chronic diarrhea in pediatric

2. What is chronic diarrhea?
• Diarrhea is loose, watery stools.
Chronic diarrhea typically lasts for
more than 2 weeks

3. WHAT ARE CAUSES OF CHRONIC DIARRHEA
IN CHILDREN
Common causes include
Infections
Functional gastrointestinal (gi) disorders
Food allergies and intolerances
Inflammatory bowel disease (ibd).
Infections, food allergies and intolerances, and ibd
may cause chronic diarrhea along with
malabsorption which leads to malnutrition.
Functional gi disorders do not cause malabsorption

4. CHRONIC DIARRHEA CAUSES ACCORDING TO
AGE :
In infancy :
formula protein intolerance-1
secondary lactase deficiency.postinfecious-2
3- microvillus inclusion disease
4- congenital defects like cong, glucose galactose
malapsorption
5-autoimmune enteropathy

5. In toddlers:
.celiac dis-1
2- giardiasis
cystic fibrosis-3
bowel dis.irritable-4
5- secretary dia. From tumors
In school age children:
irritable bowel dis.-1
2- appendicitis
lactaseprimary acquired-3
deficiency
4-milk protein intolerance
dia. From tumorcretaryseinflammatory bowel-5

6. DEFERENTIAL DIAGNOSIS
Chronic Diarrhea
Without Failure to
Thrive
1. Chronic Nonspecific Diarrhea of Childhood or Infancy
2. Infectious Colitis.
3. Disaccharide Intolerance
4. Small Bowel Bacterial Overgrowth
5. Irritable Bowel Syndrome

7. CHRONIC DIARRHEA
WITH FAILURE TO THRIVE
1. Intractable Diarrhea of Infancy.
2. Allergic Enteropathy
3. Celiac Disease
4. Inflammatory Bowel Disease
5. Immunodeficiency States
6. Congenital Secretory Diarrhea
7. Microvillous Inclusion Disease
8. Autoimmune Enteropathy
9. Neuroendocrine Tumors
10. Hirschsprung Disease
11. Cystic Fibrosis
12. Factitious Diarrhea

8. INFECTIONS
• Infections from viruses, bacteria, or parasites sometimes
lead to chronic diarrhea. After an infection,
some children have problems digesting carbohydrates, such
as lactose, or proteins, such as milk or
soy proteins These problems can cause prolonged
diarrhea— often for up to 6 weeks—after an
infection.

9. FUNCTIONAL GASTROINTESTINAL
DISORDERS
Irritable Bowel Syndrom. The most common
symptoms of IBS are cramping abdominal pain or
discomfort along with changes in bowel habits,
such as diarrhea. The pain or discomfort of IBS
typically gets better with the passage of stool or
gas. IBS does not cause symptoms such as weight
loss, vomiting, or blood in the stool. Possible causes
include problems with nerves in the intestines,
problems with nerve signals between the brain and
the intestines. Psychological problems, such as
anxiety and depression, or food sensitivity may also
play a role.

10. FOOD ALLERGIES AND INTOLERANCES
• Food allergies, celiac disease, lactose intolerance,
and dietary fructose intolerance are common
causes of chronic diarrhea.
• A food allergy is a reaction by the immune
system, the body’s natural defense system, to oneor
more proteins in certain foods.. Cow’s milk and soy
hat affect the GI tract in children. Food allergies
usually appear in the first year of life. Allergies to
other foods, such as cereal grains, eggs, or seafood,
may also affect the GI tract,allergies are the most
common food allergies

11. LACTOSE INTOLERANCE
• Lactose is a sugar found in milk or milk products.
Lactase, an enzyme produced by the small
intestine, breaks down lactose into two simpler
forms of sugar: glucose and galactose. The
bloodstream then absorbs these simpler sugars
• Congenital lactase deficiency—an extremely rare
inherited genetic disorder in which the small
intestine produces little or no lactase enzyme at
birth—can cause lactose intolerance in infants.
Children of any age may develop temporary lactose
intolerance after a viral diarrheal episode or
other infection.

12. INFLAMMATORY BOWEL DISEASE
• Inflammatory bowel disease causes irritation and
inflammation in the intestines. The two main types
of IBD are ulcerative colitis and Crohn’s disease. These
disorders can affect children at any age;
however, they commonly begin in the grade school years
or in adolescence. The causes of IBD are
unknown. Ulcerative colitis is a disease that causes
inflammation, or swelling, and ulcers in the inner
lining of the large intestine leading to bleeding,
production of pus, diarrhea, and abdominal
discomfort.
• Crohn’s disease is a disease that causes inflammation
and irritation of any part of the GI tract

14. MANAGEMENT FOR CHRONIC DIARRHEA
There are 3 phases:
Resuscitation phase (24-48 hours).
Control of diarrhea (up to 7 days).
Rehabilitation phases (up to 8 weeks).
Resuscitation phase
Correction of dehydration, shock,
electrolyte disturbance hypoglycemia
and renal failure.
IV line, vital sing monitoring and
blood investigation.
appropriate antimicrobials.

15. CONTROL OF DIARRHEA
This phase depends on our diagnosis from hx ex and inves
tigations
and is done according to each disease.

16. REHABILITATION PHASES:
:Aims
To improve the general health and nutritional state.
To correct nutritional deficiencies.
For catch-up growth.
To educate the parents especially to prevent future relapse.

17. DIETARY MANAGEMENT
:Goals
Avoid all feeds till diarrhea is at least partially controlled
Small frequent feeds
Start with high carbohydrate, low protein and no fat regime.
Avoid those substance which are responsible for the disease (cow’s
milk, eggs, gluten…ect).
Provide micronutrient and vitamins.
The diet should not be hyperosmolar and should not produce
adverse effects
or worsen the diarrhea.

20. CELIAC DISEASE

21. ETIOLOGY AND EPIDEMIOLOGY
• Celiac disease, or celiac sprue, is an immune-
mediated injury to the mucosa of the small intestine
triggered by the ingestion of gluten (a protein
component) from wheat‫قمح‬,rye‫الذرة‬,barley‫شعيز‬,and
related grains.
• Rice does not contain toxic gluten and can be eaten
freely.
• In its severe form, celiac disease causes malabsorption
and malnutrition.
• many patients have few or no obvious or classic
symptoms.
• The disease is seen in association with diabetes and
trisomy 21.

22. CLINICAL MANIFESTATIONS
• Symptoms can begin at the age when gluten-
containing foods are given.
• Diarrhea, abdominal bloating, failure to thrive,
irritability, decreased appetite, and ascites caused
• Children may be minimally symptomatic or may
be severely malnourished.
• Constipation is found in a few patients, probably
because of reduced intake.
• A careful inspection of the child’s growth curve
and determination of reduced subcutaneous fat and
abdominal distention are crucial.by
hypoproteinemia are classic

24. ASTROINTESTINALGONN
ANIFESTATIONSM
Dermatitis Herpetiformis
Dental enamel hypoplasia
of permanent teeth
Osteopenia/Osteoporosis
Short Stature
Delayed Puberty
Iron-deficient anemia
Hepatitis
Arthritis
Epilepsy with occipital
calcifications

26. LABORATORY AND IMAGING STUDIES
• Serologic markers include IgA antiendomysial
antibody and IgA tissue transglutaminase
antibody.
• An endoscopic small bowel biopsy ( definitive
diagnosis( is essential to confirm the diagnosis
and should be performed while the patient is still
taking gluten. The biopsy specimen shows varying
degrees of villous atrophy (short or absent villi),
mucosal inflammation, crypt hyperplasia, and
increased numbers of intraepithelial lymphocytes.
• Other laboratory studies should be performed to
rule out complications, including complete blood
count, calcium, phosphate, total protein and
albumin, and liver function tests

27. TREATMENT
• Treatment is complete elimination of gluten
from the diet.
• Most patients respond clinically within a few
weeks with weight gain, improved appetite, and
improved sense of well-being.
• Histologic improvement requiring several
months to normalize.