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Definition Increased frequency and water content of stools than is normal for the individual Usually: > 3 stools per day Descriptive Watery, mucoid, dysenteric Pathogenetic: Infective, non-infective
Pathogenesis of Diarrhoea
Depends on pathogen VIRUS DIARRHOEA (eg Rotavirus) Effect on villus structure and function Enzyme damage Significant effect on digestion and absorption Secretion-absorption imbalance
Paediatric Diarrhoea
Emerging issues
Food borne organisms of increasing importance with contamination of stored/transported food Campylobacter Salmonella Yersinia Bacillus cereus Vibrio parahaemolyticus Unhygienic handling of food Esch coli 0157 Staph aureus mince meat Poultry, meat Poultry, Dairy Produce Meat Reheated cereals Fish products
Secretory
eg Cholera
Mixed secretory-osmotic
eg Rotavirus
Mucosal inflammation
eg Invasive bacteria
Motility disturbance
Effects of Diarrhoea
Dehydration Biochemical disturbances Sodium, Potassium Metabolic acidosis Blood glucose Uraemia Convulsions Severe gut damage : ileus, NEC, PLE
Clinical patterns
Some associated features depend on pathogen: Rotavirus Invasive bacteria Toxigenic bacteria Fever, abdominal pain, early or late vomiting, other symptoms
Management of diarrhoea
Replace the fluids and electrolytes which are lost Drug therapy has very little place Antibiotic Antisecretory Antimotility Nutritional management Follow-up to ensure recovery
Chronic diarrhoea
Diarrhoea can be categorized as: Acute: less than 7 - 10 days Persistent: More than 7 - 10 days Chronic: More than 14 - 21 days (Persistent diarrhoea often a prolonged course of acute insult - different management)
Chronic diarrhoea
With failure to thrive and excessive stool water losses Small intestinal mucosal injury With failure to thrive but without excessive stool water losses Malabsorption syndromes Without failure to thrive Motility disorder
Lactose intolerance
Development of symptoms following lactose exposure due to lactase deficiency Luminal fermentation of undigested lactose Acid diarrhoea with lactose in stools Diagnosed:
History, low stool pH, positive reducing sugars
Lactose intolerance
Congenital deficiency very rare
Watery, acid diarrhoea from birth
Genetic primary adult lactase deficiency very common in Africa Acquired deficiency common in severe gastroenteritis, malnutrition Usually self-limiting without treatment Feed change with persistent high stool water output
Fat malabsorption
Diagnosis : stool microscopy, quantitative Pancreatic deficiency (eg cystic fibrosis)
Increased appetite cf intestinal disease Greasy floating stools, foul-smelling Treated with enzyme replacement
Food allergy
Not equivalent to food intolerance Requires exposure and sensitization before symptoms develop
GIT and/or skin, nose, resp. symptoms
Food intolerance
Symptoms after ingestion of food, the word does not indicate the pathology. Can be: Allergic or immunological Allergic enteropathy Biochemical - enzyme deficiencies Lactose intolerance Chemical Laxative, salicylate
Coeliac disease
Gluten-induced enteropathy : gliadin fraction of wheat protein Symptoms after exposure to wheat Genetic factors : HLA-B8 Auto-immune disorder Villous atrophy with malabsorption Resultant malnutrition Anti-Endomysium, -gliadin IgA, jejunal biopsies Total wheat product exclusion lifelong
Motility disorders
Irritable bowel syndrome, Toddler diarrhoea Between 6 months and 4 years Normal growth and weight gain Intermittent episodes, not at night Stools get progressively more loose through the day, may contain undigested vegetables Family history of spastic colon Reassurance most important