Chronic diarrhea in children

Chronic diarrhea in children
By
Mohammed Ayad
Member of the royal college of pediatric
and child health.

Chronic diarrhea in children
Definition
Causes
diagnosis
History
Examination
Investigations
treatment
Specific disorders

Definition
Diarrhea
In children, a stool output that
exceeds 10 mL/kg/day is considered diarrhea.
A more practical definition
is that diarrhea is present when stools increase
in frequency, fluidity (water content), or volume,
in comparison with the previously
established “normal” pattern.

What is chronic diarrhea?
It is defined as diarrhea which exceeds 2 to 3
weeks.
Despite considerable advances in the
understanding and management of diarrheal
disorders in childhood, they are still responsible
for a major burden of childhood deaths globally,
with an estimated2.5 million deaths.

Causes of chronic diarrhea
In fact, there are many causes of chronic
diarrhea, however, the best way to discuss this
point is to classify these causes according to
these two vital factors:-
1- age.
2- prevalence.

Chronic diarrhea in infants
Common causes:-
Post-infectious secondary lactase deficiency.
Coeliac disease.
Cow’s milk allergy.
Toddlers diarrhea.
Infections as giardiasis and HIV.
Cystic fibrosis.

Rare causes
Acrodermatitis enteropathica.
Hirsch sprung disease.
Primary immune defects.
Lymphangiectasia.
Eosinophilic gastroenteritis.
Intractable diarrhea syndrome.
Abetalipoproteinemia.
Shwachman syndrome.
Bacterial overgrowth.
Other rare causes.

Chronic diarrhea in older children
Common causes
Post-enteritis syndrome.
Coeliac disease.
Lactose intolerance.
Infections as giardiasis and HIV.
Irritable bowel syndrome.
Inflammatory bowel disease.

Rare causes
Immune deficiency.
Esinophilic enteritis.
Secretory tumors.

Chronic diarrhea in adolescents
Common causes
Inflammatory bowel disease.
Giardiasis.
Laxative abuse ( anorexia nervosa ).
Irritable bowel disease.
Constipation with encopresis.
Rare causes
Secretory tumors.
Addison disease.

Diagnosis
Diagnosis of the cause of chronic diarrhea is a
challenge which needs smart effort.
Diagnosis usually starts with taking a good history in
which doctors know what they want to ask and
why. This is followed by examination which needs a
plan too. The last stage of this process is
investigations and differential diagnosis.
Here we will discuss in a great way how to diagnose
these cases, however, chronic diarrhea is a
symptom which usually needs a multidisciplinary
team.

History
History is the most important step, it usually
makes the DD narrow and gives clues to the
cause of chronic diarrhea.
Personal history
Age :- it is essential as what we explained
before.
Sex :- IBD in pediatrics is common in MALE.
Residence :- Africa and poor countries, suspect
infections and HIV.

HISTORY OF THE PRESENT ILLNESS
Onset:- just before 6m of age…...> coeliac disease.
After 1 yr. ……> cow’s milk allergy. Preceded by
gastroenteritis …..> post infectious diarrhea.
Course and duration is important.
Most patients were completely free before this
episode.
Stool character is extremely important:-
This is to differentiate what is called secretory and
osmotic diarrhea. These two types of diarrhea can
be differentiated by history, examination and
investigation. And each type has its own causes.

Osmotic diarrhea
 MALABSORPTION OF WATER-SOLUBLE NUTRIENTS
-Glucose-galactose malabsorption Congenital
, Acquired Disaccharidase deficiencies.
 EXCESSIVE INTAKE OF CARBONATED FLUID
 EXCESSIVE INTAKE OF NONABSORBABLE
SOLUTES -Sorbitol Lactulose Magnesium hydroxide
stops with fasting, has a low pH, positive for reducing
substances

Secretory diarrhea
 Bacterial toxins: enterotoxins of cholera, Escherichia coli (heat-
labile), Shigella, Salmonella, Campylobacter jejuni,
Pseudomonas aeruginosa
 Hormones: vasoactive intestinal peptide, gastrin, secretin
 Anion surfactants: bile acids, ricinoleic acid
ACTIVATION OF CYCLIC GMP
 Bacterial toxins: E. coli (heat-stable) enterotoxin, Yersinia
enterocolitica toxin
CALCIUM-DEPENDENT
 Bacterial toxins: Clostridium difficileenterotoxin
 Neurotransmitters:acetylcholine, serotonin
 Paracrine agents: bradykinin

Associated symptoms
No symptoms, well child …> toddlers diarrhea.
Abdominal distension and weakness…. Coeliac disease.
Severe abdominal pain …..> IBD.
Bloody diarrhea…..> IBD.
Vomiting and rash…. Eosinophilic enteritis.
Attacks of constipation ……> hirschsprung and IBS.
Vomiting, weight loss and behavioral changes…>
anorexia nervosa.
Infant with severe napkin dermatitis resistant to most
treatment ….. Acrodermatitis enteropathica.
Oral ulcers…..> IBD.

Non GIT symptoms
Recurrent respiratory tract infections…..> CF.
Weakness, fatigue and weight loss…> IBD, Addison
and HIV.
Skin pigmentation….> Addison.
Headache and mood changes….> IBS.
Eczema…..> cow’s milk allergy and eosinophilic
enteritis.
Joint pain and arthritis….> IBD.
Generalized lymphadenopathy….> HIV.
Recurrent fever and weight loss….TB.

Family and other history
Same illness or respiratory problems….> CF.
IBD and IBS.
IMMUNODEFICIENCY….> HIV.
Travelling abroad….> infections.
Excessive juice intake.
History of previous cardiac operations …..>
intestinal Lyphangectasia.

Dietetic history
Dietetic history
 record a detailed history of feeding, prior to the onset of the
disease and during the disease.
 It may provide vital clues to the etiology, e.g., cow's milk
protein intolerance, lactose intolerance, gluten enteropathy.
Soy protein intolerance, egg protein enteropathy.
 Overfeeding, concentrated formula feeds> osmotic diarrhea..
 Chewing gums and chocolates
 plenty of undiluted fruit juices (e.g., pineapple juice has an
osmolality of 900 mOsm/L and apple juice 650 mOsm/L

Stool history
 Odorless blood tinged stools - shigellosis
 frequent mucoid stools in a healthy child without blood -
IBS
 Nocturnal diarrhea is usually associated with organic
disease rather than IBS.
Infant having chronic diarrhea, with a history
of delayed passage of meconium and if
constipation preceded diarrhea,-
Hirschsprung's disease

Drug history
History of laxative abuse ……. Anorexia nervosa.
History of prolonged course of antibiotics…..>
pseudomembranous colitis.

Red flags
Poor weight gain or weight loss.
Continuous diarrhea.
night stools.
Acid stools…… burning sensation with severe
inflammation and crying.
Blood and mucous in stool.
Failure to thrive.
Associated symptoms of systemic diseases like
fever, rash and arthritis.

Examination
Examination has a great role too. But, you should be
systematic and know what exactly are you looking for.
General examination
Weight and height should be measured and put on the
appropriate charts. Weight loss is seen in many disorders
like CF, Coeliac disease, IBD. However, weight and height
are usually normal in toddlers diarrhea.
Pallor …… IBD, CF, Coeliac disease.
Fever….. IBD, CF.
Clubbing ….> IBD, CF.

Ear effusion and adenoids……..> CF.
Oral ulcers…..> IBD.
Oral pigmentation…..> Addison.
Peri-oral rash……> acrodermatitis enteropathica.
Chest scars ….> lobectomy scar for CF. median
sternotomy scar ……> intestinal lymphangectasia.
Signs of bronchiectasis…..> CF.
Arthritis….> IBD.
Characteristic feature of coeliac disease……see later.
Recurrent infections usually need massive
treatment….> immunodeficiency ( HIV ).

Coeliac disease
Dermatitis Herpetiformis bumps and blisters
resemble herpes lesions, hence the name
“herpetiformis”, but are NOT caused by the herpes
virus. Symptoms of DH tend to come and go, and it
is commonly diagnosed as eczema. Symptoms
normally resolve when on a strict, gluten-free diet.
DH affects 15 to 25 percent of people with celiac
disease who typically have no digestive symptoms.

INVESTIGATIONS
INVESTIGATIONS which can be done in these
cases are extremely wide and good pediatrician
is able to narrow them so as to reach a
diagnosis. So investigations are usually depend
on what history and examination point to.
However, there are some investigations which
are usually done in most cases which are
** stool examination.
** CBC, ESR and CRP.

Stool examination
Fresh stool sample should be collected and
examined. Specific tests should be taken seriously.
Occult blood in stool…..> IBD and Cow’s milk allergy.
Reducing substance…..> carbohydrate
malabsorption.
Maldigested fat ….> CF.
STOOL PH.
This is beside the routine examination for
amoebiasis and giardiasis.

Other investigations should e modified according
to each case. It depends on
1- age of the child.
2- most probable causes.
3- availability of these investigations.
So we will now discuss the most common causes
of chronic diarrhea according to age and how to
diagnose and manage them at a glance.

Chronic diarrhea in infants
1-carbohydrate intolerance and Post-infectious
secondary lactase deficiency.
2-Coeliac disease.
3-Cow’s milk allergy.
4-Toddlers diarrhea.
5-Infections as giardiasis and HIV.
6-Cystic fibrosis.
7- acrodermatitis enteropathica.

Carbohydrate intolerance
Primary
Congenital lactose intolerance.
Glucose-galactose malabsorption.
Very rare, Usually starts early with watery,
explosive diarrhea and failure to thrive.
Reduced substance in stool is positive.

Secondary lactose intolerance
Usually post-infectious ( rota virus).
Bloating, abdominal discomfort and flatulence that
occur from 1 hour to a few hours after ingestion of
milk or dairy products may signify lactose
intolerance.
Stool characteristics: Loose, watery, acidic stool
often with excessive flatus and associated with
urgency that occurs a few hours after the ingestion
of lactose-containing substances is typical.

Investigations
Reducing substances in the stool is positive and the
stool is acidic with PH <5.5.
Breath hydrogen test :-
Carbohydrate malabsorption results in bacterial
fermentation of the unabsorbed sugar.
Thus, carbohydrate malabsorption can be
determined by measuring the exhaled hydrogen
concentration after a carbohydrate load is
administered.
MANAGEMENT
Lactose free diet.

Diarrhea - 45-85% of patients
Flatulence - 28% of patients
Borborygmus - 35-72% of patients
Weight loss - 45% of patients; in infants and
young children with untreated celiac disease,
failure to thrive and growth retardation are
common
Weakness and fatigue - 78-80% of patients;
usually related to general poor nutrition
Severe abdominal pain - 34-64% of patient.

investigations
The American College of Gastroenterology (ACG)
recommends that antibody testing, especially
immunoglobulin A anti-tissue transglutaminase
antibody (IgA TTG), is the best first test for
suspected celiac disease, although biopsies are
needed for confirmation; in children younger
than 2 years, the IgA TTG test should be
combined with testing for IgG-deamidated
gliadin peptides.

Other laboratory tests include the following:
Electrolytes and chemistries - Electrolyte
imbalances; evidence of malnutrition
Hematologic tests - Anemia, low serum iron level,
prolonged prothrombin time (PT)
Stool examination - Fat malabsorption
Oral tolerance tests - Lactose intolerance
Serology - Immunoglobulin A (IgA) antibodies.
Histologic Findings:- villous atrophy.

management
The primary treatment of celiac disease is
dietary. Removal of gluten from the diet is
essential, although complete avoidance of
gluten-containing grain products is relatively
difficult for patients to achieve and maintain;
certain products, such as wheat flour, are
virtually ubiquitous in the American diet.
A small percentage of patients with celiac
disease fail to respond to a gluten-free diet. In
some patients who are refractory,
corticosteroids may be helpful.

Cow’s milk protein allergy
usually starts after the first year when children are
given milk products.
Typical symptoms are
Vomiting, diarrhea, colic and constipation may
occur.
Other rare presentations are wheezes, cough,
atopic eczema and behavioral changes like
irritability, crying and milk refusal.
A challenge with milk free times may have a good
indicators. However, histopathological examination
is a diagnostic test.

Toddlers diarrhea
Called chronic non specific diarrhea of childhood.
It is a common problem. Occurs to children mainly
above 2 years.
It is a benign condition.
Usually, the children have no failure to thrive and
they present in a good nutritional state. Abdominal
pain may be present in a minority.
The stools are foul smelling, watery, and contain
mucus with undigested vegetable material. The
parents are likely to report a short mouth to anus
transit time.

Golden roles
In developed countries toddler diarrhea is the most frequent
cause of chronic diarrhea in 1–5 year old children
Toddler diarrhea has a typical dietary and clinical history
Breath hydrogen tests have no place in the diagnostic process
Treatment includes normalization of feeding patterns
according to the “four Fs”: Fat, Fibre, Fluid, and Fruit juices.

treatment
After a thorough clinical history and a simple physical
examination, the diagnosis is often obvious. The main
message to the parents is reassurance on underlying
serious gastrointestinal disorders and normalisation of
the diet. Kneepkens and Hoekstra proposed a
normalisation of the child’s feeding pattern according to
the “four Fs”: Fat, Fibre, Fluid, and Fruit juices.As it
seems that these children represent the end of a
spectrum of normality, the dietary treatment will often
be close to the borders of normal nutritional
recommendations. Fat intake should be increased to at
least 35%, even 40%, of total energy intake. Restoration
of a pattern with well defined meals and snacks
provides the opportunity for significant increases of

Fruit juices, in particular clear apple juice, and
other squashes should be limited to restore
appetite at meal times. Drinks between meals are
acceptable, but overconsumption should be
discouraged. In almost all patients the efficacy of
these dietary measures is such that it may even
serve as a confirmation of the diagnosis. Some
authors have used aspirin, loperamide or
mebeverine for cases refractory to dietary
measures. Their effects last as long as they are
given. As a consequence, medication seems to be
unwarranted for a condition that does not hamper
the child to thrive.

Giardiasis
A very common disorder. Has a wide range of
manifestations, as acute and chronic diarrhea,
abdominal pain, malabsorption syndrome and
nausea.
Stool examination is the role. Stool antigen may
be important.
Treatment
Metronidazole.

Cystic fibrosis
AR disorder.
Most patients have respiratory symptoms as
recurrent pneumonia, and adenoid.
Those patients have pancreatic insufficiency
which lead to diarrhea with greasy stool.
Failure to thrive.
Genetic diagnosis and sweat chloride test are
the main investgations.

Acrodermatitis enteropathicaa
AR disorder.
Presented with peri-oral rash, chronic diarrhea,
recurrent infection and napkin rash resistant to
treatment.
Usually starts at the time of weaning.
Tent red hair and alopecia.
Diagnosis
Serum Zink in the WBCS OR IN THE BLOOD.
Management
Serum Zink.

Post enteritis syndrome
Persistent diarrhea after gastroenteritis is caused by
Continuing infection.
Further infection.
Carbohydrate intolerance.
Post infection malabsorption syndrome.
Usually subsides, but severe cases may persist to
longer periods.
Stool analysis and stool culture.
Treatment of the cause.

Inflammatory bowel disease
This is of two types
Crohn’s disease and ulcerative colitis.
20%% of cases presents under 20 years old.
It has intestinal and extra intestinal
manifestations.

Clinical picture
Diarrhea
Abdominal pain
Growth deceleration
Weight loss
Anorexia.
Colonic Crohn disease may be clinically
indistinguishable from ulcerative colitis (UC), with
manifestations that include the following:
•Bloody mucopurulent diarrhea
•Cramping abdominal pain
•Urgency to defecate

Perianal involvement in Crohn disease may
produce the following:
Simple skin tags, fissures, abscesses, and
fistulae
•Painful defecation
•Bright-red rectal bleeding
•Perirectal pain, erythema, or discharge

examination
Growth is impaired.
Intermittent fever.
Tachycardia.
Mouth ulcers.
Anal tags.
Arthritis.
Erythema nodosum.
Pyoderma gangeriosum.
Tanner staging is important.

investigations
BLOOD
CBC… anemia.
ESR and CRP….. Elevated.
Hypoalbuminaemia.
Imaging studies
A single-contrast upper GI radiologic series with
small-bowel follow-through (SBFT).
MRI.

endoscopy
Colonoscopy with several colonic and
terminal ileal biopsies is considered a
standard diagnostic procedure.
Upper endoscopy, or
esophagogastroduodenoscopy (EGD),
should be part of the first-line investigation.
Video capsule endoscopy is increasingly
being used to evaluate for small-bowel
Crohn disease in children.

management
The general goals of treatment for children with
Crohn disease are as follows:
To achieve the best possible clinical, laboratory,
and histologic control of the inflammatory
disease with the least adverse effects from
medication
To promote growth with adequate nutrition
To permit the patient to function as normally as
possible (eg, in terms of school attendance and
participation in activities)

•Step-up approach
Patients with mild disease are treated with
preparations of 5-aminosalicylic acid (5-ASA),
antibiotics, and nutritional therapy
If no response occurs or if the disease is more severe
than was initially thought, corticosteroid and
immunomodulatory therapy with 6-mercaptopurine (6-
MP) or methotrexate (MTX) is attempted
Infliximab is effective in patients who have an
inadequate response to conventional therapy and in
patients who have fistulizing Crohn disease ..
Adalimumab is a safe and effective substitute for
patients who are allergic to infliximab or develop high
titers of human antichimeric antibodies (HACA)
Surgery is considered when medical therapy fails

Indications for surgery include the following:
Intractable disease with growth failure
Obstruction or severe stenosis
Abscess requiring drainage
Perianal fistulae
Intractable hemorrhage
Perforation

Irritable bowel syndrome
Irritable bowel syndrome (IBS) is defined as chronic
or recurrent abdominal pain, altered bowel habits,
and bloating, with the absence of structural or
biochemical abnormalities to explain these
symptoms. Irritable bowel syndrome is part of a
broader group of disorders known as functional GI
disorders. It is the most common GI diagnosis
among gastroenterology practices in the United
States and is one of the top 10 reasons for visits to
primary care physicians.

The characteristics of abdominal pain vary
between patients and even within an
individual patient.
The pain can be dull, achy, colicky, or
sharp.Pain can occur anywhere in the
abdomen but is commonly located in the
hypogastric or periumbilical regions.
The pain has no specific pattern but may be
aggravated by stress and food and partially
relieved after defecation.

Altered bowel habits include constipation, diarrhea,
or alternating constipation with diarrhea.
Stools are usually of small volume and pasty.
Constipation is associated with small, hard, pelletlike
stools. Diarrhea characteristically occurs during
waking hours and often is precipitated by meals.
Mucus can be a component of the stool in as many
as 50% of patients with irritable bowel syndrome.
In some patients, defecation is associated with a
sense of incomplete evacuation that can lead to
repeated trips to the bathroom and prolonged
straining.

Symptoms of abdominal distension (ie, bloating,
increased belching, flatulence).
Dyspeptic symptoms are present in as many as
30% of pediatric patients with irritable bowel
syndrome.
Extraintestinal manifestations are rare in
children.

Take care
The following clinical features should alert the
physician to the possibility of a disorder other than
irritable bowel syndrome:
Frequent awakening by symptoms
Steady progressive course
Fever
Weight loss
Arthritis
Rectal bleeding
Persistent vomiting.

Diagnostic Rome III criteria for
childhood irritable bowel
syndrome:

investigations
They are usually not needed except if exclusion of
other disorders is mandatory.
Recent studies have suggested that determining the
level of fecal calprotectin in stool may help
distinguish irritable bowel syndrome from
inflammatory bowel disease. A negative
calprotectin result favors a functional disorder
rather than an inflammatory process, thereby
sparing many patients from having extensive work-
up and invasive investigations, such as colonoscopy.

treatment
Educate the child and parents that irritable
bowel syndrome is a chronic illness that cannot
be cured. At the same time, reassure them that
it is not a life-threatening condition and it does
not lead to physical impairment. Tell the patient
and the family that the symptoms are real and
respond to their worries and concerns.
Reassurance is more effective if offered after a
careful history and physical examination and a
conservative diagnostic evaluation.

Dietary modification
Some patients with irritable bowel syndrome report
exacerbation of their symptoms after ingestion of
certain foods. Elimination of certain foods, such as
sorbitol, fructose, and gas-forming legumes,
achieves relief in some patients with irritable bowel
syndrome, especially those with excess gas.
A recent study in adult patients with irritable bowel
syndrome revealed that a diet low in fermentable
oligosaccharides, disaccharides, monosaccharide,
and polyols (FODMAP) is effective in reducing
functional GI symptoms.

Treatment of chronic diarrhea
In fact, treatment of the cause is the main role.
But there are some points to be checked early:-
1- assess hydration status and treat dehydration
if present.
2- make sure that the child is safe and there are
no threatening signs.
3- good communication with parents and
reassurance is extremely vital.

At the end of this presentation
Chronic diarrhea is a great challenge which
needs extensive history, examination and
investigations, however, good pediatrician
should minimize the DD so as to reach a
diagnosis as soon as possible.
Although most cases are benign, there are some
dangerous causes.
Pediatric gastroenterologist has a major role in
diagnosis of most cases.

Chronic diarrhea in children

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