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Non resolving acute diarrhea(pediatrics)
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Non resolving acute diarrhea
Anshu SrivastavaDepartment of Pediatric Gastroenterology
Sanjay Gandhi Postgraduate InstituteLucknow
Anshu SrivastavaDepartment of Pediatric Gastroenterology
Sanjay Gandhi Postgraduate InstituteLucknow
Non resolving acute diarrhea
Persistent diarrhea
Acute onset Prolonged for >2wk Mostly infection related Young <3years old
Other Causes of chronic diarrhea
Insidious onsetDuration wks to monthsAny age groupMostly not infection related
0-7days
• Acute diarrhea (watery or bloody)• Dysentery (fever , cramps, tenesmus, mucoid stools)• Bacillary dysentery (specific for shigella)
8-14days
• Prolonged diarrhea• Six-fold relative risk of progress to persistent diarrhea
>14 days
• Persistent diarrhea• ~3-20% of all acute diarrhea• 90% cases in <1 y old children
Time of attention patients with ‘prolonged’ diarrhea that is, 5–7 days in duration and notyet resolved
Current opinion gastroenterology 2011;27:19-23
Prolonged and persistent diarrheaAccounts for only 16% of episodes yet 50% of days with diarrhea
Diarrhea related deaths AWD: `35% Dysentery 20% Persistent ~45%
Who is at risk for persistent diarrhea?
• Young age <1y • Malnutrition • Previous episode of persistent diarrhea• Lack of breastfeeding & early introduction of animal
milk• Irrational use of antimicrobials• Severe diarrhoea or dysenteric illnesses• Underlying immunodeficiency?
WHO Bulletin 1996; 74:479/ Acta Pædiatrica 2012 101, pp. e452–e457
Persistent gut infection
Persistent diarrhea
Prolonged small intestinal mucosal injury
PEMSystemic infections
Ineffective villous repair
Sec Lactose intolerance
Increased absorption ofAntigenic proteins
Milk protein intolerance
Inappropriate re-feeding
Persistent diarrhea
Gut infections
Systemic infections
Micronutrient deficiencies
Immunodeficiency
Lactose intolerance
Milk/other protein sensitization
PD
Case I: 9mo boy
Persistent diarrhea 2 weeks5-6 times/day, small quantities
Acute onset, watery 15 times/day for 7 days
Top fed Bottle feeding
No fever or urinary symptoms
Cefixime 3 days Ofloxacin 5 d Norfloxacin-metranidazole 7 d
SGPGID 21
Examination
Perianal erythemaSatellite lesions around
flexures, scrotum and penis
• Oral thrush +• Soft abdomen• No hepatosplenomegaly• Other systems normal
Diagnosis
Fungal diarrhea (super-infection)
Stool• Budding yeast cells and hyphae ++• Opportunistic infections: no organism• C. difficile antigen: negative
Management
Oral fluconazole Clotrimazole paint
Supplements Diarrhea resolved in 3 days No recurrence
Case II: 11 mo boy
Persistent diarrhea 3 weeks10-14 times/day, explosive
Acute onset, watery diarrhea for 5 days
On cow’s milk
Ofloxacin 7 days
Explosive stools
SGPGI
Examination
• Soft abdomen• No hepatosplenomegaly• Other systems normal
Perianal erythema (widespread)Minimal lesion on scrotum
Diagnosis
Secondary lactose
intolerance
In doubtful cases:Stool for • Reducing substances > 0.5%• pH <6.0
Any tests required to confirm?No
Management
• Low lactose diet for 6 weeks• Supplemented with other non-lactose items
At follow-up 8 weeks:• No diarrhea• Rash healed• Reintroduction of milk: no symptoms
Diets in persistent diarrhea
Most patients respond to diet A and B
Case III: 4 mo girl
Persistent diarrhea 2 weeks5-6 times/day, small quantities
Acute onset, watery 15 times/day for 7 days
dehydration
Top fed Bottle feeding Intt. fever (1000F) 10 days
Ofloxacin , racecadotril, probiotics
SGPGID 21
Catheterized
Further course…
H/O feverCatheterizatio
nSuspect UTI
• Urine exmn: 15 WBC/ hpf
• Urine culture: E.coli
• USG-KUB: normal
Sensitive antibiotics (3rd gen cephalosporin) for 7 days
• Afebrile
• Formed stools
• MCU/ DMSA scan at follow-up (8 weeks): normal
Case IV: 3mo boy
Persistent diarrhea 20 days Explosive with perianal erythema
Acute onset, watery for 7 days
Formula fed at 2moInadequate breast
milk
Multiple antibiotics, racecadotril, probiotics, antifungals
Breast feed till 1mo age
Wt loss: 800gm
Off lactose, on soy formula
No response
SGPGI
ProblemsHigh risk patientAge , 3 monthsNot breast fedWeight lossClinical features of secondary lactose intoleranceNo response to lactose free diet
Possibilities1. Persisting systemic infection2. Fungal sepsis3. Milk protein sensitization 4. Opportunistic infection
3 months old boy
Proctosigmoidoscopy Aphthous ulcers
Rectal biopsyEosinophilic infiltrate >6/hpf and cryptitis
Hb:9.4, TLC 7600/cumm, P56, L34, E10
PLT: 4.2lac Alb: 3.5Electrolytes normal
No evidence of systemic infectionStool exam: no ova/cyst etc
Why did the child not respond to soy formula?
Co-existent soy allergy with milk protein allergyHow to manage this patient??
Child was placed on elemental formula for 3 monthsResolution of diarrhea with weight gainGradual reintroduction of other food itemsMilk and milk product free dietNo recurrence of symptoms
CMPA Lactose intolerance
All or none phenomenon Relative phenomenonImmune reaction to milk protein Deficiency of lactase enzymeMultisystem symptoms Only GI symptomsRecovers by 4-5y of age Recovers in days-weeks in secondary,
permanent in primary Diagnosis: SPT, IgE, histology-eosinophils, elimination challenge test
Diagnosis: stool-pH, reducing substances +ve, Lactose hydrogen breath test
Stop all milk and milk products Milk reduction, yogurt, lactase enzyme supplement
CMPA is not equal to lactose intolerance
0 25days
Case V: 3 year old girl
Last 1week, stools (7-8times/day), with small amount of
blood
SGPGI
ORS, ZincMultiple courses of antibiotics
Started with acute watery diarrhea requiring IV fluids initially……cont for ~18days
No history of severe pain abdomen recurrent feverinfections at other sitesabdominal distension
No family history of food allergy/asthma/ IBD
3year old girlSGPGI
ExaminationWt 12kg , height 90cmMild pallorAbdomen soft, no organomegalyPerianal area normalSystemic exam normal
Diagnosis: watery diarrhea going on to colitis
Possibility ?
Dysentery CMPA Antibiotic associated colitis Other infections amoebic,CMV Inflammatory bowel disease
3years 3years 3 months
3y old girl
Stool- negative for oppurtunistic pathogens positive for C difficile toxin
• Treated with oral vancomycin• Diarrhea passive, active child• Haemoglobin increased to 10.8 g/dl in follow-up
Diagnosis : Pseudomembranous colitis
Hb 9.8, TLC 16700/ P76%. Electrolytes/ RFT/ protein/albumin normalSigmoidoscopy: erythema, loss of vascular pattern s/o colitisNo aphthous ulcers, pseudomembranes, deep ulcers.
Antibiotic-associated diarrheaOverall complicates 2-5% of antibiotic treatment
70-80%
15-25%
2-3%?
Non specific diarrhea (osmotic ,secretory)
C. difficile diarhea and colitis
Other pathogens (C.per-figens,Staph,candida)
antibiotic specific (motilin stimulation,allergic reaction)
3.6-18% Indian pediatric data
MildSelf-limiting
Treatment of C difficile diarrhea
Mild to moderate disease
Severe diseaseNo response tometronidazole
Metronidazole20-40 mg/kg Oral/ IV
10-14days
Vancomycin40 mg/kg oral
10-14days
• Stop precipitating antibiotics Diarrhea resolves in 15-25% (mild disease)• No antimotility agents: Precipitation of ileus, toxic megacolon• Correction of fluid/electrolyte imbalance
Work-up in persistent diarrhea
• Haemogram: Hb, TLC, DLC, platelet, GBP• Serum electrolytes, creatinine• Urine-microscopy and culture (proper collection)• Stool- ova, cyst, fungal, clostridium difficile toxin• ± Blood culture• ± X ray chest• ± Sigmoidoscopy and biopsy• ± others- UGI endoscopy and biopsy, immune profile
Giardiasis
CryptosporidiumOocyst of isospora belli
Strongyloides stercoralis larvae (lugols iodine)
Always ask for stool examination
Clues in history and examination
Lactose intolerance• Explosive stools• Perianal erythema
Fungal infection• Oral thrush• Satellite lesions in perineum
Systemic infections / sepsis• Fever, lethargy• Urinary, resp, cardiac symptoms
Cow’s milk allergy• F/H atopy, allergy• Dietary history• Temporal correlation
Immunodeficiency• Recurrent infections elsewhere• Recurrent diarrhea, response to antibiotics
Antibiotic assc diarrhea• Exposure to antibiotics in last 12 weeks
Management• Admit- <4mo and top fed, dehydration, severe PEM,
systemic infection• Rehydration• Treat systemic infection• Weaning food with reduced lactose load…..A/B/C diets• Micronutrient supplementation
Oral Zinc 10 mg/ day x 2weeks Oral folic acid 1mg/day x2weeks Vitamin A 1lac unit (6-12mo age or <8kg weight), 2lac unit >1y of
age Adequate supplementation and correction of electrolytes (Na, K,
magnesium, phosphorus, calcium)J. Nutr. 2011;141: 2226–2232
Green banana diet Amylase resistant starch (ARS) Not digested in human intestine Delivered to colon
Colonic Bacteria Short chain
fatty acids
Increase salt, water absorption
Provide energyTrophic effect
Management
Infectious Non infectious Onset acute insidiousBloody stools at onset
Less, usually watery Yes
Fever at onset yes lessExposure to sick contact
yes no
Travel related yes No
Detailed history to determine onset (acute vs insidious) Consider and workup for other etiologies of chronic diarrhea e.g
celiac, lymphangiectasia, anatomical causes in select cases Especially if older child >3years as PD uncommon in these subjects
Good news: PD is decreasing
Acta Pædiatrica 2012 101, pp. e452–e457
Study from Bangladesh, children <5years
1991----2010
Conclusion
Persistent diarrhea is most common in younger children
Sepsis, lactose intolerance, protozoal /fungal infections, food
protein sensitization and micronutrient deficiency are common
reasons
Identify and manage them early (1-2wk)
Home made diet is useful in majority but specialized formulae are
required in few
Micronutrient deficiencies need to be corrected
Persistent diarrhea should not be confused with chronic diarrhea
Thanks