Management of chronic diarrhoea
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Management of chronic diarrhoea

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Management of chronic diarrhoea Management of chronic diarrhoea Presentation Transcript

  • MANAGEMENT OF CHRONIC DIARRHOEA
  • INTRODUCTION
    Definition: ↑ in total daily stool output associated with ↑ stool water content
    Infants + children  stool output greater than 10g/kg/24hr
    If diarrhoea more than 2 weeks, consider chronic
    It is result from altered intestinal water & electrolyte transport
    The transporter is located at the brush border of small & large intestines
  • CAUSES
  • OTHER CAUSES
    Intraluminal factors:
  • Mucosal factors:
  • Mucosal factors:
  • EVALUATION
    Phase 1
    Hx including amount of fluid intake/day
    PE including nutritional assessment
    Stool examination (pH, fat, ova & parasite)
    Stool culture
    Stool for Clostridium difficile toxin
    Blood test (FBC, ESR, BUSE, RP)
    Phase 2
    Sweat chloride
    72hr stool collection for fat determination
    Stool electrolyte, osmolality
    Breath H2 test
  • Phase 3
    Endoscopic study
    Small bowel biopsy
    Sigmoidoscopy with biopsy
    Barium study
    Phase 4
    Hormonal studies
    Vosoactive intestinal polypeptide
    Gastrin, Secretin
  • MANAGEMENT
    Principal:
    Maintain adequate nutritional intake to permit normal growth & development
    Height & weight must be documented
    Consider chronic non-specific diarrhoea if normal height & weight, stool examination did not show any fat
    Pathogenesis of this condition:
    Excessive carbonated fluid intake
    Low fat intake
    Excessive intake of fruits juice
  • CHRONIC NON-SPECIFIC DIARRHOEA
    Present in well appear toddler (1 – 3 years old)
    Diarrhoea is brown & watery, containing undigested food particles
    If child fluids intake > 150ml/kg/24h, it should be reduce to < 90ml/kg/h
    Child may become irritable for the 1st 2 days of fluid restriction.
    This approach will result in ↓ stool frequency & volume
    If diet hx suggest that the child ingesting significant amount of fruits juices, juice should be ↓
  • Sorbitol (non absorble sugar) found in apple, pear & prune juices
    These fruits also contain high fructose that causing diarrhoea
    White grape juice is the best alternative
    Restriction of fat intake by the parents can cause diarrhoea
    We can increase fat diet to 40 % of total calories/days
  • CARBOHYDRATE INTOLERANCE
    A trial period of lactose @ sucrose initiated
    Add lactase tablets (LactAid) & sacrosidase for lactose & sucrose digestion
    Lactose & sucrose free diet
    If no improvement
    If no improvement
  • If patient present with weight loss & stool examination shows fat chronic diarrhoea 2° to malabsorption syndrome
    Common cause is post gastroenteritis malabsorption syndrome
    This patient respond well to predigested formula
    If patient intolerance to oral feeding with predigested formula (pregestimil, alimentum), nasogastric drip feeding with elemental formula should be considered for 3 – 4 weeks
  • Patient suspected with small intestinal bacterial overgrowth should be evaluated for surgical, medical & nutritional support
    Surgery if patient has malrotation or partial small bowel obstruction
    Antibiotic – metronidazole + ampicillin @ trimethoprim-sulfamethoxazole
    Patient present with secretory diarrhoea in the 1st month of life need to have nutritional support the most likely cause is congenital defect in transport protein