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chronic diarrhoea nar new.pptx
- 2. • Definition of diarrhoea • Chronic diarrhoea
- 3. Definition • Diarrhoea : Frequency & Consistency • Infants : >10 g/kg/day • 1-3 yrs : >15 g/kg/day • Children : >200 g/day
- 4. Chronic vs Persistent Diarrhoea • Chronic : Duration > 2 weeks, irrespective of etiology • Persistent : Duration > 2 weeks, infectious etiology
- 5. Epidemiology • Incidence : 1-5% • Diarrhoea accounts for 13.2 % of all childhood deaths • 50% due to chronic diarrhoea
- 9. Etiology
- 11. Pathophysiology
- 12. • Classification of chronic diarrhoea
- 13. Organ Involved • Small bowel • Large bowel • Pancreatic diarrhoea • Bile acid disorders
- 14. Characteristic of Stool • Watery : secretory/osmotic • Fatty diarrhoea • Inflammatory • Functional/ motility related disorders
- 15. • Osmotic vs Secretory • Large bowel vs Small bowel • Malabsorption vs Maldigestion • Inflammatory vs Non inflammatory
- 16. Osmotic Vs Secretory Characteristic Osmotic Secretory Volume of stools <200 ml/day >200 ml/day Peri anal redness Present Absent Purge Watery, explosive stools, lots of gas Watery non explosive , no gas Response to fasting Diarrhoea stops Diarrhoea continues Stool sodium <70 mEq/l >70 mEq/l Reducing substance Positive Negative Stool pH <5.5 >5.5 Osmotic gap >100 <50
- 17. Small bowel vs Large bowel Clinical features Small bowel Large bowel Frequency Low to moderate High Quantity Large Small Consistency Liquid/semisolid Liquid/semisolid Characteristics Watery,mushy, bulky, undigested Bloody, mucus Pain abdomen +/- + Tenesmus _ + Etiology Bacterial/giardiasis/TB/Cro hn’s Bacterial/amobiasis/UC/TB /Crohn’s
- 18. Malabsorption vs Maldigestion Features Malabsorption Maldigestion Stool fat ++ +++ Fatty acid crystal +++ - Flatulence /bloating ++ - Anemia ++ - Hypoalbuminemia ++ - Stool volume ++++ ++
- 19. Malabsorptive Stool MalDigestive Stool
- 20. FEATURES Inflammatory Non Inflammatory 1. Volume Small Large 2. Fever + - 6. Urgency + - 7. Tenesmus + - 8. Site of pain Lower Lf Quadrant - 9. Relief in pain No relief on defecation Defecation relieves pain 11. Blood/ Pus in Stools + - 12. Site Mostly Colon Mostly SI
- 21. Osmotic Diarrhoea • Lactase deficiency ( Primary/ Secondary) • Other Disaccharides deficiencies • Non absorbable carbohydrate • Gluten • Osmotic Laxatives
- 22. Secretory Diarrhea Infectious • Bacterial- E. Coli, V. Cholerae • Protozoal- Giardia, Cryptosporidium • Viral – Rota virus, Norovirus Non infectious • Peptide Hormones • Malabsorbed bile salts/Fatty acids • SIBO • Congenital transporter defect- Na, Cl,
- 23. Fatty Diarrhea Malabsorptive • Celiac disesase • SIBO • Short Bowel Syndrome • Other mucosal disaese Maldigestive • Pancreatic exocrine insufficiency • CF • Bile acid disorders
- 24. Inflammatory Diarrhea • Infections – Yeresinia, E.Histolytica, Campylobacter, CD, TB, CMV, HSV • IBD • PID/SID • Diverticulitis • Radiation Colitis • Ischemic Colitis
- 25. Functional/Motility Diarrhea • IBS • Post vagotomy diarrhea / Post sympathectomy • Hyperthyroidism • Addison’s Disease • CIPO
- 26. • Approach to chronic diarrhoea • History & examination
- 27. Approach to Chronic Diarrhoea • History - age of onset - characteristic of stool - nocturnal diarrhoea - dietary factors - deficiency of nutrients - pain abdomen - extra intestinal manifestations - past h/o surgery - family history
- 28. Examination • Detailed anthropometry • Signs of dehydration • Signs of deficiency • Pedal edema/ anasarca • Clubbing • Skin changes • Oral thrush • Peri anal area • Abdominal examination- organomegaly/ascites/gaseous distension /previous scars • Anorectal sphincter continence • Examination of stool
- 29. Celiac Disease
- 30. Erythema Nodosum Pyoderma Gangrenosum
- 31. Categorize • Type of diarrhoea : Mechanism • Small bowel/large bowel • Malabsorption/maldigestion
- 32. • Investigations
- 33. Investigations • Hematology : CBC, PBS, ESR, coagulation profile • Biochemistry • Iron studies/vit B12/ folate • Stool examination • Lactose intolerance test • Hydrogen breath test • Fecal fat test • Chymotrypsin & fecal elastase • D- Xylose absorption test • Endoscopy • Radiology : BMFT, USG, MRI, CT • EUS • Specific tests
- 35. CMPA
- 36. Tuberculosis
- 38. Crohn’s Colitis
- 39. Approach to Secretory Diarrhoea • Cholestyramine trial for bile acid disorders Secretory Diarrhoea Exclude infection – bacterial/other pathogens Exclude Structural Diseases USG/CT Scan abd Small bowel radiology/ Ba enema Colonoscopy with biopsy Specific Tests
- 40. Approach to Osmotic Diarrhoea Osmotic Darrhoea Dietary review Stool analysis – pH,Mg output, laxative abuse Hydrogen breath test, lactase assay Reduction of CHO Low lactose diet Low fructose diet
- 41. Approach to Inflammatory Diarrhoea Inflammatory Diarrhoea Exclude infection – bacterial/other pathogens Exclude Structural Disease Colonoscopy with biopsy USG/CT Scan BMFT/Ba enema
- 42. Approach to Fatty Diarrhoea Fatty Diarrhoea Exclude structural disease – Celiac workup/ USG/CT scan/small bowel biopsy Exclude pancreatic insufficiency – Stool chymotrypsin/elastase/lipase, USG/CT scan, sweat chloride/CFTR, Secretin tests Rule out PID – Ig profile/lymphocyte subset/ NBT
- 43. MANAGEMENT • Correction of dehydration • Correction of electrolyte imbalance • Nutrition – enteral feeding • Intractable diarrhoea – TPN • Micronutrient deficiencies • Symptomatic hypoalbuminemia • Calorie & protein build up • Prevention of NRS/refeeding syndrome
- 44. Thank You