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Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
Non resolving acute diarrhea(pediatrics)
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Non resolving acute diarrhea(pediatrics)

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Non resolving acute diarrhea(pediatrics)

Non resolving acute diarrhea(pediatrics)

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  • 1. Non resolving acute diarrhea Anshu Srivastava Department of Pediatric Gastroenterology Sanjay Gandhi Postgraduate Institute Lucknow Anshu Srivastava Department of Pediatric Gastroenterology Sanjay Gandhi Postgraduate Institute Lucknow
  • 2. Non resolving acute diarrhea Persistent diarrhea Acute onset Prolonged for >2wk Mostly infection related Young <3years old Other Causes of chronic diarrhea Insidious onset Duration wks to months Any age group Mostly not infection related
  • 3. 0-7 days • Acute diarrhea (watery or bloody) • Dysentery (fever , cramps, tenesmus, mucoid stools) • Bacillary dysentery (specific for shigella) 8-14 days • Prolonged diarrhea • Six-fold relative risk of progress to persistent diarrhea >14 days • Persistent diarrhea • ~3-20% of all acute diarrhea • 90% cases in <1 y old children
  • 4. Time of attention patients with ‘prolonged’ diarrhea that is, 5–7 days in duration and not yet resolved Current opinion gastroenterology 2011;27:19-23 Prolonged and persistent diarrhea Accounts for only 16% of episodes yet 50% of days with diarrhea Diarrhea related deaths AWD: `35% Dysentery 20% Persistent ~45%
  • 5. Who is at risk for persistent diarrhea? • Young age <1y • Malnutrition • Previous episode of persistent diarrhea • Lack of breastfeeding & early introduction of animal milk • Irrational use of antimicrobials • Severe diarrhoea or dysenteric illnesses • Underlying immunodeficiency? WHO Bulletin 1996; 74:479/ Acta Pædiatrica 2012 101, pp. e452–e457
  • 6. Persistent gut infection Persistent diarrhea Prolonged small intestinal mucosal injury PEMSystemic infections Ineffective villous repair Sec Lactose intolerance Increased absorption of Antigenic proteins Milk protein intolerance Inappropriate re-feeding Persistent diarrhea
  • 7. Gut infections Systemic infections Micronutrient deficiencies Immuno deficiency Lactose intolerance Milk/other protein sensitization PD
  • 8. Case I: 9mo boy Persistent diarrhea 2 weeks 5-6 times/day, small quantities Acute onset, watery 15 times/day for 7 days Cefixime 3 days Ofloxacin 5 d Norfloxacin-metranidazole 7 d SGPGI D 21
  • 9. Examination
  • 10. Diagnosis Fungal diarrhea (super-infection) Stool • Budding yeast cells and hyphae ++ • Opportunistic infections: no organism • C. difficile antigen: negative
  • 11. Management
  • 12. Case II: 11 mo boy Persistent diarrhea 3 weeks 10-14 times/day, explosive Acute onset, watery diarrhea for 5 days On cow’s milk Ofloxacin 7 days Explosi ve stools SGP GI
  • 13. Examination Perianal erythema (widespread)
  • 14. Diagnosis Secondary lactose intolerance No
  • 15. Management • Low lactose diet for 6 weeks • Supplemented with other non-lactose items At follow-up 8 weeks: • No diarrhea • Rash healed • Reintroduction of milk: no symptoms
  • 16. Diets in persistent diarrhea Most patients respond to diet A and B
  • 17. Case III: 4 mo girl Persistent diarrhea 2 weeks 5-6 times/day, small quantities Acute onset, watery 15 times/day for 7 days dehydration Ofloxacin , racecadotril, probiotics SGPG I D 21 Catheterized
  • 18. Further course… H/O fever Catheterization Suspect UTI Sensitive antibiotics (3rd gen cephalosporin) for 7 days • Afebrile • Formed stools • MCU/ DMSA scan at follow-up (8 weeks): normal
  • 19. Case IV: 3mo boy Persistent diarrhea 20 days Explosive with perianal erythema Acute onset, watery for 7 days Formula fed at 2mo Inadequate breast milk Multiple antibiotics, racecadotril, probiotics, antifungals Breast feed till 1mo age Off lactose, on soy formula No response SGPGI
  • 20. Problems High risk patient Age , 3 months Not breast fed Weight loss Clinical features of secondary lactose intolerance No response to lactose free diet Possibilities 1. Persisting systemic infection 2. Fungal sepsis 3. Milk protein sensitization 4. Opportunistic infection
  • 21. 3 months old boy Rectal biopsy Eosinophilic infiltrate >6/hpf and cryptitis
  • 22. Why did the child not respond to soy formula? Co-existent soy allergy with milk protein allergy How to manage this patient?? Child was placed on elemental formula for 3 months Resolution of diarrhea with weight gain Gradual reintroduction of other food items Milk and milk product free diet No recurrence of symptoms
  • 23. CMPA Lactose intolerance All or none phenomenon Relative phenomenon Immune reaction to milk protein Deficiency of lactase enzyme Multisystem symptoms Only GI symptoms Recovers by 4-5y of age Recovers in days-weeks in secondary, permanent in primary Diagnosis: SPT, IgE, histology- eosinophils, elimination challenge test Diagnosis: stool-pH, reducing substances +ve, Lactose hydrogen breath test Stop all milk and milk products Milk reduction, yogurt, lactase enzyme supplement CMPA is not equal to lactose intolerance
  • 24. 0 25days Case V: 3 year old girl SGPG I ORS, Zinc Multiple courses of antibiotics Started with acute watery diarrhea requiring IV fluids initially……cont for ~18days No history of  severe pain abdomen recurrent fever infections at other sites abdominal distension No family history of food allergy/asthma/ IBD
  • 25. 3year old girl SGPG I Examination Wt 12kg , height 90cm Mild pallor Abdomen soft, no organomegaly Perianal area normal Systemic exam normal Diagnosis: watery diarrhea going on to colitis Possibility ?  Dysentery  CMPA  Antibiotic associated colitis  Other infections amoebic,CMV  Inflammatory bowel disease
  • 26. 3years 3y old girl Stool- negative for oppurtunistic pathogens positive for C difficile toxin Diagnosis : Pseudomembranous colitis Hb 9.8, TLC 16700/ P76%. Electrolytes/ RFT/ protein/albumin normal Sigmoidoscopy: erythema, loss of vascular pattern s/o colitis No aphthous ulcers, pseudomembranes, deep ulcers.
  • 27. Antibiotic-associated diarrhea Overall complicates 2-5% of antibiotic treatment 70-80% 15-25% 2-3% ? Non specific diarrhea (osmotic ,secretory) C. difficile diarhea and colitis Other pathogens (C.perfigens,Staph,can dida) 3.6-18% Indian pediatric data Mild Self-limiting
  • 28. Treatment of C difficile diarrhea Mild to moderate disease Severe disease No response to metronidazole Metronidazole 20-40 mg/kg Oral/ IV 10-14days Vancomycin 40 mg/kg oral 10-14days • Stop precipitating antibiotics Diarrhea resolves in 15-25% (mild disease) • No antimotility agents: Precipitation of ileus, toxic megacolon • Correction of fluid/electrolyte imbalance
  • 29. Work-up in persistent diarrhea • Haemogram: Hb, TLC, DLC, platelet, GBP • Serum electrolytes, creatinine • Urine-microscopy and culture (proper collection) • Stool- ova, cyst, fungal, clostridium difficile toxin • ± Blood culture • ± X ray chest • ± Sigmoidoscopy and biopsy • ± others- UGI endoscopy and biopsy, immune profile
  • 30. Giardiasis CryptosporidiumOocyst of isospora belli Strongyloides stercoralis larvae (lugols iodine) Always ask for stool examination
  • 31. Clues in history and examination
  • 32. Management • Admit- <4mo and top fed, dehydration, severe PEM, systemic infection • Rehydration • Treat systemic infection • Weaning food with reduced lactose load…..A/B/C diets • Micronutrient supplementation  Oral Zinc 10 mg/ day x 2weeks  Oral folic acid 1mg/day x2weeks  Vitamin A 1lac unit (6-12mo age or <8kg weight), 2lac unit >1y of age  Adequate supplementation and correction of electrolytes (Na, K, magnesium, phosphorus, calcium) J. Nutr. 2011;141: 2226–2232
  • 33. Green banana diet Amylase resistant starch (ARS) Not digested in human intestine Delivered to colon Colonic Bacteria Short chain fatty acids Increase salt, water absorption Provide Management
  • 34. Infectious Non infectious Onset acute insidious Bloody stools at onset Less, usually watery Yes Fever at onset yes less Exposure to sick contact yes no Travel related yes No  Detailed history to determine onset (acute vs insidious)  Consider and workup for other etiologies of chronic diarrhea e.g celiac, lymphangiectasia, anatomical causes in select cases  Especially if older child >3years as PD uncommon in these subjects
  • 35. Good news: PD is decreasing Acta Pædiatrica 2012 101, pp. e452–e457 Study from Bangladesh, children <5years 1991----2010
  • 36. Conclusion  Persistent diarrhea is most common in younger children Sepsis, lactose intolerance, protozoal /fungal infections, food protein sensitization and micronutrient deficiency are common reasons  Identify and manage them early (1-2wk)  Home made diet is useful in majority but specialized formulae are required in few Micronutrient deficiencies need to be corrected Persistent diarrhea should not be confused with chronic diarrhea
  • 37. Thanks

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