Chronic Diarrhoea & Malabsorption GIT Lec. 3 Chronic Diarrhoea & Malabsorption By Dr. Athal Humo 2015-2016

CHRONIC DIARRHEA Chronic diarrhea is defined as a diarrheal episode that lasts for ≥14 days.

Etiology Enteric infections Small intestinal bacterial overgrowth INFECTIOUS ETIOLOGIES    Enteric infections Small intestinal bacterial overgrowth Postenteritis syndrome DIARRHEA ASSOCIATED WITH EXOGENOUS SUBSTANCES Excessive intake of laxatives containing lactulose   

Congenital or acquired lactase deficiency ABNORMAL DIGESTIVE PROCESSES: Cystic fibrosis Chronic cholestasis NUTRIENT MALABSORPTION: Congenital or acquired lactase deficiency IMMUNE AND INFLAMMATORY: Food allergy (cow's milk or soy proteins, others) Celiac disease   

Congenital sodium diarrhea STRUCTURAL DEFECTS Microvillus inclusion disease Lymphangiectasia DEFECTS OF ELECTROLYTE AND METABOLITE TRANSPORT: Congenital chloride diarrhea Congenital sodium diarrhea

Neuroendocrine hormone-secreting tumors ( VIPoma) MOTILITY DISORDERS Hirschsprung disease Thyrotoxicosis NEOPLASTIC DISEASES Neuroendocrine hormone-secreting tumors ( VIPoma) CHRONIC NONSPECIFIC DIARRHEA Functional diarrhea (toddler's diarrhea) Irritable bowel syndrome

Evaluation of Patients medical approach should be based on diagnostic algorithms : clinical and epidemiologic factors: History Age Personal & family history(cong, allergy, inflam) Previous episode of acute GE. Association with specific foods Polyhydromnios Specific amount of fluid ingested /day

NOTE: Nutritional evaluation: include Examination: General & nutritional status NOTE: Nutritional evaluation: include Diatery hx Nutritional state, growth parameters, anthropometric evaluation→estimate the severity of diarrhea Biochemical markers Nutritional inv Biochemical markers assist in grading malnutrition, the half life of serum proteins can differentiate between short & long term malnutition.

Stepwise diagnostic work-up for children with chronic diarrhea Intestinal microbiology (GSE, microscopy for parasites, viruses, stool cultures), stool electrolytes, pH & reducing substances, H2 breath test Blood studies (CBC, ESR, electrolytes, blood urea, creatinine) Screening test for celiac disease Noninvasive tests for: •     Intestinal function    •    Pancreatic function and sweat test    •    Intestinal inflammation Tests for food allergy    •    Prick/patch tests

STEP 2 Intestinal morphology •    Standard jejunal/colonic histology    •    Morphometry   

STEP 3 Special investigations •    Intestinal immunohistochemistry    •    Hormonal studies    •    Autoantibodies    •    Brush border enzymatic activities    •  others

Treatment Empirical antibiotic therapy Human immunoglobulins Zinc Replacement of fluid and electrolyte Empirical antibiotic therapy nutritional rehabilitation Human immunoglobulins Zinc Treatment of underlying cause

General therapeutic approaches to management of chronic diarrhea

Lactose Intolerance

What is Lactose Intolerance? Inability to digest significant amounts of lactose, which is the predominant sugar in milk A result of lactase insufficiency, the enzyme essential for the conversion of lactose into glucose and galactose

Types of Lactose Intolerance Congenital Very rare Primary Develops after 2 years of age Secondary Usually resolves in 1-2 weeks

Clinical Manifestation Nausea, cramping, bloating, abdominal pain, gas, diarrhea, perianal excoriation

DIAGNOSIS Stool pH < 5.5. Positive reducing substance in stool. Low lactase activity in jejunal mucosa. Increased H2 in expired air.

TREATMENT Reduce lactose in diet . (SOY PROTEIN FORMULA) ISOMIL

ISOMIL 20cal/oz palm olein, soy, coconut, sunflower oil Isomil/Prosobee 20cal/oz palm olein, soy, coconut, sunflower oil Corn syrup/sucrose Protein, 17 g/L soy isolate and L-MET Iron 12mg/L Vitamin D 405 IU/L 200 mOsm/kg H2O DHA and AA added (docosahexaenoic acid and arachidonic acid)

SOY PROTEIN FORMULA

COW’S MILK ALLERGY

What is Milk Allergy? An abnormal immune system reaction to proteins in the cow’s milk Triggered by a combination of genetically inherited factors and early introduction of cow’s milk or soy protein into an infant’s diet

Symptoms of Milk Allergy An immune system reaction Gastrointestinal Manifestations : vomiting, diarrhea, malabsorption, protein-losing enteropathy, colic, GIT bleeding, FTT. Systemic Manifestations : anaphylaxis, rhinitis, wheezing, pulmonary hemosiderosis, peripheral eosinophilia, IDA 2ry to GIT bleeding.

DIAGNOSIS Mainly Clinical Symptoms disappear after withdrawal of cow’s milk . Very cautious CHALLENGE WITH FEW CC of cow’s milk produces the symptoms again.

TREATMENT SOY PROTEIN [ (30-50%) are also allergic to soy protein. HYDROLYSED MILK FORMULA )Pregestemile).

HYDROLYSED MILK FORMULA

Protein Hydrolysate Formulas Alimentum Advance Pregestimil/Pregestimil Lipil Nutramigen Lipil Protein Casein hyrolysate + free AA’s Fat (Alimentum and Pregestimil) Medium chain + Long chain triglycerides; (Nutramigen) Long chain triglycerides Carbohydrate: Lactose free

PROGNOSIS Most cases recover spontaneously within 1-2 years.

TODDLERS DIARRHOEA

TODDLERS DIARRHOEA A pattern of intermittent loose stools, occurs commonly between 1 and 3 yr of age. These otherwise healthy growing children often drink excessive carbohydrate-containing beverages. The stools typically occur during the day and not overnight. The volume of fluid intake is often excessive; limiting sugar-containing beverages and increasing fat in the diet often leads to resolution of the pattern of loose stools.

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