1. Persistent diarrhea
Dr.P.soundararajan

2. 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

3. 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]

5. 25% of the global burden is in India

6. Causes
• Persistent multiple infections
• Parasitosis
• Malabsorption
• Protein allergy/ intolerance

9. 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

10. 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

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

12. • 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

13. • 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

14. 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

15. Antibiotics
• Blood in stool [quinolones]
• Systemic sepsis [ampicillin & amikacin]
• Severe malnutrition
• Young infants
• Discharge criteria
• Regular diet: when?

16. Probiotics?
• Lactobacillus GG
• Saccharomyces boulardii
• Bifidobacteria

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

18. CHRONIC DIARRHEA

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

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

21. 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

22. Osmotic diarrhea
• Lactase deficiency
• Carbonated drinks
• Antacids

23. Secretory diarrhea
• Activation of cAMP
• Activation of cGMP
• Activation of intracellular calcium
E.Coli
Shigella
Salmonella
cholera

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

25. 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

26. 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

28. 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?

29. 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?

30. 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?

31. Thank you