Approach and work up of chronic diarrhoea

1. Chronic Diarrhoea

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

6. • Etiopathogenesis

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

34. Giardiasis Celiac Disease

35. CMPA

36. Tuberculosis

37. Ulcerative Colitis

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