Chronic diarrhea: clinical

approach

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 Objectives
• Definitions
• Epidemiology
• Etiology
• Pathophysiology
• Diagnosis, diagnostic approach
• Management

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 Chronic Diarrhea
Definition
• persistence of loose
stools (generally with an
increase in stool Chronic
frequency) for at least
14 days
• Volume definition:
> 10 g/Kg/d for infants
Persistent Protracted
> 200 g/d for older
children and adolescents

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 Chronic Diarrhea
Epidemiology
• Infectious etiology are common in resource-
limited region
• Risk factors:
age < 2 years
malnutrition
other concurrent infections

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Main etiological groups of chronic diarrhea in population of 354 children.
(Guarino A, Vecchio AL, Canani RB. Chronic diarrhea in children. Best Practice & Research
Clinical Gastroenterology 26 (2012) 649–661)

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Causes of chronic diarrhea in Saudi Arabia

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 Chronic Diarrhea
Pathophysiology

Osmotic
Secretory
Inflammatory
Malabsorptive
Motility disorder
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Osmotic Secretory

Stops with fasting Continues with fasting

Moderate volumes of Large volume of

stools watery stools

High contents of stool

Low stool electrolytes
electrolytes

Osmotic gap > Osmotic gap

125mOsm/kg <50mOsm/kg

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Inflammatory
• inflammation and exudation of the intestinal
• Stool usually mix with blood and mucous
Malabsorptive
• Defective fat digestion/absorption as pancreatic
enzyme defect, SI disease and villous atrophy
• Copious, offensive , greasy stool that stain
the toilet

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• Motility defect/functional
in Toddler’s diarrhea/ IBS
in bacterial overgrowth

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 Absorption and transport of
nutrients and electrolytes

enterocyte differentiation
and polarization

enteroendocrine cells
differentiation

modulation of intestinal
immune response
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 Chronic Diarrhea
Etiology
• Usually severe form
with underlying
serious AEs
• Many lead to
intractable diarrhea
and intestinal failure

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 Chronic Diarrhea
Patient evaluation
History
• Age of onset of diarrhea
• Character of stool (watery, inflammatory,
steatorrhea, undigested food), frequency of
stool passage
• Nocturnal diarrhea, fecal inconstancy
• Type of milk, how formula is prepared
• Temporal relation to a specified food
• Hospital admission, IVF replacement therapy
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• Associated symptoms (chest problems,
arthritis, skin lesions)
• Past hx of repeated infections
• Family history of atopy, similar disease,
consanguinity
• Perinatal history (polyhydramnos)

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 Examination
Assessment of nutritional status
• Weight
• Height
weight for height is the simplest index of growth
• Weight for height
failure secondary to malnutrition.
• MAC
• Triceps skin fold thickness
• Signs of nutritional deficiencies
• Delayed puberty

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• Skin lesions

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• Investigations
Start with stepwise approach with non-invasive
tests
Non-invasive tests for intestinal digestive-absorptive
functions

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Non-invasive tests for intestinal inflammation

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Other Investigations
• Blood samples:
➢ CBC with diffrential WBCS count
➢ ESR, CRP
➢ serum albumin (assess malnutrition)
➢ ABG, electrolytes
➢ hypocholeremic metabolic acidosis (CLD)
➢ hypocholeremic metabolic alkalosis (CF)
• Selected tests
➢ Serum TGs and cholesterol, acanthocytes (ABLP)
➢ Immunological tests
➢ CD serology (EMA IgA/IgG, tTG IgA/IgG)

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 Applied cases

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 Case 1
• A 15 month-old boy presented with diarrhea,
3-5 times of large explosive stools per day for
the last 8 weeks. Stool is not malodorous and
no blood or mucus. Mother describes it as
mixed with food particles.
• On examination, weight= 12 kg, height=84 cm.
His abdomen is non-distended with no
organomegaly. No perianal lesion. Stool was
heme negative

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Q1- The first studies to be ordered include:
A. Stool for fat, reducing substances and pH
B. A stool culture and fecal leukocyte
C. Parasitological examination of stool
D. All of the above
E. Non of the above

Q2- The most likely diagnosis of this infant is:

A. Chronic non-specific diarrhea of childhood
B. CHO malabsoprtion
C. Postinfectious malabsoprtion syndrome
D. Bacterial infection
E. Cystic fibrosis

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Q3- chronic diarrhea of this infant is due to:
A. Excess intake of fruit juices
B. Excess intake of CHO
C. Too little fat in his diet
D. All of the above
E. Non of the above

Q4- the treatment here includes:

A. Reassurance and limiting dietary excess
B. Clear liquids when diarrhea occurs> 5 times/d
C. Diphenoxylate/atropine when diarrhea occurs> 5 times/d
D. A and B
E. B and C

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Rome III criteria for diagnosis of chronic non-
specific diarrhea of childhood (Toddler’s
diarrhea)
1. Daily painless, recurrent passage of three or more
large, unformed stools
2. Symptoms that last more than 4 weeks
3. Onset of symptoms that begins between 6 and 36
months of age
4. Passage of stools that occurs during waking hours
5. There is no failure-to-thrive if caloric intake is
adequate

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 Case 2
• 8 month-old girl is presented with a history of
bloody diarrhea for the last 3 weeks. She is full
term infant, who has exclusive breast feeding for
six months. She started weaning and now she
receives potatoes, apples, and yogurt. She
received metronidazole and intestinal antiseptic
for treatment of assumed infectious cause of
diarrhea with no improvement.
• The examination: mild pallor, lax abdomen, no
masses. DRE: no masses, +ve blood on examining
finger
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Q1- The most probable diagnosis:
A. Infectious colitis
B. Lactose intolerance
C. Cow’s milk protein allergy
D. Fat malabsorption
E. Intussusception

Q2- treatment should include

A. Soy formula
B. Hydrolyzed formula
C. Await stool culture
D. Restrict cow’s milk in maternal diet
E. Lactose free formula

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 Case 3
A 15-month-old boy with failure to thrive. His birth
weight was 3.17 kg, he gained weight well initially
and was weaned at 6 months. His appetite has been
poor over the last couple of months. He has no
vomiting, passing loose smelly stool 5 times/day.
On examination: pale-looking infant, miserable and
cries easily. his abdomen is distended. There are no
signs of tenderness, masses or organomegaly. The
oral cavity and perianal area appear normal.

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Q1- the most likely diagnosis is:
A. Early Crohn’s disease
B. Celiac disease
C. Cystic fibrosis
D. Growth hormone deficiency
E. Immune deficiency

Q2- the lab test to confirm diagnosis

A. Hydrogen breath test
B. Tissue transglutaminase IgA
C. CBC and ESR
D. Sweat chloride test
E. pANCA

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Q3- treatment of this disorder include:
A. Gluten free diet
B. Evaluation for anemia
C. Evaluation for hypothyroidism
D. All of the above
E. Non of the above

Q4- this condition is more likely in:

A. 1st degree relative with celiac disease
B. Type 1 DM
C. Down syndrome
D. All of the above
E. Non of the above

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 Case 4
• 14 year-old girl with history of diarrhea for 6
weeks. Stool contains mucus and blood and she
has to wake up at night frequently to clear her
bowel. She has crampy abdominal pain and her
mouth sores. She has lost 4 kg over 4 weeks and
she does feel not well.
• Examination: body temprature 38.6˚ C, pale, thin.
Abdominal exam. revealed tenderness but no
guarding or rebound and no organomegaly.

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• Haemoglobin 10.9 g/dL
• WBC 15.2 10 /L 9

• Platelets 623 10 /L 9

• ESR 87 mm/h 15 mm/h

• CRP 36 mg/L
• Serum albumin 3 g/dl
• Stool – no bacterial growth, no ova, cysts or
parasites

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Q1- the most likely diagnosis:
A. Ulcerative colitis
B. Crohn’s disease
C. Infectious colitis
D. Food allergy
E. Immune deficiency

Q2- extraintestinal manifestations include:

A. Erythema nodosum
B. Uveitis
C. Pubertal delay
D. Arthritis
E. All of the above

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