Non resolving acute diarrhea

Anshu SrivastavaDepartment of Pediatric Gastroenterology

Sanjay Gandhi Postgraduate InstituteLucknow

Anshu SrivastavaDepartment of Pediatric Gastroenterology

Sanjay Gandhi Postgraduate InstituteLucknow

Non resolving acute diarrhea

Persistent diarrhea

Acute onset Prolonged for >2wk Mostly infection related Young <3years old

Other Causes of chronic diarrhea

Insidious onsetDuration wks to monthsAny age groupMostly not infection related

0-7days

• Acute diarrhea (watery or bloody)• Dysentery (fever , cramps, tenesmus, mucoid stools)• Bacillary dysentery (specific for shigella)

8-14days

• Prolonged diarrhea• Six-fold relative risk of progress to persistent diarrhea

>14 days

• Persistent diarrhea• ~3-20% of all acute diarrhea• 90% cases in <1 y old children

Time of attention patients with ‘prolonged’ diarrhea that is, 5–7 days in duration and notyet resolved

Current opinion gastroenterology 2011;27:19-23

Prolonged and persistent diarrheaAccounts for only 16% of episodes yet 50% of days with diarrhea

Diarrhea related deaths AWD: `35% Dysentery 20% Persistent ~45%

Who is at risk for persistent diarrhea?

• Young age <1y • Malnutrition • Previous episode of persistent diarrhea• Lack of breastfeeding & early introduction of animal

milk• Irrational use of antimicrobials• Severe diarrhoea or dysenteric illnesses• Underlying immunodeficiency?

WHO Bulletin 1996; 74:479/ Acta Pædiatrica 2012 101, pp. e452–e457

Persistent gut infection

Persistent diarrhea

Prolonged small intestinal mucosal injury

PEMSystemic infections

Ineffective villous repair

Sec Lactose intolerance

Increased absorption ofAntigenic proteins

Milk protein intolerance

Inappropriate re-feeding

Persistent diarrhea

Gut infections

Systemic infections

Micronutrient deficiencies

Immunodeficiency

Lactose intolerance

Milk/other protein sensitization

PD

Case I: 9mo boy

Persistent diarrhea 2 weeks5-6 times/day, small quantities

Acute onset, watery 15 times/day for 7 days

Top fed Bottle feeding

No fever or urinary symptoms

Cefixime 3 days Ofloxacin 5 d Norfloxacin-metranidazole 7 d

SGPGID 21

Examination

Perianal erythemaSatellite lesions around

flexures, scrotum and penis

• Oral thrush +• Soft abdomen• No hepatosplenomegaly• Other systems normal

Diagnosis

Fungal diarrhea (super-infection)

Stool• Budding yeast cells and hyphae ++• Opportunistic infections: no organism• C. difficile antigen: negative

Management

Oral fluconazole Clotrimazole paint

Supplements Diarrhea resolved in 3 days No recurrence

Case II: 11 mo boy

Persistent diarrhea 3 weeks10-14 times/day, explosive

Acute onset, watery diarrhea for 5 days

On cow’s milk

Ofloxacin 7 days

Explosive stools

SGPGI

Examination

• Soft abdomen• No hepatosplenomegaly• Other systems normal

Perianal erythema (widespread)Minimal lesion on scrotum

Diagnosis

Secondary lactose

intolerance

In doubtful cases:Stool for • Reducing substances > 0.5%• pH <6.0

Any tests required to confirm?No

Management

• Low lactose diet for 6 weeks• Supplemented with other non-lactose items

At follow-up 8 weeks:• No diarrhea• Rash healed• Reintroduction of milk: no symptoms

Diets in persistent diarrhea

Most patients respond to diet A and B

Case III: 4 mo girl

Persistent diarrhea 2 weeks5-6 times/day, small quantities

Acute onset, watery 15 times/day for 7 days

dehydration

Top fed Bottle feeding Intt. fever (1000F) 10 days

Ofloxacin , racecadotril, probiotics

SGPGID 21

Catheterized

Further course…

H/O feverCatheterizatio

nSuspect UTI

• Urine exmn: 15 WBC/ hpf

• Urine culture: E.coli

• USG-KUB: normal

Sensitive antibiotics (3rd gen cephalosporin) for 7 days

• Afebrile

• Formed stools

• MCU/ DMSA scan at follow-up (8 weeks): normal

Case IV: 3mo boy

Persistent diarrhea 20 days Explosive with perianal erythema

Acute onset, watery for 7 days

Formula fed at 2moInadequate breast

milk

Multiple antibiotics, racecadotril, probiotics, antifungals

Breast feed till 1mo age

Wt loss: 800gm

Off lactose, on soy formula

No response

SGPGI

ProblemsHigh risk patientAge , 3 monthsNot breast fedWeight lossClinical features of secondary lactose intoleranceNo response to lactose free diet

Possibilities1. Persisting systemic infection2. Fungal sepsis3. Milk protein sensitization 4. Opportunistic infection

3 months old boy

Proctosigmoidoscopy Aphthous ulcers

Rectal biopsyEosinophilic infiltrate >6/hpf and cryptitis

Hb:9.4, TLC 7600/cumm, P56, L34, E10

PLT: 4.2lac Alb: 3.5Electrolytes normal

No evidence of systemic infectionStool exam: no ova/cyst etc

Why did the child not respond to soy formula?

Co-existent soy allergy with milk protein allergyHow to manage this patient??

Child was placed on elemental formula for 3 monthsResolution of diarrhea with weight gainGradual reintroduction of other food itemsMilk and milk product free dietNo recurrence of symptoms

CMPA Lactose intolerance

All or none phenomenon Relative phenomenonImmune reaction to milk protein Deficiency of lactase enzymeMultisystem symptoms Only GI symptomsRecovers by 4-5y of age Recovers in days-weeks in secondary,

permanent in primary Diagnosis: SPT, IgE, histology-eosinophils, elimination challenge test

Diagnosis: stool-pH, reducing substances +ve, Lactose hydrogen breath test

Stop all milk and milk products Milk reduction, yogurt, lactase enzyme supplement

CMPA is not equal to lactose intolerance

0 25days

Case V: 3 year old girl

Last 1week, stools (7-8times/day), with small amount of

blood

SGPGI

ORS, ZincMultiple courses of antibiotics

Started with acute watery diarrhea requiring IV fluids initially……cont for ~18days

No history of severe pain abdomen recurrent feverinfections at other sitesabdominal distension

No family history of food allergy/asthma/ IBD

3year old girlSGPGI

ExaminationWt 12kg , height 90cmMild pallorAbdomen soft, no organomegalyPerianal area normalSystemic exam normal

Diagnosis: watery diarrhea going on to colitis

Possibility ?

Dysentery CMPA Antibiotic associated colitis Other infections amoebic,CMV Inflammatory bowel disease

3years 3years 3 months

3y old girl

Stool- negative for oppurtunistic pathogens positive for C difficile toxin

• Treated with oral vancomycin• Diarrhea passive, active child• Haemoglobin increased to 10.8 g/dl in follow-up

Diagnosis : Pseudomembranous colitis

Hb 9.8, TLC 16700/ P76%. Electrolytes/ RFT/ protein/albumin normalSigmoidoscopy: erythema, loss of vascular pattern s/o colitisNo aphthous ulcers, pseudomembranes, deep ulcers.

Antibiotic-associated diarrheaOverall complicates 2-5% of antibiotic treatment

70-80%

15-25%

2-3%?

Non specific diarrhea (osmotic ,secretory)

C. difficile diarhea and colitis

Other pathogens (C.per-figens,Staph,candida)

antibiotic specific (motilin stimulation,allergic reaction)

3.6-18% Indian pediatric data

MildSelf-limiting

Treatment of C difficile diarrhea

Mild to moderate disease

Severe diseaseNo response tometronidazole

Metronidazole20-40 mg/kg Oral/ IV

10-14days

Vancomycin40 mg/kg oral

10-14days

• Stop precipitating antibiotics Diarrhea resolves in 15-25% (mild disease)• No antimotility agents: Precipitation of ileus, toxic megacolon• Correction of fluid/electrolyte imbalance

Work-up in persistent diarrhea

• Haemogram: Hb, TLC, DLC, platelet, GBP• Serum electrolytes, creatinine• Urine-microscopy and culture (proper collection)• Stool- ova, cyst, fungal, clostridium difficile toxin• ± Blood culture• ± X ray chest• ± Sigmoidoscopy and biopsy• ± others- UGI endoscopy and biopsy, immune profile

Giardiasis

CryptosporidiumOocyst of isospora belli

Strongyloides stercoralis larvae (lugols iodine)

Always ask for stool examination

Clues in history and examination

Lactose intolerance• Explosive stools• Perianal erythema

Fungal infection• Oral thrush• Satellite lesions in perineum

Systemic infections / sepsis• Fever, lethargy• Urinary, resp, cardiac symptoms

Cow’s milk allergy• F/H atopy, allergy• Dietary history• Temporal correlation

Immunodeficiency• Recurrent infections elsewhere• Recurrent diarrhea, response to antibiotics

Antibiotic assc diarrhea• Exposure to antibiotics in last 12 weeks

Management• Admit- <4mo and top fed, dehydration, severe PEM,

systemic infection• Rehydration• Treat systemic infection• Weaning food with reduced lactose load…..A/B/C diets• Micronutrient supplementation

Oral Zinc 10 mg/ day x 2weeks Oral folic acid 1mg/day x2weeks Vitamin A 1lac unit (6-12mo age or <8kg weight), 2lac unit >1y of

age Adequate supplementation and correction of electrolytes (Na, K,

magnesium, phosphorus, calcium)J. Nutr. 2011;141: 2226–2232

Green banana diet Amylase resistant starch (ARS) Not digested in human intestine Delivered to colon

Colonic Bacteria Short chain

fatty acids

Increase salt, water absorption

Provide energyTrophic effect

Management

Infectious Non infectious Onset acute insidiousBloody stools at onset

Less, usually watery Yes

Fever at onset yes lessExposure to sick contact

yes no

Travel related yes No

Detailed history to determine onset (acute vs insidious) Consider and workup for other etiologies of chronic diarrhea e.g

celiac, lymphangiectasia, anatomical causes in select cases Especially if older child >3years as PD uncommon in these subjects

Good news: PD is decreasing

Acta Pædiatrica 2012 101, pp. e452–e457

Study from Bangladesh, children <5years

1991----2010

Conclusion

Persistent diarrhea is most common in younger children

Sepsis, lactose intolerance, protozoal /fungal infections, food

protein sensitization and micronutrient deficiency are common

reasons

Identify and manage them early (1-2wk)

Home made diet is useful in majority but specialized formulae are

required in few

Micronutrient deficiencies need to be corrected

Persistent diarrhea should not be confused with chronic diarrhea

Thanks