Professional Documents
Culture Documents
Pathophysiology of Diarrhoea: Occasional Review
Pathophysiology of Diarrhoea: Occasional Review
H R Jenkins MA MD FRCP FRCPCH is Consultant Paediatric Gastroenterolo- Mechanism of water and solute absorption in the small
gist in the Department of Paediatric Gastroenterology at the Children’s intestine
Centre, University Hospital of Wales, Cardiff, UK. Conflicts of interest: Overall water absorption is dependant on the movement of
none. electrolytes, especially sodium. The primary mechanism
PAEDIATRICS AND CHILD HEALTH 22:10 443 Ó 2012 Published by Elsevier Ltd.
OCCASIONAL REVIEW
of sodium absorption is by the glucoseesodium transporter The colon is also important for the adequate reabsorption of
1 (SGT1), which promotes the active absorption of sodium, allied fluid and whilst the majority of water and electrolyte absorption
to the absorption of glucose, with water moving down the elec- takes place in the small intestine, it is often the adequacy of
trochemical gradient that is created as jejunal contents are colonic function that determines whether or not the patient
broken down. A second mechanism is via an active, linked experiences diarrhoea. The maximal absorptive capacity of the
sodiumehydrogen exchanger. The active sodium/glucose and adult large bowel is 2e3 litre/day and, if the amount of fluid
sodium/hydrogen pumps cause sodium to be absorbed into the secreted from the small bowel exceeds this, then diarrhoea
cells (enterocytes) lining the gut with the sodium that has moved results.
into the cells then actively pumped from epithelial cells into the
circulation via the sodium/potassium ATPase located in the Pathophysiology of diarrhoea
basolateral membrane (Figure 1).
Diarrhoea is the result of a disruption in the delicate balance
The movement of sodium provides energy for the active
between the absorptive and secretory processes within the
transport of amino acids, glucose and galactose across the
bowel. In general, diarrhoea can be considered to be either
membrane. Di and tripeptide amino acid transport over the brush
osmotic or secretory.
border is coupled with hydrogen ion reabsorption, and so helps
to create the electropotential across the brush border which again
aids the transport of sodium.
The ATPase sodium/potassium pump is located in the
basolateral membrane of the intestinal crypt and villus tip cells.
The epithelial cells at the tips of the villi are active in net
absorption, whereas the cells in Lieberkuhn’s crypts function as Osmotic diarrhoea Secretory diarrhoea
net secretors of electrolytes and water. In these crypts there is
Excess osmotically active Bowel mucosa secretes
also a luminal bidirectional sodium/chloride channel which is
particles in the gut lumen excess water into the lumen
opened when there are higher levels of cyclic AMP and calcium
Stops when the child Continues when the child is fasted
ions. When these channels are open there is a net movement of
is fasted
sodium, chloride and water into the lumen. Consequently, if
Underlying causes Underlying causes
there is a slight change in the flow across this channel then
secretion dramatically increases. Cholera toxin and Escherichia
C Osmotic laxatives C Cholera toxin
coli cause an increase in the levels of cAMP, so driving chloride
C Excessive solutes within C Other infective causes
flow across the brush border into the lumen, and hence the net
the lumen C Specific electrolyte transport
movement of water with it. This results in watery, secretory
C Inflammation within defects (e.g. congenital
diarrhoea.
the mucosa chloride-losing diarrhoea)
The reabsorption of ions such as chloride and bicarbonate in
C Motility disorders or structural abnormalities
general is linked to the reabsorption of sodium with an additional
(e.g. microvillous atrophy)
chloride/bicarbonate exchange pump present in both the ileum
and colon.
Osmotic diarrhoea
Lumen Serosa When excessive numbers of osmotically active particles are
present in the lumen, more fluid passively moves into the bowel
Na Na lumen down the osmotic gradient which may exceed the
ATPase) absorptive capacity of the gut and hence diarrhoea occurs.
Osmotic diarrhoea therefore will stop when the child is not fed.
Glucose K
Excessive numbers of osmotically active particles can be
present for a number of reasons including:
Ingestion of solutes that cannot be absorbed e.g. osmotic
H2O
laxatives such as lactulose
Malabsorption of specific solutes e.g. disaccharide defi-
ciency, glucoseegalactose malabsorption
Na Damage to the absorptive area of the mucosa resulting in
less fluid absorption e.g. acute gastroenteritis, cow’s milk
H protein allergy, coeliac disease and Crohn’s disease
Motility disorders such as those seen in gastroschisis,
irritable bowel syndrome, and hyperthyroidism which
result in reduced contact with the bowel lumen and
Figure 1 Diagrammatic representation of enterocyte electrolyte and water consequently a higher concentration of solutes within the
movement in the small intestine. lumen.
PAEDIATRICS AND CHILD HEALTH 22:10 444 Ó 2012 Published by Elsevier Ltd.
OCCASIONAL REVIEW
Secretory diarrhoea of water and solutes will exceed the secretion and will ensure the
This occurs when the bowel mucosa secretes excessive amounts child remains hydrated until the infective organism is eradicated.
of fluid, either due to activation of a specific pathway by a toxin The ORS recommended by the WHO in 2002 contains 75 mmol/
(such as cholera toxin), or inherent abnormalities in the enter- litre sodium, 75 mmol/litre glucose, and has a total osmolarity of
ocytes, (e.g. congenital microvillous atrophy). Often absorptive 247 mOsm/litre. Of note, other traditional rehydration solutions
mechanisms, although present, are overwhelmed, resulting in such as coca-cola and apple juice have a significantly lower
diarrhoea. In the case of secretory diarrhoea, this does not stop if content of sodium and a very high osmolarity and are thus
the child’s enteral feeds are withheld. inadequate as oral rehydration solutions.
In some instances both osmotic and secretory diarrhoea can ORS has been shown to be effective in both developing and
occur together, in acute or chronic disease, depending on the developed countries for the rehydration of children. Studies have
underlying cause. shown that less than 5% of children with acute diarrhoea,
regardless of the underlying cause, fail to improve with oral
Aetiology and management of acute diarrhoea therapy and IV rehydration, with its consequent risks, is rarely
needed.
Acute diarrhoea can be caused in a number of ways, the com-
monest being infective. In this case diarrhoea may be a beneficial
Refeeding: breastfed infants should continue to be breastfed
physiological response to harmful material within the bowel,
during an episode of acute diarrhoea as it promotes faster
thus expelling the harmful bacteria and toxins from the body.
recovery and rehydration. Artificially fed infants may return to
Infective causes e results from either normal feeding after a 6 h period of oral rehydration solution if
damage to the mucosa (e.g. in rotavirus) they recover well. The long held myth that a lactose-free diet is
toxins produced by the infective organism itself (e.g. in necessary after diarrhoea is not evidence-based and the 3% of
cholera). children who develop reducing substances in their stools
Causative pathogens include: following diarrhoea will recover within 5 days (NICE guidance
on the management of acute gastroenteritis).
PAEDIATRICS AND CHILD HEALTH 22:10 445 Ó 2012 Published by Elsevier Ltd.
OCCASIONAL REVIEW
Cryptosporidium parvum e cryptosporidiosis. This proto- Nutritional status including height and weight and skin
zoan organism can cause chronic diarrhoea. Diagnosis is made fold thickness.
by specific antigen testing and although usually self-limiting may Suggested initial Investigations
be treated with nitazoxanide for 3 days. Full blood count
Viruses e in immunosuppressed children viruses such as C-reactive protein
cytomegalovirus can cause chronic diarrhoea and must be Erythrocyte sedimentation rate
considered in the differential diagnoses. Coeliac disease screen e anti-tissue transglutaminase
antibody and total serum IgA
Non-infective causes: Stool culture (including clostridium difficile and giardia).
Secondary to damage to the mucosa e in coeliac disease or Further specific investigations e secondary care
inflammatory bowel disease, inflammatory mediators act locally Stool assessment
within the intestinal mucosa to stimulate secretion and inhibit Stool electrolytes:
reabsorption of electrolytes. They also act on enteric neurones, to Other stool assessments:
increase motility.
Specific and rare abnormalities of enterocytes or the brush
border membrane e these are rare conditions usually presenting
as congenital or chronic diarrhoea from early infancy. Examples
include, congenital microvillus inclusion disease where there is
a net reduction in the surface area of the bowel and there is
massive excretion of electrolytes in the stools. Another rare cause Secretory Osmotic
is autoimmune enteropathy where anti-enterocyte antibodies
(IgG) damage the bowel mucosa. Osmotic gap <50 mOsm/kg >135 mOsm/kg
Specific and rare electrolyte transport defects Chloride concentration >40 meq/litre <35 meq/litre
Carbohydrate malabsorption: primary (very rare) or pH >6.0 <5.5
secondary lactose intolerance, sucroseeisomaltase deficiency, Sodium concentration >70 meq/litre <70 meq/litre
congenital glucoseegalactose malabsorption cause osmotic
diarrhoea due to the high osmolality of luminal contents.
Excessive fructose intolerance, usually the result of excessive
intake of fruit juices (especially apple juice) is known to cause
osmotic diarrhoea in children and should be considered as Imaging
a differential diagnosis in chronic diarrhoea. Barium meal and follow through/MRI enterography
Congenital chloride losing diarrhoea in which the chloride/ Endoscopy and biopsy.
bicarbonate transporter does not function resulting in high luminal
chloride levels and secretion of fluid. In this situation, the Na H
exchangers continue to operate, so hydrogen is secreted in the faces
without bicarbonate to neutralize it, thus resulting in a metabolic
alkalosis.
Pancreatic and biliary disorders e cystic fibrosis may lead to
pancreatic insufficiency and protein and fat malabsorption. The Test Normal values Implications/possible
contents of the intestinal lumen are therefore of a higher osmolality, diagnosis
resulting in osmotic diarrhoea. The liver disease, cholestasis may
cause reduced bile salts and insufficient fat malabsorption, thereby Alpha 1 antitrypsin <0.9 mg/g Protein-losing
causing diarrhoea secondary to highly osmolar luminal contents. levels enteropathy
Disorders of intestinal motility e these disorders may cause Steatocrit <2.5% (in older Fat malabsoprtion
rapid transport through the gut resulting in less overall absorp- than 2 years)
tion of electrolytes and water. Faecal elastase >200 micrograms/g Pancreas function
IBS variant of childhood e “chronic non-specific diarrhoea of Faecal calprotectin <50 micrograms/g Inflammation of the gut
childhood” or irritable bowel variant of childhood is a useful Faecal reducing Absent Carbohydrate
term for what used to be called toddler diarrhoea. This diagnosis substances malabsorption
is one of exclusion, but can be useful as many parents have heard
of it and there is often a positive family history.
PAEDIATRICS AND CHILD HEALTH 22:10 446 Ó 2012 Published by Elsevier Ltd.
OCCASIONAL REVIEW
PAEDIATRICS AND CHILD HEALTH 22:10 447 Ó 2012 Published by Elsevier Ltd.