Diarrhea and malabsorption:

*diarrhea is considered chronic when it is more than 2 weeks in duration.

*how do you know from the history that the baby is losing fat in stool? Ask
about greasy skin after passing stool ‫بكون زي الفازلين بس تغسلو‬
*case 1: 6 weeks old infant, presented with diarrhea since 3 weeks what is you
differential diagnosis?
A) Cystic fibrosis: 90% of the cases presented at the first year.
-85% of the infant who failed to pass meconium will be diagnosed in cystic
fibrosis.
-ask about:
1) Recurrent Respiratory infection
2) Steatorrhea
3) Jaundice (increase in direct bilirubin)
4) Ask about family history of cystic fibrosis or consanguinity between the
mother and father.
B) Cow milk protein allergy
c) Hirschsprung disease: initially may be presented as enterocolitis
- In normal embryology innervation starts from proximal to distal.
Aganglion lesion
Lesion < 5 cm Ultra-short
Lesion = 5 cm Short
Lesion more than 5 cm long

*work up:
1) Stool RBC: positive in inflammatory process (infectious and allergy)
2) Stool WBC: must be <5
*rotavirus is not invasive so you can’t see RBC or WBC in the stool.
3) Stool ph: normally it is above 5.5.
*if the patient doesn’t have stool RBC or WBC and his stool is acidic think about
carbohydrate malabsorption (because of the fermentation)
How do we get sure that it is carbohydrate malabsorption? By test called: stool
reducing substance, it should be increased in carbohydrate malabsorption.
4) Stool elastase: this is for cystic fibrosis
5) Stool coefficient ratio: for fat malabsorption and cystic fibrosis,
You ask the patient to write everything that he eats for 3 days and collect the
stool for these days and see how much it contains fats, and let the nutrition
calculate the patient intake of fats from his food.
Normally 90% of fats are absorbed.
6) Sudan stain: not effective, because normally there is a small percentage of
fats in the stool.
Now we finished this case.

Types of diarrhea:
A) Secretory diarrhea: diarrhea is persistent even if the patient is not eating
anything and this occurs in cholera and neuroblastoma.
B) Osmotic diarrhea
How to differentiate clinically? Ask the patient to stop eating for 24 hours and
see if he is improving or not, if he improves than It is osmotic.
And to get sure calculate the stool osmotic gap
Stool osmotic gap: measured stool osmolality – calculated stool osmolality
Calculated stool osmolality= (stool sodium + potassium) *2
And measured osmolality is considered usually 290
*high anion gap = osmotic diarrhea
*low anion gap= secretory diarrhea
*proteins:
-now how to know that the stool contains protein?
There is a protein once it goes into the gut it can’t be absorbed again, this
protein is alpha 1 antitrypsin, so do “stool alpha 1 antitrypsin test”

If the diarrhea started from the first day of his life?

Think about:
A) Glucose-galactose malabsorption:
-autosomal recessive
-the infant has lactase but he has allergy to monosaccharides
b) Congenital chloride diarrhea:
-the infant can’t absorb chloride, so chloride goes into stool and this
increases the bicarbonate (Hco3-) in the blood and cause alkalosis
c) Congenital sodium diarrhea: same idea as the above
*so hypo chloric hypokalemic metabolic alkalosis occurs in: b, c, pyloric
stenosis, cystic fibrosis and bartter syndrome (in which there is tumor
that secrete furosemide like substance)

Now we will talk about toodler syndrome:

-occurs because of high sorbitol levels (high amounts of fruit juices)
-Occurs between the ages of 6 weeks – 2months
-Doesn’t affect the growth – no weight loss-
-no pain
-comes at the night

*if the previous patient is 1 year old what your differential diagnosis is:
1-infection
2-immunodefict
3-cystic fibrosis
4-celiac disease
-ask about: stool, intake, when he stops increasing in weight, what the
child eats, and recurrent infection and if he drinks fresh water (giardia).
*work up:
1-stool ph, RBC, WBC, culture
2-CBC:
A) Eosinophils
B) MCV normally above 28
c) MCH normally above 80
d) IRW: iron width increases in iron deficiency.
e) Hemoglobin
**if the patient has hypochromic microcytic anemia think of thalassemia
or sideroblastic and iron deficiency anemia so do mintzer index
**mintzer index: MCV /RBC normally it is 11-13
If it is below 11 so it is thalassemia and if it is above 13 so it is iron
deficiency anemia.
*please know that the platelets increase in iron deficiency and ferritin
increase in inflammatory process

3-total protein and albumin

4-immunoglobulin
5-vitamin D
6-pt/INR (for the assessment of vitamin K levels)
7-serum carotene levels (for the assessment of vitamin A levels)
8-vitamin E
9-serum iron
10-serum ferritin
**if the patient has hypochromic microcytic anemia think of thalassemia
or sideroblastic and iron deficiency anemia so do mintzer index
**mintzer index: MCV /RBC normally it is 11-13
If it is below 11 so it is thalassemia and if it is above 13 so it is iron
deficiency anemia.
*please know that the platelets increase in iron deficiency and ferritin
increase in inflammatory process
11-celiac disease tests:
A) Anti tissue Trans glutamate IgA (TTGIgA) and if the patient has IgA
deficiency do (TTGIgG)
b) Anti endosomal antibody
12- Cystic fibrosis tests:
a) Stool elastase
B) Sweet chloride test: by putting 2 electrodes on the skin and see the
conductivity
1- <40 normal
2- 40-60 you should repeat it ‫مشكوك فيه‬
3- above 60 cystic fibrosis
But there is false negative in dehydration of if he is taking diuretic and
also we have false positive.

Now we will take about cystic fibrosis:

-autosomal recessive
-the most important gene that cause it (delta f508)
-mostly the patient failed to pass meconium
-recurrent respiratory infections
-nasal polyps
The patient will get chronic lung disease and infertility and low life
expectancy.
Now if the child is 8 years old what is your differential diagnosis?
A) Giardia
b) Cystic fibrosis
c) Celiac
D) Inflammatory bowel disease (high ESR)
1-crohn disease (you will find ASCA)
2- Ulcerative colitis (you will find ANCA)