This document discusses the management of chronic diarrhea. It defines chronic diarrhea as increased stool output lasting more than two weeks. The causes can be intraluminal factors, mucosal factors, or other systemic diseases. Evaluation involves a thorough history, physical exam including nutrition assessment, and various stool, blood, and imaging tests. Management focuses on maintaining adequate nutrition and identifying the underlying cause. Treatment depends on the cause but may include fluid restriction, modifying diet to reduce fruits/juices high in sorbitol or fructose, supplementing lactase for lactose intolerance, or using predigested formulas for malabsorption.

1. MANAGEMENT OF CHRONIC DIARRHOEA

2. INTRODUCTION Definition: ↑ in total daily stool output associated with ↑ stool water content Infants + children  stool output greater than 10g/kg/24hr If diarrhoea more than 2 weeks, consider chronic It is result from altered intestinal water & electrolyte transport The transporter is located at the brush border of small & large intestines

3. CAUSES

4. OTHER CAUSES Intraluminal factors:

5. Mucosal factors:

6. Mucosal factors:

7. EVALUATION Phase 1 Hx including amount of fluid intake/day PE including nutritional assessment Stool examination (pH, fat, ova & parasite) Stool culture Stool for Clostridium difficile toxin Blood test (FBC, ESR, BUSE, RP) Phase 2 Sweat chloride 72hr stool collection for fat determination Stool electrolyte, osmolality Breath H2 test

8. Phase 3 Endoscopic study Small bowel biopsy Sigmoidoscopy with biopsy Barium study Phase 4 Hormonal studies Vosoactive intestinal polypeptide Gastrin, Secretin

9. MANAGEMENT Principal: Maintain adequate nutritional intake to permit normal growth & development Height & weight must be documented Consider chronic non-specific diarrhoea if normal height & weight, stool examination did not show any fat Pathogenesis of this condition: Excessive carbonated fluid intake Low fat intake Excessive intake of fruits juice

10. CHRONIC NON-SPECIFIC DIARRHOEA Present in well appear toddler (1 – 3 years old) Diarrhoea is brown & watery, containing undigested food particles If child fluids intake > 150ml/kg/24h, it should be reduce to < 90ml/kg/h Child may become irritable for the 1st 2 days of fluid restriction. This approach will result in ↓ stool frequency & volume If diet hx suggest that the child ingesting significant amount of fruits juices, juice should be ↓

11. Sorbitol (non absorble sugar) found in apple, pear & prune juices These fruits also contain high fructose that causing diarrhoea White grape juice is the best alternative Restriction of fat intake by the parents can cause diarrhoea We can increase fat diet to 40 % of total calories/days

12. CARBOHYDRATE INTOLERANCE A trial period of lactose @ sucrose initiated Add lactase tablets (LactAid) & sacrosidase for lactose & sucrose digestion Lactose & sucrose free diet If no improvement If no improvement

13. If patient present with weight loss & stool examination shows fat chronic diarrhoea 2° to malabsorption syndrome Common cause is post gastroenteritis malabsorption syndrome This patient respond well to predigested formula If patient intolerance to oral feeding with predigested formula (pregestimil, alimentum), nasogastric drip feeding with elemental formula should be considered for 3 – 4 weeks

14. Patient suspected with small intestinal bacterial overgrowth should be evaluated for surgical, medical & nutritional support Surgery if patient has malrotation or partial small bowel obstruction Antibiotic – metronidazole + ampicillin @ trimethoprim-sulfamethoxazole Patient present with secretory diarrhoea in the 1st month of life need to have nutritional support the most likely cause is congenital defect in transport protein