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PERSISTENT DIARRHEA
CHRONIC DIARRHEA
Moderator Presented by
Dr. Sumit Das Dr. Fahad Muhamed Shareef A T
Ass. Prof. PG in P...
• Diarrhea
– 3 times in 24 hours
– Consistency important over frequency
• Acute Diarrhea
• Persistent Diarrhea
• Chronic D...
PERSISTENT DIARRHEA
• Starts as acute, lasts at least 14 days with
the exclusion of chronic or recurrent
diarrheal conditi...
?WHY
• 10% of total diarrhea
• 35% of diarrheal deaths
• For every 100 children, 7 suffers
• PD in Malnutrition – 20%
• 60...
RISK FACTORS & CAUSES
• Repeated enteric infections
• Malabsorption of CHO & fats
• Malnutrition
• Very young age
• Recent...
PATHOGENESIS
“PSIMI”
Mucosal injury d/t invasive pathogens
Malabsorption of macro & mircronutrients
Prolongation of mucosa...
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 i...
• Nutritional management is the cornerstone
– Dietary management
– Supplemental vitamins & minerals
• Two third cases – OP...
When to hospitalize?
• Age < 4 mon & not breast fed
• Dehydration
• Severe malnutrition
– W/L < 70%
– W/A < 60%
– Pedal ed...
Dietary Management
< 6 months
• Encourage exclusive breast feeding
• Reestablish breast feeding
• Replace animal milks wit...
>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 w...
Principles
• Total elimination of milk not necessary
• Limit intake to 2g/kg/day lactose (50-60
ml)
• Start feeding asap
•...
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
Puff...
DIET B
lactose free with reduced starch(15-20%)
Ingredients Measures Wt/Vol
Egg white 3 tsp Half egg white
Puffed rice pow...
DIET C
Monosaccharide based
Ingredients Measures Wt/Vol
Egg white 3 tsp Half egg white
Or Chicken puree 5 tsp 15 g
Glucose...
Supplementation
• 2 x RDA of multivitamins and minerals for
2-4 weeks
• At least Vit A (single dose) & Zinc 10-
20mg (2 we...
Monitoring response
• Dec in no. of diarrheal stools
– <= 2 liquid stools/day for 2 consec. Days
• Adeq. Food intake
• Wei...
When to change diet
• Marked increase in stool freq (10/day)
• Return of signs of dehydration
• Failure to establish wt ga...
PARENTERAL NUTRITION
• PD with oral intolerance after 10 days
• Severe forms of IBD+ resistant colitis
• Severe NEC
COMPLI...
Antimicrobial Therapy
• Gross blood in stools
• Asso systemic infection
• Severe malnutrition
• Screen for UTI and treat
•...
PREVENTION
• Improving nutritional status
• Prevention and rational treatment of acute
diarrhea
• Promote exclusive breast...
CHRONIC DIARRHEA
• Diarrhea for >= 14 days with exclusion of
persistent diarrhea.
• Infections
• Malabsorption
• Metabolic...
INFECTIONS
• Tuberculosis
• Eosinophilic gastroenteritis
• IBD
• NEC
• Henoch Scholein
MALABSORPTION
• Pancreatic diseases...
INTESTNAL MALABSORPTION
• CELIAC DISEASE (TVA)
• GIARDIASIS
• BACTERIAL OVERGROWTH
• MALNUTRITION PVA
• TROPICAL SPRUE
• A...
Miscellaneous
• TODDLER’S DIARRHEA
• CHRONIC NON SPECIFIC DIARRHEA
• IRRITABLE BOWEL SYNDROME
• AUTOIMMUNE ENTEROPATHY
• M...
Clinical evaluation
• Onset
– At birth chloride diarrhea, microvillous inclusion dis.
– 6 mon autoimmune enteropathy
– Inf...
STOOL CHARACTERISTICS
• Blood Dysentry
• Oil/ food particlesMalabsorption, maldigestion
• White/ tan colour Celiac disease...
• Plain x-ray abdomen
• Ultrasonography
• Colonoscopy
• Capsule endoscopy
STEP 1 Intestinal microbiology
• Stool cultures
• Microscopy for parasites
• Viruses
• Stool electrolytes
• H2 breath test...
TEST NORMAL VALUES IMPLICATION
α1-Antitrypsin concentration <0.9 mg/g stool
Increased intestinal permeability
and protein ...
STEP 2 INTESTINAL MORPHOLOGY
• Standard jejunal/colonic histology
• Morphometry
• PAS staining
• Electron microscopy
STEP ...
TREATMENT
• General supportive measures
– Replacement of fluids & electrolytes
• Nutritional rehabilitation
• Elimination ...
CELIAC DISEASE
• Immunologically mediated small intestinal
enteropathy
• Sensitivity to gluten
• Multiple associations
• C...
• Older children
– Diarrhea, nausea, vomiting
– Abd pain, bloating,
– Weight loss & constipation
• Extraintestinal symptom...
• DIAGNOSIS
• Serology
– Anti-gliadin IgA & IgG
– Anti-reticulin IgA
– Anti- endomysial Ig A - high
– Anti-TTG high
• Inte...
PERSISTENT v/s CHRONIC
• Onset
• Age group
• Wt. loss
• Dehydration
• Recurrence
• Etiology
persistent diarrhea & Chronic diarrhea
persistent diarrhea & Chronic diarrhea
persistent diarrhea & Chronic diarrhea
persistent diarrhea & Chronic diarrhea
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persistent diarrhea & Chronic diarrhea

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persistent diarrhea & Chronic diarrhea

  1. 1. PERSISTENT DIARRHEA CHRONIC DIARRHEA Moderator Presented by Dr. Sumit Das Dr. Fahad Muhamed Shareef A T Ass. Prof. PG in Pediatrics Dept. of Pediatrics
  2. 2. • Diarrhea – 3 times in 24 hours – Consistency important over frequency • Acute Diarrhea • Persistent Diarrhea • Chronic Diarrhea TERMS & DEFINITIONS
  3. 3. 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
  4. 4. ?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
  5. 5. 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
  6. 6. 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
  7. 7. PRESENTATION • Several loose stools • Dehydration absent • If present, inc stool output dec oral intake • Features of PEM
  8. 8. 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
  9. 9. • Nutritional management is the cornerstone – Dietary management – Supplemental vitamins & minerals • Two third cases – OPD • Assess dehydration • Hospitalization necessary or not • Avoid unnecessary antibiotics TREATMENT
  10. 10. When to hospitalize? • Age < 4 mon & not breast fed • Dehydration • Severe malnutrition – W/L < 70% – W/A < 60% – Pedal edema • Systemic infection
  11. 11. 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
  12. 12. >6 months • Continue Breast feeding • Mixed diet • Initiate DIET A • DIET B • DIET C
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. DIET B lactose 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
  17. 17. DIET C Monosaccharide 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. Antimicrobial Therapy • Gross blood in stools • Asso systemic infection • Severe malnutrition • Screen for UTI and treat • Group B Salmonella isolated in stool
  23. 23. 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
  24. 24. CHRONIC DIARRHEA • Diarrhea for >= 14 days with exclusion of persistent diarrhea. • Infections • Malabsorption • Metabolic • Miscellaneous
  25. 25. INFECTIONS • Tuberculosis • Eosinophilic gastroenteritis • IBD • NEC • Henoch Scholein MALABSORPTION • Pancreatic diseases • Liver diseases • Intestinal diseases
  26. 26. INTESTNAL MALABSORPTION • CELIAC DISEASE (TVA) • GIARDIASIS • BACTERIAL OVERGROWTH • MALNUTRITION PVA • TROPICAL SPRUE • ABETALIPOPROTEINEMIA • LYMPHANGIECTASIA • ENZYME DEF.
  27. 27. Miscellaneous • TODDLER’S DIARRHEA • CHRONIC NON SPECIFIC DIARRHEA • IRRITABLE BOWEL SYNDROME • AUTOIMMUNE ENTEROPATHY • MOTILITY DOSORDERS • ENDOCRINE • NEOPLASTIC DISORDERS • MANCHAUSEN BY PROXY
  28. 28. 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
  29. 29. STOOL CHARACTERISTICS • Blood Dysentry • Oil/ food particlesMalabsorption, maldigestion • White/ tan colour Celiac disease, absence of bile • Loose & bulky Celiac disease • Greasy & yellowish exocrine pancreatic insuff • Liquid as water Cong. Chloride diarrhea
  30. 30. • Plain x-ray abdomen • Ultrasonography • Colonoscopy • Capsule endoscopy
  31. 31. 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
  32. 32. TEST NORMAL VALUES IMPLICATION α1-Antitrypsin concentration <0.9 mg/g stool Increased 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 h Exocrine pancreatic dysfunction Fecal occult blood Absent Fecal 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 ±0.018 Increased intestinal permeability NON INVASIVE TESTS
  33. 33. 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
  34. 34. TREATMENT • General supportive measures – Replacement of fluids & electrolytes • Nutritional rehabilitation • Elimination diet • Treat the cause
  35. 35. 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
  36. 36. • 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
  37. 37. • 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
  38. 38. PERSISTENT v/s CHRONIC • Onset • Age group • Wt. loss • Dehydration • Recurrence • Etiology

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