Approach to chronic diarrhoea (1)

APPROACH TO CHRONIC DIARRHOEA

1. APPROACH TO CHRONIC DIARRHOEA DR.D.RASIKAPRIYA 1 st YEAR PEDIATRICS

2. OBJECTIVES INTRODUCTION DEFINITION ETIOLOGY PATHOPHYSIOLOGY RISK FACTOR APPROACH TO CHRONIC DIARRHOEA History Examination Red flags Investigation Management TAKE HOME MESSAGE

3. INTRODUCTION a stool output that exceeds 10 mL/kg/day is considered diarrhoea. Practical definition - diarrhoea is present when stools increase in frequency, fluidity (water content), or volume, in comparison with the previously established “normal” pattern . M ajor burden of childhood deaths globally, with an estimated 2.5 million deaths.

4. DEFINITION   Defined as diarrhoea which exceeds 2 to 3 weeks. PERSISTENT DIARRHOEA CHRONIC DIARRHOEA Diarrhoea that begins acutely and last for 14 days or more Usually infective in origin Usually non infective in origin.

5. WHY???? As per WHO in 2011 10 % of total diarrhoea 35 % of diarrheal deaths For every 100 children, 7 suffers PD in Malnutrition – 20% 60% < 6 months 90 % < 1 year

6. ETIOLOGY <2YR >2YR Infection Bacterial- Enteroaggregative E.coli, Atypical E.coli, Shigella, Heat stable/labile enterotoxin producing E.coli Viral- Rotavirus Parasites- Cryptosporidium, Giardia Post infection Post enteritis diarrhoea syndrome Abnormal digestive processes Schwachman-Diamond syndrome, Primary bile acid malabsorption Cystic fibrosis Nutrient malabsorption Congenital lactase deficiency, Glucose-galactose malabsorption. Short bowel Immune/Inflammatory Immunodeficiencies, Food allergy-cow’s milk protein. Celiac disease, IBD, Eosinophilic gastroenteritis. Structural defects Microvillus inclusion disease, Tufting enteropathy Rare Defects in electrolyte and metabolism transport Congenital chloride diarrhoea, Abetalipoprotinemia, Acrodermatitis enteropathica Late onset chloride diarrhea.

7. ETILOGY < 2YRS >2YRS Motility disorder Hirsch sprung disease, Intestinal pseudo obstruction Thyrotoxicosis Diarrhoea associated with exogenous substances Excessive intake of carbohydrate, foods or drinks containing mannitol or sorbitol SAME Chronic nonspecific diarrhea Functional diarrhea IBS Neoplastic diseases Neuroendocrine hormone secreting tumors. SAME CONTD….

8. COMMON CAUSES INFANCY Post gastroenteritis malabsorption syndrome (persistent ) Cows milk/soy protein intolerance Secondary disaccharidase deficiencies and Cystic fibrosis CHILDHOOD Chronic nonspecific diarrhoea Secondary disaccharidase deficiencies Giardiasis and Post gastroenteritis malabsorption syndrome Celiac disease and Cystic fibrosis ADOLESCENCE Irritable bowel syndrome Inflammatory bowel disease Giardiasis Lactose intolerance

9. PATHOPHYSIOLOGY O smotic diarrhoea S ecretory diarrhoea, Mutations in apical membrane transport proteins, Reduction in anatomic surface area Alteration in intestinal motility, Inhibition of transport of electrolytes by inflammatory mediators

10. RISK FACTORS  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

11. APPROACH TO A CHRONIC DIARRHOEA CHILD

12. HISTORY History is the most important step, it usually makes the DD narrow and gives clues to the cause of chronic diarrhoea. Personal history Age Sex :- IBD in paediatrics is common in MALE. HISTORY OF THE PRESENT ILLNESS Onset :- just before 6m of age- coeliac disease. After 1 year- cow’s milk allergy. Preceded by gastroenteritis- post infectious diarrhoea. Course and duration is important. Most patients were completely free before this episode . Stool character is extremely important:- differentiate - secretory and osmotic diarrhoea.

13. STOOL HISTORY Odourless blood tinged stools - shigellosis F requent mucoid stools in a healthy child without blood - IBS Nocturnal diarrhoea is usually associated with organic disease rather than IBS. Infant having chronic diarrhoea, with a history of delayed passage of meconium and if constipation preceded diarrhoea- Hirschsprung's disease

14. Associated symptoms  No symptoms, well child- toddlers diarrhoea. Abdominal distension and weakness- Coeliac disease . Severe abdominal pain, Bloody diarrhoea and oral ulcers - IBD . Vomiting and rash- Eosinophilic enteritis. Attacks of constipation - Hirsch sprung and IBS. Infant with severe napkin dermatitis resistant to most treatment - Acrodermatitis enteropathica .

15. NON GI SYMPTOMS Recurrent respiratory tract infections- CF. Weakness , fatigue and weight loss - IBD, Addison and HIV. Headache and mood changes - IBS. Eczema- cow’s milk allergy and Eosinophilic enteritis . Generalized lymphadenopathy - HIV . Recurrent fever and weight loss-TB .

16. Family and other history Same illness or respiratory problems- CF. IBD and IBS. Dietetic history : R ecord a detailed history of feeding, prior to the onset of the disease and during the disease. P rovide vital clues to the aetiology, e.g., cow's milk protein intolerance, lactose intolerance, gluten enteropathy. Soy protein intolerance, egg protein enteropathy. Overfeeding , concentrated formula feeds> osmotic diarrhoea. Drug history : History of prolonged course of antibiotics- pseudomembranous colitis.

17. EXAMINATION 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. weight and height are usually normal in toddlers diarrhoea. Pallor - CF, Coeliac disease. Fever- Infection, TB, CF and HIV. Clubbing- CF

18. Hyperpigmentation- Addison’s disease, Coeliac disease Generalized lymphadenopathy- Lymphoma, HIV. Periorificial and acral vesicular and scaly lesions- Acrodermatitis enteropathica. Stomatitis and Perianal fistula- Crohn’s disease.  Hepatomegaly -lymphomas, metastatic carcinoid, IBD and Whipple’s disease . Ascites - TB and lymphoma

19. Poor weight gain or weight loss . Continuous diarrhoea. 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.

20. DIAGNOSTIC WORK UP STEP 1 Intestinal microbiology Stool- culture/parasite/electrolytes. Screening test for celiac disease( transglutaminase 2 autoantibodies ) Non invasive test Intestinal function/inflammation Pancreatic function and sweat test Test for food allergy (prick/patch test)

21. STEP 2 INTESTINAL MORPHOLOGY • BIOPSY STEP 3 SPECIAL INVESTIGATIONS Intestinal immunohistochemistry Anti-enterocyte antibodies Serum chromogranin and catecholamine Autoantibodies 75SeHCAT measurement Brush border enzymatic activities Motility and electrophysiological studies

22. DIAGNOSIS IN INDIA TYPE TEST DIAGNOSIS in INDIA Osmotic vs Secretory Stool pH, Reducing substances(Good) Stool electrolyte Stool osmotic gap Breath hydrogen test Based only on stool pH/reducing substance and response to keeping child nil orally. Fatty diarrhoea Sudan stain(Good) Acid steatocrit 72hr stool fat Based on fat globules in normal microscopy and Sudan stain at some centers Protein losing enteropathy Fecal Alpha 1 antitrypsin Based on clinical picture, low serum albumin and by exclusion Pancreatic insufficiency Fecal elastase/chymotrypsin Secretin test Based on ruling out other cause of fatty diarrhea.

23. SPECIFIC ETIOLOGY Cow’s milk protein allergy- colitis with blood and mucus in stools. Celia disease- Response to gluten free diet by 8-12 weeks. Giardiasis/ Amebiasis - stool microscopy Immunodeficiency associated diarrhea Cystic fibrosis- clinical picture and Sweat test Intractable diarrhea of infancy-with/without villous atropy

24. PROBLEM AREAS IN MANAGEMENT Awareness – CMPA, Celiac disease and Immunodeficiency associated diarrhoea. Lack of availability of many specific diagnostic tests and cost in most part of country.

25. TREATMENT General supportive measures Replacement of fluids & electrolytes Nutritional rehabilitation Elimination diet Treat the cause

26. CMPA- need extensively hydrolysed 100% bovine casein infant formula or Elemental amino acid formula Celiac disease- gluten free diet Lactose intolerance- Lactose free formula Intractable diarrhea of infancy- Elemental formula

27. PREVENTION Improvement in nutrition and hygiene status of infants and children. Cost effective intervention Promotion of breast feeding, Promotion of safe drinking water Low osmolality ORS and Zinc supplementation Avoid unnecessary antibiotics and continued feeding during diarrhoea.