Chronic diarrhea

Question 1

Definition

Answer 1

Chronic diarrhea – WHO
 ≥ 3 loose /watery stools/day
 Stool weight
 >10 g/kg/day – infants and toddler
 > 200 g/day older children

 Lasting more than 2 weeks

Question 2

Causes of chronic diarrhea

Answer 2

 Toddler diarrhea
 Post enteritis syndrome
 Lactose intolerance
 Food allergies
 Celiac disease
 Cystic fibrosis
 Giardiasis
 Inflammatory bowel disease
 Pseudomembranous colitis
 Acrodermatitis enteropathica
 Primary intestinal lymphagiectasia
 Hormone secretory diarrhea (neuroendocrine tumor)

Question 3

Etiologic suspicions from age of onset

Answer 3

EARLY INFANT
(1-6 MO)

INFANT AND TODDLERS
(6 MO-4 YRS)

 Post infectious
 Allergic
 Chronic infection
 Fat mal digestion
 Pancreatic insufficiency
 Cholestasis

…..Also consider
 Celiac disease
 Functional (Irritable
Bowel Disease)
 Dietary
 Antibiotic medication
associated

SCHOOL
AGE/ADOLESCENT
….Also consider
 Inflammatory bowel
disease
 Functional (IBS)
 Lactose intolerance

Question 4

History / Clinical exam (1)

Answer 4

 Age of onset
 Stool characteristics
 Frequency
 Volume
 Blood, mucus
 Nocturnal
 Symptoms associated
 Intestinal
 Urgency
 Tenesmus
 Extraintestinal
 Joint
 Skin

 Nutritional status

Question 5

History / Clinical exam (2)

Answer 5

Inflammatory
 Colonic mucosal inflammation (mucus, blood in stool): allergic, IBD, infections
 Fatty – Fat digestion/malabsorbtion (oily, greasy stool, but, my appair
watery – fatty, bile acids stimulate secretion) – malnutrition!
 Small intestinal mucosal disease
 Immunmediated: celiac, allergic enteropaty,Crohn disease
 Infection (Giardia)
 Postinfection enteropaty
 Pancreatic exocrin insufficiency
 Cystic fibrosis
 Bile acid defficiency
 Chronic Colestasis
 Terminal ileal disease
 Intestinal resection

 Watery
 no nocturnal diarrea, normal growth
 Specific trigger
 Carbohydrat ingestion
 Lactase insufficiency
 Dietary excess of sorbitol, fructosis
 Osmotic laxative
 Non- specific trigger (Roma IV criteria)
 Irritable bowel disease
 Functional diarrea
 Nocturnal diarrea/fasting (secretory mixted)
 Infection (giardia)
 ….(see fatty stool)

Question 6

Toddler diarrhea

Answer 6

 Toddler diarrhea (6 - 36 mo),
 Normal clinical aspect. No malnutrition. No
malabsorption
 Frequently in “health children”
 Etiopatogeny - not clear
 Post-enteritis syndrome
 Dietetic errors
 High intake of carbohydrates and fruits
 Low lipids intake

Question 7

Toddler diarrhea symptoms and treatment

Answer 7

Symptoms:
 3-6 stools/day,
 with/without maldigestion food,
 with/without mucus,
 Consistently in the morning, fluids in the second part of
day

 The growth charts – normal
 Treatment:
 Correction nutritional errors
 Increase lipids intake
 Normal fiber intake
 Limited fruits and juice intake

Question 8

Postenteritis syndrome

Answer 8

 Prolonged diarrhea (>2 weeks) after acute
diarrhea episode (generally in children <2 yrs),
without weight recovery
 Etiology:
 Persistent infection
 Re-infection with another pathogens
 Immunological sensitization to food allergens
 Secondary lactose intolerance
 SIBO (small intestinal bowel overgrowth)

Question 9

Postenteritis syndrome
Labs and diet

Answer 9

 Labs
 Culture
 Coprocitogramm
 Occult blood losing
 Nutritional evaluation (complete blood count, iron,
calcium, protein etc)

 Diet:
 Increase caloric intake (nasogastric tube)
 Lactose free formulas – suspected lactose intolerance
 Eliminate Cow milk protein – suspected CMA

Question 10

Lactose intolerance

Answer 10

 Types:
 Congenital lactase deficiency – rarely
 Adult type deficiency (congenital)
 Secondary lactose deficiency
 Acute gastroenteritis
 Inflammatory bowel disease
 Celiac disease
 Etc

Question 11

Adult type lactose deficiency

Answer 11

 Gradually decrease lactase activity
 Autosomal recessive
 Prevalence :
 2% Scandinavia
 70% Italy
 20% USA – white population
 Up to 100% Asia
 Clinically manifest – adolescent/older child

Question 12

Diagnostics

Answer 12

 Lactose Breath
test

 Activity level lactase
(biopsy)

 pH stool (< 5)

Question 13

Celiac disease

Answer 13

 Classic definition :
 Gluten sensitive enteropathy in genetically
predisposed individuals
 Mucosal lesions are due to an immune
response triggered by gluten

 Classically , chronic diarrhea with steatorrhea,
abdominal distension, failure to thrive,
asthenia, irritability
 Important : the gastrointestinal manifestations
may be missing

Question 14

Celiac disease definition

Answer 14

check lecture

Question 15

What is gluten?

Answer 15

 Term defined a group of protein witch find in
theory only in wheat.
 In practice, term is use for any protein witch cause
symptoms.
 In reality, the prolamines are those that allows us to
eat a certain cereal when we suffer from celiac
disease
 Each of grain prohibited contain one prolamine:
 Wheat contain gliadin,
 Rye contain …… secalin
 Barley contain …..hordein

Question 16

Active celiac disease
Symptoms

Answer 16

 Failure to thrive
 diarrhea
 Irritability
 Vomiting
 Anorexia
 fetid stool
 Abdominal pain
 Rectal prolapse

Question 17

Active celiac disease
Signs

Answer 17

 Height < 25 P
 Body weight < 25 P
 Wasted muscles
 Abdominal distension
 Edema
 Finger clubbed

Question 18

Non intestinal manifestations and association of celiac
disease:

Answer 18

 Dental enamel hypoplasia of permanent teeth
 Osteopenia/osteoporosis
 Short stature
 Delayed puberty
 Iron deficiency anemia non responder to oral iron
therapy
 Hepatitis (elevated liver enzyme)
 Arthritis
 Epilepsy (with or without occipital calcification )
 Headache
 Depression
 Ataxia
 Myelopaty

Question 19

Celiac disease
Autoimmunity
Syndromes
Malignancy

Answer 19

 Autoimmunity
 Diabetes mellitus type 1
 Tyroiditis
 Primary biliar cirrhosis
 Addison disease
 Dermatitis herpetiforms
 Syndromes
 Turner
 Down
 William
 Malignancy

Question 20

Celiac disease
Labs

Answer 20

 Anti-tissue transglutaminase IgA antibody test
(TTG) –highly sensitive and specific
 Anti-endomisium IgA antidody (EMA) –
interpretation is operator depedente
 Anti gliadin IgA and IgG – lack specificity

! Important – check IgA deficiency

Question 21

Celiac disease
Small intestinal biopsy

Answer 21

 Small intestinal biopsy (Marsh criteria’s)
 the characteristic histological changes include:
 partial or total villous atrophy,
 crypt elongation and decrease villous/crypt ratio
 Increase number of intraepitelial lymphocytes
 Genetic test – DQ2, DQ8 –

 If the Anti-tissue transglutaminase IgA
antibody (TTG) - 10X NV and genetic test
positive – is not necessary the biopsy

Question 22

Who should be tested for CD?

Answer 22

Lecture

Question 23

Changes since 2012

Answer 23

Lecture

Question 24

Celiac disease

Answer 24

 The only treatment is lifelong exclusion of
gluten
 Wheat free diet
 Barley free diet
 Rye free diet

Question 25

Cystic fibrosis
GI manifestations

Answer 25

 Meconial ileus
 Intestinal obstruction
 Rectal prolapse
 Chronic diarrhea
 Gallstones
 Chronic liver disease

Question 26

Presenting features of more than 20.000 cystic fibrosis patients in USA

Answer 26

Lecture

Question 27

Cystic fibrosis
Treatment

Answer 27

 Treatment respiratory tract

 Nutritional treatment
 Pancreatic enzyme replacement- high doses
 Vitamin and mineral supplementation

 In specialized department

Question 28

Malabsorption
SOS

Answer 28

lecture