Persistent diarrhea

Dr.P.soundararajan

Definitions

• Diarrhea with passage of 3 or more loose stools of presumed infectious etiology starting acutely and lasting for more than 14 days.

• Chronic diarrhea; noninfectious etiology• Protracted diarrhea– Persistent diarrhea with weight loss and malnutrition

Disease burden

• 24 lakh child deaths in India each year• 5 children die every minute • 25% of the global burden is in India• More in infancy [31 episodes per 100 child

years]

25% of the global burden is in India

Causes

• Persistent multiple infections• Parasitosis• Malabsorption• Protein allergy/ intolerance

Pathology

• Delay in repair of damaged epithelium of gut• Damage of mucosal absorptive surface• Loss of brush border enzymes• Bacterial overgrowth altered intestinal flora

• Prolonged cell mediated immune form of damage of small intestinal mucosa

Presentation • Mild form

– Several motions– No significant weight loss– No significant dehydration

• Moderate form– Several motions– Marginal weight loss– Without dehydration– Non tolerance to milk

• Severe form– Dehydration with several motions– Weight loss– Non tolerance to milk & cereals– Secondary infection

Diagnosis

• Asses dehydration.• Asses malnutrition.• Stool - R/E, • Stool culture, • Reducing sugar, pH.

• Mild PD: low milk diet – 50ml milk+2tsp puffed rice powder+ 1tsp oil+ 1.5

tsp sugar +100ml boiled water– Rice with curd– Milk sooji gruel– 85kcal, 2g protein.– 6-7 feeds / day

• Moderate PD: no milk diet– Egg white 1.5 + 3tsp cooked rice+ glucose & oil 1.5tsp+

120ml boiled water– 90cal, 2.4g protein.

• Severe PD: no milk, no cereal diet.– Phase I: Resuscitation < 24 hours– Phase II: PPN(1-4 days), IV fluids, plasma, antimicrobials, electrolyte balance– Phase III: > 5 days Nutritional rehabilitation with calorie dense, lactose free

formulae

– Chicken puree 5tsp or 1.5 egg white + glucose & oil 1.5 tsp+150 ml water

– 67cal , 3g protein

Micronutrients

• Vitamin A: single dose 2L iu >1yr child• Twice RDA of zinc, copper, folate, vitamin D• Zinc: 20mg/day 2-4weeks• Mg sulphate i.m 0.2ml/kg/day bid 2-3days• Potassium 5-6meq/kg/day

Antibiotics

• Blood in stool [quinolones]• Systemic sepsis [ampicillin & amikacin]• Severe malnutrition• Young infants

• Discharge criteria• Regular diet: when?

Probiotics?

• Lactobacillus GG• Saccharomyces boulardii • Bifidobacteria

Prevention

• Prompt treatment of AWD• Judicious use of antibiotics• Diet management• Vaccines• Promotion of breast feeding

CHRONIC DIARRHEA

Definition• Diarrhea of more than 2 weeks duration or 3 attacks during last 3 months.• With specific congenital, biochemical or

metabolic disorders.• Non infectious

• Osmotic• Secretory• Reduced anatomic surface• Altered intestinal motility• Inflammation

Causes

• CMPA / soy protein allergy• PEM• Lactose intolerance• Post GE malabsorption• Parasites• Celiac disease • Excessive intake of carbonated drinks• Inflammatory bowel disease• Irritable bowel syndrome

Osmotic diarrhea

• Lactase deficiency• Carbonated drinks• Antacids

Secretory diarrhea

• Activation of cAMP• Activation of cGMP• Activation of intracellular calcium

E.Coli ShigellaSalmonellacholera

CMPA

• Few weeks after introducing cow milk• Diarrhea, vomiting, colic, GI bleed, FTT.• Due to IgA deficiency?

Celiac disease

• Intolerance to wheat gliadin• Features– Chronic diarrhea– Abd distension– FTT, anorexia, irritable– Foul, greasy,bulky stool.

• Diagnosis: – anti endomysial antibody– Villous atrophy

• Management

Work up • History of intake of fluids• Nutrition assessment• Stool pH / RS / WBC / ova ,cyst / cl.difficile culture

• Stool fat estimate• Breath H2 estimate• Stool electrolytes• Sweat chloride

• Small bowel biopsy / endoscopy• Barium studies

• Hormones assay

Case scene 1.

• 8 month old child presents with 18 days of loose stools, many episodes per day following milk feeds. initially treated with antibiotics for 1 week.

• On exam, no dehydration, 3% weight loss+, perianal excoriation +

• What stool exam you do?• Diagnosis & management?

Scene 2

• 7 month old child 2 weeks after introduction of cow’s milk, cries irritably frequently, loose stools many episodes,

• O/E ; irritable, poor weight gain,• Stool occult blood positive.• One more stool exam to do?• Diagnosis?

Scene3

• 2year old child,3 weeks diarrhea, stools are bulky, oily, foul smelling, not responding to 2 weeks of antibiotics.

• O/E poor weight gain, abd distension,• Stool test to do?• Diagnosis?

Thank you