MANAGEMENT OF CHRONIC DIARRHOEA

INTRODUCTION

Definition: ↑ in total daily stool output associated with ↑ stool water content

Infants + children stool output greater than 10g/kg/24hr If diarrhoea more than 2 weeks, consider chronic It is result from altered intestinal water & electrolyte

transport The transporter is located at the brush border of small &

large intestines

CAUSES

INFANCY CHILDHOOD ADOLESCENCE Post gastroenteritis

malabsorption syndrome

Cow’s milk/soy protein intolerance

2° disaccharide deficiencies

Cystic fibrosis

Chronic non- specific diarrhoea

2° disaccharide deficiencies

Giardiasis Post gastroenteritis

malabsorption syndrome

Celiac disease Cystic fibrosis

Irritable bowel syndrome

Inflammatory bowel disease

Giardiasis Lactose

intolerance

OTHER CAUSES

Intraluminal factors:

BILE ACID DISORDER

PANCREATIC DISORDER

INTESTINAL DISORDER

Chronic cholestasis

Terminal ileum resection

Bacterial over growth

1° bile acid malabsorption

Cystic fibrosis Chronic pancreatitis Isolated pancreatic

enzyme deficiencies

Carbohydrate malabsorption

Cong + acq sucrase, lactase deficiencies

Cong + acq monosaccharide deficiencies

Mucosal factors:

ALTERED INTEGRITY

ALTERED IMMUNE FUNCTION

ALTERED DIGESTIVE FUNCTION

Infections Infestation Cow’s milk/soy

protein intolerance IBD

Autoimmune enteropathy

Eosinophilic gastroenteropathy

AIDS IgG + IgA

deficiencies

Enterokinase deficiency

Glucoamylase deficiency

Mucosal factors:

ALTERED SURFACE AREA

ALTERED SECRETORY FUNCTION

ALTERED ANATOMIC STRUCTURES

Celiac disease Post gastro-

enteritis syndrome

Microvillus inclusion syndrome

Short bowel syndrome

Enterotoxin producing bacteria

Tumours secreting vasoactive peptide

Hirschprung disease Partial small bowel

obstruction Malrotation

EVALUATION

Phase 1Hx including amount of fluid intake/day

PE including nutritional assessment

Stool examination (pH, fat, ova & parasite)

Stool culture

Stool for Clostridium difficile toxin

Blood test (FBC, ESR, BUSE, RP)

Phase 2Sweat chloride

72hr stool collection for fat determination

Stool electrolyte, osmolality

Breath H2 test

Phase 3Endoscopic study

Small bowel biopsy

Sigmoidoscopy with biopsy

Barium study

Phase 4Hormonal studies

Vosoactive intestinal polypeptide

Gastrin, Secretin

MANAGEMENT

Principal: Maintain adequate nutritional intake to permit normal growth & development

Height & weight must be documented

Consider chronic non-specific diarrhoea if normal height & weight, stool examination did not show any fat

Pathogenesis of this condition:

Excessive carbonated fluid intake

Low fat intake

Excessive intake of fruits juice

CHRONIC NON-SPECIFIC DIARRHOEA

Present in well appear toddler (1 – 3 years old) Diarrhoea is brown & watery, containing undigested food

particles If child fluids intake > 150ml/kg/24h, it should be reduce

to < 90ml/kg/h Child may become irritable for the 1st 2 days of fluid

restriction. This approach will result in ↓ stool frequency & volume If diet hx suggest that the child ingesting significant

amount of fruits juices, juice should be ↓

Sorbitol (non absorble sugar) found in apple, pear & prune juices

These fruits also contain high fructose that causing diarrhoea

White grape juice is the best alternative Restriction of fat intake by the parents can cause

diarrhoea We can increase fat diet to 40 % of total calories/days

CARBOHYDRATE INTOLERANCE

A trial period of lactose @ sucrose initiated

Add lactase tablets (LactAid) & sacrosidase for lactose & sucrose digestion

Lactose & sucrose free diet

If no improvement

If no improvement

If patient present with weight loss & stool examination shows fat chronic diarrhoea 2° to malabsorption syndrome

Common cause is post gastroenteritis malabsorption syndrome

This patient respond well to predigested formula If patient intolerance to oral feeding with predigested

formula (pregestimil, alimentum), nasogastric drip feeding with elemental formula should be considered for 3 – 4 weeks

Patient suspected with small intestinal bacterial overgrowth should be evaluated for surgical, medical & nutritional support

Surgery if patient has malrotation or partial small bowel obstruction

Antibiotic – metronidazole + ampicillin @ trimethoprim-sulfamethoxazole

Patient present with secretory diarrhoea in the 1st month of life need to have nutritional support the most likely cause is congenital defect in transport protein