3/24/2015

Cause of referral: Diarrhea!

Diarrhea in children

Erling Tjora
Consultant, PhD, Barneklinikken
Haukeland universitetssjukehus

Is it diarrhea?

Benjamin Spock 1903-1998.

Professor in pediatrics. Olympic gold medalist in rowing 1924

Is it diarrhea? Basic diarrheology in a nutshell

• What is diarrhea?? • Secretory
– Watery. Large volumes. No effect of fasting.
• Intestinal losses of • Osmotic
– Water – Watery. Lesser volumes. Improves by fasting.
– Electrolytes • Caused by malabsorption
– (and/or) Nutritional elements – Porridgy. Loss of nutritional elements. May be oily.
• Caused by motilitydisorders
– Hyper‐ or hypomobility

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History History
• Duration • What kind of diarrhea
• How often ( bowel movements per day) – Watery?  Porridgy?
– Blood?  Mucus?
• Other symptoms?
– Pain?
– Vomiting?
– Weight loss?

History The diarrheological history

• History of diseases
– In the child?
– Parents? Siblings?
• Short history of food intake
– Much milk? Regular meals?
– Fruit juices? Sweets? Fruits?
– Symptoms related to food intake?
• Travel history

Failure to thrive (Ikke mistrivsel)

Clinical examination
• Height and weight! • Impaired growth rate
– Find the centiles – Weight to age
– Head circumference in children < 1‐2 years – Weight to height
• General somatic examination – Head circumference
– Remember: The buttocks (and between) are parts  – Combined measures
of the body! • Weight to height
• Body mass index to age
• Often impaired general condition

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Distinguish between Typical course in grave FTT

• Following a low centile channel • Initial flattening of weight development
– Rule of thumb: Below 2.5 to 10th centile
• Crossing centile lines
– Rule of thumb: Crossing 2 centile lines • Followed by flattening of height development

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Possible accompanying findings Causative mechanisms

• Reduced subcutaneous fat • In principle three mechanisms
• Reduced muscular mass – Too little food available
• Alopecia – The child eats too little food
• Dermatitis – The child cannot utilize the food that has been
• Malnutrition syndromes eaten
– Kwashiorkor and marasmus

• But: Deviation in height, weight and head 

circumference most important diagnostic keys!

Causes in Norway Harms from failure to thrive

• Non‐organic failure to thrive • Delays somatic development
– Parental neglect causes failure to thrive
• Neglect causes the child to refuse eating
• Delays cerebral development
• Too little food – Early failure to thrive may inflict damage on later 
• Wrong food cognitive, social and emotional development
– Organic failure to thrive • Especially when caused by neglect
• Gastrointestinal disease
• Neurological disease • Deficiencies of nutritional elements
• Cardiological disease
• Malignant disease
• …

Treatment Return to the girl with diarrhea…

• Treat causative condition • Is it diarrhea?
• Ensure adequate nutrition • Is there failure to thrive?
• Clinical reasons to suspect
– Malabsorption?
– Inflammatory bowel disease?
– Infection?
– Constipation?
– Allergy or intolerance?
– Toddler’s diarrhea?

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Malabsorption Commonest causes in Norway

• Causative mechanisms • Intestinal diseases
– Intestinal diseases – Celiac disease
• Reduced functional mucosal area – Food intolerance / allergies
• Maldigestion – Inflammatory bowel disease
– Diseases of liver or bile
• Exocrine pancreas
– Diseases of the exocrine pancreas
– Cystic fibrosis

Initial diagnostic work‐up Inflammatory bowel disease

• Simple malabsorption status • May also occur in children
– Hematology, iron status, folic acid, cobalamines,  • Often more aggressive course than in adults
albumin, calcium, (fat soluble vitamins)
• Celiac disease most common! • Typical onset symptoms
– Wide indication for celiac serology – Diarrhea
• Even when clinical suspicion is not very strong – Pain
• Liver status – Blood and mucus in stools
• Exocrine pancreas – Weight loss / failure to thrive
– (Fecal elastase) – Perianal dermatitis / fistulas

Initial diagnostic work‐up Toddler’s diarrhea

• Blood samples • Clinical presentation
– Hematology, albumin, CRP, sedimentation rate,  – 1‐3 years of age
liver samples
– Often a lot of sweets and fruit juices
• Stool samples
– Loose stools several times a day
– Calprotectin. Occult fecal blood.
– Healthy appearance
• Rule out infection
– No failure to thrive
– Pathogenic intestinal bacteria, virus, parasites
– «Peas and carrots diarrhea»

• Refer to specialist for endoscopy and imaging

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Diagnostic work‐up and measures
• Diagnosis is based on history and clinical
presentation
– Blood samples seldom indicated, but consider Intussusception
screening for celiac disease
• Measures
Appendix
– Reassure parents
– Limit sweets and fruit juices
– Follow clinics and growth development

Intussusception Symptoms
• Intestine invaginates into itself • Typical: Pain intervals
– Causes intestinal obstruction – Small children crouches and cry
– Norwegian: invaginasjon
– May be symptomfree between intervals
• Dangerous!
• Typical age of onset • Cerebral symptoms may dominate
– 3 months to 6 years – Apathy, aloofness
– Most common < 2 years – Pain may be less evident in infants
• Ethiology • May have normal stools
– Idiopathic – Typically bloody mucus per rectum (currant jelly)
– Often after viral infections
• If left untreated: More typical mechanical ileus

Clinical findings Diagnosis and treatment

• Abdominal pain on palpation • Imaging
– May be less evident between pain intervals – Ultrasound: The doughnut sign
– Barium enema
• In textbooks: Palpable resistance in upper
– Normal plain abdominal x‐ray does not exclude
right quadrant… diagnosis
• May find bloody mucus on rectal examination • Treatment
– Reposition by barium enema
• Make a radiologist’s day!
• Clinical diagnosis may be difficult!
– Surgery
– Non‐typical is typical

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Imaging Differential diagnosis

• Don’t forget otoscopy!