2. Diarrhoea is defined as the passage of three or more liquid or watery stools
within 24 hours
Diarrhoea may have any of the following characteristics:
• Increase in frequency of stoob
• Increase in fluidity of stools
• Increase in weight of stools
The normal stool output in children is 5 g/kg/24 hours.
However,in diarrhoea the stool output is more than 10 g/kg/24 hours.
3. The following conditions are not considered diarrhoea
• Frequent passage of formed stools (irritable bowel syndrome)
• Passage of pasty stools in a breastfed infant
• Passage of watery stools by a newborn after 3-4 days of birth
• Passage of stools during or immediately after feeding in a newborn (due to the
initiation of gastrocolic reflex)
The watery stool passed by a newborn after 3-4 days of birth are called transitional
stools. These stools are mucoid to watery, not foul smelling, and are not associated with
dehydration. The frequency of stool may be up to 15 times per day. This condition is
frequently mistaken for diarrhoea and the neonate is often referred to a paediatrician.
No treatment is needed for this condition; reassuring the mother is sufficient if the baby
is taking breaatfeeds normally
4. History taking in diarrhoeal disorders
AGE
Aetiology of diarrhoea differs as the child
grows older. Causes of diarrhoea at different
ages. Infants below 3 months of age
should be treated in a hospital as they are
prone to complications
SEX
Toddler's diarrhoea is chronic non-specific
diarrhoea due to maturational delay in
intestinal motility. It ismore common in boys
5. Place of Residence
• Cholera should be suspected in a person who resides in an epidemic area.
• Food poisoning is common in places where there are poor storage facilities.
• Infections causing diarrhoea are common in areas affected by natural calamities such
as flood
Chief Complaints
An example of presenting complaint. in a case of diarrhoea is as follows:
Fever-3 days
Loose stooI--3 days
Decreased urination-1 day
6. History of Present Illness
The history of present illness consists of details of the complaint. in chronological order
• Onset
• Duration
• Frequency
• Stools
Consistency watery/rice waterlike/semisolid-Colour
Volume (small or large)
Foul smelling or not
Character frothy/oily/sticky to pan
Associated with blood and/or mucous
Use of laxatives
Whether associated with drug intake
Presence of worms in stools
7. • Precipitating and relieving factors-whether
precipitated by particular type of food
• Coexisting symptoms like vomiting ,abdominal
pain ,abdominaldistension, altered sensorium
• Feature of dehydration
• Bladder history
• Some diarrhoea may co exist as part of other
illnes
H/o drug intake which may prediapose to
side effects that may resemble diarrhoea or its
complications.
Ex –Drug --Ampicillin
Side effects
Loose stools
8. History of Past Illness
Treatment History
1. H/o hospitafuation
• Duration of stay in hospital
• Nature of treatment
• Any complications
2. H/o drugs----antibiotics-induced diarrhoea
• Antineoplastc drugs (can cause enteritis)
• Antibiotics-ampicillin (can cause diarrhoea)
3. Radiation-radiation enteritis
Contact history – H/o of k/c/o TB
9. Birth History--Full term/preterm {are prone to infections and breast milk intolerance)
• Mode of delivery {babies delivered vaginally are prone to aspirate L. monocytogenes or
Escherichia coli from the mother, both of which can predispote to diarrhoea in a newborn
Neonatal History
Low birth weight (are prone to infections)
• Prematurity/ Birth asphyxia/Septicaemia (can present with diarrhoea)
• Intra-abdominal sepsis (can present with diarrhoea)
• Procedures--umbilical cord catheterisation willpredispose to septicaemia
• Umbilical sepsis will predispose to septicaemia
Growth and development
Any delay in milestones / retardation in growth
Family and sibling history ex chronic dia,IBD,
10. Socio-Economic History
• Home-pukka/thatched
• living area per family member
• Per capita income
• Water and sanitation facilities / workshorp near and contaminating water
Nutritional History
Enquiries about diet during onset of illness, during episodes of diarrhoea and during
remissions.
Enquiries about food allergy or intolerance to certain fuods by asking the following:
Diarrhoea following the intake of cow’s milk-cow milk protein allergy
Diarrhoea following the intake of wheatceliac disease
Diarrhoea following the intake of milklactose intolerance
11. GENERAL EXAMINATION
Conciousness—normal/altered sensorium/unconscious
2. General appearance-the child looks chronicallyill
(a) Nutritional status of the child undernourished/well nourished
(b) Signs of nutritional deficiency--AcrodermatitUi enteropathica-zincdeficiency
Dermatitis (pellagra- niacin deficiency)
• Signs of vitamin D deficiency (in malabsorptionsyndrome)- bossing, open
anterior fontanel, alopecia
• Vitamin A deficiency (in malabsorption syn
Sign of dehydration –sunken eye,dry tongue, abs tears
Pallor/Jaundice/Clubbing
Lymhpadenapathy
Pedal edema (protein energy mal)
Oral cavity- oral thrush
Skin
hands
12. Vital Signs
• Pulse-weak in severe dehydration
• Temperature-hypothermia in severe dehydration
• Respiratory rate-tachypnoea (due to acidosis)
EXAMINATION OF ABDOMEN
Abdominal distension-uniform or localised
2. Flanks-free or full
3. All quadrants move well with respiration
4. Vein of abdominal wall-visible, dilated,
tortuous
5. visible gastric pulsations
6. Visible intestinal pulsations
Skin –stretched,shiny
Hernia
External gentialia
13. Palpation
e Soft/tense
• Local tendernen
e Guarding/rigidity
• Palpable masses
Auscultation
Normal frequency of bowel sound is 3-5 sounds per minute. It should be checked
whether they are decreased or increased.
RECTAL EXAMINATION
In cases with dysentery, rectal examination is essential
to rule out other causea of rectal bleeding
14. EXAMINATION SYSTEMS -
The examiner should look for the presence of
associated infections such as pneumonia, otits media
and urinary tract infectiona.
Cardiovascular System
In cases with dehydration, there will be tachycardia,
in early stages, followed by bradycardia.
Respiratory System
In severe dehydration, respiratory rate is increased if
metabolic acidosis is present (acidotic breathing).
Central Nervous System
• Altered sensorium
• Irritability in moderate dehydration
• Drowsiness in severe dehydration
15. CLASSIFICATION OF DIARRHOEA
According to Duration
Depending on the duration, diarrhoea can be classified as follows:
1. Acute diarrhoea usually lasts for less than 7 daysbut can persilt up to 14 days.
2. Chronic diarrhoea last for more than 14 daysand is of non-infective origin.
3. Persisent diarrhoea starts as acute diarrhoea but lasts for more than 14 day. It it
associated with a series of enteral infections without any time to recover between the
episodes of diarrhoea.There may be peraistent coloni.ation of small
intestines with microbes. Most cases are due to Giardia lamblia causing simple
disaccharide intolerance and respond to diet modifications.
4. Protracted diarrhoea lasts fur more than 14 days and it associated with malnutrition.
Both persistent and chronic diarrhoeas are associated with this condition (Table 7.4) . It
does not respond to diet modifications such as avoiding sugar.
16.
17.
18.
19. Definition Persistent Diarrhea
The World Health Organization (WHO) has defined persistent diarrhea (PD) as a diarrheal
illness with passage of three or more loose stools of presumed infectious etiology, starting
acutely and lasting for more than 14 days.
Etiology
Common causes of persistent diarrhea include persistent infection with one or more
enteric pathogens, secondary malabsorption of carbohydrates and fat, intestinal parasitosis
and infrequently dietary protein allergy/ intolerance
20.
21.
22.
23. Clinical Presentation
Three clinical types of persistent diarrhea are recognized: 1. Mild form is characterized by
several motions/day without significant weight loss and dehydration and can be managed
successfully as outpatients with good follow-up.
2. Moderate form is characterized by several motions/ day with marginal weight loss,
without dehydration and non-tolerance to milk and milk products and need frequent
admissions due to acute exacerbations with complications, improper treatment and no
follow-up.
3. Severe form of persistent diarrhea is often lifethreatening and is heralded by
dehydration, weight loss and nontolerance to milk and cereals. Secondary infection often
coexists with this category and these infants need to stay in the tertiary care hospitals for
indefinite period till they recover, needing intestinal biopsy, total care including
total/partial parenteral and enteral nutrition support with elemental diets. The mortality is
still high in most of the centers in developing countries
24. SIMPLE PERSISTENT DIARRHOEA
It last for ~14 days, which responds to diet modification.
Aetiological factors
• Infections by G. 'lamblia
• Agents that predispose to simple disaccharide intolerance
Features Healthy looking child without dehydration or toxic symptoms
No weight loss
Appetite preserved
Perianal. excoriation
Treatment
Modification of diet like avoiding sugars in the diet and treatment of giardiuis/similar
infestation
Prognosis Prognosis is good
25. PERSISTENT PROTRACTED DIARRHOEA
It lasts for 14 days, which does not respond to diet modification
Aetiological Factor
Infections-by bacteria, virus, fungi
or parasites. These may cause
small-bowel bacterialover growth
Postinfective sequelae like malabsorption
(dietary protein intolerance)
Extraintestinal infections such as UTI and chronic
suppurative otitis media (CSOM)
26. Predisposing Factors
Acute diarrhoea which has not been treated properly
Protein energy malnutrition
Lack of breastfeeding
Bottle feeding
Allergy to cow's milk
Inappropriate use of antibiotics
Starvation during acute diarrhoeal disorders
Vitamin A and zinc deficiency
Extra intestinal infections
27. Clinical Features
It is common in malnourished and young children.Usual presenting features are
• loose stools and
• growth failure.
Persistent protracted diarrhoea is associated with malnutrition, infections and dehydration
INVESTIGATIONS
1.Complete haemogram
2. Peripheral smear
3. Urine routine and culture
4. Blood culture-to detect persistent infection
5. Stool examination-Ieucocytosis, RBC, ova/cyst, pH, reducing substances, culture for E.
coli (enteroaggregative), Shigella, Salmonella,Cryptosporidium
6. Serum proteins
7. HIV screening tests
8. Serum electrolytes
9. Tests for usociated infections-X-ray chest
28. 10. Therapeutic challenge tests for sugar, cow milk protein intolerance
11. Serology for amoebiasis-Entamoeba histolytica infection
12. Tissue diagnosis (wherever possible lymphnode,peritoneal or rectal mucosal biopsy, liver
biopsy,etc.) for diseases like inflammatory bowel disease
13. Barium meal studies-contrast small-bowel study, large-bowel study (enema) to find out
structure abnormalities surgical conditions and infammatory bowel disease
14. Jejunal mucosal biopsy
Specific changes (lymphangiectasis,lymphoma, primary immunodeficiency,cow's milk protein
intolerance)
Non-specific changes-diffuse or focal mucosal lesions of upper small intestines
15. Proctosigmoidoscopy-colitis
16. Sterile swab (rectum) fur culture
17. Screening for malabsorption Faecalfat
• D-xylose
• Hydrogen breath test
• Schillings test
29. 18. Duodenal aspirate (bacterial colony count,
culture and sensitivity)
19. Serum immunoglobulin-T- and B-cell
functional defects (immune deficiency states)
Rare Seletive but Definitive Tests
1. Pancreatic function tests for pancreatic exocrine
enzyme deficiency
2. Liver function tests--for liver and biliary
disorders
3. Sweat chloride test fur cystic fibrosis
4. disaccharidasc: enzyme assays (to assess intestinal
damage)
30.
31. MANAGEMENT
Treat dehydration according to its severity. The mainstay of treatment in persistent diarrhoea is dietary
management. These patients should be treated in hospital setting.
Treat infection& and associated conditions such as dyselectrolytemia and hypoglycaemia. Multivitamins,
micronutrients, albumin transfusion, blood transfusion and immunoglobulins may also be given
Dietary management
Continue breastfeeding in a previously breastfed child
(b) Diet-low-lactose diet (Plan A)
(c) If there is no improvement in 2-3 days, change to lactose-free diet (Plan B)
(d) Criteria for changing the plan from A to B or B to C
Tendency for dehydration/reappearance of dehydration at any time
High purge volume
High purge rate or more stools/ day at the end of 7 days
34. Indications for Antibiotics in Persistent Diarrhoea
Neonates and young infants below 3 months
Gross malnutrition
Enteral infections due to invasive pathogens (such as Shigella, Salmonella),
small-bowel bacterial overgrowth; protozal diarrhoea (Entamoeba histolytica, G.
lamblia), fungal diarrhoea
Parenteral diarrhoea (diarrhoea due to infections such as urinary tract infections,
respiratory tract infections, retrocardiac pneumonitis or septicaemia outside the gut)
Positive parameters fur occult sepsis
Blood, mucus, pus cells (> lO/Hpf) in the stools
Immune deficiency states
35. Intravenous Parenteral Nutrition
In conditions where there is extensive damage to the intestinal mucosa or conditions where
oral feeds are contraindicated, nutrient can be supplied through parenteral route. The
required calories and proteins are supplemented as a whole or partially
Partial Parenteral Nutrition
The required calories and proteins are supplemented partially through parenteral route and
partially through oral route
Full Parenteral Nutrition
36.
37. 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
38. Pathophysiology
Chronic diarrhea results from breakdown of intraluminal factors responsible for digestion
and mucosal factors responsible for digestion as well as secretion. The mechanisms of
diarrhea with the involved intestinal sites are as follows:
• Osmotic diarrhea in which the undigested nutrients get fragmented to short chain fatty
acids and increase the intraluminal osmotic load in colon. It shows good response to
fasting.
• Secretory diarrhea is one in which due to noxious agents or exotoxins there is increase
of intracellular adenosine monophosphate or guanosine monophosphate (GMP) which
results in sodium and fluid secretion.
• Mutation in apical membrane transport protein like chloride bicarbonate exchange
transporter which results in chronic diarrhea from neonatal period with failure to thrive.
• Reduction in anatomic surface area of the gut due to extensive resection in necrotizing
39. enterocolitis, midgut volvulus or intestinal atresia results in loss of fluid, electrolyte
and nutrients from the gut.
• Alteration in intestinal motility as in malnutrition and diabetes mellitus causes
secretory diarrhea.
• Inflammatory processes like regional enteritis and ulcerative colitis involving a
significant portion of the gut causes chronic diarrhea.
43. Treatment
Treatment depends upon the cause. • Restriction of carbonated drinks or excess fruit
juice will reduce stool frequency in chronic nonspecific diarrhea. In diarrhea, due to
secondary carbohydrate intolerance, reduction of lactose or sucrose in the diet will help.
Lactase can be used to aid in digestion of lactose. If diarrhea persists, elimination of
lactose/sucrose depending upon the situation is indicated.
• If stool examination reveals more fat, malabsorption syndrome (MAS) remains a
distinct possibility. Postgastroenteritis MAS needs predigested formula to which a great
proportion Respond favorably
Infants presenting with secretory diarrhea in the first month of life need nutritional
support as the likely cause is congenital defect in transport proteins.
• In instances, where chronic diarrhea is a manifestation of a disease, the etiology should
be established and specific treatment instituted.
• Nitazoxanide therapy can be instituted where Giardia lamblia or Cryptosporidium
parvum are suspected or found.
44. Specific Etiology
Cow’s milk protein allergy (CMPA): It typically causes colitis with blood and mucus in
stools. Immunoglobulin profile and proctosigmoido-scopy with biopsy are diagnostic and
can be done in many centers.
2. Celiac disease: It is being increasingly recognised (Serological studies and intestinal
biopsy are widely available in many centers in North India.Characteristic histological
changes in the duodenal biopsy (Marsh grade ≥ III), a positive serological test (IgA
antiendomyseal antibody of tissue transglutaminase antibody) and response to gluten free
diet by 8-12 weeks, is essential for diagnosis. Serological test for celiac disease should be
done in all cases of chronic diarrhea.
3. Giardiasis/Amebiasis: Microscopic examination of a freshly passed stool on three
consecutive days is recommended for detection of Entameba
45. Reference
Aruchamy Clinical Pediatrics
IAP Guidelines for management of diarrhea in children; 1994. 9. IAP Specialty
series on Pediatric Gastroenterology, Vol. 5 and 6; 2008. pp. 42-76.
Persistent Diarrhea Lead Author
Riyaz a Indian Academy of Pediatrics (IAP)
