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Program MCPS/MRCGP/CEFM CME ©

Course Paediatrics

Module GI

Topic Chronic Diarrhea

Credit Hours 1 CME credit hour

Total
Educational 2 educational hour
hours

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

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Prof. Nasir Shah
MCPS, FCPS, MRCGP [INT], FRCGP [INT]

Dean Family Medicine Faculty, College of Physicians

and Surgeons Pakistan

Convener National Family Medicine Committee of

Pakistan

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CHRONIC DIARRHEA ®
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• Diarrhea persisting >4wk

• Clarify what is meant by diarrhea

• Careful history is vital

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CAUSES OF CHRONIC DIARRHEA ®

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1. Malabsorption (celiac, lactose intolerance)
2. Infections and infestations (giardia, TB)
3. Inflammatory Bowel Disease
4. Intestinal lymphoma
5. Overfeeding

6. Irritable Bowel Syndrome (Diagnosis of exclusion)

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

MALABSORPTION ®
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1. Abdominal gaseous distention
2. Abdominal pain
3. Vomiting
4. Chronic or recurrent diarrhea
5. Pasty or foul-smelling stools (Steatorrhea)

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

MALABSORPTION ®
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Lack of bile Lack of digestive
enzymes

Less fats
Excess carbs
Excess food/fluid

Giardia TB Celiac Disease

Lymphoma Lactose intolerance
MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea
CAUSES OF CHRONIC DIARRHEA ®
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• Infections (TB)

1. GI Symptoms
2. Fever, Weight loss
3. Abdominal Cramps
4. Intestinal obstruction

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

INFLAMMATORY BOWEL DISEASE ®

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• GI symptoms
- Diarrhea
- Rectal bleeding
- Abdominal pain
• General symptoms
- Growth failure
- Malnutrition
- Pubertal delay
- Bone demineralization

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

INTESTINAL LYMPHOMA ®
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• Acute or subacute presentation (Duration of symptoms <1m)

1. Generalized or migratory bone pain (Cytopenias are

uncommon and suggest acute leukemia)

2. Symptoms of localized disease: Lymphadenopathy, tonsillar

hypertrophy, cough, dyspnea, chest pain, and dysphagia

3. Abdominal pain, constipation, masses, or ascites

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

ENDOCRINE (DM, THYROID) ®

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• Type 1 DM
• Polyuria, polydipsia, polyphagia, abdominal pain, vomiting

• Symptoms of Hyperthyroidism

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

INDIGESTION (BILE, PANCREAS) ®
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• Difficult to diagnose unless high index of suspicion

• Steatorrhea and weight loss

• Watery diarrhea (Osmotic load)

• Steatorrhea: Pale, bulky, malodorous stools, float on top, with

oily droplets, difficult to flush

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

OVERFEEDING OF MILK AND DIET ®

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• Fluid intake by young children of >100 mL/kg/d may result in
looser stools

• Fat intake of less than 3 g/kg/d may contribute to toddler's

diarrhea

• Worse if excessive fluid and carbohydrate intake (fruit juice

intake)

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CONSEQUENCE OF CHRONIC DIARRHEA ®
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1. Weakness & fatigue
2. Failure to thrive (protein, carbohydrates, fats deficiency)
3. Microcytic anemia (Iron deficiency)
4. Macrocytic anemia (Folate and B 12 deficiency)
5. Skin changes, angular stomatitis, glossitis, hair changes (B-
complex, minerals)
6. Vision changes (vitamin A)
7. Mental retardation (Iron)

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CHRONIC DIARRHEA | HISTORY ®

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• Nature of the diarrhea: Color, consistency, blood/mucus
• Contact with anyone else with similar symptoms
• Travel history
• Associated symptoms, e.g., fever, abdominal pain, abdominal
distension, vomiting, weight loss
• Association with other factors (e.g., food intolerance, stress)
• Family history: Inflammatory bowel, celiac disease, TB, cancer

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CHRONIC DIARRHEA: HISTORY ®
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Symptoms suggestive of malabsorption
• Steatorrhea—excess fat in faeces
• The stool is pale-colored
• Foul smelling
• Floats (‘difficult to flush’), in WC

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CHRONIC DIARRHEA: HISTORY ®

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Symptoms suggestive of organic disease
• Nocturnal symptoms
• Continuous diarrhea
• Significant weight loss
• Liquid stools with blood

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CHRONIC DIARRHEA | HISTORY ®
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Past medical history:
• Surgery (especially ileal resection or cholecystectomy)
• Pancreatic disease
• Systemic disease (e.g., DM, thyrotoxicosis)

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CHRONIC DIARRHEA: EXAMINATION ®

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Full examination
1. General Physical examination
2. Skin, hair, angles of mouth, tongue
3. Pulse
4. Detailed abdominal examination

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CHRONIC DIARRHEA: INVESTIGATIONS ®
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1. CBC with indices
2. ESR/CRP
3. LFTs
4. TFTs
5. Celiac serology
6. Stool microscopy C&S ± fecal calprotectin (useful in primary
care for distinguishing between IBS and inflammatory bowel
disease if <40y

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CALPROTECTIN ®
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• Protein biomarker in the faeces when intestinal inflammation
occurs
• Used to differentiate between IBD and IBS
• NICE recommends as a first-line test, in patients presenting
with gastrointestinal symptoms indicative of IBS or IBD.
• Rules out IBD if negative
• Avoid unnecessary endoscopy in IBS
• Also used in monitoring of IBD

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CHRONIC DIARRHEA | MANAGEMENT ®
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1. Treat the cause of chronic diarrhea
2. Refer if danger signs
3. Treat the consequence of chronic diarrhea
• Nutritional deficiencies
• Secondary lactose intolerance

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CELIAC DISEASE ®
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• Gluten sensitivity results in inflammation of the bowel and
malabsorption
• In children at ~4y
• Associated with HLA-DQ2 or DQ8
• Genetic predisposition
− First-degree relative (parent, sibling, child)
− Down’s/Turner syndrome

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

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MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CELIAC DISEASE ®
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MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CELIAC DISEASE | SYMPTOMS AND SIGNS ®
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• Chronic/intermittent diarrhea (50%)
• Recurrent abdominal pain/cramping/bloating
• Other persistent unexplained GI symptoms e.g., nausea/ vomiting
• Failure to thrive/faltering growth in children
• Sudden or unexpected weight loss
• Unexplained anemia (iron deficiency or other)

Failure to thrive GI symptoms Nutritional deficiencies

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CELIAC DISEASE ®
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• The examination is usually normal
• Some patients may have examination findings including:
1. Low weight
2. Skin rashes such as dermatitis herpetiformis
3. Mouth ulcers
4. Clubbing
5. Anemia and other nutritional deficiencies
6. Abdominal distension

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CELIAC DISEASE ®
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MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

DERMATITIS HERPETIFORMIS ®
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MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CELIAC DISEASE | SEROLOGICAL TESTING ®
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1. IgA anti-Tissue Transglutaminase antibodies (Anti TTG) or
2. Anti-Endomysial Antibodies (Anti EMA)

Test only if eaten >1 meal/d containing gluten for ≥6wk

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CELIAC DISEASE: TYPES OF ANTI TTG ®

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• Anti TTG IgA
• (Sometimes negative, but if strong clinical suspicion) check;

• Anti TTG IgG (with/without serum IgA level)

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CELIAC DISEASE: ENDOSCOPY ®
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Endoscopy and duodenal biopsy:

• Mucosal changes can be patchy

• At least four biopsies from different areas of the duodenum

are needed.

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CELIAC DISEASE ®
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Also consider??
• CBC
• ESR/CRP
• Vitamin B12
• Folate
• Ferritin
• LFTs
• And stool sample for Microscopy and C&S (if diarrhea)

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CELIAC DISEASE ®
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Initial management
• Refer

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CELIAC DISEASE MANAGEMENT ®

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• Patient education
• Gluten free diet (avoid wheat, barley, rye)
• Suggest alternates (maize, mallets, pulses, etc)
• Supplement the lost nutrients
- Iron, Calcium, Zinc, magnesium
- Water soluble vitamins (B, C)
- Fat soluble vitamins (A, D, E)
• Monitor growth and weight
• Pneumococcal vaccine
• Concomitant secondary lactose intolerance

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

GLUTEN CONTAINING FOODS ®
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MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CELIAC DISEASE MANAGEMENT ®

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Gluten-free diet
• Cornerstone of management of coeliac disease
• Should be followed lifelong
• Avoid proteins derived from wheat, rye or barley
• Avoidance of oats is controversial
• Refer to a dietician for specialist advice

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

TYPES OF FLOUR ®
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• Wheat ‫گندم‬
• Barley ‫جو‬
• Rye ‫رائی‬, ‫ديو گندم‬, ‫گهٹيا گندم‬
• Oat ‫جئی‬
• Maize ‫مکئی‬
• Millet ‫باجره‬
• Gram flour ‫بيسن‬

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

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Wheat Barley

Rye Oat

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

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MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

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Opposite Emporium Mall Gate | Johar Town, Lahore 0333 4271429

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

CELIAC DISEASE | COMPLICATIONS ®
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Long-term complications
• Osteoporosis in adult hood
• Lymphoma or carcinoma of the small intestine

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

LACTOSE INTOLERANCE ®
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• Inability to digest lactose in diet
• Deficiency of lactase enzyme on intestinal mucosa
• Primary: From birth and life long
• Secondary: Due to any illness affecting intestinal
mucosa. Transient.

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

DIAGNOSIS OF LACTOSE INTOLERANCE ®
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1. Lactose Hydrogen breath test

2. A 3-week trial of a diet that is free of milk and milk products

is a satisfactory trial to diagnose lactose intolerance

• Foods to be avoided – milk products

• Take yogurt

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

TREATMENT OF LACTOSE INTOLERANCE ®

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• Avoid milk products
• Take yogurt

• Take Lactase enzyme tablets

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

GIARDIA INFECTION ®
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MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

TREATMENT OF GIARDIA CYSTS ®

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• Chronic diarrhea due to Giardia cysts

• Metronidazole 30 mg/kg in 3 divided doses for 10 days (DNS)

• Not mentioned in any book/guideline

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

REFERENCES ®
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• https://www.nice.org.uk/guidance
• https://www.patient.co.uk
• https://www.aafp.org
• https://www.mayoclinic.org
• https://www.medscape.com
• https://www.who.int
• https://www.webmd.com
• Oxford Handbook of General Medicine, 5th edition

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea

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MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Chronic Diarrhea