1. Chronic Diarrheal Diseases Mohammed al-matrafi

2. Diarrhea more than 2 weeks

3. CHRONIC DIARRHEA Pathogenesis  Digestion lactase , C.F., Bile   Absorption celiac, glucose -galactose malabsorption Food intolerance Cows milk allergy  Loss Lemphangectasia  Na pump, cl diarrhea Unknown Toddlers diarrhea Intractable diarrhea of infancy Inflammation Ulcerative Colitis Immune def./Drugs HIV, Laxatives, Ab

4. Malabsorption = Steatorrhea =  Stool fat

6. Chronic Non specific diarrhea ( Toddlers diarrhea/Peas & carrots Syndrome ) Cause is unknown. Juice sugars ?. Between 6 months - 3years Diarrhea is the only symptom growth & activity not affected Dx history R +  juices ( if applicable) reassure parents Loperamide??

7. Lactose intolerance. Congenital or post infectious. Diarrhea, bloating, cramps,  flatus & excoriation at diaper area. Dx  Stool reducing substance Lactose free formula Intestinal biopsy & enzyme assessment R+ lactose free diet

8. Glucose-Galactose Malabsorption Inherited disease Diarrhea with feeding Stopping feeding stops diarrhea Dx History & intestinal biopsy R + Glucose & Galactose free formula (Galaktamine19)

9. Celiac Disease Glutine sensitive entropathy

10. Celiac Disease Glutine??

11. Celiac Disease Glutine Wheat Oat Barley Rye

12. Celiac Disease Glutine sensitive entropathy  Vellus atrophy + Crypts Hyperplasia  Chronic diarrhea (Steatorrhea) Starts at introduction of cereals (< 2years) Typical appearance Dx intestinal biopsy + serology R + Gluten free diet for life

15. Normal mucosa Normal mucosa Mucosa of a patient suffering from coeliac disease Mucosa of a patient suffering from coeliac disease normal Coeliac disease

16. Milk Protein allergy Immune mediated in about 1-7% 50% allergic to soy protein Over diagnosed Diarrhea (bloody), poor growth, urticaria&wheeze Dx - CBC  esoinophils  Hgb -Protein  serum  stool - challenge test R+ Replace cows milk

17. Intractable diarrhea of infancy Affects infants around 3-6 months. Secretary diarrhea (explosive& watery) May start with fever & vomiting Babe will be cachectic & marasmic with abdominal distention Stopping feeding dose not stops diarrhea No etiology defined  mortality

19. Cystic fibrosis Autosomal recessive Lung disease Hx of meconium plug or rectal prolepses Pancreatic enzyme def.  Steatorrhea Fecal fat (qualitative & quantitative) Dx  sweat chloride R + Antibiotic & enzymes replacement

20. Protein losing interopathy Intestinal loss of protein & diarrhea. Etiology -  intestinal permeability e.g. post infection - lymphangectasia * Primary * Secondary -Allergic Dx -History -Stool Protein (Fecal alpha 1-antitrypsin) -Serum Protein (albumin & TP) Isotope scan R+ as per etiology

22. Other Causes Small bowel bacterial over growth Bile salt deficiency Abetalipoprotienemia Acrodermatitis enteropathica

23. Inflammatory Bowel Disease (IBD) Crohn’s Disease Ulcerative colitis

24. Chronic Diarrhea

25. Approach Good detailed History Physical Examination -nutritional status -specific signs Proper Investigations -general -specific