CHRONIC DIARRHOEA  

CHRONIC DIARRHOEA Definition:- Diarrhoea of at least two weeks duration or 3 attacks of Diarrhoea during the last Three Months is called as chronic Diarrhoea EPIDEMIOLOGY:- Risk factors – Lack of breast feeding Underlying malnutrition Injudicious use of antibiotics Poor socio economic status H.I.V

AETIOLOGY INTRALUMINAL FACTORS a)Intestinal disorders Carbohydrate mal absorption Excessive intake of sorbitol, Carbonated fluids b)Pancreatic disorders cystic fibrosis shwachman-Diamond syndrome chronic pancreatitis Pearson syndrome c)Bile acid disorders Chronic Cholestasis Primary Bile Acid Malabsorption

B.MUCOSAL FACTORS a)Altered integrity Infection,Infestations, Coeliac disease, Inflammatory bowel disease b)Altered Immune function Eosinophilic Gastroenteropathy Autoimmune enteropathy AIDS c)Altered function Defects in Cl ̅ /HCO¯3, Na+ / H+ transport

Enterokinase deficiency d)Altered digestive function Enterokinase deficiency e)Altered surface area Short bowel syndrome Microvillus inclusion disease Post-Gastroenteritis syndrome, f) Altered Secretary Function Tumors secreting vasoactive peptides like VIP, calcitonin, histamines

a) small bowel diarrhoea b) Large bowel diarrhoea CLASSIFICATION:- Aetiology a) Organic b)Non-Organic II. Organ involved a) small bowel diarrhoea b) Large bowel diarrhoea c) pancreatic diarrhoea d)Bile acid diarrhoea

III.Characteristic of stools Watery diarrhea Inflammatory diarrhea Fatty diarrhea Factitious diarrhea IV.Mechanism of diarrhea a)secretory diarrhea b) Osmotic diarrhea c) Exudative diarrhea d) Deranged motility diarrhea

Evaluation of Chronic Diarrhea Phase-I Clinical history, Physical Examination Stool examination and culture Blood studies Phase-II 72- Hrs stool collection for fat determination Sweat chloride test Breath H2 teats Phase-III Endoscopic studies Small bowel biopsy, Barium studies Phase-IV Hormonal studies

Approach to Chronic Watery Diarrhea Characteristics Secretory Osmotic Volume of stools > 200 ml /24 Hrs < 200 ml/24 Hrs Stool PH Stool Na >5 >70meq/Lit <5 <70meq/Lit Perianal redness Absent Present Response to fasting Diarrhea continues Diarrhea stops

Exclude structural disease Cholestyramine trail for bile acid diarrhea secretory Exclude infection Stool Culture Stool Microscopy Special Stains Bacterial Infections Parasitic infections Fugal Infections Exclude structural disease Colanoscopy, USG/CT Scan Hormonal Studies ZES, VIPoma, carcinoids, MEN syndrome neuroblastoma Cholestyramine trail for bile acid diarrhea

Osmotic Diarrhea Stool Analysis Dietary Review Excessive intake of Fruit Juices Dietary Review Stool Analysis Low PH, Reducing substances + High Mg, Laxative Carbohydrate malaatebsorption Factitious Diarrhea H2 Breath Test Small Bowl biopsy, assay for disaccharidases Lactose intolerance Sucrose intolerance Monosaccharide malabsorption

Inflammatory diarrhoea Exclude Structural Disease Small Bowel Boipsy Sigmoidoscopy colonoscopy BMFT USG Barium enerra Exclude infection Bacterial Pathogens c. difficile Mycobacterium tuberculosis Y ersinia Others E. Histolytica Strongyloidosis CMV Herpes simplex

Fatty diarrhoea Exclude Structural Disease Exclude Pancreatic Small Bowel Boipsy and aspirate For Giardia Coeliac ( Serological AGA, EMA) USG, CT Scan of Abd Exclude Pancreatic Excocrine insufficiely Direct tesnsecretin, Cholecystokinin Stimulation tests Indirect – Bentromide Pancreolauryltest 74 Hr Fecal fat Blood Test serum Trypsinogen Others Sweat Chloride test Bone Marrow Exam ERCP Immune deficiency T – Cell Function Ig.

MANAGEMENT Acute phase (upto 5 days) a) Resuscitation phase b) Specific Treatment Rehabilitation phase

Resuscitation Phase Correct fluid and electrolyte imbalance Correct shock Anemia Hypoproteinaemia

Specific Treatment Conditions Treatment Infections a) Salmonella Ampicillin, Chloramphenicol Trimethoprim- sulfamethoxazole, b) Shigella Trimethoprim- sulfamethoxazole c) C.Jejuni Erythromycin d) Giardia Metronidizole e) Amoebiasis Metronidizole

Conditions Treatment Bile acid diarrhoea Cholestyramine Fat Malabsorption Medium chain Triglycerides Hydrolyzed proteins lipase Lactose intolerance Lactose free diet Lactose tab Sucrose intolerance Sucrose free diet Add Sucrosidase Inflammatory bowel disease 5- aminosalicyclic acid Mesalamine etc.,

Rehabilitation Phase: - Aims: 1) To improve health and nutritional status 2) Catch up growth 3) To prevent further attacks TPN, PPN Suppliment T multivitamins Minerals Nutritional education

Prognosis Depends upon the underlying Aetiology Nutritional status and age of the child age

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