persistent diarrhea & Chronic diarrhea
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persistent diarrhea & Chronic diarrhea
- 1. PERSISTENT DIARRHEA CHRONIC DIARRHEA Moderator Presented by Dr. Sumit Das Dr. Fahad Muhamed Shareef A T Ass. Prof. PG in Pediatrics Dept. of Pediatrics
- 2. • Diarrhea – 3 times in 24 hours – Consistency important over frequency • Acute Diarrhea • Persistent Diarrhea • Chronic Diarrhea TERMS & DEFINITIONS
- 3. PERSISTENT DIARRHEA • Starts as acute, lasts at least 14 days with the exclusion of chronic or recurrent diarrheal conditions – Celiac disease Tropical Sprue – Biochemical Congenital – Metabolic
- 4. ?WHY • 10% of total diarrhea • 35% of diarrheal deaths • For every 100 children, 7 suffers • PD in Malnutrition – 20% • 60% < 6 months • 90% < 1 year
- 5. RISK FACTORS & CAUSES • Repeated enteric infections • Malabsorption of CHO & fats • Malnutrition • Very young age • Recent introduction of animal milk • Irrational usage of antibiotics • Lack of breast feeding/ bottle feeding • Improper therapy of ADD • Protein dietary intolerance
- 6. PATHOGENESIS “PSIMI” Mucosal injury d/t invasive pathogens Malabsorption of macro & mircronutrients Prolongation of mucosal injury & delayed intestinal repair mechanisms (ineff. villous repair) Sequential infection with multiple pathogens Increased absorption of foreign proteins Malnutrition
- 7. PRESENTATION • Several loose stools • Dehydration absent • If present, inc stool output dec oral intake • Features of PEM
- 8. Clinical Evaluation • History & Physical Examn. • Should be excluded from Chronic diarrhoea • To R/o associated systemic infections – CBC – URE & C/S – CXR • Stool microscopy • Stool pH & reducing substance
- 9. • Nutritional management is the cornerstone – Dietary management – Supplemental vitamins & minerals • Two third cases – OPD • Assess dehydration • Hospitalization necessary or not • Avoid unnecessary antibiotics TREATMENT
- 10. When to hospitalize? • Age < 4 mon & not breast fed • Dehydration • Severe malnutrition – W/L < 70% – W/A < 60% – Pedal edema • Systemic infection
- 11. Dietary Management < 6 months • Encourage exclusive breast feeding • Reestablish breast feeding • Replace animal milks with curds or lactose free formula • Cooked rice may be mixed if necessary
- 12. >6 months • Continue Breast feeding • Mixed diet • Initiate DIET A • DIET B • DIET C
- 13. Milk cereal mixtures v/s milk free diet • Highly palatable • Provide good quality protein • Some micronutrients • Faster weight gain • No significant increase in stool output • No increasing risk of dehydration
- 14. Principles • Total elimination of milk not necessary • Limit intake to 2g/kg/day lactose (50-60 ml) • Start feeding asap • 6-7 feeds per day • Start with 110kcal/kg and inc to 150kcal/kg over 2 weeks • If enteral intake diff, start NG feed
- 15. DIET A reduced lactose diet (65-70%) Ingredients Measures Wt/Vol Milk 1/3 katori 50ml Sugar 1.5 tsp 7g Oil 1 tsp 4.5g Puffed rice powder 2 tsp 6.0g Water 2/3 katori 100ml Calories/100g 85 kcal Proteins/100g 2.0g How to prepare
- 16. DIET B lactose free with reduced starch(15-20%) Ingredients Measures Wt/Vol Egg white 3 tsp Half egg white Puffed rice powder 3 tsp 9.0g Glucose 1.5 tsp 7g Oil 1.5 tsp 7g Water 3/4 katori 120ml Calories/100g 90 kcal Proteins/100g 2.4g How to prepare
- 17. DIET C Monosaccharide based Ingredients Measures Wt/Vol Egg white 3 tsp Half egg white Or Chicken puree 5 tsp 15 g Glucose 1.5 tsp 7 g Oil 1.5 tsp 7 g Water 1 katori 150ml Calories/100g 67 kcal Proteins/100g 3 g How to prepare
- 18. Supplementation • 2 x RDA of multivitamins and minerals for 2-4 weeks • At least Vit A (single dose) & Zinc 10- 20mg (2 weeks) • In severe malnutrition, – 50% Mg sulfate 0.2ml/kg/dose twice a day for 3 days – Potassium 5-6meq/kg/day
- 19. Monitoring response • Dec in no. of diarrheal stools – <= 2 liquid stools/day for 2 consec. Days • Adeq. Food intake • Weight gain Most children lose wt in the initial 1-2 days and then show a steady gain
- 20. When to change diet • Marked increase in stool freq (10/day) • Return of signs of dehydration • Failure to establish wt gain by day 7 after discharge little milk after 10 days No signs of lactose intolerance Milk qty increased and normal diet ovr a week
- 21. PARENTERAL NUTRITION • PD with oral intolerance after 10 days • Severe forms of IBD+ resistant colitis • Severe NEC COMPLICATIONS PARTIAL PARENTERAL NUTRITION • Isolyte P - 250ml 25%D – 150ml • A.A – 100ml NaHCO3 – 20ml • KCl – 5ml MVI – 2ml • 50-60 ml/kg/d
- 22. Antimicrobial Therapy • Gross blood in stools • Asso systemic infection • Severe malnutrition • Screen for UTI and treat • Group B Salmonella isolated in stool
- 24. PREVENTION • Improving nutritional status • Prevention and rational treatment of acute diarrhea • Promote exclusive breast feeding • Ensure safe complemetary feeding practices • Zinc supplementaton • Avoid irrational & unnecessary use of antibiotics
- 26. CHRONIC DIARRHEA • Diarrhea for >= 14 days with exclusion of persistent diarrhea. • Infections • Malabsorption • Metabolic • Miscellaneous
- 27. INFECTIONS • Tuberculosis • Eosinophilic gastroenteritis • IBD • NEC • Henoch Scholein MALABSORPTION • Pancreatic diseases • Liver diseases • Intestinal diseases
- 28. INTESTNAL MALABSORPTION • CELIAC DISEASE (TVA) • GIARDIASIS • BACTERIAL OVERGROWTH • MALNUTRITION PVA • TROPICAL SPRUE • ABETALIPOPROTEINEMIA • LYMPHANGIECTASIA • ENZYME DEF.
- 29. Miscellaneous • TODDLER’S DIARRHEA • CHRONIC NON SPECIFIC DIARRHEA • IRRITABLE BOWEL SYNDROME • AUTOIMMUNE ENTEROPATHY • MOTILITY DOSORDERS • ENDOCRINE • NEOPLASTIC DISORDERS • MANCHAUSEN BY PROXY
- 30. Clinical evaluation • Onset – At birth chloride diarrhea, microvillous inclusion dis. – 6 mon autoimmune enteropathy – Infant Hirschsprung’s dis – Abrupt Infections – Gradual Rest • Weight loss : Malabsorption,neoplasm • Dietary history – Lactose intolerance, cow’s protein, soy protein, egg protein – Overfeeding, chewing gum diarrhea, Non specific diarrhea • Treatment history – Antibiotics, prpnl, digitalis, cholestyramine, Munchausen • Family history : IBD, IBS
- 31. STOOL CHARACTERISTICS • Blood Dysentry • Oil/ food particlesMalabsorption, maldigestion • White/ tan colour Celiac disease, absence of bile • Loose & bulky Celiac disease • Greasy & yellowish exocrine pancreatic insuff • Liquid as water Cong. Chloride diarrhea
- 33. • Plain x-ray abdomen • Ultrasonography • Colonoscopy • Capsule endoscopy
- 34. STEP 1 Intestinal microbiology • Stool cultures • Microscopy for parasites • Viruses • Stool electrolytes • H2 breath test Screening test for celiac disease (transglutaminase 2 autoantibodies) Noninvasive tests for: • Intestinal function • Pancreatic function and sweat test • Intestinal inflammation Tests for food allergy • Prick/patch tests DIAGNOSTIC WORK UP
- 35. TEST NORMAL VALUES IMPLICATION α1-Antitrypsin concentration <0.9 mg/g stool Increased intestinal permeability and protein loss Steatocrit <2.5% (>2 yr old) Fecal fat loss Fecal reducing substances Absent Carbohydrate malabsorption Elastase concentration >200 µg/g stool Exocrine pancreatic dysfunction Chymotrypsin concentration >7.5 U/g >375 U/24 h Exocrine pancreatic dysfunction Fecal occult blood Absent Fecal blood loss, distal intestinal inflammation Calprotectin concentration 100 µg/g stool Intestinal inflammation Fecal leukocytes <5/microscopic field Colonic inflammation Nitric oxide in rectal dyalisate <5 µM of NO2 −/NO3 − Rectal inflammation Dual sugar (cellobiose/mannitol) absorption test Urine excretion ratio: 0.010 ±0.018 Increased intestinal permeability NON INVASIVE TESTS
- 36. STEP 2 INTESTINAL MORPHOLOGY • Standard jejunal/colonic histology • Morphometry • PAS staining • Electron microscopy STEP 3 SPECIAL INVESTIGATIONS Intestinal immunohistochemistry Anti-enterocyte antibodies Serum chromogranin and catecholamines Autoantibodies 75SeHCAT measurement Brush border enzymatic activities Motility and electrophysiological studies
- 37. TREATMENT • General supportive measures – Replacement of fluids & electrolytes • Nutritional rehabilitation • Elimination diet • Treat the cause
- 38. CELIAC DISEASE • Immunologically mediated small intestinal enteropathy • Sensitivity to gluten • Multiple associations • Classic form : – 6m- 24m – Chronic diarrhea, anorexia,vomiting – Abd pain & distension – Poor weight gain & wieght loss
- 39. • Older children – Diarrhea, nausea, vomiting – Abd pain, bloating, – Weight loss & constipation • Extraintestinal symptoms • In Late presentation • Short stature, IDA • DH, delayed puberty • Hepatitis, osteopenia • Arthritis, Epilepsy
- 40. • DIAGNOSIS • Serology – Anti-gliadin IgA & IgG – Anti-reticulin IgA – Anti- endomysial Ig A - high – Anti-TTG high • Intestinal biopsy & HPE – Villous atrophy wt crypt hyperplasia – Abnormal surface epithelium – Full clinical & histological remission • TREATMENT • Strict gluten free diet
- 41. PERSISTENT v/s CHRONIC • Onset • Age group • Wt. loss • Dehydration • Recurrence • Etiology
Editor's Notes
- Mix milk, sugar, rice together….. Add boiled water and mix well. Add oil
- Whip the egg white well. Add puffed rice powder, glucose, oil and mix well. Add boiled water and mix rapidly to avoid clumping
- Boil chicken, remove bones and make chicken puree. Mix chicken puree with glucose and oil. Add boiled water to make a smoothi flowing feed