| ID | 377 |
|---|---|
| Name | PERSISTENT DIARRHOEA |
| Cause | Endocrine disorders — An overactive thyroid (hyperthyroidism) can cause chronic diarrhea and weight loss. Diabetes can cause chronic diarrhea if the nerves that supply the digestive tract are injured. Food allergy or sensitivity — Food allergies and hypersensitivity can cause chronic diarrhea Some infections, food allergies and intolerances, digestive tract problems, abdominal surgery, and long-term use of medicines can cause chronic diarrhea. Some infections from bacteria and parasites that cause diarrhea do not go away quickly without treatment |
| Signs Symptoms | Diarrhea persists beyond two days with no improvement. Become dehydrated. Have severe abdominal or rectal pain. Have bloody or black stools. Have a fever above 102 F (39 C). |
| Diagnosis | |
| Investigations | Investigations: 1. Blood- routine count, Hb%. morphology & S. electrolytes. 2. Stool: a. R/M/E&C/S. b. Reducing substance. c. PH <5 indicates CHO intolerence, but it does not mean to withdraw CHO. d. T.L.C- thin layer chromatography for CHO e. Electrolytes & osmolality f. ELISA test for Rota virus or electron micros-copy. 3. Urine: a. Routine test. b. Reducing subs.- to exclude galactosemia. c. C/S - if > 105 - significant pyuria. 4. Intestinal test a. duodenal juice (m/E. C/S.). b. Jejunal biopsy - to see mucosal injury- total or subtotal atrophy of villous & damage of brush border. Ind: H/O disaccharidase deficiency, c. Disaccharidase assay. 5. X-ray chest. 6. M.T- for individualization. |
| Management | Management: A. Correction of dehydration- Dehydration should be corrected by i.v fluid (viz. cholera saline). But mild to moderate dehydration can be corrected by rice- ORS as it has low osmotic load; WHO ORS- has more osmotic effect as it contains lllmmoles of glucose, causing an osmolality of 300mosmol/l which may precipitate diarrhoea further. B. Nutritional management- 1. Breast-fed child should be continued with breast-feeding. 2. Dietary manipulation- diet should be selected with consideration to the underlying cause of diarrhoea. In case of any intolerence, suitable dietary formula should be selected out by trial with different types of foods; such as, - lactose free milk- based diet (young child). - lactose free rice-based diet (older child). - Rice suji. - Khichuri (mixed rice & vegetables). - Comminuted chicken formula (mostly used in west. - simple rice-dal combination. Some formula food preparations may be advised in less severely ill patients.Such as, pregistimil, which contains glucose polymer, medium chain triglycerides, & casein hydrolase. This formula has the advantage of being free of disaccharide, milk protein, soyaprotein & long chain fatty acids. Food should be adequate in energy, protein, fat a vitamins-Energy should be given at least 110 kcal/kg/day. Protein should be given at least 4-5 gm/kg/day. Duration of feeding varies from 3-8 weeks before going back to normal feeding schedule. 3. Total Parenteral Nutrition (TPN)- i.v alimentation is indicated in cases of intractable diarrhoea, when diarrhoea continues despite nothing by mouth. It should be continued for a period till the diarrhoea ceases. But prolonged i.v. feeding reduces recovery of mucosal enzymes & leads to atrophy of intestinal mucosa. Some available prepns. for TPN- viz. a. Amino acid prepns. b. Fatty acid prepns. c. 25% & 50% dextrose prepns. C. Vitamins & Minerals: 1. Vitamin- A capsule (high potency 2 lac units/capsule) Dose : Above 2 years 2 lac units & below 2 years 1 lac units to be given 1st & 2nd day and 1 or 2 weeks later, then followed by 1 capsule (2 lac units) every 6 monthly upto 6 years. 2. Syp. Potassium (k+) 3-5 meq/kg/day (2-3 wks.) (7 meq/5ml). 3. Syp. ZnSO4 (50mg/5ml)- < 6 mon 3mg/day for 2-3 wks. 6mon-lyr 5mg/day for 2-3 wks. > 1 yr -10 mg/day for 2-3 wks. D. Use of antimicrobials: No drugs have been found useful in persistent diarrhoea; but in some conditions, such as- 1. Bacterial overgrowth: Erobic organisms - e.g. Co-trimoxazole. Anerobic organisms - e.g. Metronidazole. Gram - ve organisms- e.g. Gentamicin. 2. Other infections: Commonly ARI, UTI, septicemia etc- appropriate antibiotic should be given. E Hospitalization: In P.D hospitalization or only removing the child to another place may cause much improvement in some cases. |
| Introduction | The diarrhoea which starts acutely & persists for more than 2 or 3 weeks with or without growth failure, is defined as persistent diarrhoea (P.D.) A considerable number of pathogens causing acute diarrhoea may be isolated from this group of diarrhoea. The specific chronic diseases causing diarrhoea will not be included under persistent diarrhoea; such as,- coeliac disease, ulcerative colitis, chron’s disease, cystic fibrosis etc. |
| History | |
| Etiology | Etiologic factors of P.D: Host factors: 1. Age- most common under the age 2 yrs. 2. Nutritional status- PEM 3. Immunological status more in low immunity. 4. Feeding- more in bottle feeding children. 5. Sanitation & hygiene- poor. 6. Recurrent acute diarrhoea. 7. Indiscriminate use of drugs. Causative factors: 1. Persistence of acute diarrhoeal agents, organisms: a. Shigella Flexneri b. EPEC/EIEC (Enteropathogenic & enteroinvasive E. coli) c. Salmonella d. Giardia e. Camphylobactor jejuni f. Enta. histolytica g. Cl. defficile h. G. lamblia i. Yersinia enterolytica & j. viral agents of acute diarrhoea rarely causes P. diarrhoea.. 2. Lactose intolerence. 3. Cow’s milk protein intolerance. 4. Soya protein intolerence. 5. Small bowel bacterial growth. 6. Infection in infancy, septicemia. 7. systemic infectious diseases- measles is the first implicating disease causing persistant diarrhoea. 8. Cong. chloriduria etc. |
| Clinical Features | Clinical features: 1. Purging or diarrhoea for > 2-3 weeks. 2. Dehydration- May be mild, moderate or severe (according to purging rate & volume). 3. Vomiting- may be present. 4. Anorexia - may be present initially. 5. Features of malnutrition- in long standing cases. 6. Systemic infection may be present. 7. Mouth- oral thrush may develop. 8. Eye signs: vita-A deficiency signs- xerophthalmia. 9. Subcutaneous fat- may be low or absent. 10. Anal region- perianal excoriation or fungal infection. 11. Signs of allergy or hypersensitivity. |
| Preventions | Drink only bottled water, even for tooth brushing. Avoid eating food from street vendors. Avoid ice made with tap water. Eat only those fruits or vegetables that are cooked or can be peeled. Be sure that all foods you eat are thoroughly cooked and served steaming hot. |
| Treatment | Opiate antidiarrheals. ... Bile acid binders for bile acid diarrhea. Clonidine for diabetes-related diarrhea. Eluxadoline for IBS-related diarrhea. Antibiotics or antiparasitics for infections. Fiber supplements, such as psyllium, to add bulk to your poop and slow down its transit. |
| Complications | Dehydration, electrolyte imbalance, kidney failure and organ damage |
| Prognosis | |
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| Pathology |
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