Persistent Diarrhoea & Chronic Diarrhoea

8/14/2019 Persistent Diarrhoea & Chronic Diarrhoea

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PERSISTENTDIARRHOEA IN

CHILDREN

Dr. Gadadhar Sarangi The Child

B.K. Road, Ranihat, Cuttack - 753 001,

ORISSA



Definition

• Prolongation of acute diarrhoea /dysentery for more than 14 days

• Generally associated with weightloss.



Cause of PersistentDiarrhoea

• Persistent infection with one ormore enteric pathogens

•Secondary malabsorption of carbohydrates & fat.

• Intestinal parasitosis.

• Dietary protein allergy/intolerance.



Pathology

• Damage to the absorptive mucosalsurface of small intestine

• Delay in repair of the damagedepithelium (Normal <5 days)

• Carbohydrate, fat and protein mal -absorption ensues as consequence

• Direct absorption of macromoleculesleads to protein allergy.



Clinical Presentation

• Mild form

– Several motions

– No significant weight loss

– No significant dehydration

• Moderate form

– Several motions

– Marginal weight loss

– Without dehydration– Non tolerance to milk

• Severe form

– Dehydration with

several motions– Weight loss

– Non tolerance tomilk & cereals

– Secondary infectionoften coexists



Diagnosis

• Asses dehydration.

• Asses malnutrition.

• Stool - R/E, Culture, Reducing sugar,pH.



Management

• Mild form - Try low milk formula feeds.

• Moderate form - Do not try milk, permit cereal basedfeeds.

• Severe form

– Phase I: Resuscitation < 24 hours

– Phase II: Partial parenteral nutrition (1-4 days), IV fluids, colloid,

antimicrobials, electrolyte balance– Phase III: Nutritional rehabilitation with calorie dense, > 5 days,

lactose free formulae

If fails - Chicken/egg white, glucose, oil - feed

If fails - Total parenteral nutrition



Indication ForAntimicrobials

• Presence of gross blood in stool

• Stool leukocytes > 10 / HPF

• Shigella / Salmonella in stool culture

• Associated systemic infection.

• Severe malnutrition.



Vitamin & MineralSupplement

• Twice the RDA of vitamins andminerals.

• Special attention for Vit. A and Zn.

• In malnutrition :

– Magnesium sulphate IM

–Potassium oral.



Prevention

• Promotion of breast feeding.

• Active management of acutediarrhoea.

• Appropriate dietetic management.

• Judicious administration of drugs.



CHRONIC DIARRHOEA



Definition

• Diarrhoea of more than 2 weeksduration.

OR• 3 attacks during last 3 months.

• Without specific congenital,

biochemical or metabolicdisorders.



EVALUATION OF PATIENTS



EVALUATION OF PATIENTSWITH CHRONIC

DIARRHOEAPHASE – I

• Clinical History.

• Nutrition assessment.

• Stool exam – pH, reducing substances,leukocyte count, fat, ova, parasites.

• Stool culture.

• Stool for Clostridium difficile toxin.

• Blood studies – CBC, ESR, Electrolytes,Urea, Creatinine.




EVALUATION OF PATIENTSWITH CHRONIC DIARRHOEA –

Contd..PHASE - II

• Sweat chloride.

•72 hours stool fat estimation.• Stool electrolytes, Osmolarity.

• Stool for phenolphthalein, magnesiumsulphate, phosphate.

• Breath H2 test.





Contd..PHASE - III

• Endoscopic studies.

• Small bowel Biopsy.• Sigmoidoscopy or colonoscopy with

biopsies.

• Barium studies.





Contd.. PHASE - IV

• Hormonal studies

– Vasoactive intestinal polypeptide.

– Gastrin.

– Secretin.

– 5-hydroxyindoleacetic assay.



THERAPY

• Depends upon the cause.• Secondary carbohydrate intolerance

– by reduction of the sugar load.

• Lactase for digestion of lactose.• Post gastroenteritis malabsorption –

Needs predigested formula.

• Specific diseases to be treated.



DYSENTERY



DEFINITION

• It is a Syndrome of Bloody diarrhoea withvisible red blood, fever, abdominalcramps, rectal pain & tensemus, mucoidstool.

• Does not include :-– Blood streaks on formed stool.– Microscopic red blood cell in stool.– Malena.



CAUSES OF DYSENTERY

• Shigella

• Entero invasive & Enterohaemorrhagic Ecoli

• Salmonella

• Campylobacter jejuni

• Entamoeba histolytica



DISEASE BURDEN

• 80 million cases globally each year.

• 70 thousand deaths each year.

• 70% cases and 60% death in under fives.

• 15% of all diarrhoeal episodes.



PATHOGENESIS

• Spread by feco-oral contamination.

• Bacterial invasion of colonic epithelium.

• Results in inflammatory colitis.

• Recto sigmoid area maximally affected.• Host defense

– Copious mucoid secretion

– Epithelial regeneration.

• Shigella causes disease with 10 to 100organisms.



EPIDEMIOLOGY

• Endemic in developing world.

• Regresses after 5 years of age.

• Food and waterborne out breaks areknown.



CLINICAL SPECTRUM

• Watery diarrhoea to fatal dysentery.

• Incubation period – 12 hours to 1 week.

• High fever.

• Abdominal cramps.

• Vomiting• Abdominal tenderness & rectal tenderness.

• Blood & mucus in the stool.

• Tenesmus and straining.

• Rectal Prolapse.• Self limiting course in most bacterial infection in 10

days.

• Bacterimia is uncommon.



COMPLICATIONS

• Seizures – Mostly with shigella shiga(Type –I)

• Dyselectrolytemia & dehydration• Rectal prolapse

• Malnutrition – Protein losing

enteropathy.• Hemolytic Uremic Syndrome.

• Non suppurative arthritis.



DIAGNOSIS

• Stool Examination – for leukocytes,RBCs, trophozoites of EH

• Stool Culture

• Peripheral blood smear –Leukocytosis with more band cells.

•Blood culture in toxic, malnourished& very young infants.

• Electrolytes in severe dehydration.



THERAPY

In children without Risk factors :• TMP-SMZ - 7 to 10 mg TMP/day in two divided

doses.

• ORS to treat and prevent dehydration.• Continue Breast Feeding.

• Frequent feeding to continue.

• No response in 2 days, change to Nalidixic acid

– Dose : 55 mg/kg/day divided in 3 to 4 doses.

• Total therapy for 5 days.

g s actors n



g s actors nDysentery

with higher mortality rate• Infants < 1 year

• Non breast fed babies.

• Dehydration• Malnutrition

• H/o Convulsion or measles



Therapy of Dysentery withHigh Risk factors

• Hospitalise

• ORS for dehydration / IV fluid.

• Zn 20 mgs. daily above 6 months &10mg below 6 months.

• Ciprofloxacin – 10mg/kg/dose in two

doses daily.• Good Response Complete 5 days.



No Response in 2 days.

• Consider Cefixime – 8 mg/kg/day in singledose X 5 days.

OR

• Ceftriaxone – 50–100mg./kg/day in singledose X 5 days.

• Complete 5 days of therapy

• If no response look for alternate diagnosis



Therapy of Amoebicdysentery

• Diloxanide furoate – 20mg/kg/day in 3 divideddoses X 10 days

• Metronidazole – 35 – 50mg/kg/day in threedivided doses X 10 days

Alternative• Paromomycin - 25-30 mg/kg/day in 3 divided

doses X 5 to 10 days.

• Dehydroemetine hydrochloride – 1.0 to 1.5mg/kg/day IM X 5 days

• For severe cases two oral medicines can becombined.



CONTROL

• Prevention of fecal oraltransmission.

• Breast feeding

• Hand washing before handlingfood.



Thank

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Persistent Diarrhoea & Chronic Diarrhoea