Chronic diarrhea in children

By

Mohammed AyadMember of the royal college of pediatric and child

health.

Chronic diarrhea in children

DefinitionCausesdiagnosisHistoryExaminationInvestigationstreatmentSpecific disorders

Definition

Diarrhea In children, a stool output thatexceeds 10 mL/kg/day is considered diarrhea.

A more practical definitionis that diarrhea is present when stools increase in frequency, fluidity (water content), or volume, in comparison with the previouslyestablished “normal” pattern.

What is chronic diarrhea?It is defined as diarrhea which exceeds 2 to 3 weeks.

Despite considerable advances in the understanding and management of diarrheal disorders in childhood, they are still responsible for a major burden of childhood deaths globally, with an estimated2.5 million deaths.

Causes of chronic diarrhea

In fact, there are many causes of chronic diarrhea, however, the best way to discuss this point is to classify these causes according to

these two vital factors-:1 -age.

2 -prevalence.

Chronic diarrhea in infants

Common causes-:Post-infectious secondary lactase deficiency.Coeliac disease.Cow’s milk allergy.Toddlers diarrhea.Infections as giardiasis and HIV.Cystic fibrosis.

Rare causesAcrodermatitis enteropathica.Hirsch sprung disease.Primary immune defects.Lymphangiectasia.Eosinophilic gastroenteritis.Intractable diarrhea syndrome.Abetalipoproteinemia.Shwachman syndrome.Bacterial overgrowth.Other rare causes.

Chronic diarrhea in older children

Common causesPost-enteritis syndrome.Coeliac disease.Lactose intolerance.Infections as giardiasis and HIV.Irritable bowel syndrome.Inflammatory bowel disease.

Rare causesImmune deficiency.Esinophilic enteritis.Secretory tumors.

Chronic diarrhea in adolescents

Common causesInflammatory bowel disease.Giardiasis.Laxative abuse ( anorexia nervosa ).Irritable bowel disease.Constipation with encopresis.

Rare causesSecretory tumors.Addison disease.

Diagnosis

Diagnosis of the cause of chronic diarrhea is a challenge which needs smart effort.

Diagnosis usually starts with taking a good history in which doctors know what they want to ask and why. This is followed by examination which needs a plan too. The last stage of this process is investigations and differential diagnosis.

Here we will discuss in a great way how to diagnose these cases, however, chronic diarrhea is a symptom which usually needs a multidisciplinary team.

History

History is the most important step, it usually makes the DD narrow and gives clues to the cause of chronic diarrhea.

Personal historyAge :- it is essential as what we explained before.Sex :- IBD in pediatrics is common in MALE.

Residence :- Africa and poor countries, suspect infections and HIV .

HISTORY OF THE PRESENT ILLNESSOnset:- just before 6m of age…...> coeliac disease. After 1 yr. ……> cow’s milk allergy. Preceded by gastroenteritis …..> post infectious diarrhea.Course and duration is important.

Most patients were completely free before this episode.Stool character is extremely important-:

This is to differentiate what is called secretory and osmotic diarrhea. These two types of diarrhea can be differentiated by history, examination and

investigation. And each type has its own causes .

Osmotic diarrhea MALABSORPTION OF WATER-SOLUBLE

NUTRIENTS -Glucose-galactose malabsorption  Congenital , Acquired Disaccharidase deficiencies.

EXCESSIVE INTAKE OF CARBONATED FLUID EXCESSIVE INTAKE OF NONABSORBABLE

SOLUTES -Sorbitol Lactulose Magnesium hydroxide

stops with fasting, has a low pH, positive for reducing substances

Secretory diarrhea Bacterial toxins: enterotoxins of cholera, Escherichia

coli (heat-labile), Shigella, Salmonella, Campylobacter jejuni, Pseudomonas aeruginosa   

Hormones: vasoactive intestinal peptide, gastrin, secretin   

Anion surfactants: bile acids, ricinoleic acidACTIVATION OF CYCLIC GMP Bacterial toxins: E. coli (heat-stable) enterotoxin,

Yersinia enterocolitica toxinCALCIUM-DEPENDENT   Bacterial toxins: Clostridium difficileenterotoxin    Neurotransmitters:acetylcholine, serotonin    Paracrine agents: bradykinin

Associated symptomsNo symptoms, well child …> toddlers diarrhea.Abdominal distension and weakness…. Coeliac disease.Severe abdominal pain …..> IBD.Bloody diarrhea…..> IBD.Vomiting and rash…. Eosinophilic enteritis.Attacks of constipation ……> hirschsprung and IBS.

Vomiting, weight loss and behavioral changes…> anorexia nervosa.

Infant with severe napkin dermatitis resistant to most treatment ….. Acrodermatitis enteropathica.Oral ulcers…..> IBD .

Non GIT symptomsRecurrent respiratory tract infections…..> CF.

Weakness, fatigue and weight loss…> IBD, Addison and HIV.Skin pigmentation….> Addison.Headache and mood changes….> IBS.

Eczema…..> cow’s milk allergy and eosinophilic enteritis.Joint pain and arthritis….> IBD.Generalized lymphadenopathy….> HIV.Recurrent fever and weight loss….TB .

Family and other historySame illness or respiratory problems….> CF.IBD and IBS.IMMUNODEFICIENCY….> HIV.Travelling abroad….> infections.Excessive juice intake.

History of previous cardiac operations …..> intestinal Lyphangectasia.

Dietetic historyDietetic history record a detailed history of feeding, prior to the onset of

the disease and during the disease. It may provide vital clues to the etiology, e.g., cow's milk

protein in tolerance, lactose intolerance, gluten enter opathy. Soy protein intolerance, egg protein enteropathy.

Overfeeding, concentrated formula feeds> osmotic diarrhea..

Chewing gums and chocolates plenty of undiluted fruit juices (e.g., pineapple juice has

an osmolali ty of 900 mOsm/L and apple juice 650 mOsm/L

Stool history Odorless blood tinged stools - shigellosis frequent mucoid stools in a healthy child without

blood -IBS Nocturnal diarrhea is usually associated with

organic disease rather than IBS.Infant having chronic diarrhea, with a history

of delayed passage of meconium and if constipation preceded diarrhea,-Hirschsprung's disease

Drug history

History of laxative abuse ……. Anorexia nervosa.History of prolonged course of antibiotics…..> pseudomembranous colitis.

Red flags

Poor weight gain or weight loss.Continuous diarrhea.night stools.

Acid stools…… burning sensation with severe inflammation and crying.Blood and mucous in stool.Failure to thrive.

Associated symptoms of systemic diseases like fever, rash and arthritis.

Examination

Examination has a great role too. But, you should be systematic and know what exactly are you looking for.

General examinationWeight and height should be measured and put on the appropriate charts. Weight loss is seen in many disorders like CF, Coeliac disease, IBD. However, weight and height are usually normal in toddlers diarrhea.Pallor …… IBD, CF, Coeliac disease.Fever….. IBD, CF.Clubbing ….> IBD, CF .

Ear effusion and adenoids……..> CF.Oral ulcers…..> IBD.Oral pigmentation…..> Addison.Peri-oral rash……> acrodermatitis enteropathica.

Chest scars ….> lobectomy scar for CF. median sternotomy scar ……> intestinal lymphangectasia.Signs of bronchiectasis…..> CF.Arthritis….> IBD.Characteristic feature of coeliac disease……see later.

Recurrent infections usually need massive treatment….> immunodeficiency ( HIV ).

Characteristic skin signs

IBD

Coeliac disease

Dermatitis Herpetiformis bumps and blisters resemble herpes lesions, hence the name “herpetiformis”, but are NOT caused by the herpes virus. Symptoms of DH tend to come and go, and it is commonly diagnosed as eczema. Symptoms normally resolve when on a strict, gluten-free diet.DH affects 15 to 25 percent of people with celiac disease who typically have no digestive symptoms.

Dermatitis herpetiformis

Acrodermatitis enteropathica

Addison pigmentation

INVESTIGATIONS

INVESTIGATIONS which can be done in these cases are extremely wide and good pediatrician is able to narrow them so as to reach a diagnosis. So investigations are usually depend on what history and examination point to. However, there are some investigations which are usually done in most cases which are

**stool examination. **CBC, ESR and CRP .

Stool examination

Fresh stool sample should be collected and examined. Specific tests should be taken seriously.Occult blood in stool…..> IBD and Cow’s milk allergy.Reducing substance…..> carbohydrate malabsorption.Maldigested fat ….> CF.STOOL PH.

This is beside the routine examination for amoebiasis and giardiasis.

Other investigations should e modified according to each case. It depends on

1 -age of the child.2 -most probable causes.

3 -availability of these investigations.So we will now discuss the most common causes of chronic diarrhea according to age and how to

diagnose and manage them at a glance .

Chronic diarrhea in infants

1-carbohydrate intolerance and Post-infectious secondary lactase deficiency.

2-Coeliac disease.3-Cow’s milk allergy.4-Toddlers diarrhea.

5-Infections as giardiasis and HIV.6-Cystic fibrosis.

7 -acrodermatitis enteropathica.

Carbohydrate intolerance

PrimaryCongenital lactose intolerance.Glucose-galactose malabsorption.

Very rare, Usually starts early with watery, explosive diarrhea and failure to thrive.Reduced substance in stool is positive.

Secondary lactose intolerance

Usually post-infectious ( rota virus).Bloating, abdominal discomfort and flatulence that occur from 1 hour to a few hours after ingestion of milk or dairy products may signify lactose intolerance.

Stool characteristics: Loose, watery, acidic stool often with excessive flatus and associated with urgency that occurs a few hours after the ingestion of lactose-containing substances is typical.

InvestigationsReducing substances in the stool is positive and the stool is acidic with PH <5.5.

Breath hydrogen test-: Carbohydrate malabsorption results in bacterial fermentation of the unabsorbed sugar.

Thus, carbohydrate malabsorption can be determined by measuring the exhaled hydrogen concentration after a carbohydrate load is administered.

MANAGEMENTLactose free diet .

Coeliac disease

Diarrhea - 45-85% of patientsFlatulence - 28% of patientsBorborygmus - 35-72% of patientsWeight loss - 45% of patients; in infants and young children with untreated celiac disease, failure to thrive and growth retardation are commonWeakness and fatigue - 78-80% of patients; usually related to general poor nutritionSevere abdominal pain - 34-64% of patient.

investigations

The American College of Gastroenterology (ACG) recommends that antibody testing, especially immunoglobulin A anti-tissue transglutaminase antibody (IgA TTG), is the best first test for suspected celiac disease, although biopsies are needed for confirmation; in children younger than 2 years, the IgA TTG test should be combined with testing for IgG-deamidated gliadin peptides.

Other laboratory tests include the following:

Electrolytes and chemistries - Electrolyte imbalances; evidence of malnutritionHematologic tests - Anemia, low serum iron level, prolonged prothrombin time (PT)Stool examination - Fat malabsorptionOral tolerance tests - Lactose intoleranceSerology - Immunoglobulin A (IgA) antibodies.Histologic Findings:- villous atrophy.

algorithm

management

The primary treatment of celiac disease is dietary. Removal of gluten from the diet is essential, although complete avoidance of gluten-containing grain products is relatively difficult for patients to achieve and maintain; certain products, such as wheat flour, are virtually ubiquitous in the American diet.A small percentage of patients with celiac disease fail to respond to a gluten-free diet. In some patients who are refractory, corticosteroids may be helpful.

Cow’s milk protein allergy

usually starts after the first year when children are given milk products.

Typical symptoms areVomiting, diarrhea, colic and constipation may occur.

Other rare presentations are wheezes, cough, atopic eczema and behavioral changes like irritability, crying and milk refusal.

A challenge with milk free times may have a good indicators. However, histopathological examination is a diagnostic test.

Toddlers diarrhea

Called chronic non specific diarrhea of childhood.It is a common problem. Occurs to children mainly above 2 years.It is a benign condition.

Usually, the children have no failure to thrive and they present in a good nutritional state. Abdominal pain may be present in a minority.

 The stools are foul smelling, watery, and contain mucus with undigested vegetable material. The parents are likely to report a short mouth to anus transit time.

Golden roles

In developed countries toddler diarrhea is the most frequent cause of chronic diarrhea in 1–5 year old children

Toddler diarrhea has a typical dietary and clinical history

Breath hydrogen tests have no place in the diagnostic process

Treatment includes normalization of feeding patterns according to the “four Fs”: Fat, Fibre, Fluid, and Fruit juices.

treatmentAfter a thorough clinical history and a simple physical examination, the diagnosis is often obvious. The main message to the parents is reassurance on underlying serious gastrointestinal disorders and normalisation of the diet. Kneepkens and Hoekstra proposed a normalisation of the child’s feeding pattern according to the “four Fs”: Fat, Fibre, Fluid, and Fruit juices.As it seems that these children represent the end of a spectrum of normality, the dietary treatment will often be close to the borders of normal nutritional recommendations. Fat intake should be increased to at least 35%, even 40%, of total energy intake. Restoration of a pattern with well defined meals and snacks provides

the opportunity for significant increases of fibre intake .

Fruit juices, in particular clear apple juice, and other squashes should be limited to restore appetite at meal times. Drinks between meals are acceptable, but overconsumption should be discouraged. In almost all patients the efficacy of these dietary measures is such that it may even serve as a confirmation of the diagnosis. Some authors have used aspirin, loperamide or mebeverine for cases refractory to dietary measures. Their effects last as long as they are given. As a consequence, medication seems to be unwarranted for a condition that does not hamper the child to thrive.

Giardiasis

A very common disorder. Has a wide range of manifestations, as acute and chronic diarrhea, abdominal pain, malabsorption syndrome and nausea.

Stool examination is the role. Stool antigen may be important.Treatment Metronidazole.

Cystic fibrosis

AR disorder.Most patients have respiratory symptoms as recurrent pneumonia, and adenoid.

Those patients have pancreatic insufficiency which lead to diarrhea with greasy stool.Failure to thrive.

Genetic diagnosis and sweat chloride test are the main investgations.

Acrodermatitis enteropathicaa

AR disorder.Presented with peri-oral rash, chronic diarrhea, recurrent infection and napkin rash resistant to treatment.Usually starts at the time of weaning.Tent red hair and alopecia.

DiagnosisSerum Zink in the WBCS OR IN THE BLOOD.

ManagementSerum Zink.

Chronic diarrhea in older children

Common causesPost-enteritis syndrome.Coeliac disease.Lactose intolerance.Infections as giardiasis and HIV.Irritable bowel syndrome.Inflammatory bowel disease.

Post enteritis syndrome

Persistent diarrhea after gastroenteritis is caused byContinuing infection.Further infection.Carbohydrate intolerance.Post infection malabsorption syndrome.

Usually subsides, but severe cases may persist to longer periods.Stool analysis and stool culture.

Treatment of the cause .

Inflammatory bowel disease

This is of two typesCrohn’s disease and ulcerative colitis.

20%% of cases presents under 20 years old.It has intestinal and extra intestinal manifestations.

Clinical pictureDiarrheaAbdominal painGrowth decelerationWeight lossAnorexia.Colonic Crohn disease may be clinically indistinguishable from ulcerative colitis (UC), with manifestations that include the following:

•Bloody mucopurulent diarrhea•Cramping abdominal pain

•Urgency to defecate

Perianal involvement in Crohn disease may produce the following:

Simple skin tags, fissures, abscesses, and fistulae

•Painful defecation•Bright-red rectal bleeding

•Perirectal pain, erythema, or discharge

examination

Growth is impaired.Intermittent fever.Tachycardia.Mouth ulcers.Anal tags.Arthritis.Erythema nodosum.Pyoderma gangeriosum.Tanner staging is important.

investigations

BLOODCBC… anemia.ESR and CRP….. Elevated.Hypoalbuminaemia.

Imaging studiesA single-contrast upper GI radiologic series with small-bowel follow-through (SBFT).MRI.

endoscopy

Colonoscopy with several colonic and terminal ileal biopsies is considered a standard diagnostic procedure.Upper endoscopy, or esophagogastroduodenoscopy (EGD), should be part of the first-line investigation.Video capsule endoscopy is increasingly being used to evaluate for small-bowel Crohn disease in children.

management

The general goals of treatment for children with Crohn disease are as follows:

To achieve the best possible clinical, laboratory, and histologic control of the inflammatory disease with the least adverse effects from medicationTo promote growth with adequate nutritionTo permit the patient to function as normally as possible (eg, in terms of school attendance and participation in activities)

•Step-up approachPatients with mild disease are treated with preparations of 5-aminosalicylic acid (5-ASA), antibiotics, and nutritional therapyIf no response occurs or if the disease is more severe than was initially thought, corticosteroid and immunomodulatory therapy with 6-mercaptopurine (6-MP) or methotrexate (MTX) is attemptedInfliximab is effective in patients who have an inadequate response to conventional therapy and in patients who have fistulizing Crohn disease .. Adalimumab is a safe and effective substitute for patients who are allergic to infliximab or develop high titers of human antichimeric antibodies (HACA) Surgery is considered when medical therapy fails 

Indications for surgery include the following:Intractable disease with growth failureObstruction or severe stenosisAbscess requiring drainagePerianal fistulaeIntractable hemorrhagePerforation

Irritable bowel syndrome

Irritable bowel syndrome (IBS) is defined as chronic or recurrent abdominal pain, altered bowel habits, and bloating, with the absence of structural or biochemical abnormalities to explain these symptoms. Irritable bowel syndrome is part of a broader group of disorders known as functional GI disorders. It is the most common GI diagnosis among gastroenterology practices in the United States and is one of the top 10 reasons for visits to primary care physicians.

The characteristics of abdominal pain vary between patients and even within an individual patient.The pain can be dull, achy, colicky, or sharp.Pain can occur anywhere in the abdomen but is commonly located in the hypogastric or periumbilical regions.The pain has no specific pattern but may be aggravated by stress and food and partially relieved after defecation.

Altered bowel habits include constipation, diarrhea, or alternating constipation with diarrhea.

Stools are usually of small volume and pasty. Constipation is associated with small, hard, pelletlike stools. Diarrhea characteristically occurs during waking hours and often is precipitated by meals.

Mucus can be a component of the stool in as many as 50% of patients with irritable bowel syndrome.

In some patients, defecation is associated with a sense of incomplete evacuation that can lead to repeated trips to the bathroom and prolonged straining.

Symptoms of abdominal distension (ie, bloating, increased belching, flatulence).

Dyspeptic symptoms are present in as many as 30% of pediatric patients with irritable bowel syndrome.

Extraintestinal manifestations are rare in children.

Take care

The following clinical features should alert the physician to the possibility of a disorder other than irritable bowel syndrome:

Frequent awakening by symptomsSteady progressive courseFeverWeight lossArthritisRectal bleedingPersistent vomiting.

Diagnostic Rome III criteria for childhood irritable bowel syndrome:

investigations

They are usually not needed except if exclusion of other disorders is mandatory.

Recent studies have suggested that determining the level of fecal calprotectin in stool may help distinguish irritable bowel syndrome from inflammatory bowel disease. A negative calprotectin result favors a functional disorder rather than an inflammatory process, thereby sparing many patients from having extensive work-up and invasive investigations, such as colonoscopy.

treatment

Educate the child and parents that irritable bowel syndrome is a chronic illness that cannot be cured. At the same time, reassure them that it is not a life-threatening condition and it does not lead to physical impairment. Tell the patient and the family that the symptoms are real and respond to their worries and concerns. Reassurance is more effective if offered after a careful history and physical examination and a conservative diagnostic evaluation.

Dietary modificationSome patients with irritable bowel syndrome report exacerbation of their symptoms after ingestion of certain foods. Elimination of certain foods, such as sorbitol, fructose, and gas-forming legumes, achieves relief in some patients with irritable bowel

syndrome, especially those with excess gas .A recent study in adult patients with irritable bowel syndrome revealed that a diet low in fermentable oligosaccharides, disaccharides, monosaccharide, and polyols (FODMAP) is effective in reducing functional GI symptoms.

Treatment of chronic diarrhea

In fact, treatment of the cause is the main role. But there are some points to be checked early-:

1 -assess hydration status and treat dehydration if present.

2 -make sure that the child is safe and there are no threatening signs.

3 -good communication with parents and reassurance is extremely vital.

At the end of this presentation

Chronic diarrhea is a great challenge which needs extensive history, examination and investigations, however, good pediatrician should minimize the DD so as to reach a diagnosis as soon as possible.

Although most cases are benign, there are some dangerous causes.

Pediatric gastroenterologist has a major role in diagnosis of most cases.

Good luck