1. Chronic Diarrhoea & Malabsorption
GIT Lec. 3
Chronic Diarrhoea & Malabsorption By
Dr. Athal Humo

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

3. 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   

4. 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   

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

6. 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

7. 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

8. 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.

9. 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

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

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

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

13. General therapeutic approaches to management of chronic diarrhea

15. Lactose Intolerance

16. 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

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

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

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

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

22. 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)

23. SOY PROTEIN FORMULA

24. COW’S MILK ALLERGY

26. 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

27. 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.

28. 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.

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

30. HYDROLYSED MILK FORMULA

31. 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

32. PROGNOSIS
Most cases recover spontaneously within 1-2 years.

33. TODDLERS DIARRHOEA

34. 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.

35. THANKS