1. CHRONIC DIARRHOEA

2. CHRONIC DIARRHOEA
Definition:- Diarrhoea of at least two weeks duration or 3 attacks of Diarrhoea during the last Three Months is called as chronic Diarrhoea
EPIDEMIOLOGY:-
Risk factors – Lack of breast feeding
Underlying malnutrition
Injudicious use of antibiotics
Poor socio economic status
H.I.V

3. AETIOLOGY
INTRALUMINAL FACTORS
a)Intestinal disorders
Carbohydrate mal absorption
Excessive intake of sorbitol,
Carbonated fluids
b)Pancreatic disorders
cystic fibrosis
shwachman-Diamond syndrome
chronic pancreatitis
Pearson syndrome
c)Bile acid disorders
Chronic Cholestasis
Primary Bile Acid Malabsorption

4. B.MUCOSAL FACTORS
a)Altered integrity
Infection,Infestations,
Coeliac disease,
Inflammatory bowel disease
b)Altered Immune function
Eosinophilic Gastroenteropathy
Autoimmune enteropathy
AIDS
c)Altered function
Defects in Cl ̅ /HCO¯3, Na+ / H+ transport

5. Enterokinase deficiency
d)Altered digestive function
Enterokinase deficiency
e)Altered surface area
Short bowel syndrome
Microvillus inclusion disease
Post-Gastroenteritis syndrome,
f) Altered Secretary Function
Tumors secreting vasoactive peptides like VIP, calcitonin, histamines

6. a) small bowel diarrhoea b) Large bowel diarrhoea
CLASSIFICATION:-
Aetiology
a) Organic
b)Non-Organic
II. Organ involved
a) small bowel diarrhoea
b) Large bowel diarrhoea
c) pancreatic diarrhoea
d)Bile acid diarrhoea

7. III.Characteristic of stools
Watery diarrhea
Inflammatory diarrhea
Fatty diarrhea
Factitious diarrhea
IV.Mechanism of diarrhea
a)secretory diarrhea
b) Osmotic diarrhea
c) Exudative diarrhea
d) Deranged motility diarrhea

8. Evaluation of Chronic Diarrhea
Phase-I Clinical history, Physical Examination
Stool examination and culture
Blood studies
Phase-II 72- Hrs stool collection for fat determination
Sweat chloride test
Breath H2 teats
Phase-III Endoscopic studies
Small bowel biopsy, Barium studies
Phase-IV Hormonal studies

11. Approach to Chronic Watery Diarrhea
Characteristics
Secretory
Osmotic
Volume of stools
> 200 ml /24 Hrs
< 200 ml/24 Hrs
Stool PH
Stool Na
>5
>70meq/Lit
<5
<70meq/Lit
Perianal redness
Absent
Present
Response to fasting
Diarrhea continues
Diarrhea stops

12. Exclude structural disease Cholestyramine trail for bile acid diarrhea
secretory
Exclude
infection
Stool Culture
Stool Microscopy
Special Stains
Bacterial Infections
Parasitic infections
Fugal Infections
Exclude structural disease
Colanoscopy,
USG/CT Scan
Hormonal Studies
ZES, VIPoma, carcinoids, MEN syndrome neuroblastoma
Cholestyramine trail for bile acid diarrhea

13. Osmotic Diarrhea Stool Analysis Dietary Review
Excessive intake of Fruit Juices
Dietary
Review
Stool Analysis
Low PH, Reducing substances +
High Mg, Laxative
Carbohydrate malaatebsorption
Factitious Diarrhea
H2 Breath Test
Small Bowl biopsy, assay for disaccharidases
Lactose intolerance
Sucrose intolerance
Monosaccharide malabsorption

14. Inflammatory diarrhoea
Exclude Structural
Disease
Small Bowel
Boipsy
Sigmoidoscopy
colonoscopy
BMFT
USG Barium enerra
Exclude
infection
Bacterial Pathogens c. difficile
Mycobacterium tuberculosis
Y ersinia
Others E. Histolytica
Strongyloidosis CMV
Herpes simplex

15. Fatty diarrhoea Exclude Structural Disease Exclude Pancreatic
Small Bowel
Boipsy and aspirate
For Giardia
Coeliac ( Serological
AGA, EMA)
USG, CT Scan of
Abd
Exclude
Pancreatic
Excocrine
insufficiely
Direct tesnsecretin,
Cholecystokinin
Stimulation tests
Indirect – Bentromide
Pancreolauryltest
74 Hr Fecal fat
Blood Test
serum
Trypsinogen
Others Sweat
Chloride test
Bone Marrow
Exam ERCP
Immune
deficiency
T – Cell
Function Ig.

16. MANAGEMENT Acute phase (upto 5 days) a) Resuscitation phase
b) Specific Treatment
Rehabilitation phase

17. Resuscitation Phase Correct fluid and electrolyte imbalance
Correct shock
Anemia
Hypoproteinaemia

18. Specific Treatment Conditions Treatment Infections
a) Salmonella Ampicillin, Chloramphenicol
Trimethoprim sulfamethoxazole,
b) Shigella Trimethoprim sulfamethoxazole
c) C.Jejuni Erythromycin
d) Giardia Metronidizole
e) Amoebiasis Metronidizole

19. Conditions Treatment Bile acid diarrhoea Cholestyramine
Fat Malabsorption Medium chain Triglycerides Hydrolyzed proteins lipase
Lactose intolerance Lactose free diet Lactose tab
Sucrose intolerance Sucrose free diet Add Sucrosidase
Inflammatory bowel disease aminosalicyclic acid Mesalamine etc.,

20. Rehabilitation Phase: -
Aims:
1) To improve health and nutritional status
2) Catch up growth
3) To prevent further attacks
TPN, PPN
Suppliment T multivitamins
Minerals
Nutritional education

21. Prognosis Depends upon the underlying Aetiology Nutritional status and
age of the child age

22. THNKYOU