PERSISTENT AND

CHRONIC
DIARRHEA
 Objectives
• Definition of diarrhea
• Incidence
• Etiopathogenesis
• Approach and Evaluation of a child with CD
• Management
• Case scenario
definition
• Diarrhea is a condition characterized by a change in the consistency
and frequency of stools compared to the normal bowel habit of the
child.
 Definition

• Stool consistency and frequency

• Stool volume >10 g/kg per day in infants and toddlers and >200
g/day in older children
• >14 days of symptoms
• Increase in Stool looseness, volume and frequency – relative to
usual pattern of individual
3<liquid stools per day
• Infants – have semi-liquid stools
• Breast fed babies have -10 loose stools, acidic, peculiar smell
Epidemiology
• About 60% PD occurs before 6 month and 90% below 1 year of age.
• According to WHO, PD account only 10% of diarrheal episodes but about 35% of diarrheal death
in children below 5 years is due to it.
 Secretion Motility

Exudation
Osmosis (inflammation
)
Basic
Pathophysiology
 PERSISTENT DIARRHEA CHRONIC DIARRHEA

Duration >=14 Days >14 Days

Etiology Infectious Usually non

infectious(CMPA,Celiac
disease,Giardiasis/amebiasis
,Immunodeficiency,Cystic
fibrosis,Intractible diarrhea
of infancy,hormone
mediated)
Onset Acute Insidious
Factors that contribute to Persistent
Diarrhea:
although persistent diarrhea start as acute infectious diarrhea but
prolongation is not entirely due to infection. It is contributed by
following factors-

Primary malnutrition leading to enteropathy

Infection with pathogenic E.coli(specially the enteroaggregative and entero adherent), shigella, salmonella,
campylobacter
Other bacterial infections such as urinary tract infections, otitis media ,etc.
Host factors(macro , micro nutrients deficiency and immunocompromised state)
HIV infection and cryptosporidiosis
Antibiotic associated diarrhea
Secondary lactose intolerance
Natural history of diarrhea
 Approach to a chronic
diarrhea
1.Is it Chronic Diarrhea

. ?
2. Secretory or Osmotic Diarrhea ?
3. Small bowel or Large Bowel Diarrhea ?
4. Inflammatory or Non-Inflammatory
Diarrhea?
5. Malabsorption or Maldigestion
Basic tests in diagnosis of chronic diarrhea
Type
Osmotic vs Secretory diarrhea
Fatty diarrhea
Protein losing enteropathy
Pancreatic Insufficiency
Tests
Stool pH, reducing substance
Stool electrolytes
Stool osmotic gap
Breath hydrogen test
Sudan stain
Acid steatocrit
72 hr stool fat
Fecal Alpha-1-antitrypsin
Fecal elastase/chymotrypsin
Secretin test
 Specific Tests in diagnosis of chronic
diarrhea
Cow’s milk protein allergy (CMPA): Immunoglobulin profile and proctosigmoido-
scopy with biopsy .
Celiac disease Duodenal biopsy (Marsh grade ≥ III), a positive
serological test (IgA antiendomyseal antibody of
tissue transglutaminase antibody) and response
to gluten free diet by 8-12 weeks, is essential for
diagnosis.

Giardiasis/Amebiasis: Microscopic examination of freshly passed stool

Immunodeficiency associated diarrhea : Immunoglobulin profile,

Cystic fibrosis:
Hormone mediated secretory diarrhea:
and tests for HIV as well as for the enteric pathogens
(Shigella, Salmonella, Cryptospori-
Dium, Campylobacter)
Sweat chloride
Serum
gastrin, VIP, somatostatin, and calcitonin.
 Chronic
Diarrhea

No weight loss Wt Loss, Fever,

Wt Loss
Nutrition-N inflammation

Non-specific
symptoms Malabsorption
Rectosigmoidoscopy

ROME 4- IBS UGIE

Exclude fruits Serology- tTga

Management
There are three principles of management:
1. Control of diarrhea and its consequences
2. Treatment of infections, if any
3. Nutritional rehabilitation and correction of malnutrition
Need of hospital admission
• Age <4 months and not breast feed.
• Presence of dehydration.
• Severe acute malnutrition.
• Presence or suspicion of systemic infection.
Control of diarrhea and its consequences
• Assessment of dehydration and management of it by plan A,B and C.
• Correction of electrolyte imbalance
• Correction of hypoglycemia.
Identifying and treatment of infection
• A thorough clinical examination for chest infection , otitis media or signs of sepsis
• Examination of perineum and oral cavity for superadded fungal infection
• CBC, CRP, total protein and albumin, blood sugar, electrolytes, blood and urine cultures, and chest
radiograph
• Stool routine examination and culture usually have no role in management of PD
• Stool for opportunistic infections such as fungal hyphae, cryptosporidium, and assay of
Clostridium difficile toxin A and B in appropriate clinical setting are advisable.
• Start antibiotics: Quinolones/oral third generation cephalosporins in the presence of gross blood
in stools; parenteral ampicillin and aminoglycosides in sepsis, children <3 month of age or
associated extra gut infections and HIV.
• Start antifungals fluconazole 6 mg/kg/dose for 4–6 weeks if there is oral thrush, or perineum
showed fungal infection
Nutritional Management
• Feeding should be started at the earliest.
• Initially 6-7 feeds/day, a total calorie intake 100 kcal/kg/day.
• Calorie intake should be increased gradually over 1-2 weeks to
150kcal/kg/day.
Choice of diet
• Always start with diet A(low lactose diet) for 7 days.
• If there is no response after a week then start diet B(lactose free diet).
• If no response to diet A/B then start diet C for 7 days.
• If no response after a week, then elemental diet such as hydrolysed or
amino acid formula may be started .
• If still no response after a week then child may require total
parenteral nutrition and refer to paediatric gastroenterologist.
Indications for the change from initial diet(diet A) to the next
diet(diet B or diet C):
the diet should be changed to the next level, if the child shows
• Marked increase in stool frequency (>10 watery stools/day) at any
time after 48 hr of initiating diet.
• Features of dehydration any time after initiating treatment.
• Failure to gain weight gain by day 7 (in absence of any systemic
infection )
Nutritional supplement
• A dose of parenteral vitamin K should be given at admission.
• After the infant has begun to improve and gaining weight, 3mg
/kg/day of iron is added.
Green banana diet
• Green banana diet is gaining acceptance for treatment of PD. The
amylase resistant starch present in this is not digested in small
intestine and reaches colon. Colonic bacteria ferment this to short
chain fatty acids which have trophic effects for colon and increase the
absorption of salt and water.
Strategies to prevent DIARRHEA
• promotion of exclusive breastfeeding.
• safe complementary feeding practices.
• promotion of safe drinking water.
• low osmolality ORS.
• zinc supplementation.
• avoiding unnecessary antibiotics.
• continued feeding during diarrhea.
Thank you