This document discusses chronic diarrhea, defining it as diarrhea lasting more than 2 weeks. It outlines different types of diarrhea based on duration, including acute (<2 weeks), prolonged (7-14 days), and persistent (>14 weeks). The causes of chronic diarrhea are discussed for different age groups, including post-gastrointestinal infections, cow's milk protein intolerance, and celiac disease in infants. Pathophysiological causes of chronic diarrhea include secretory, osmotic, steatorrheal, inflammatory, and dysmotility mechanisms. The importance of a thorough history and physical exam is emphasized to guide diagnostic testing and treatment approaches, which may be curative, suppressive, or empirical depending on the underlying cause.

1. CHRONIC DIARRHOEA
Dr. Virendra Kumar Gupta
Assistant Professor
Department Of Pediatric Gastroentero-hepatology &
Liver Transplantation
NIMS Medical College & Hospital , Jaipur

2. DIARRHOEA
 Diarrhoea defined as excessive loss of fluid and
electrolyte in stool.
 For infants stool output >10 ml/kg/24 hr and
>200g/24hr for older children.
When there is an  in frequency, volume or liquidity
(Recent change in consistency) of the bowel
movement relative to the usual habit of each individual
Nelson Textbook of Pediatrics, 20th ed

3. • Acute diarrhea
Duration <2 wks, usually of infectious origin
• Prolonged diarrhea
Diarrhea of duration 7-14 days of presumed infectious
etiology. It may be an indicator for children with a high risk
of progression to Persistent diarrhea
• Chronic diarrhea
Diarrhea of more than 2 weeks duration.
• Dysentry
Bloody diarrhea, visible blood and mucus present.
Nelson Textbook of Pediatrics, 20th ed
DEFINITIONS

4. Persistent diarrhea
 Persistent diarrhea (PD) is an episode of diarrhea of
presumed infectious etiology, which starts acutely but
lasts for more than 14 days, and excludes chronic or
recurrent diarrheal disorders such as tropical sprue,
gluten sensitive enteropathy or other hereditary
disorders[WHO] (INDIAN PEDIATRICS, JAN 2011)
 passage of >=3 watery stools per day for >2 weeks in
a child who either fails to gain weight or loses
weight.(ESPGHAN)

5. Chronic Diarrhoea
 Diarrhoea lasting for more than 2
weeks
 Mainly non infections causes

6. INFANCY
 Postgastroenteritis malabsorption syndrome (persistent)
 Cow's milk/soy protein intolerance
 Secondary disaccharidase deficiencies
 Cystic fibrosis
CHILDHOOD
 Chronic nonspecific diarrhea
 Secondary disaccharidase deficiencies
 Giardiasis
 Postgastroenteritis malabsorption syndrome
 Celiac disease
 Cystic fibrosis
ADOLESCENCE
 Irritable bowel syndrome
 Inflammatory bowel disease
 Giardiasis
 Lactose intolerance

7. Pathogenesis
1. Secretory causes
2. Osmotic causes
3. Steatorrheal causes
4. Inflamatory causes
5. Dysmotility causes
6. Factitial causes

8. Secretory causes
 Derangements in fluid and electrolyte transport
across entero colonic mucosa
 Watery, large volume fecal output, painless and
persits with fasting
1)medications—ethanol,laxatives
2)bowel resection,mucosal d/s,enterocolic
resection—idiopathic secretory diarrhoea
3)hormones- serotonin,prostaglandins,kinins
4)congenital defects in Fe absorption

9. Osmotic causes
 Osmotically active solutes
1)osmotic laxatives—Mg2+,(po4)3-,(so4)2-
2)carbohydrate malabsorption—lactase
deficiency

10. Differential Diagnosis of
Osmotic Vs Secretory Diarrhea
OSMOTIC DIARRHEA
SECRETORY
DIARRHEA
Volume of stool <200 mL/24 hr >200 mL/24 hr
Response to fasting Diarrhea stops Diarrhea continues
Stool Na+ <70 mEq/L >70 mEq/L
Reducing substances[*] Positive Negative
Stool pH <5 >6

11. Steatorrheal
causes
1) intraluminal maldigestion—Ch. pancreatitis,
fibrosis,pancreatic duct obstruction
2)mucosal malabsorption—celiac d/s,tropical
spure,whipples d/s
3)post mucosal lymphatic obstruction—congenital
intestinal lymphangiectasia,acquired lymphatic
obstruction(trauma,tumour)

12. Inflamatory
causes
 Pain,fever,bleeding,other manifestations
ofinflamation
eg: IBD,
immunodeficiencies
eosinophilic gastrits

13. Dysmotility
causes
 Hyper motility
 Diabetic diarrhoea—peripheral andgeneralised
autonomic neuropathy

14. Factitial causes
 15% of unexplained diarrhoea
 Eg: munchausen syndrome, eating disorders
(psychiatric illness)

15.  Proper history and physical examination very
important
 HISTORY—onset,duration,pattern,aggrevating and
relieving factors etc
wt.loss,pain,exposures(travel,medications etc)
.FAMILY HISTORY—ibd,sprue
Approach To Patient

16. PHYSICAL EXAMINATION
-- anemia,edema,clubbing(features of
malabsorption,IBD)
--muco cutaneous manifestations of systemic
d/s(dermatitis herpetiformis,erythema
nodosum,oral ulcers etc)
--abdominal mass or tenderness
--abnormalities of rectal mucosa,rectal defects

17.  Diagnostic evaluation directed by a careful history
and physical examination
 If not revealing triage tests required to direct the
choice of complex investigations

20. Traetment
 Curative,suppressive,empirical
1)curative—antibiotic for whipples
d/s,discontinuation of drug
2)suppressive—elimination of dietry lactose,PPI for
gastrinoma,pancreatic enzyme replacement
3)emperical—mild
opiates(loperamide),clonidine,fluid and electrolyte
replition