Chronic Diarrhea in Children

Chronic Diarrhea in
Children
Definition
Duration more than 3 weeks

Increase of frequency or decrease of consistency of stool in
comparison with before!; infants – 5-10g/kg/d, after the age of 3
= adults – 200g/d
Acute gastroenterites
5-7 days, good prognosis
 Etiology – Rota virus, ЕЕС, Salmonella,Shigella, Campylobacter j.,
Clostridium difficile и аб, Giardia lamblia,Cryptosporidium рarvum,
Entamoeba histolytica; 40% - not identified.
• Under the age of 1y – Rota virus; 1-5 – Rota; above 5y- Camp.j.
• Death rate: 1980 г. – 4,6 mln/y.; 2009г. – 1,1mln/y.
• Causes for death in children under 5 y in developed countries:
pneumonia-19%, acute diarrhea-15, measles-8, mallaria-7
Pathophysiology - overlap between
categories
Osmotic
carbohydrates are malabsorbed; hypertonic osmotic load in the
distal small intestine and colon; increased fluid losses
Metabolism of carbohydrates – short-chain fatty acids, H2, CO2
Test: it stops when feeding is discontinued; pH=5
Mucosal injury, inborn conditions, motility disorders - IBS, excess of
apple juice
Secretory
a change in the balance between the two unidirectional processes
(secretion and absorption of intestinal fluids and electrolytes) can
markedly alter the total intestinal fluid absorption and result in
secretory D
It is mediated by GI peptides – VIP, associated with tumors
(ganglioneuroblastoma) ; bile acids, fatty acids, congenital
disorders of fluid and electrolyte metabolism
Motility disorders
rarely cause malabsorption; IBS(chronic nonspecific diarrhea in
toddlers)
severe impairment of intestinal motility results in intestinal stasis -
bacterial overgrowth - inflammation, bile acid deconjugation,
malabsorption Hirschprung disease
Inflammatory
CD, IBD, infections
Pathophysiology of diarrhoea
 Reduction of absorption surface

– Intestinal ressection, enteropathies
 Reduced time of contact with intestinal
mucosa
– Inflamation (Crohn’s disease)
– Acceleration of intestinal transit (large intestinal
volume)
 Increased time of transit
– Bacterial overgrowth
Small bowel mucosa lesion
Infection + bacterial
Malabsorption Pancreatic
overgrowth
hypofunction
Diarrhea
Immunodeficiency
Malnutrition
Figure 1. Pathogenesis of chronic diarrhea

Acute gastroenterites
 Physioligical act of dis-balance between water and electrolytes; to clean

the GI
 Presentation – 3 stages of dehydration; to remember the most important
- turgur,RR, time of capillary filling(under 1,5-2 sec)
 Lab.data – no need of stool culture, ex.: chronic diarrhea, ab treatment?(
Im deficiency), IBD; epidemiological burst. Serum HCO3 – the only useful
marker to assess dehydration.
 Treatment:
1. OR – 3-4 h ОRS - 60ммол/л натрий Na- 60 mmol/l
HCO3 – 10
Glu – 74-110
K - 20
Cl - 60
Treatment
2. Intravenous rehydration
3. Antibiotics: in special cases (……Shigella,

Campylobacter jejuni - Cs); multiple resistance, slow excretion of
the patogen
4. Feeding – early /предимства/, the usual food; no need of low-

lactose formula; breast feeding is promoted.
5. Probiotics (LB GG, Sacharomyces bul.), Zn, anti-Rota

vaccine.
Post-enteritis syndrome(chronic persistent
diarrhea)
1. Acute onset, at least 4 days.
2. Risk factors – Immunity, malnutrition, breast feeding,

microelements; prevalence - 0-1% of acute diarrhea in
developed countries; up to 20% in developing, high mortality
rate.
3. Etiology – the same.
4. There is need of lactose-free diet. рН of stools under 5.
Chronic diarrhea
 Definition – more than 2 weeks, it usually starts after n acute

episode, causes severe malnutrition and malabsorption
 Developed/developing countries
Diarrhea varies markedly with age
Diarrhea in pediatric age group may arise through a variety of
different mechanisms and from many different causes. As in
most of pediatrics the DD of Diarrhea varies markedly with age,
especially in case of chronic D.
Major causes of chronic D in infants – they cause malabsorption

and malnutrition
– Milk and soy protein intolerance
– Congenital transport deffects - cong.chloridorrhea,
cong.glucose-galactose malabsorption, cong. lactase deficiency,
cong.sucrose-isomaltase deficiency – diarrhea from birth
Lactase deficiency
 Secondary
– Transient
– Segmental
– Parcial
 Adult type
 Congenital
Diagnostic steps
 Stop feeding  Diarrhea stops!
– osmotic!
 Oral glucose solution  No Diarrhea
 Sugar in water  Reducing substances 3+
– (2g/kg in 10%) = Diagnosis!!!

Chronic diarrhea in toddlers
 IBS (chronic nonspecific diarrhea) ! Mistaken with food allergy,

viral enteritis; “peanuts and carrots syndrome”!; normal growth;
no symptoms of chronic disease; normal lab.data; self-limiting;
diet.
 Protracted viral enteritis- no need of lactose-free diet; whole milk
is a good source of protein and fat and its restriction often
results in hypocaloric, hyperosmolar feedings that exacerbate
diarhhea .
 Giardiasis - and crampy abdominal pain, ELISA.
 Tumors; Cystic fibrosis - greasy, foul-smelling stools, lung
disease; sweat test.
 Ulcerative Colitis.
Celiac disease
1. Malabsorption resulting from inflammatory injury to the mucosa
of small intestine after the ingestion of gluten
2. CD is an immune-mediated systemic disorder elicited by gluten
and related prolamines in genetically (mainly HLA) susceptible
individuals, characterized by the presence of variable
combination of gluten-dependent clinical manifestations, CD
specific antibodies, HLA DQ2 and DQ8 haplotypes and
enteropathy.
3. Prevalence in Europe – 0,5 – 1:100 – 1:460 population.
Spectrum of Celiac Disease
Symptomatic CD
Gastrointestinal and extragastrointestinal symptoms and signs
1. classical form - diarrhea, failure to thrive, abdominal distension, anorexia,
apathy, irritability; first 2-3 y of life
2. atypical, mild symptoms: short stature, delayed puberty, iron-deficient
anemia;dental enameldefects, alopecia, lymphoma, unexplained seizures,
aminotransferase elevation, recurrent abdominal pain, recurrent aphthous
stomatitis, arthralgia
Silent CD
Presence of CD-associated antibodies, HLA and small bowel biopsy compatible with
CD, but without sufficient symptoms and signs to warrant clinical suspicion
Potential CD
Presence of CD-associated antibodies, compatible HLA but without histogical
abnormalities at the jejunal biopsy. May be symptomatic or asymptomatic.
Associated disorders - at-risk groups to be screened: first-
degree relatives, IgA-deficiency, IDDM, Down syndrome,
Autoimune diseases( thyroid diseases)
New definition
 Systemic autoimmune disease
 НLА – DQ2/DQ8
 Permanent intolerance to gluten in food
 Clinical picture
 Positive celiac antibodies
 Histology – entheropathy; DD of SVA : cow milk/soy
protein intolerance, postenteritis diarrhea,Giardiasis,
tropical sprue, HIV, primary immune deficiency,
postradiation enteritis
 ESPGHAN (1SIB, no challenge); no SIB if HLA
positive
 Treatment: GFD, lactose, milk, pancreatic enzymes;
steroides
 Prognosis
20
In Celiac Disease enteropathy may
be variable in severity
Low-grade or mild Severe enteropathy

enteropathy
Epidemiology
23
Chronic diarrhea in school-aged children
 IBD - ulcerative colitis and Crohn disease: blood and mucous,

growth failure, perianal disease, right lower quadrant
tenderness; colonoscopy, barium follow through
 Celiac Disease
 Primary acquired lactase deficiency - flatulence, abdominal
pain, loose tools following ingestion of milk; extremely rare
before 5 years of age; it is more common cause of abdominal
pain than diarrhea
 Constipation with encopresis
Ulcerative colitis and Crohn Disease
Evaluation of the patient
1. History, Examination
Symptoms of chronic disease, abdominal distension, perianal
fissures
2. Screening tests in diarrhea and interpretation
• Stool for occult blood inflammation - usually colonic

• Stool pH<5,5 carbohydrate malabsorptionq - usually
proximal small bowel injury
• Stool for WBC inflammation - usually colonic
• Stool for WBC inflammation - usually colonic
• acute diarrhea - pH<5,5 suggests viral pathogen
blood and WBC positive - suggest the need for stool
culture
Laboratory data
 CBC
 Serum albumines
 Inflammatory markers - ESR, CRP, Plt
 Sweat test
– Genetic testing (chromosome 7)
 Pancreatic elastase; fats in stools
 Fecal calprotectin, α-1-antitrypsin
 microbiology
 Anti-tTG antibodies (IgA); ЕМА
 pANCA, ASCA
 Anti-enterocyte antibodies; auto-antibodies
Investigations
 Endoscopy
 Biopsy
• Histology
• Electron microscopy
• Stainings
• Immunohistochemistry
IMPORTANT POINTS
 The differential diagnosis of chronic diarrhea varies markedly
with age.
 The most common cause of chronic diarrhea in small infants is
formula protein intolerance.
 There is up to a 50% crossover in intolerance between cow milk
and soy protein formulas.
 Lactose intolerance is rarely a problem in infants and toddlers
who have chronic diarrhea.
 Test – stop feeding
 Detailed feeding history among 3-6 y old children with diarhhea.
 CD might be diagnosed if suspected.
 Evaluation of growth – growth curves - WHO.
 Acute diarhhea – early refediing and ORT.

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Chronic Diarrhea in

Duration more than 3 weeks

 Reduction of absorption surface

Figure 1. Pathogenesis of chronic diarrhea

 Physioligical act of dis-balance between water and electrolytes; to clean

3. Antibiotics: in special cases (……Shigella,

4. Feeding – early /предимства/, the usual food; no need of low-

5. Probiotics (LB GG, Sacharomyces bul.), Zn, anti-Rota

2. Risk factors – Immunity, malnutrition, breast feeding,

 Definition – more than 2 weeks, it usually starts after n acute

Major causes of chronic D in infants – they cause malabsorption

 Stop feeding  Diarrhea stops!

 Oral glucose solution  No Diarrhea

 Sugar in water  Reducing substances 3+

– (2g/kg in 10%) = Diagnosis!!!

 IBS (chronic nonspecific diarrhea) ! Mistaken with food allergy,

Low-grade or mild Severe enteropathy

 IBD - ulcerative colitis and Crohn disease: blood and mucous,

• Stool for occult blood inflammation - usually colonic

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