Approach to chronic diarrhea in childeren

1. CHRONIC
DIARRHEA
By:-
Jwan Ali Ahmed AlSofi

2. List of Contents
•Definition
•Causes and mechanisms
•Approach
•Management

3. Definition
•Chronic diarrhea is defined as
stool volume of more than 10 g/kg/day in toddlers/infants and greater
than 200 g/day in older children
lasts for 14 days or more.
In practice, this usually means having loose or watery stools more than
3 times a day.
•The term protracted diarrhea is when chronic diarrhea is
associated with failure to thrive (FTT). needs intervention, but
there is no clear distinction between protracted and chronic diarrhea.
•Awakening at night to pass stool is often a sign of an organic
cause of diarrhea.

4. Etiologies of Chronic Diarrhea
•Persistent diarrhea: is the result of an intestinal infection that
persisted longer than expected.
•Malabsorption: defective digestion in the lumen or defective
mucosal absorption.
•Intractable: The most severe etiology of chronic diarrhea, includes
a number of heterogeneous congenital conditions leading to
syndromes related to intractable diarrhea. This is often the result
of a permanent defect in the structure or function of the
enterocyte, leading to progressive, potentially irreversible
intestinal failure..

5. Mechanism and causes
•Many causes like infective, inflammatory, dietary, but chronic
non-specific and lactose intolerance are common causes during
early childhood.
•Abnormal digestive processes e.g., Cystic fibrosis (CF).
•Infections e.g., Giardia.
•Nutrient malabsorption e.g., Lactose intolerance.
•Immune/inflammatory e.g., Food allergy, I.D., celiac disease.
•Structural defects e.g., Microvillous inclusion disease.

6. •Defects of electrolyte and metabolite transport e.g., congenital
Chloride diarrhea, acrodermatitis Enteropathica.
•Motility disorders e.g., Thyrotoxicosis.
•Neoplastic diseases e.g., VIPOMA.
•Diarrhea associated with exogenous substances e.g., drugs,
carbonated fluids.
•Chronic nonspecific diarrhea.
•Antibiotics cause pseudomonas colitis (clostridium difficile): Is
treated with oral metronidazole (1st line) and oral vancomycin
(2nd line).

7. starts watery then becomes fatty
• Chronic pancreatic insufficiency (CF)
• Whipple
• Tropical sprue
• VIPoma
• ZES/Gastrinoma
• Carcinoid
pancreatic insufficiency

8. History
•Regarding stool history:-
• Onset
• Duration
• N. of stools / day
• Fluidity?
• Contents of the stool? Undigested food?
• Fatty?
• Bloody?
• Contain mucus?
• Improves with fasting?
• Normal bowel habit
•Other GIT s/s:- vomiting, abd pain, flatus, distention,

9. History
“Must ask” questions include:
•What are stools like? e.g., frothy (indicates carbohydrate intolerance, e.g.,
lactose intolerance), contain blood…
•What precipitated the diarrhea?
•Fasting? can improve symptoms in lactose intolerance.
•Are there any associated symptom? Healthy or weight loss and abdominal
pain? In an infant with faltering growth, consider coeliac disease / CF / cow’s
milk protein allergy-(Nelson says wt will be normal but illustrated says there is wt
loss) .
•Napkin rash may suggest lactose intolerance or nutritional deficiency.
•Associated systemic signs and symptoms: respiratory symptoms in CF.
•Family history of same problem
•History of long-term drug use or underlying disease
•In an otherwise well toddler with undigested vegetables in the stool, consider
chronic non-specific diarrhoea.

10. Examination
•Anthropometric measures.
•Weight is
oNormal in chronic non-specific diarrhea and lactose intolerance,
oLow in CF and celiac / cow’s milk protein allergy (Malabsorption).
•Signs of nutritional deficiency.
•Abdominal examination (classically distended in Celiac disease with
wasting of the buttocks) / Abdominal distension and flatulence in CH
intolerance .
•Finger clubbing. Indicates IBD or CF.
•Anorectal examination like
- perianal fistula suggests Crohn's disease,
- napkin rash suggest lactose intolerance (because the stool is acidic due to
lactose fermentation).
•Extra intestinal systems if suggested.

12. Cow milk protein
intolerance
CF
Celiac disease

14. • Rectal biopsy for Hirschsprung disease.
• Intermittent diarrhea occurs because the immobility due to absence of ganglion cells
leads to recurrent enterocolitis due to bacterial overgrowth.
• Overflow diarrhea occurs in it, too.
/ bacterial overgrowth syndrome

16. Management
•According to underlying cause and after correction of
dehydration and nutritional rehabilitation.
•Zinc supplement indicated with good evidence.
•Probiotic use controversial.
•Antimicrobial agents accordingly like amebiasis, or in
immune-compromised.

17. Case -1

18. Carbohydrate intolerance
•It is of two types:
1. Congenital lactase deficiency (primary alactasia). Has a
prevalence of 70% in the middle east.
2. Acquired lactase deficiency (post-gastroenteritis syndrome).
Other types:
•Glucose galactose malabsorption.
•Sucrase-isomaltase deficiency.

19. Clinical manifestations
•Explosive watery acidic stool.
•Improved by fasting.
• Recurrent Abdominal Pain
•Abdominal distension and flatulence.
•Excoriated diaper area.
•No weight loss.

20. Investigations
•Breath hydrogen test.
•Stool pH (<5.5)
•Examination of stool for reducing substance (Clinitest tablets).
•Intestinal biopsy with direct assay of brush border enzyme
activity. [because it’s a process of defective digestion].

21. Treatment
•Rehydration
•Nutritional rehabilitation. [Lactose-free formula]
1. Infant.
2. Later childhood.

22. Celiac disease
•Celiac disease is an immune-mediated systemic disorder elicited by
gluten and related prolamins in genetically susceptible individuals.
•Classical presentation:- (are present in most cases)
“a profound malabsorptive syndrome at 8–24 months of age after the
introduction of wheat-containing weaning foods”
Failure to thrive,
anorexia, and irritability.
abdominal distention,
ascites caused by hypoproteinemia
muscle wasting,
chronic diarrhea,
vomiting,
•Occasionally there is constipation(because of reduced intake),
rectal prolapse, or intussusception.

23. •The most common extraintestinal manifestation of
celiac disease is iron-deficiency anemia, unresponsive to
iron therapy.
•Treatment is dietary gluten restriction for life. All
sources of wheat, rye, and barley are eliminated.

24. Extraintestinal
Manifestations
of Celiac Disease

25. Extraintestinal
Manifestations
of Celiac Disease

26. Asymptomatic (silent) celiac is misdiagnosed as IBS

30. •The diagnosis of celiac disease is based on a combination
of symptoms, antibodies, HLA, and duodenal histology.
Antibodies:
•IgA anti-tissue transglutaminase.
- First screening test.
- is cheap and sensitive,
- Because celiac disease might be associated with IgA deficiency, a falsely
negative with IgA TTG test may occur.
- Thus, The measurement of total serum IgA levels are often performed
together with IgA TTG.
•IgA anti-endomysial
•IgA/IgG anti-deamidated gliadin peptide antibodies.
- Is more sensitive for those less than 2 years old, so if anti-tTG Ab is negative
and still have high suspicion, do it.
- In cases of IgA deficiency, IgG deamidated gliadin peptide (DGP-IgG)
is the preferred test.

32. Endoscopic small intestinal biopsy (DOUDENAL): patients should remain on
a diet containing gluten until biopsy. 5 biopsies are done because the
distribution is patchy.
• Characteristic duodenal biopsy findings on light microscopy are villous atrophy and
increased numbers of intraepithelial lymphocytes.
HLA system: Is expensive but should be done if the patient is at high risk. High
risk patients include:
• DM
• Thyroiditis
• IgA deficiency
• Addison biliary cirrhosis syndrome
• Turner’s syndrome
• William’s syndrome
• Down’s syndrome
According to new guidelines a diagnosis
can be made if HLA-DQ2&DQ8 and
serology are positive. I.e., biopsy is not
necessary in that case.
The sensitivity of serology is low in case
of IgA deficiency, so you might want to do
serum IgA to assess that.

33. Complications
•Iron deficiency anemia.
•Osteoporosis due to Ca and vitamin D deficiency.
•Dental hypoplasia of permanent teeth.
•Ataxia, depression, short stature, delayed puberty.
•Hepatitis, and dermatitis herpetiform.
•Malignancies:
• Non-Hodgkin lymphoma
• Adenocarcinoma of the small intestine
• Enteropathy-associated T-cell lymphoma (EATL)

34. Note
•When biopsies are indicated at least 4 fragments should be obtained from
the descending part of the duodenum and at least 1 from the duodenal
bulb.
•The diagnosis is confirmed by an antibody decline and preferably a
clinical response to a gluten-free diet.
•Gluten challenge and repetitive biopsies will only be necessary in
selected cases in which diagnostic uncertainty remains.
•The intestinal mucosa should normalize by 6–12 months while lactose
intolerance resolves often within a few weeks.
• Symptoms improve within a week.
• Lactose intolerance improves within a few weeks.
• ATTG Ab decreases within 6 months of gluten free diet and is used to monitor compliance.

35. Note
•If a case stopped gluten, serology and biopsy will be negative.
•Do gluten challenge by starting the patient on a gluten diet.
•Do serology again at 1 month, if it is positive do biopsy to confirm,
if negative continue gluten and ensure adequate gluten intake and
redo the tests at 3 months, if negative repeat at 6 months. If the
serology is negative at 6 months exclude celiac.
•DO NOT ADVICE A GLUTEN-FREE DIET BEFORE
CONFIRMING CELIAC. It makes the patient’s life hard.

37. Normal villi Villous atrophy

38. Chronic Non-specific Diarrhea
(Toddler’s diarrhea)
•Thought to be “IBS” of this age group.
•Alteration in gastrointestinal motility are thought to be
of primary importance, a number of additional factors
have been noted to increase symptoms, including:
Chilled food or fluids.
Excessive fluid intake especially of fruit juice.
A low fat,
high CHO diet.
Stress and anxiety.

39. Clinical manifestation
•Age usually ranged from 6 months to 36 months.
•Early morning stools typically are large and semi-formed.
•Stool gets progressively looser as day progress.
•Diarrhea is variable in severity, usually not severe.
•Undigested food particularly vegetables and mucus are
observed in the stool.
•Abdominal cramping may be present.
•Activity and appetite are usually normal.
•Growth is generally unaffected.

40. Treatment
•Symptoms usually resolve spontaneously by 3-4
years of age.
•Specific measures that can be of help include:
•Decreasing fluid intake specially of fruit juice
•providing high fat foods to slow gastric emptying.
•Increasing fiber intake through the use of bulking agents.
•Pharmacologic intervention, rarely required.

41. Cow’s milk protein intolerance
Clinical manifestation
•Is a non-allergic food sensitivity
•is more common in males than females and in young infants with
a family history of atopy.
•The estimated prevalence is 0.5%–1.0%.
•The most common form is a healthy infant with flecks of blood in
the stool (Blood-streaked stools).
•Rhinorrhea, wheezing, and eczema, and frequently are
accompanied by eosinophilia and an elevated serum IgE level.
•Anaphylaxis is rarely observed but may be life threatening.
•Can occur in breast-fed infants too if the mother is drinking cow
milk.
•Blood is due to enterocolitis or proctocolitis???

42. Diagnosis
•Clinical symptoms. Gold standard.
•Guaiac test is positive (occult blood). Before doing it,
first eliminate cow milk from diet (mother’s diet in case
of breastfeeding) then after several weeks reintroduce
cow milk (challenge test), symptoms will reappear
within 48 hours.
•Eosinophils in feces and in rectal mucosa
•Skin testing is not reliable and not indicated.

43. Treatment
•Hydrolysate based formula (first line) is preferred to
soya-based milk because about 40% have allergy to soy
proteins too.
•Soya based formula.
•80-90% back on a normal diet by the 3rd birthday.

44. •Cow milk allergy:-
①Immediate (IgE mediated) within minutes of feeding →vomiting pallor
urticaria lip swelling shook like state
②Delayed (T Cells mediated) : Indolent course & GI Sx

45. Note
•Allergic colitis in young infants is self-limited, usually
disappearing by 8–12 months of age.
•Since no long-term consequences of this problem have
been identified, some suggest that if the symptoms are
mild and the infant is thriving, no treatment may be
indicated.

47. Giardiasis
•Giardiasis is diarrheal disease
•caused by a flagellated protozoan (Giardia Lamblia)
•Adheres to the microvilli of the duodenal and jejunal epithelia,
•Mechanism of diarrhea is multifactorial:
1. Atrophy of microvilli.
2. Malabsorption.
3. Secondary lactose intolerance.
•G. lamblia is transmitted through ingestion of cysts, from
- contact with an infected individual
- from food or freshwater or well water contaminated with infected
feces.

49. Clinical Manifestations
Is common among infants in daycare centers.
1. Asymptomatic carrier state.
2. Acute diarrhea with
- crampy abdominal distention,
- Steatorrhea / watery diarrhea
- anorexia.
3. Chronic diarrhea with
- Malabsorption.
- weight loss
4. Secondary lactose intolerance

50. Diagnosis
•GSE. [3 fresh stools in 3 successive days to
increase sensitivity]
•Duodenal juice examination. [String test]
•Duodenal biopsy: in severe cases it causes
-subtotal villous atrophy (like celiac)
- produce secondary disaccharidase deficiency.
•ELIZA test.

51. Treatment
•Furazolidone 8 mg/kg/day for 10 days is the drug of
choice.
•Tinidazole 50 mg/kg/day single dose orally provides
cure in 80% of children.
•Metronidazole 15 mg/kg/day every 8hrs.

52. Note
•Children and adults who have giardia infection without
symptoms usually don't need treatment unless they’re
likely to spread the parasites.
•Many people who do have problems often get better on
their own in a few weeks.
•When signs and symptoms are severe or the infection
persists, doctors usually treat giardiasis with medications.

53. •Common cause of chronic diarrhea during early childhood:
A. Celiac disease
B. Chronic non-specific diarrhea
C. Inflammatory bowel disease
D. Irritable bowel syndrome
E. Thyrotoxicosis
B. Chronic non-specific diarrhea

54. •An 18-month-old girl had vomiting, diarrhea of 10/day and a
fever for 5 days then start to recover but she continues to pass
loose frothy stools three to four times a day for a further 2
months with napkin rash resist usual topical treatment. most
likely diagnosis?
•Toddler's diarrhea
•Drug induced
•Amebiasis
•Lactose intolerance
•Celiac disease
D.
Lactose
intolerance

55. Regarding Giardia infection, all of the following true EXCEPT:
A. Infection may be asymptomatic.
B. It is a cause of chronic malabsorption.
C. It may cause partial villous atrophy.
D. It usually causes bloody diarrhea.
E. Giardia is an infection of upper small intestine.
D. It usually causes bloody diarrhea.

56. Features of carbohydrate intolerance include:
A. Characterized by explosive stool.
B. Reducing substances in the stool are negative.
C. Usually inherited.
D. Commonly follows salmonella infection.
A.
Characterized
by
explosive
stool.

57. •A 3-year-old girl has a 2-month history of loose stools. Her
parents are very concerned. The stools often contained
“undigested food”. She is otherwise well and thriving. What is
the most probable diagnosis and how you manage her?

58. •A 2-year-old girl had vomiting, diarrhea of 10/day and a fever
for 5 days then start to recover but she continues to pass loose
stools three to four times a day for 2 months with napkin rash
resist usual topical treatment. Parents are concerned and asked
whether due to toddler diarrhea or celiac.
1. Definition and causes.
2. Mechanism
3. Approach
4. Investigations needed?
5. What do we mean by “toddlers’ diarrhea”?
6. What do we mean by “celiac”?