chronic diarrhea & acute gastroenteritis in pediatrics

1. Acute Gastroentritis
Name: nur aisyah binti idris
Matrix no.: 68

2. Chronic diarrhea
• An insidious onset diarrhea of >2weeks
duration in children & >4weeks in adults.
• Term not synonymous with persistent diarrhea

3. Approach
• Age of onset
• Small or large bowel type of diarrhea- features
in history & examination
-large volume diarrhea without blood &
mucus suggest small bowel types
-small volume stool with blood & mucus suggest
large bowel type.
• Gastrointestinal versus systemic causes

4. • Age of onset
Age < 6 month Age >6month-5years Age > 5years
Cow milk Protein
Allergy (CMPA)
Lymphangiectasia
UTI
Short Bowel syndrome
Immunodeficiency
states
Cystic fibrosis
Anatomical defects
Autoiimune
enteropathy
Cow milk protein allergy
Celiac disease
Giardiasis
Toddler diarrhea
Lymphangiectasia
Short bowel syndrome
Tuberculosis
Inflammatory Bowel Disease
Immunodeficiency
Bacterial overgrowth
Pancreatic insufficiency
Celiac disease
Giardiasis
Gastrointestinal
tuberculosis
Inflammatory bowel
disease
Immunodeficiency
Bacterial overgrowth
Lymphangiectasia
Tropical sprue
Immunoproliferative
small intestinal disease
Pancreatic
insufficiency

5. • Small or large bowel type of diarrhea
Features Small bowel diarrhea Large bowel diarrhea
Stool volume
Blood in stool
Rectal symptoms( urgency, tenesmus)
Steatorrhea
Carbohydrate malabsorption
Protein malabsorption
Pain
Color of stool
Smell of stool
Nutrient deficiency
Large
No
No
Yes
Yes
Yes
Periumbilical, no
reduction after
passage of stool
Pale
Unusually offensive
frequent
Small
Usually present
Yes
No
No
No
Hypogastric, reduced
after passage of stool
Normal
Normal
Can occur due to
blood loss

6. Celiac disease
• Enteropathy caused by
permanent sensitivity to
gluten
• Most common cause of
chronic diarrhea in children
over 2 years
• High risk group: types 1 DM,
Down syndrome, selective IgA
deficiency, autoimmune
thyroid disease, turner
syndrome, williams syndrome,
autoimmune liver disease, first
degree relatives of celiac
disease.
Sign & symptoms:
• Small bowel diarrhea
• Growth failure
• Anemia
• Loss of subcutaneous fat
• Clubbing
• Sign of other vitamin
deficiencies

7. Investigation
• Serology
 IgA antibody against tissue transglutaminase
 Recommend for initial testing
 High sensitivity& specificity
 IgA antiendomysial antibody equal accurate test
 Should not based only on celiac serology
• Upper GI endoscopy
 Shows absence of fold/ scalloped folds
 Endoscopic biopsies should be taken
• Histology
 Increased intraepithelial lymphocytes
 Increased crypt length
 Partial–total villous atrophy
 Decreased Villous:crypt ratio
 Infiltration of plasma cells & lymphocytes in lamina propria

8. Treatment
• Life long GFD
• Correction of iron
• Folate
• Vitamin/ mineral supplementation

9. Cow Milk Protein Allergy
• Affects 2-5% of all children
in west- high 1Years of life
• In India, account for 13%of
all malabsorption cases in
children <2years
• Family history of atopy
common in children with
CMPA
• 50% outgrow of allergy by
1 year, 95% by 5 years
• 2 reactions to cow milk:
1) immediate
2) delayed
Sign & symptoms
• Diarrhea with blood & mucus
• May have small bowel, large
bowel / mixed type diarrhea
• Reflux symptoms
• Hematemasis
• Respiratory symptoms
• Atopic manifestations
• Iron deficiency anemia
• Hypoprotenemia
• Eosinophilia

10. Investigation
• Sigmoidoscopy
• Rectal biopsy
• Food allergy elimination & challenge test
Treatment
• Milk product have to be removed from diet
• Soy / extensive hydrolised formula used as
alternative
• calcium supplementation.

11. Intestinal lymphangiectasia
• Characterized by ectasia
of the bowel lymphatic
system which on
rupture causes leakage
of lymph in bowel.
• Often associated with
abnormal lymphatics in
extremities
Sign & symptoms:
• Peripheral edema
(bilateral & pitting
/asymmetrical & non pitting)
• Diarrhea
• Abdominal distension
• Abdominal pain
• Abdominal/thoracic
chylous effusion
• Hypoalbuminemia
• Low immunoglobulins
• Hypocalcemia
• lymphopenia

12. Investigation
• Barium meals
• Endoscopy
• Duodenal biopsy
Treatment
• Low fat, high protein diet
with MCT oil, calcium &
fat soluble vitamin
supplementation
• Iv albumin( symptomatic
management)
• Total parenteral nutrition (
manage chylous effusion)
• resection

13. Inflammatory bowel disease
• Chronic inflammatory
disease of GIT
• 2types: Crohn disease ,
ulcerative colitis
• 25% of all IBD presents in
pediatric age group
• Age presentation ~10-
11yr
• Genetic risk factor
Clinical features
• UC-diarrhea & rectal
bleeding
• CD-abdominal pain,
diarrhea & growth failure,
fever, fatigue, anorexia
• Extraintestinal
manifestation-altralgia,
uveitis,erythema
nodosum, sclerosing
cholangitis

14. Crohn disease Ulcerative colitis
Distribution
Bloody diarrhea
Abdominal pain
Growth failure
Perianal disease
Serology
Endoscopy
Histopathology
Entire gastrointestinal tract
Discontinuous lesion
Less common
Common
Common
Abscess, fistulae
Anti sacchromyces cereviisae
antibody (ASCA) positive
Deep irregular serpigenous/
aphthous ulcers with normal
intervening mucosa
Transmural inflammation
with non caseating
granuloma
Colon only
Continuous involvement
Common
Less common
Less common
Absent
Perinuclear anti neutrophilic
cytoplasmic antibody (p-
ANCA) positive
Granularity, loss of vascular
pattern, diffuse ulceration
Mucosal disease with
cryptitis, crypt distortion,
crypt abscess & goblet cell
depletion.

15. Evaluation
• Detailed clinical, family
& treatment history
• Rectal examination
• Simple lab test- ESR,
hemogram, c reactive
protein, total protein
• Upper GI endoscopy
with biopsy
• BMFT, CT enteroclysis
Treatment
• 5-aminosalicylates
• Steroids
• Immunomodulators
• Monoclonal antibodies
• Calcium& vitamin D
supplementation
• Surgery- hemorrhage,
perforation, obstruction

16. Abdominal tuberculosis
• GIT, peritoneum, lymph
node & solid vicera can
involved in abd. TB
• Peritoneal 2 types: wet
& dry type
• Intestinal – ulcerative,
hypertrophic/
ulcerohypertrophic type
Clinical presentation
• Chronic diarrhea
• Features of subacute
intestinal obstruction
• Ascites
• Lump in abdomen
• Systemic manefestation

17. Investigation
• FNAC from lymph node
• Endoscopic biopsies
• Ziehl-Neelson staining
• CT abdomen- shows
enlarged lymph nodes
with central necrosis
Treatment
• Antitubercular drugs
 Isoniazid
 Rifampicin
 Pyrazinamide
 Ethambutol
• Surgery- bowel
perforation,
obstruction, massive
hemorrhage

18. Acute gastroentritis
Etiology
Viral: norovirus, rotavirus,
calcivirus, astrovirus, enteric
adenovirus
Bacterial: campylobacter,
salmonella, shigella, EHEC, ETEC,
clostridium difficile
Parasite: giardia, cryptosporidium
Non infectious: food allergy,
intolerance & malabsorption
pathophysiology
• Damage to the villous brush
border of the intestine,
causing malabsorption of
intestinal contents & leading
to osmotic diarrhea
• Release of toxins that bind to
specific enterocyte receptor &
cause release of chloride ions
into the intestinal lumen ,leads
to secretory diarrhea.

19. • Sign & symptoms
• Diarrhea
• Vomitting
• Abdominal pain
• Increase / decreaase in
urinary frequency
• Fever, chills, myalgias
• Weight loss, lethargy,
irritability
Investigation
• CBC
• Stool culture
• Urine culture
Treatment
• Plan A
• Plan B
• Plan C

20. Reference
• Essential Pediatrics, OP Ghai, 8th edition
• www.medscape.com

21. Thank You 