APPROACH TO CHRONIC

DIARRHEA
3 years old girl came to your clinic
with loose stools for 2 months
 What questions will you ask in History?

 How will you Examine?

 Difference between Osmotic and Secretory Diarrhea?

 Demographic history
 Age

 Sex :- IBD in pediatrics is common in MALE.

 Residence :- Africa and poor countries, suspect

infections and HIV.
HISTORY OF THE PRESENT ILLNESS
 Onset
 Just before 6m of age…...> coeliac disease.
 After 1 yr. ……> cow’s milk allergy.
 Preceded by gastroenteritis …..> post infectious
diarrhea.

 Course and duration

 Stool character: To differentiate what is called secretory

and osmotic diarrhea.
 Associated GI symptoms
 No symptoms, well child toddlers diarrhea.
 Abdominal distension and weakness Celiac disease
 Severe abdominal pain IBD.
 Bloody diarrhea IBD
 Oral ulcersIBD.
 Vomiting and rash Eosinophilic enteritis.
 Attacks of constipation  hirschsprung and IBS
 Vomiting, weight loss and behavioral
changesanorexia nervosa
 Infant with severe napkin dermatitis resistant to most
treatment  Acrodermatitis enteropathica
 Associated Non-GI symptoms
 Recurrent respiratory tract infections CF
 Weakness, fatigue and weight loss IBD, Addison
and HIV.
 Skin pigmentation Addison
 Headache and mood changes IBS
 Eczema cow’s milk allergy and eosinophilic
enteritis
 Joint pain and arthritis IBD.
 Generalized lymphadenopathy HIV
 Recurrent/Prolonged fever and weight lossTB
 Same illness or respiratory problems Cystic
Fibrosis ,IBD and IBS
 IMMUNODEFICIENCY HIV
 Travelling abroad infections
 Excessive juice intake
 History of previous cardiac operations  intestinal
Lyphangectasia
 Dietary History
 Record a detailed history of feeding prior to the onset
of the disease and during the disease  clues to the
etiology, e.g., cow's milk protein intolerance, lactose
intolerance, gluten enteropathy. Soy protein
intolerance, egg protein enteropathy.

 Overfeeding, concentrated formula feeds osmotic

diarrhea..
 Chewing gums and chocolates

 Plenty of undiluted fruit juices (e.g., pineapple juice

has an osmolality of 900 mOsm/L and apple juice 650
mOsm/L
 Stool history
 Odorless blood tinged stools  shigellosis

 Frequent mucoid stools in a healthy child without

blood  IBS

 Nocturnal diarrhea  organic disease rather than IBS.

 Infant having chronic diarrhea, + history of delayed

passage of meconium  Hirschsprung's disease

 Greasy stools, difficult to flush

 Drug history
 History of laxative abuse  Anorexia nervosa.

 History of prolonged course of antibiotics 

pseudomembranous colitis.
 Red flags
 Poor weight gain or weight loss
 Bloody/loose stools with continuous crying
 Blood and mucous in stool.
 Failure to thrive.
 Associated symptoms of systemic diseases like fever,
rash and arthritis.
 Examination
 General examination: Weight and height
 Weight loss CF, Celiac disease, IBD
 Weight and height  normal in toddlers diarrhea. Pallor
…… IBD, CF, Celiac disease
 Fever….. IBD, CF
 Clubbing ….> IBD, CF.
 Ear effusion and adenoids……..> CF.
 Oral ulcers…..> IBD.
 Oral pigmentation…..> Addison.
 Peri-oral rash/nappy ……> acrodermatitis enteropathica.
 Chest scars ….> lobectomy scar for CF.
 Median sternotomy scar ……> intestinal lymphangectasia.
 Signs of bronchiectasis…..> CF. Arthritis….> IBD.
 Osmotic Diarrhea Secretory Diarrhea

Volume of Stool <200lm/24hrs > 200ml/ 24Hrs

Response to fasting Diarrhea stops Diarrhea continues

Stool Na < 70 mEq/L >70 mEq/L

Reducing substance Positive Negative

Stool pH <5 >6

Osmolality >(Na+K)+2 <(Na+K)+2

(Fecal osmotic gap)
Osmotic diarrhea

• MALABSORPTION OF WATER-SOLUBLE
NUTRIENTS
•-Glucose-galactose malabsorption Congenital ,
Acquired Disaccharidase deficiencies.

•EXCESSIVE INTAKE OF CARBONATED FLUID

•EXCESSIVE INTAKE OF NONABSORBABLE

SOLUTES -Sorbitol Lactulose Magnesium hydroxide
stops with fasting, has a low pH, positive for reducing
substances
Secretory diarrhea

• Bacterial toxins:
• Enterotoxins of cholera, Escherichia coli (heat-
labile), Shigella, Salmonella, Campylobacter jejuni,
Pseudomonas aeruginosa

• Hormones:
• Vasoactive intestinal peptide, gastrin, secretin
Case 2.
Mother brings her 2 years old boy, with
complaints of loose stools, which has increased his
fusiness and stomach aches. His weight is at 10th
centile, height at 25th centiles.

1. How will you approach?

2. What are your differential diagnosis?

3. What Investigations will you advise?

4. Treatment?
 Approach:

 Exclude Celiac disease and infectious etiology

 Consider Functional Diarrhea
 Selective testing of stools
 Specific testing
Infants
Older Children
Aldolescents
Thank You