1. Chronic Diarrhea in Children
Dr.Vishnu D. Biradar
Consultant Pediatric Gastroenterologist &
Hepatologist
Mobile: 8600800123
E-mail ID: vishnubiradar@yahoo.com

2. Case 1
• 5 yr old boy, born out of nonconsaginous
marriage
• Sindhi by caste
• Chronic diarrhoea for last 2 years
– 1-2 stools/day, large volume
• Abd pain – periumbilical
• Weakness, Lethargy
• Not gaining weight and height
• H/o Skin lesions and oral ulcerations

3. Cntd…
• Past history NAD
• 2nd BBO, Elder 7 yr
old sister, Wt 16 kg,
Ht 105 cm
• Complementary feed
including Wheat,
started from 5th
month of age
• Severe pallor
• Pedal edema
• Oral ulcerations
and glossitis
• Dry, scaly skin
• Dental enamel
defect
• Platynychia
• S/E-NAD

4. Case 1: 5 yr old
O/E:
Wt 13 kg (<3rd centile)
Ht 95 cm (<3rd centile)
MAC 13cm
Tooth
Enamel
Defect
Short
Stature

5. Investigations
• Hb 7.3
• TLC 10.000
• Plt Adeq
• MCV 57.3
• MCH 13.9
• MCHC 24.3
• Hypo, Micro
• Tissue
transglutaminase
(tTG) IgA
– 296 Positive
– N upto 20 U/ml
• Stool RM – NAD
• RFT - Normal

6. UGIE
Reduced duodenal folds
DII- Scalloping
DII- No villi
Mosaic pattern

7. Case No. 1
• Atrophic villi Normal
• Villous/crypt ratio is less than 0.5 (Normal >2.5)
• Disarray of glandular arrangement

8. Case No. 1……..
• Lamina propria shows lymphoplasmocytic
infiltration
• Intraepithelial increase in Lymphocytes
Normal : One lymphocyte/enterocyte

9. Celiac disease

10. Treatment
• Gluten Free Diet
• Iron
• Folic acid
• F/u after 3 months
• Wt 15 kg
• Ht 105 cm
Unequivocal
response to GFD

11. Case 2: Family screening
• Elder sister of
previous child
• 7 yr old girl
• No complaints
except constipation
x 4 yrs
• Wt 16.5 kg
• Ht 112 cm
• Tooth enamel defect
• S/E NAD

12. Investigations
• Hb 11.6
• TLC 8400
• Plt Adeq
• MCV 90
• MCH 25.3
• MCHC 32
• tTG IgA 49

13. UGIE
• Mosaic pattern
• Scalloping
• Reduced duodenal folds
– No villi seen
• D2 Bx – Marsch grade 3c

14. Treatment
• Gluten Free Diet
• Iron
• Folic acid
• F/u after 2 months
• Wt 17.8 kg
• Ht 115 cm

15. Case 3
• 3 ½ month old boy
• Hindu- Maharashtrian
• Born of nonconsaginous marriage
• Loose motions 1 ½ months
– 20-25 times/day explosive
– Watery, loose, green colored,
– Containing blood & mucus
• Fever 7 days
• Not gaining weight

16. Case history
• Started Cow’s milk from 2nd month of age for
inadequate breast milk ?
• Shifted to Nusobee for first episode of AGE
at 2 ½ months of age
• Admitted thrice in last 1 month, received
antibiotic, antifungal etc without much relief
• Only child
• FTLSCS del, CIAB, No NICU admission
• B weight 3.5 kg
• Immunized for age

17. Examination
• Wt 3.7 kg
(Gain of 200 gm since
birth i.e. <20gm/day)
• Length 55 cm
• HC 37 cm
• Vitals N
• Pallor
• Dehydrated
• Sick looking
• S/E NAD
Intractable Diarrhea of Infancy

18. Lab parameters
• Hb 6 Gm%
• TLC 9900/cmm
• DLC 47/50/1/2
• Platelet 2.67 lac/cmm
• RFT, Electrolytes N
• Stool RM - few pus cells, Occult blood positive
• Urine RM – Alb trace, Pus cells 2-3/hpf
• CXR PA NAD
• Blood CS, Urine CS Neg

19. Proctosigmoidoscopy
• Seen upto splenic flexure
– Mucosa showed aphthous ulceration with
loss of vascularity
Normal

20. Histopathology
• Rectal Bx :
– Crypt
architecture is
distorted
– Cryptitis+
– Increase in
cellularity in
lamina propria
– Eosinophils 15-
20/hpf

21. Diagnosis :
Cow’s Milk Protein Allergy
1. Stopped milk, milk
products and
Soya milk
2. All antibiotics
stopped
3. Started on Green
Banana Diet

22. Follow up
• After 1 ½ months:
no diarrhea
• His weight: 4.9 kg
• Weight gain of 1.4
kg i.e. >30gm/day
• Age 8 months
• No diarrhea
• Weight: 6.4 kg
• Length: 64 cm

23. Case 4
• 12 yr old boy
• Loose motions 2 years
– 6-8/day, 2-3/night
– Containing blood & mucus
– Urgency, Frequency +
– Tenesmus +
– Associated with abdominal pain
• Fever on & off 1 year
• H/o oral ulcers in past
• No joint pain / rashes/ red eye

24. Examination
• Wt 32 kg (Thin)
• Ht 127 cm
• Severe pallor
• Edema of feet + Pitting
• PA: Mild tenderness all over abd
• Rest systemic exam NAD

25. Laboratory parameters
• Hb 6 Gm%
• TLC 2000/cmm
• DLC 21/67/7/5
• Platelet 1 lac
• ESR 70 mm at end of 1 hr
• LFT N except
• Total protein 5.3 Gm/dl
• Albumin 2.1 Gm/dl
• HIV neg

26. Colonoscopy
• Symmetrical &
continuous inflammation
• Decrease or loss of
normal vascular pattern
• Erythema & edema of
mucosa
• Ulcerations
• Colonic Bx showed
ulcerations and loss
of crypt architecture
with cryptitis and
abscesses

27. Management
• Diagnosed as Ulcerative colitis
• Started on Steroid and Mesacol
• On follow up diarrhoea frequency
reduced to 2/day and no abd pain /
blood in stool
• Gained weight

28. Case 5
• 13yr boy
• Fever X 1 yr
• Anorexia, lethargy X 10-12 months
• AnasarcaX 6 wk. Wt loss of 15 kg (from 40 to 25
kg)
• Loose stool for 10 days
• No addominal pain, distension,
vomiting,constipation
• Started on steroids
for last 2 weeks for ?NS
• No h/0 TB family
20
Ob %
2
3
14
Wt 25kg 67%
Ht 145% 93%

29. Examination
• Emaciated
• HR 120/min, RR 36/min, BP 104/68mm of Hg
• JVP not raised.
• Skin changes: crazy paving, flaky paint
dermatosis
• Pallor+, Anasarca (pitting edema)
• RS: Air entry decreased more on left. B/l basal
crepts+
• PA: No liver, spleen, any mass palpable. Mild
ascites
• CVS: S1,S2 normal.
• CNS: NAD

30. Investigations:
Hb TLC DLC Pl PS
9.3 16700 73/26/1 81000 Nc/nc
TSB Conj TP Alb SGO
T
SGP
T
Al P GGT Cal Ph
1.4 0.5 3.8 1.4 61 20 242 49 6.9 2.4
27/03/2010 06/04/2010

31. Investigations:
• USG abdo: Gut wall of distal 3.6 cm segment of terminal
ileum and caecal wall is edematous with echogenic surrounding.
Moderate ascites, Enlarged messenteric LN (12mm).
• GA for AFB negative
• ECHO: Good contractility. Mild pericardial effusion.
• Immunodeficiency work up: HIV negative. IgA: 263mg/dl,
IgG 1020, IgM 142
• Upper GI endoscopy: Normal Oesophagus, antrum, Deodenum.

32. Colonoscopy
• Rectum, sigmoid, descending colon normal.
• Hepatic flexure, narrow segment with
ulceration, nodularity and friability( scope
not negotiable)
• Multiple holes (Sinuses ? Fistula) proximal
to stricture.
• Biopsies taken from the ulcer and nodules

33. Colonoscopy

34. Impression
• Colonic Biopsy showed multiple epitheliod
granuloma with AFB positive
Colonic tuberculosis

35. Further course
• Started on ATT
• Pneumonia: IV Antibiotics
Complications: Pulmonary edema:
?Volume overload/? Refeeding
syndrome
• Ventilated and now extubated.
• Recovered fully
• After 6 months Weight of 35 kg

36. Case 6
• 12 year, girl
• Chronic diarrhoea x 6 years
– 4-6/day, mod. Vol., Oily
• Progressively increasing
asymmetrical limb swelling
• Abdominal distension x 9 months

37. Present history
• O/e : Wt 31 kg (10th percentile) - wt age 11 yr
Ht 131 cm (<5th percentile) - Ht age 9 yr
Asymmetrical limb edema
non pitting, Lt > Rt
Facial puffiness
Clubbing + Gr II
PA : No organomegaly. Ascites ++
Rest system normal

38. Asymmetrical limb edema

39. Investigations
• Hb 13.6 Gm%
• TLC 12,000 cells/cmm
• Absolute lymphocyte count 4000
• Total protein 4.8
• Albumin 2.3
• Lipid profile normal
UGIE – after fat loading showed
white plaques in D2 and D3 region

40. UGIE

41. Diagnosis : Intestinal
Lymphangiectasia
Started on MCT based protein
rich diet

42. Follow up
• Diarrhea improved after MCT based
diet
• Ascites decreased
• Limb swelling same

43. Cases for discussion

44. Case 1
• 2 yr old girl
• H/O two abdominal surgeries at 18 mths
age for features s/o intestinal
obstruction after diarrheal episode
• No improvement in wt gain, abd
distension

45. Examination
• Irritable child, loss of subcutaneous fat
• Vitals – stable
• Wt – 8.9kg, ht – 77cm (both < 5th centile)
• P/A – abdomen distended
liver, spleen - not palpable
• Other systems - normal

47. July` 10

48. Nov`10

49. Investigations
• CBC – hypochromic microcytic anaemia
• LFT – normal
• tTG IgA > 200 u/ml ( N < 20u/ml))
• Duodenal biopsy s/o total villous
atrophy

50. Celiac disease
Started on GFD

52. Feb`11

54. 2).10 month, boy, Dysentery

55. 3).13 yr old girl, Colitis

56. 4).2 yr old child, Chronic
diarrhea

57. 5).Chr. Diarrhea

58. 6).12 yr old boy

59. Colonoscopy

60. 7).4 yr old boy, Diarrhea +
Distension

61. Radiology

62. My experience at Pune
Total 92 cases
• Celiac – 16
• CMPA – 21
• Ulcerative colitis – 5
• Crohn’s disease - 7
• Abd. Tb – 4
• Toddler’s diarrhea – 9
• Intestinal
lymphangiectasis – 2
• Systemic infection – 11
• ALPS + CVID + CMV
colitis – 1
• Candidiasis - 1
• Amoebiasis – 3
• Giardia – 4
• Cryptosporidiasis – 1
• Microsporidia - 1
• Lactose intolerance – 4
• Other - 2

63. TThhaannkk yyoouu .. .. ..