Persistent Diarrhoea & Chronic Diarrhoea
Transcript of Persistent Diarrhoea & Chronic Diarrhoea
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PERSISTENTDIARRHOEA IN
CHILDREN
Dr. Gadadhar Sarangi The Child
B.K. Road, Ranihat, Cuttack - 753 001,
ORISSA
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Definition
• Prolongation of acute diarrhoea /dysentery for more than 14 days
• Generally associated with weightloss.
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Cause of PersistentDiarrhoea
• Persistent infection with one ormore enteric pathogens
•Secondary malabsorption of carbohydrates & fat.
• Intestinal parasitosis.
• Dietary protein allergy/intolerance.
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Pathology
• Damage to the absorptive mucosalsurface of small intestine
• Delay in repair of the damagedepithelium (Normal <5 days)
• Carbohydrate, fat and protein mal -absorption ensues as consequence
• Direct absorption of macromoleculesleads to protein allergy.
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Clinical Presentation
• Mild form
– Several motions
– No significant weight loss
– No significant dehydration
• Moderate form
– Several motions
– Marginal weight loss
– Without dehydration– Non tolerance to milk
• Severe form
– Dehydration with
several motions– Weight loss
– Non tolerance tomilk & cereals
– Secondary infectionoften coexists
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Diagnosis
• Asses dehydration.
• Asses malnutrition.
• Stool - R/E, Culture, Reducing sugar,pH.
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Management
• Mild form - Try low milk formula feeds.
• Moderate form - Do not try milk, permit cereal basedfeeds.
• Severe form
– Phase I: Resuscitation < 24 hours
– Phase II: Partial parenteral nutrition (1-4 days), IV fluids, colloid,
antimicrobials, electrolyte balance– Phase III: Nutritional rehabilitation with calorie dense, > 5 days,
lactose free formulae
If fails - Chicken/egg white, glucose, oil - feed
If fails - Total parenteral nutrition
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Indication ForAntimicrobials
• Presence of gross blood in stool
• Stool leukocytes > 10 / HPF
• Shigella / Salmonella in stool culture
• Associated systemic infection.
• Severe malnutrition.
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Vitamin & MineralSupplement
• Twice the RDA of vitamins andminerals.
• Special attention for Vit. A and Zn.
• In malnutrition :
– Magnesium sulphate IM
–Potassium oral.
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Prevention
• Promotion of breast feeding.
• Active management of acutediarrhoea.
• Appropriate dietetic management.
• Judicious administration of drugs.
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CHRONIC DIARRHOEA
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Definition
• Diarrhoea of more than 2 weeksduration.
OR• 3 attacks during last 3 months.
• Without specific congenital,
biochemical or metabolicdisorders.
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EVALUATION OF PATIENTS
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EVALUATION OF PATIENTSWITH CHRONIC
DIARRHOEAPHASE – I
• Clinical History.
• Nutrition assessment.
• Stool exam – pH, reducing substances,leukocyte count, fat, ova, parasites.
• Stool culture.
• Stool for Clostridium difficile toxin.
• Blood studies – CBC, ESR, Electrolytes,Urea, Creatinine.
EVALUATION OF PATIENTS
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EVALUATION OF PATIENTSWITH CHRONIC DIARRHOEA –
Contd..PHASE - II
• Sweat chloride.
•72 hours stool fat estimation.• Stool electrolytes, Osmolarity.
• Stool for phenolphthalein, magnesiumsulphate, phosphate.
• Breath H2 test.
EVALUATION OF PATIENTS
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EVALUATION OF PATIENTSWITH CHRONIC DIARRHOEA –
Contd..PHASE - III
• Endoscopic studies.
• Small bowel Biopsy.• Sigmoidoscopy or colonoscopy with
biopsies.
• Barium studies.
EVALUATION OF PATIENTS
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EVALUATION OF PATIENTSWITH CHRONIC DIARRHOEA –
Contd.. PHASE - IV
• Hormonal studies
– Vasoactive intestinal polypeptide.
– Gastrin.
– Secretin.
– 5-hydroxyindoleacetic assay.
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THERAPY
• Depends upon the cause.• Secondary carbohydrate intolerance
– by reduction of the sugar load.
• Lactase for digestion of lactose.• Post gastroenteritis malabsorption –
Needs predigested formula.
• Specific diseases to be treated.
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DYSENTERY
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DEFINITION
• It is a Syndrome of Bloody diarrhoea withvisible red blood, fever, abdominalcramps, rectal pain & tensemus, mucoidstool.
• Does not include :-– Blood streaks on formed stool.– Microscopic red blood cell in stool.– Malena.
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CAUSES OF DYSENTERY
• Shigella
• Entero invasive & Enterohaemorrhagic Ecoli
• Salmonella
• Campylobacter jejuni
• Entamoeba histolytica
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DISEASE BURDEN
• 80 million cases globally each year.
• 70 thousand deaths each year.
• 70% cases and 60% death in under fives.
• 15% of all diarrhoeal episodes.
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PATHOGENESIS
• Spread by feco-oral contamination.
• Bacterial invasion of colonic epithelium.
• Results in inflammatory colitis.
• Recto sigmoid area maximally affected.• Host defense
– Copious mucoid secretion
– Epithelial regeneration.
• Shigella causes disease with 10 to 100organisms.
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EPIDEMIOLOGY
• Endemic in developing world.
• Regresses after 5 years of age.
• Food and waterborne out breaks areknown.
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CLINICAL SPECTRUM
• Watery diarrhoea to fatal dysentery.
• Incubation period – 12 hours to 1 week.
• High fever.
• Abdominal cramps.
• Vomiting• Abdominal tenderness & rectal tenderness.
• Blood & mucus in the stool.
• Tenesmus and straining.
• Rectal Prolapse.• Self limiting course in most bacterial infection in 10
days.
• Bacterimia is uncommon.
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COMPLICATIONS
• Seizures – Mostly with shigella shiga(Type –I)
• Dyselectrolytemia & dehydration• Rectal prolapse
• Malnutrition – Protein losing
enteropathy.• Hemolytic Uremic Syndrome.
• Non suppurative arthritis.
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DIAGNOSIS
• Stool Examination – for leukocytes,RBCs, trophozoites of EH
• Stool Culture
• Peripheral blood smear –Leukocytosis with more band cells.
•Blood culture in toxic, malnourished& very young infants.
• Electrolytes in severe dehydration.
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THERAPY
In children without Risk factors :• TMP-SMZ - 7 to 10 mg TMP/day in two divided
doses.
• ORS to treat and prevent dehydration.• Continue Breast Feeding.
• Frequent feeding to continue.
• No response in 2 days, change to Nalidixic acid
– Dose : 55 mg/kg/day divided in 3 to 4 doses.
• Total therapy for 5 days.
g s actors n
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g s actors nDysentery
with higher mortality rate• Infants < 1 year
• Non breast fed babies.
• Dehydration• Malnutrition
• H/o Convulsion or measles
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Therapy of Dysentery withHigh Risk factors
• Hospitalise
• ORS for dehydration / IV fluid.
• Zn 20 mgs. daily above 6 months &10mg below 6 months.
• Ciprofloxacin – 10mg/kg/dose in two
doses daily.• Good Response Complete 5 days.
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No Response in 2 days.
• Consider Cefixime – 8 mg/kg/day in singledose X 5 days.
OR
• Ceftriaxone – 50–100mg./kg/day in singledose X 5 days.
• Complete 5 days of therapy
• If no response look for alternate diagnosis
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Therapy of Amoebicdysentery
• Diloxanide furoate – 20mg/kg/day in 3 divideddoses X 10 days
• Metronidazole – 35 – 50mg/kg/day in threedivided doses X 10 days
Alternative• Paromomycin - 25-30 mg/kg/day in 3 divided
doses X 5 to 10 days.
• Dehydroemetine hydrochloride – 1.0 to 1.5mg/kg/day IM X 5 days
• For severe cases two oral medicines can becombined.
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CONTROL
• Prevention of fecal oraltransmission.
• Breast feeding
• Hand washing before handlingfood.
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Thank