Meconium

Dark (almost black)

color, sticky
consistency, and
odorless nature.
Normal passage of
meconium should
include at least one
stool in the first 48
hours after birth
and end with the
onset of transitional
stools by day 4.
Transitional
Stool
Change from meconium
to the normal yellow,
seedy stools that
characterize infants
feeding on milk only
Here, the dark color of
meconium is still visible,
but lighter, yelowish
curds can also be seen.
Exclusively breastfed
infants should have
transitional stools by
day4 if feeding is
adequate
Yellow
Stool
Normal appearance of
stool in an infant who is
exclusively breastfed
Typically described as
bright yellow and
seedy.
Note that a significant
amount of liquid stool
absorbed into the
diaper with only some
solid material on top.

Normal
stool
This is the stool of a 2
weeks old infant who
was fed extensively on
hydrolyzed formula.
The stool is normal, but
has less of bright yellow,
seedy consistency of a
breast-fed infant stool.
Meconium
Plug
Not a normal stool
It is a very viscous
congealed mass of
meconium that may
either be spontaneously
passed or may create an
obstruction and be the
cause of delayed
stooling.
Typically, after the
infant passed the plug,
the subsequent stool is
normal.
Normal phenomena
The number ,color &
consistency of stools
varies with age & diet :
Meconium
Transitional stools
Milk stools
Color of stools
Presence of solid
particles



Definitions
Diarrhea : excessive loss of fluids &
electrolytes in stool
More than 10ml(5g)/kg /day
Defined based on:
consistency of the stool (loose or watery) &
frequency (usually at least three stools in a 24
hour period)

Definitions (cont)
Pseudodiarrhea & hyperdefecation
Increase in number of bowel movement
Encopresis
the voluntary or involuntary passage of feces into
inappropriate places at least once a month for 3
consecutive months once a chronologic or
developmental age of 4 yr has been reached.
Dysentery : small volume , frequent, bloody,
tenesmus , urgency


Pathophysiology
A total of 8 to 9 L of fluid enters the healthy intestines on a daily basis.
Only 1 to 2 L are derived from food and liquid intake; the rest is from
salivary, gastric, pancreatic, biliary, and intestinal secretions.
Each day, about 90% of this fluid is absorbed in the small intestine, ~1 L
enters the colon, and about 100 mL is excreted in stool.
Normal stool output is approximately 100
to 200 g/day.
Diarrhea is defined as stool output
greater than 200 g/day in children older
than 2 years of age and greater than 10
mL/kg/day in children younger than 2
years of age.
It is also described more practically as an
increase in liquidity and frequency of
bowel movements.
Categorizing
Diarrhea
Duration:
acute (2 weeks) or chronic (>2 weeks), or by
Mechanism:
osmotic or secretory.
It can also be categorized by the presence or
absence of malabsorption




Both secretory and osmotic
diarrhea are caused by defective
or impaired mucosal absorption.
Osmotic Diarrhea
Excess amounts of non-absorbed substances, such as lactose,
lactulose, fructose, or sorbitol, remain in the intestinal lumen,
causing luminal water retention.
After these luminal substances enter the colon, they are processed by
colonic flora, producing large amounts of organic acids, increased
flatulence, and faster transit.

The fecal osmolar gap [290 mOsm/L {2
(measured stool sodium + measured stool
potassium)}] is usually greater than 50 mOsm/L in
the setting of osmotic diarrhea.
When an abnormal gap is found, reducing
substances, stool pH, and fecal fat should be
measured.
Osmotic diarrhea improves with fasting.
Examples of osmotic diarrhea include lactase
deficiency, celiac disease, and short bowel
syndrome.

Secretory diarrhea
Abnormal ion transport in epithelial cells, leading to decreased absorption
of electrolytes and increased secretion of fluid.
The fecal osmolar gap is less than 50 mOsm/L, and the diarrhea persists
despite fasting.
Examples include congenital chloride and sodium diarrhea, cholera, and
neuroendocrine tumors.


Dysmotility
Another important underlying mechanism of
diarrhea is dysmotility.
For example, pseudo-obstruction may result in
bacterial stasis, overgrowth and resultant
diarrhea, while hyperthyroidism may be
associated with diarrhea because of rapid
intestinal transit.

Stool Character
The character of the stool can help to
determine the origin of diarrhea.
Disease of small intestine origin:
Watery, voluminous, non-bloody stool with few or
no white blood cells (WBCs) and low pH (<5.5)
Colonic origin:
Low-volume, mucusy, often bloody diarrhea with
a large number of WBCs and higher pH

The most common electrolyte
abnormalities related to diarrhea
include hypokalemic metabolic
acidosis caused by bicarbonate and
potassium losses in stool.

Bloody Diarrhea
A concerning symptom.
The most common cause is infection, especially in
a setting of fever and acute onset.
If bloody diarrhea is progressive and persistent,
chronic inflammatory causes should be
considered.
The age of the patient is also important.
In infants, milk proteininduced enterocolitis is a
common cause of bloody stools.

Acute
Diarrhea
Etiology & Pathogenesis
The most common cause of acute
diarrhea is infection.
In young children, this is most often
viral, with the most common agents
being rotavirus, adenovirus,
astrovirus, and norovirus.
Rotavirus is a leading cause of death
in children younger than 5 years of
age worldwide
In immunocompromised hosts,
viruses, including cytomegalovirus,
Epstein-Barr virus, and BK virus,
should be considered.
It is estimated that 70% of infectious diarrhea is
foodborne, and thus a detailed history of exposures
is very important.
Exposure to untreated water may cause giardiasis.






Use of public swimming pools poses a risk of
Shigella, Giardia, Cryptosporidium, and
Entamoeba infection, with the last three being
chlorine resistant.

Home pets can transmit infections.
For example, turtles carry Salmonella spp.




History of foreign travel may narrow
exposures based on the specific destination.
The most common etiology of travelers
diarrhea remains enterotoxigenic Escherichia
coli.




Cryptosporidium and Giardia spp. are
responsible for most parasitic infections in
developed countries.
Clostridium difficile infection, previously thought to
affect only hospitalized patients or those taking
antibiotics, is now responsible for 40% of community-
acquired diarrhea.
A recent increase in C. difficile infections has been
observed, some attributable to the resistant strain, BI/
NAP1.
An overgrowth of toxin-producing Clostridium organ-
isms causes pseudomembranous colitis, which may be
a potentially life-threatening condition.
Vibrio cholerae remains a cause of illness and death in
war zones and developing countries.
The mechanism of infectious diarrhea is
primarily secretory.
It can quickly lead to electrolyte abnormalities
and acidosis.
Infection may result in villous atrophy, which
can add an osmotic component.
Mucosal healing after infection may lead to
transient postinfectious diarrhea.
Other causes of Acute Diarrhea
Particularly concerning in
afebrile children
Intussusception, a telescoping
of two segments of bowel that
occurs mostly in children
between 6 months and 2 years
of age, may present with bloody
diarrhea.
The typical presentation is colicky
abdominal pain, vomiting, and an
abdominal mass.
Currant jelly stools do not occur
in all patients with intussusception
but are pathognomonic for the
condition.
Hemolytic- uremic syndrome (HUS) is an
uncommon but potentially fatal illness that
may present with acute bloody diarrhea.
HUS begins as a mild gastroenteritis that evolves
into hematochezia, microangiopathic hemolytic
anemia, thrombocytopenia, and acute renal
failure.
Less commonly, appendicitis may present with
abdominal pain and diarrhea as a result of
colonic irritation from the inflamed appendix

Other acute causes of diarrhea include
inflammatory bowel disease,
overfeeding (caused by increased osmotic loads),
antibiotic-associated diarrhea (likely caused by
changes in bowel flora),
extra-intestinal infections (otitis media, urinary
tract infection, pneumonia), and
toxic ingestions.


Clinical Presentation
In any patient presenting with acute diarrhea,
a thorough history and physical examination
should guide the immediate and subsequent
evaluation and therapy.
It is important to quantify the duration and
frequency of stooling in addition to emesis,
liquid intake, and urine output to assess for
hydration status.

A travel history
should be
obtained.
Recent antibiotic
use may suggest
pseudomembra
nous colitis with
C. difficile.

History Taking
The presence of
abdominal pain may
occur in infectious
enteritis; however,
it may also be indicative
of
intussusception
(colicky, episodic) or
appendicitis
(periumbilical, right
lower quadrant).
Bloody diarrhea is usually typical in bacterial
enteritis but may be seen in viral illness, HUS,
or colitis.
Associated vomiting suggests viral
gastroenteritis.

In infectious diarrhea, there is usually a 1- to 8-
day incubation period with a sudden onset of
symptoms.
There may be associated fever, vomiting, crampy
abdominal pain, bloody stools, tenesmus, loss of
appetite, and dehydration.
The immune state of the child should be
determined because an immunocompromised
child may present with more unusual organisms.


Physical Examination
Begins with the general appearance of the
child
does the child look malnourished or has he or she
lost weight?
Vital signs then help to guide evaluation and
management.
Fever usually indicates infection.
Pulse and blood pressure changes may
indicate dehydration, shock, or sepsis.
A careful abdominal examination should look
for bowel sounds (to evaluate for obstruction)
and masses (to evaluate for intussusception).
A stool sample should be guaiac tested for
microscopic blood.


Evaluation & Management
Patients should be assessed for hydration
status and electrolyte abnormalities, with
correction as indicated.
Acute viral gastroenteritis often requires
aggressive rehydration with intravenous fluids
or oral rehydration solutions.
Stool should be sent for viral polymerase chain
reaction, culture, and C. difficile toxin assay.
Most gastrointestinal (GI) infections, except for C.
difficile, do not require treatment.
Antibiotics tend to prolong diarrhea and result in
a carrier state.
There are special circumstances, such as
Salmonella enteritis in young infants and
immunocompromised patients, for which
antibiotic therapy is indicated.


Most infections resolve in 14 days
in healthy children.
Antidiarrheal agents are typically
not effective and should be
avoided in children.
Serious complications, such as
sepsis, HUS, pancreatitis, urinary
tract infection, and perforation,
are uncommon.

Thank
you