cow’s protein, soy protein, egg protein

– Overfeeding, chewing gum diarrhea, Non specific diarrhea

• Treatment history

– Antibiotics, prpnl, digitalis, cholestyramine, Munchausen

• Family history : IBD, IBS

STOOL CHARACTERISTICS

• Blood Dysentry

• Oil/ food particles Malabsorption, maldigestion

• White/ tan colour Celiac disease, absence of bile

• Loose & bulky Celiac disease

• Greasy & yellowish exocrine pancreatic insuff

• Liquid as water Cong. Chloride diarrhea

• Plain x-ray abdomen

• Ultrasonography

• Colonoscopy

• Capsule endoscopy

STEP 1 Intestinal microbiology

• Stool cultures

• Microscopy for parasites

• Viruses

• Stool electrolytes

• H2 breath test

Screening test for celiac disease (transglutaminase 2 autoantibodies)

Noninvasive tests for:

• Intestinal function

• Pancreatic function and sweat test

• Intestinal inflammation

Tests for food allergy

• Prick/patch tests

DIAGNOSTIC WORK UP

TEST NORMAL VALUES IMPLICATION

α1-Antitrypsin concentration <0.9 mg/g stoolIncreased intestinal permeability

and protein loss

Steatocrit <2.5% (>2 yr old) Fecal fat loss

Fecal reducing substances Absent Carbohydrate malabsorption

Elastase concentration >200 µg/g stool Exocrine pancreatic dysfunction

Chymotrypsin concentration>7.5 U/g

>375 U/24 hExocrine pancreatic dysfunction

Fecal occult blood AbsentFecal blood loss, distal intestinal

inflammation

Calprotectin concentration 100 µg/g stool Intestinal inflammation

Fecal leukocytes <5/microscopic field Colonic inflammation

Nitric oxide in rectal dyalisate <5 µM of NO2−/NO3

− Rectal inflammation

Dual sugar (cellobiose/mannitol)

absorption test

Urine excretion ratio:

0.010 ±0.018Increased intestinal permeability

NON INVASIVE TESTS

STEP 2 INTESTINAL MORPHOLOGY

• Standard jejunal/colonic histology

• Morphometry

• PAS staining

• Electron microscopy

STEP 3 SPECIAL INVESTIGATIONS

Intestinal immunohistochemistry

Anti-enterocyte antibodies

Serum chromogranin and catecholamines

Autoantibodies

75SeHCAT measurement

Brush border enzymatic activities

Motility and electrophysiological studies

TREATMENT• General supportive measures

– Replacement of fluids & electrolytes

• Nutritional rehabilitation

• Elimination diet

• Treat the cause

CELIAC DISEASE

• Immunologically mediated small intestinal

enteropathy

• Sensitivity to gluten

• Multiple associations

• Classic form :

– 6m- 24m

– Chronic diarrhea, anorexia,vomiting

– Abd pain & distension

– Poor weight gain & wieght loss

• Older children

– Diarrhea, nausea, vomiting

– Abd pain, bloating,

– Weight loss & constipation

• Extraintestinal symptoms• In Late presentation

• Short stature, IDA

• DH, delayed puberty

• Hepatitis, osteopenia

• Arthritis, Epilepsy

• DIAGNOSIS

• Serology

– Anti-gliadin IgA & IgG

– Anti-reticulin IgA

– Anti- endomysial Ig A - high

– Anti-TTG high

• Intestinal biopsy & HPE

– Villous atrophy wt crypt hyperplasia

– Abnormal surface epithelium

– Full clinical & histological remission

• TREATMENT

• Strict gluten free diet

PERSISTENT v/s CHRONIC

• Onset

• Age group

• Wt. loss

• Dehydration

• Recurrence

• Etiology