Non resolving acute diarrhea(pediatrics)

1. Non resolving acute diarrhea
Anshu Srivastava
Department of Pediatric Gastroenterology
Sanjay Gandhi Postgraduate Institute
Lucknow
Anshu Srivastava
Department of Pediatric Gastroenterology
Sanjay Gandhi Postgraduate Institute
Lucknow

2. Non resolving acute diarrhea
Persistent
diarrhea
Acute onset
Prolonged for >2wk
Mostly infection related
Young <3years old
Other
Causes of
chronic
diarrhea
Insidious onset
Duration wks to months
Any age group
Mostly not infection
related

3. 0-7
days
• Acute diarrhea (watery or bloody)
• Dysentery (fever , cramps, tenesmus, mucoid
stools)
• Bacillary dysentery (specific for shigella)
8-14
days
• 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

4. Time of attention
patients with
‘prolonged’ diarrhea
that is, 5–7 days in
duration and not
yet resolved
Current opinion gastroenterology 2011;27:19-23
Prolonged and persistent diarrhea
Accounts for only 16% of episodes
yet 50% of days with diarrhea
Diarrhea related deaths
AWD: `35%
Dysentery 20%
Persistent ~45%

5. 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

6. Persistent gut infection
Persistent diarrhea
Prolonged small intestinal mucosal injury
PEMSystemic infections
Ineffective villous repair
Sec Lactose intolerance
Increased absorption of
Antigenic proteins
Milk protein intolerance
Inappropriate re-feeding
Persistent diarrhea

7. Gut infections
Systemic
infections
Micronutrient
deficiencies
Immuno
deficiency
Lactose intolerance
Milk/other protein
sensitization
PD

8. Case I: 9mo boy
Persistent diarrhea 2
weeks
5-6 times/day, small
quantities
Acute onset, watery
15 times/day for 7 days
Cefixime 3
days
Ofloxacin 5 d Norfloxacin-metranidazole
7 d
SGPGI
D 21

9. Examination

10. Diagnosis
Fungal diarrhea
(super-infection)
Stool
• Budding yeast cells and hyphae ++
• Opportunistic infections: no organism
• C. difficile antigen: negative

11. Management

12. Case II: 11 mo boy
Persistent diarrhea 3 weeks
10-14 times/day, explosive
Acute onset,
watery
diarrhea for 5
days
On cow’s
milk
Ofloxacin 7 days
Explosi
ve
stools
SGP
GI

13. Examination
Perianal erythema
(widespread)

14. Diagnosis
Secondary
lactose intolerance
No

15. 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

16. Diets in persistent diarrhea
Most patients respond to diet A and B

17. Case III: 4 mo girl
Persistent diarrhea 2
weeks
5-6 times/day, small
quantities
Acute onset, watery
15 times/day for 7 days
dehydration
Ofloxacin ,
racecadotril,
probiotics
SGPG
I
D 21
Catheterized

18. Further course…
H/O fever
Catheterization
Suspect
UTI
Sensitive antibiotics (3rd gen cephalosporin) for 7 days
• Afebrile
• Formed stools
• MCU/ DMSA scan at follow-up (8 weeks): normal

19. Case IV: 3mo boy
Persistent diarrhea 20 days
Explosive with perianal
erythema
Acute onset,
watery
for 7 days
Formula fed at
2mo
Inadequate
breast milk
Multiple antibiotics, racecadotril, probiotics,
antifungals
Breast feed
till 1mo age
Off lactose,
on soy formula
No
response
SGPGI

20. Problems
High risk patient
Age , 3 months
Not breast fed
Weight loss
Clinical features of secondary lactose intolerance
No response to lactose free diet
Possibilities
1. Persisting systemic infection
2. Fungal sepsis
3. Milk protein sensitization
4. Opportunistic infection

21. 3 months old boy
Rectal biopsy
Eosinophilic infiltrate >6/hpf
and cryptitis

22. Why did the child not respond to soy formula?
Co-existent soy allergy with milk protein allergy
How to manage this patient??
Child was placed on elemental formula for 3 months
Resolution of diarrhea with weight gain
Gradual reintroduction of other food items
Milk and milk product free diet
No recurrence of symptoms

23. CMPA Lactose intolerance
All or none phenomenon Relative phenomenon
Immune reaction to milk protein Deficiency of lactase enzyme
Multisystem symptoms Only GI symptoms
Recovers 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

24. 0 25days
Case V: 3 year old girl
SGPG
I
ORS, Zinc
Multiple courses of
antibiotics
Started with acute watery
diarrhea requiring IV fluids
initially……cont for ~18days
No history of
 severe pain abdomen
recurrent fever
infections at other sites
abdominal distension
No family history
of food allergy/asthma/ IBD

25. 3year old girl
SGPG
I
Examination
Wt 12kg , height 90cm
Mild pallor
Abdomen soft, no organomegaly
Perianal area normal
Systemic exam normal
Diagnosis: watery diarrhea
going on to colitis
Possibility ?
 Dysentery
 CMPA
 Antibiotic associated colitis
 Other infections amoebic,CMV
 Inflammatory bowel disease

26. 3years
3y old girl
Stool- negative for oppurtunistic pathogens
positive for C difficile toxin
Diagnosis : Pseudomembranous colitis
Hb 9.8, TLC 16700/ P76%. Electrolytes/ RFT/ protein/albumin normal
Sigmoidoscopy: erythema, loss of vascular pattern s/o colitis
No aphthous ulcers, pseudomembranes, deep ulcers.

27. Antibiotic-associated diarrhea
Overall 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.perfigens,Staph,can
dida)
3.6-18% Indian pediatric
data
Mild
Self-limiting

28. Treatment of C difficile diarrhea
Mild to moderate
disease
Severe disease
No response to
metronidazole
Metronidazole
20-40 mg/kg Oral/
IV
10-14days
Vancomycin
40 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

29. 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

30. Giardiasis
CryptosporidiumOocyst of isospora belli
Strongyloides stercoralis larvae (lugols iodine)
Always ask for stool examination

31. Clues in history and examination

32. 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

33. 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
Management

34. Infectious Non infectious
Onset acute insidious
Bloody stools at
onset
Less, usually watery Yes
Fever at onset yes less
Exposure 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

35. Good news: PD is decreasing
Acta Pædiatrica 2012 101, pp. e452–e457
Study from Bangladesh, children <5years
1991----2010

36. 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

37. Thanks