Management of chronic diarrhoea

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Management of chronic diarrhoea

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

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