This document discusses chronic diarrhea and its causes and management. It defines persistent diarrhea as acute diarrhea lasting over 2 weeks, while chronic diarrhea has a more insidious onset and is usually due to non-infectious causes lasting over 2 weeks. Common causes of persistent diarrhea include malnutrition, infections, and food allergies. Chronic diarrhea requires further evaluation to identify underlying inflammatory, malabsorptive, intestinal, metabolic, or other conditions as the cause. Management of both involves rehydration, controlling diarrhea, identifying the cause, and rehabilitation.

1. CHRONIC DIARRHEA
Dr M.Sanjeevappa
M.D.(Paeds)
Asst.Professor,
Dept. of Paediatrics
Govt.Medical College
Ananthapuramu.

2.  Most diarrheal disorders resolve within the first
week of the illness.
 1 to 3% of acute diarrhoeas become chronic, With
a high mortality and morbidity.
 Chronic diarrhea has been defined as an episode
that begins acutely but lasts for 14 days or longer.
 Two entities :
1) Persistent diarrhea.
2) Chronic diarrhea.

3. PERSISTENT DIARRHEA
 starts as acute diarrhea, but instead of subsiding
in the usual time, the child goes on purging for a
period of more than 2 weeks.
risk factors :
 Protein-energy malnutrition
 Younger age < 18 months
 Lack of breast-feeding
 Bottle-feeding
 Cow's milk,Soy protein allergy.
 Inappropriate use of antibiotics

4. PERSISTENT DIARRHEA
Risk factors :
 Improper therapy of ADD.
 Use of antimotility drugs like loperamide.
 Starvation during ADD.
 Vitamin A deficiency.
 Zinc deficiency.
 Poor hygiene leading to reinfection.
 Certain extra intestinal infections, e.g :UTI

5. CHRONIC DIARRHEA
Definition :
 Chronic diarrhea is defined as diarrhea greater than
2 weeks duration, with an insidious onset and
usually due to noninfectious cause. Almost all
patients need a complete workup for underlying
malabsorptive state.
1. Inflammatory causes :
 Tuberculosis.
 Eosinophilic gastroenteritis.
 Crohn's disease.
 Necrotising enterocolitis.
 Allergic colitis.
 Henoch-Schonlein vasculitis.

6. CHRONIC DIARRHEA
2. Malabsorption states :
 Pancreatic diseases.
 Cystic fibrosis.
 Chronic pancreatitis.
 Hereditary pancreatitis.
 Congenital lipase deficiency.
 Congenital trypsin deficiency.

7. CHRONIC DIARRHEA
3.Intestinal diseases :
 Tropical sprue
 Coeliac disease
 Whipple's diseae
 Intestinal lymphangiectasia
 Enterokinase deficiency.
 Vitamin B12 malabsorption
 Juvenile pernicious anaemia.
 Transcobalamin II deficiency.
 Lactase deficiency-congenital/acquired.
 Sucrase-isomaltase deficiency.
 Glucose-galactose malabsorption.

8. CHRONIC DIARRHEA
4.Metabolic disorders :
 Darrow's syndrome (congenital chloride diarrhea).
 Abetalipoproteinaemia.
 Acrodermatitis enteropathica.
5.Endocrine causes :
 Hypoparathyroidism, Hyperthyroidism.
 Diabetes mellitus.
 Adrenal insufficiency.
6.Congenital alterations in electrolyte transport :
 Congenital chloride diarrhea

9. CHRONIC DIARRHEA
7.Immune defects :
 Agammaglobulinaemia.
 Isolated IgA deficiency.
 Defective CMI.
 Combined immunodeficiency.
8.Neoplasms :
 lmmunoproliferative small intestinal disease
(IPSID orMediterranean lymphoma).
 Western lymphoma.
 Ganglioneuroma.
 Vernor-Morrison syndrome (pancreatic cholera)
 Zollinger-Ellison syndrome.

10. CHRONIC DIARRHEA
Liver diseases :
 Cholestatic jaundice.
 Primary bile acid malabsorption.
Motility disorders :
 Toddler´s diarrhoea
 Hyperthyroidism
 Idiopathic bowel pseudo-obstruction
 Irritable bowel syndrome
Anatomical or surgical disorder :
 Necrotizing enterocolitis
 Short bowel syndrome
 Blind loop syndrome
 Hirschprung’s disease
 Intestinal lymphangiectasia

11. PATHOPHYSIOLOGY
OSMOTIC DIARRHEA
presence of nonabsorbable solutes.
colonic bacteria ferment the nonabsorbed sugar to
short-chain organic acids
osmotic load
water secreted

12. CAUSES FOR OSMOTIC DIARRHEA
 malabsorption of water-soluble nutrients
-glucose-galactose malabsorption
-congenital, acquired disaccharidase deficiencies.
 excessive intake of carbonated fluid.
 excessive intake of nonabsorbable solutes.
-sorbitol, lactulose, magnesium hydroxide.
 stops with fasting.
 has a low pH.
 positive for reducing substances

13. PATHOPHYSIOLOGY
SECRETORY DIARRHEA
activation cAMP, cGMP, and intracellular calcium.
active chloride secretion (crypt cells)+ inhibit
the neutral coupled sodium chloride absorption.
alter the paracellular ion flux( toxin-mediated
injury to the tight junctions)
secretory diarrhea

14. CAUSES OF SECRETORY DIARRHEA
ACTIVATION OF CYCLIC AMP
 Bacterial toxins: enterotoxins of cholera, Escherichia coli
(heat-labile), Shigella, Salmonella, Campylobacter jejuni,
Pseudomonas aeruginosa
 Hormones: vasoactive intestinal peptide, gastrin, secretin
 Anion surfactants: bile acids.
ACTIVATION OF CYCLIC GMP
 Bacterial toxins: E. coli (heat-stable) enterotoxin, Yersinia
enterocolitica toxin
CALCIUM-DEPENDENT
 Bacterial toxins: Clostridium difficile enterotoxin
 Neurotransmiters: acetylcholine, serotonin
 Paracrine agents: bradykinin

16. EVALUATION OF A CHILD WITH
CHRONIC DIARRHEA
STOOL HISTORY :
 SBD : profuse, watery, usually offensive stools,
without blood.
 LBD: small quantity, frequently with blood and
mucus.
 Odourless blood tinged stools - shigellosis
 Frequent mucoid stools in a healthy child without blood -
IBS
 Nocturnal diarrhoea favours organic disease over IBS.
 History of delayed passage of meconiurn and if
constipation preceded diarrhoea,- Hirschsprung's
disease

17. DIETETIC HISTORY
 It may provide vital clues to the aetiology, e.g., cow's milk
protein intolerance, lactose intolerance, gluten enteropathy,
soy protien intolerance, egg protien enteropathy.
 Overfeeding, concentrated formula feeds> osmotic
diarrhoea.
 Chewing gums and chocolates.
 plenty of undiluted fruit juices (e.g., pineapple juice has
an osmolality of 900 mOsm/L and apple juice 650 mOsm/L

18. TREATMENT HISTORY
 If achild on antibiotics develops diarrhea, -
pseudomembranous colitis.
 Drugs - neomycin, colchicine, cholestyrarnine, digitalis,
and propranolol.
 Laxatives abuse(Factitious diarrhoea by proxy)
 A family history- IBS.

19. DIAGNOSIS
 A complete clinical history is mandatory.
 Age of onset
 Nutritional assessment
 Associated symptoms: fever, vomiting, abdominal pain,
anorexia.
 Stool characteristics: blood, mucous, non digested
substances, steatorrhea.
 Physical examination: FTT, abdominal distension,
 visceromegaly, tenderness, presence of abdominal
masses.
 Other organs affected, e.g. skin, respiratory system.

20. DIAGNOSIS
 Hyperpigmentation- Addison's disease, coeliac
disease ,Whipple's disease.
 Generalized lymphadenopathy- lymphoma, AIDS or
Whipple's disease.
 In a child born of consanguinous parents with
malabsorption and chronic lung disease, cystic
fibrosis should be ruled out.

21. DIAGNOSIS
 Recurrent fever- tuberculosis, lynphoma, and IBD
 Marked loss of weight- malabsorption, lymphomas,
IBD, TB.
 periorifcial lesions : acrodermatitis emeropathica.
 perianal fistula - Crohn's disease.
 Clubbing - malabsorption syndromes, IBD.
 Chronic liver disease- IBD
 Hepatomegaly -lymphomas, metastatic carcinoid,
IBD and Whipple's disease.
 Ascites - TB and lymphoma.

22. INVESTIGATION
STOOL EXAMINATION
Microscopy :
 Polymorphs and RBCs - bacterial colitis, whipworm
colitis, amoebic colitis and in IBD.
 Eosinophils are seen in milk or soya protein intolerance.
pH and Reducing Substance :
 A stool pH < 5.5 (on cow's milk) or < 5 (on breast milk) is
suggestive of carbohydrate malabsorption and proximal
small bowel damage.
 Stool pH gives a clue to the amount of organic acids in
stool while the increased amounts of reducing substances
indicate the presence of unabsorbed sugars.

23. DEMONSTRATION OF REDUCING SUGARS IN STOOL
 Benedict's test : 1 ml of distilled water is added to 0.5
ml liquid stool and shaken well. 8 drops of this are
added to 5 ml of preboiled Benedict's solution and
boiled for 1 minute.The solution is cooled and the
precipitate is examined for colour change.
 Stool Culture :
Stool culture is positive only in 20% of patients with
acute diarrhoea and it is even lower in PD.
 Occult Blood :
In acute diarrhoea- bacterial or parasitic colitis.
Chronic diarrhoea- IBD like ulcerative colitis and
Crohn's colitis and IPSID(Immunoproliferative small
intestinal desease).

24. INVESTIGATION
Peripheral Blood Picture
 iron deficiency anaemia or dimorphic anaemia.
 abetalipoproteinaemia (acanthocytes)
Biochemical Investigations
 Serum electrolytes,
 blood urea,
 RBS and plasma proteins.
Blood and Urine Culture
 Systemic infections are important causes of CD in
infancy. Cultures from various sites, before starting
antibiotics, are extremely useful in detecting these
infections.

25. INVESTIGATION
 Barium meal follow through:
This will detect ulcers and strictures of small bowel.
 Small bowel biopsy:
tropicalsprue, coeliac disease, tuberculosis,
lymphoma,abetalipoproteinaetnia, Whipple's
disease, amyloidosis, lymphangicetasia.

26. INVESTIGATION
 Proctosigmoidoscopy:
 To differentiate SBD from LBD(colitis).
 To visualize pseudomernbrane/polyps/ulcers/tumours.
 Direct swabs for microscopy and culture.
 Rectal biopsy.
 Rectal Biopsy :
 Ulcerative colitis.
 Crohn's disease.
 Schistosomiasis.
 Trichuriasis.
 Amyloidosis.
 Whipple's disease

27. INVESTIGATION
Tests for Tuberculosis :
 Mantoux test.
 X-ray chest.
 Barium meal follow-through for ulcers, strictures,
malabsorption pattern etc.
 Barium enema-if colonic lesion is suspected.
 Duodenal, jejunal or colonic biopsy-for tissue
diagnosis.

28. MANAGEMENT
 About 30% of patients with PD require
hospitalization, if they have 1 or more of the
following:
 Age: Less than 4 months and not breast feed.
 Severe PEM.
 Dehydration
 Presence of systemic infections.

29. MANAGEMENT
The management of PD consists of 3 phases:
 Resuscitation phase (24-48 hours).
 Control of diarrhoea (up to 7 days).
 Rehabilitation phase (up to 8 weeks).

30. MANAGEMENT
RESUSCITATION PHASE
 IV line , vital signs monitored and blood group and
cross matching.
 Correction of dehydration, shock, electrolyte
disturbance, hypoglycaemia and renal failure.
 Appropriate antibiotics.
 first 24 hours the child is given iv fluids and nil
orally, except sips of ORS.

31. MANAGEMENT
CONTROL OF DIARRHEA
The major factors responsible for PD
 Bacterial contamination of the gut.
 Systemic infections.
 Food allergen (cow milk, soy protein, egg protein).
 Lactose intolerance.
 Toxins.
 Bile acids.

32. MANAGEMENT
 Many infants with PD are very sick and have features of
systemic infections like septicaemia and
bronchopneumonia.
 Combination of I.V. Amikacin and I.V. cefotaxime is
extremely effective in sick infants.
 In infants less than 3 months I.V. Amikacin and I.V.
Ampicillin are more effective.
 In a recent study cotrimoxazole was found to be very
useful in children with PD.
 Albendazole.
 Shigellosis – ciprofloxcacin.
 Amebiasis – metronidazole.

33. MANAGEMENT
REHABILITATION PHASE AND AIMS
 To improve the general health and nutritional
status.
 To correct nutritional deficiencies.
 For catch-up growth.
 To educate the parents, especially to prevent future
relapse.

34. MANAGEMENT
DIETARY MANAGEMENT AND GOALS :
 Small frequent feeds.
 Start with a high carbohydrate, low protein, and no fat
regime, as the patient improves, coconut oil may be
added.
 Always avoid those food substances, which may be
responsible for PD e.g., milk and milk products in
cow's milk allergy.
 Provide adequate micronutrients and vitamins.
 The diet should not be hyperosmolar.

35. MANAGEMENT

36. MANAGEMENT

37. MANAGEMENT

38. MANAGEMENT
INDICATORS OF TREATMENT FAILURE :
 Passage of >7 stools per day at the end of one
week.
 Weight loss or poor weight gain, in spite of an oral
intake of at least 100 ml/kg/day, over the previous
3 days.
 If the child develops dehydration at anytime.
 Significant increase in diarrhoea with in 48 hr

39. MANAGEMENT
Problems and Remedies :
 Anorexia - try nasogastric feeding.
 Intolerance - change diet, postpone alimentation.
 Poor weight gain - add fat and pancreatic enzymes.
 Trace element deficiency - oral zinc, Mg.
 Hypothermia - wrap the baby well.

40. THANK YOU