2. ⢠Diarrhea
â 3 times in 24 hours
â Consistency important over frequency
⢠Acute Diarrhea
⢠Persistent Diarrhea
⢠Chronic Diarrhea
TERMS & DEFINITIONS
3. PERSISTENT DIARRHEA
⢠Starts as acute, lasts at least 14 days with
the exclusion of chronic or recurrent
diarrheal conditions
â Celiac disease Tropical Sprue
â Biochemical Congenital
â Metabolic
4. ?WHY
⢠10% of total diarrhea
⢠35% of diarrheal deaths
⢠For every 100 children, 7 suffers
⢠PD in Malnutrition â 20%
⢠60% < 6 months
⢠90% < 1 year
5. RISK FACTORS & CAUSES
⢠Repeated enteric infections
⢠Malabsorption of CHO & fats
⢠Malnutrition
⢠Very young age
⢠Recent introduction of animal milk
⢠Irrational usage of antibiotics
⢠Lack of breast feeding/ bottle feeding
⢠Improper therapy of ADD
⢠Protein dietary intolerance
6. PATHOGENESIS
âPSIMIâ
Mucosal injury d/t invasive pathogens
Malabsorption of macro & mircronutrients
Prolongation of mucosal injury & delayed intestinal repair
mechanisms (ineff. villous repair)
Sequential infection with multiple pathogens
Increased absorption of foreign proteins
Malnutrition
7. PRESENTATION
⢠Several loose stools
⢠Dehydration absent
⢠If present, inc stool output
dec oral intake
⢠Features of PEM
8. Clinical Evaluation
⢠History & Physical Examn.
⢠Should be excluded from Chronic
diarrhoea
⢠To R/o associated systemic infections
â CBC
â URE & C/S
â CXR
⢠Stool microscopy
⢠Stool pH & reducing substance
9. ⢠Nutritional management is the cornerstone
â Dietary management
â Supplemental vitamins & minerals
⢠Two third cases â OPD
⢠Assess dehydration
⢠Hospitalization necessary or not
⢠Avoid unnecessary antibiotics
TREATMENT
10. When to hospitalize?
⢠Age < 4 mon & not breast fed
⢠Dehydration
⢠Severe malnutrition
â W/L < 70%
â W/A < 60%
â Pedal edema
⢠Systemic infection
11. Dietary Management
< 6 months
⢠Encourage exclusive breast feeding
⢠Reestablish breast feeding
⢠Replace animal milks with curds or lactose
free formula
⢠Cooked rice may be mixed if necessary
12. >6 months
⢠Continue Breast feeding
⢠Mixed diet
⢠Initiate DIET A
⢠DIET B
⢠DIET C
13. Milk cereal mixtures
v/s
milk free diet
⢠Highly palatable
⢠Provide good quality protein
⢠Some micronutrients
⢠Faster weight gain
⢠No significant increase in stool output
⢠No increasing risk of dehydration
14. Principles
⢠Total elimination of milk not necessary
⢠Limit intake to 2g/kg/day lactose (50-60
ml)
⢠Start feeding asap
⢠6-7 feeds per day
⢠Start with 110kcal/kg and inc to 150kcal/kg
over 2 weeks
⢠If enteral intake diff, start NG feed
15. DIET A
reduced lactose diet (65-70%)
Ingredients Measures Wt/Vol
Milk 1/3 katori 50ml
Sugar 1.5 tsp 7g
Oil 1 tsp 4.5g
Puffed rice powder 2 tsp 6.0g
Water 2/3 katori 100ml
Calories/100g 85 kcal
Proteins/100g 2.0g
How to prepare
16. DIET B
lactose free with reduced starch(15-20%)
Ingredients Measures Wt/Vol
Egg white 3 tsp Half egg white
Puffed rice powder 3 tsp 9.0g
Glucose 1.5 tsp 7g
Oil 1.5 tsp 7g
Water 3/4 katori 120ml
Calories/100g 90 kcal
Proteins/100g 2.4g
How to prepare
17. DIET C
Monosaccharide based
Ingredients Measures Wt/Vol
Egg white 3 tsp Half egg white
Or Chicken puree 5 tsp 15 g
Glucose 1.5 tsp 7 g
Oil 1.5 tsp 7 g
Water 1 katori 150ml
Calories/100g 67 kcal
Proteins/100g 3 g
How to prepare
18. Supplementation
⢠2 x RDA of multivitamins and minerals for
2-4 weeks
⢠At least Vit A (single dose) & Zinc 10-
20mg (2 weeks)
⢠In severe malnutrition,
â 50% Mg sulfate 0.2ml/kg/dose twice a day for
3 days
â Potassium 5-6meq/kg/day
19. Monitoring response
⢠Dec in no. of diarrheal stools
â <= 2 liquid stools/day for 2 consec. Days
⢠Adeq. Food intake
⢠Weight gain
ďąMost children lose wt in the initial 1-2 days
and then show a steady gain
20. When to change diet
⢠Marked increase in stool freq (10/day)
⢠Return of signs of dehydration
⢠Failure to establish wt gain by day 7
ďą after discharge little milk after 10 days
No signs of lactose intolerance
Milk qty increased and normal diet ovr a
week
21. PARENTERAL NUTRITION
⢠PD with oral intolerance after 10 days
⢠Severe forms of IBD+ resistant colitis
⢠Severe NEC
COMPLICATIONS
PARTIAL PARENTERAL NUTRITION
⢠Isolyte P - 250ml 25%D â 150ml
⢠A.A â 100ml NaHCO3 â 20ml
⢠KCl â 5ml MVI â 2ml
⢠50-60 ml/kg/d
22. Antimicrobial Therapy
⢠Gross blood in stools
⢠Asso systemic infection
⢠Severe malnutrition
⢠Screen for UTI and treat
⢠Group B Salmonella isolated in stool
23.
24. PREVENTION
⢠Improving nutritional status
⢠Prevention and rational treatment of acute
diarrhea
⢠Promote exclusive breast feeding
⢠Ensure safe complemetary feeding
practices
⢠Zinc supplementaton
⢠Avoid irrational & unnecessary use of
antibiotics
25.
26. CHRONIC DIARRHEA
⢠Diarrhea for >= 14 days with exclusion of
persistent diarrhea.
⢠Infections
⢠Malabsorption
⢠Metabolic
⢠Miscellaneous
34. STEP 1 Intestinal microbiology
⢠Stool cultures
⢠Microscopy for parasites
⢠Viruses
⢠Stool electrolytes
⢠H2 breath test
Screening test for celiac disease (transglutaminase 2 autoantibodies)
Noninvasive tests for:
⢠Intestinal function
⢠Pancreatic function and sweat test
⢠Intestinal inflammation
Tests for food allergy
⢠Prick/patch tests
DIAGNOSTIC WORK UP
35. TEST NORMAL VALUES IMPLICATION
Îą1-Antitrypsin concentration <0.9 mg/g stool
Increased intestinal permeability
and protein loss
Steatocrit <2.5% (>2 yr old) Fecal fat loss
Fecal reducing substances Absent Carbohydrate malabsorption
Elastase concentration >200 Âľg/g stool Exocrine pancreatic dysfunction
Chymotrypsin concentration
>7.5 U/g
>375 U/24 h
Exocrine pancreatic dysfunction
Fecal occult blood Absent
Fecal blood loss, distal intestinal
inflammation
Calprotectin concentration 100 Âľg/g stool Intestinal inflammation
Fecal leukocytes <5/microscopic field Colonic inflammation
Nitric oxide in rectal dyalisate <5 ÂľM of NO2
â/NO3
â Rectal inflammation
Dual sugar (cellobiose/mannitol)
absorption test
Urine excretion ratio:
0.010 Âą0.018
Increased intestinal permeability
NON INVASIVE TESTS
36. STEP 2 INTESTINAL MORPHOLOGY
⢠Standard jejunal/colonic histology
⢠Morphometry
⢠PAS staining
⢠Electron microscopy
STEP 3 SPECIAL INVESTIGATIONS
Intestinal immunohistochemistry
Anti-enterocyte antibodies
Serum chromogranin and catecholamines
Autoantibodies
75SeHCAT measurement
Brush border enzymatic activities
Motility and electrophysiological studies
37. TREATMENT
⢠General supportive measures
â Replacement of fluids & electrolytes
⢠Nutritional rehabilitation
⢠Elimination diet
⢠Treat the cause
38. CELIAC DISEASE
⢠Immunologically mediated small intestinal
enteropathy
⢠Sensitivity to gluten
⢠Multiple associations
⢠Classic form :
â 6m- 24m
â Chronic diarrhea, anorexia,vomiting
â Abd pain & distension
â Poor weight gain & wieght loss
39. ⢠Older children
â Diarrhea, nausea, vomiting
â Abd pain, bloating,
â Weight loss & constipation
⢠Extraintestinal symptoms
⢠In Late presentation
⢠Short stature, IDA
⢠DH, delayed puberty
⢠Hepatitis, osteopenia
⢠Arthritis, Epilepsy
40. ⢠DIAGNOSIS
⢠Serology
â Anti-gliadin IgA & IgG
â Anti-reticulin IgA
â Anti- endomysial Ig A - high
â Anti-TTG high
⢠Intestinal biopsy & HPE
â Villous atrophy wt crypt hyperplasia
â Abnormal surface epithelium
â Full clinical & histological remission
⢠TREATMENT
⢠Strict gluten free diet