7. Approach to a child with diarrhea & constipation Year 4

7. Approach to a child with diarrhea & constipation Year 4 · Paediatrics Collection: 4TH YEAR ALL NOTES / PAEDS / OTHER NOTES -- Chronic Diarrhea in Children\nGiven by: Dr. Asaad M. Assiri\nNotes by: Deema Alfaris\nSlides - Doctors Notes - Important - Book Notes\nTutorial Objec?ves:\n1. Know how to evaluate a child who has chronic diarrhea, including appropriate\nelements of history, physical examinaAon, stool analysis, and blood tesAng.\n2. Be familiar with the many disorders that cause chronic diarrhea, both with and\nwithout failure to thrive.\n3. Know the therapies for the many causes of chronic diarrhea.\n\nIntroduc?on Recurrent, chronic, infanAle diarrhea with malnutriAon, causes the death of 4.6 million\nchildren globally each year. In the last 25 years, the following specific prevenAve measures have reduced further the\nnumber of infants who have this condiAon:\n- Renewed emphasis on breasMeeding reducAon in the use of parAal starvaAon regimens\nduring diarrheal episodes and increased availability of age-appropriate infant food for\nchildren living in poverty encourage feeding infants with diarrhea I want you to think: early diarrhea is either congenital or infecAon Pathophysiology OsmoAc diarrhea is caused by a failure to absorb a luminal solute,\nresulAng in secreAon of fluids and net water retenAon across an\nosmoAc gradient. Secretory diarrhea occurs when there is a net secreAon of\nelectrolyte and fluid from the intesAne without compensatory\nabsorpAon. IntesAnal dysmoAlity (e.g. hyperthyroidism) typically occurs in the\nseRng of intact absorpAve abiliAes. IntesAnal Transit Ame is\ndecreased, the Ame allowed for absorpAon is minimized, and fluid\nis retained within the lumen. Inflammatory diarrhea may encompass all of the above\npathophysiologic mechanisms\n\n -Now we’ll go over ten scenarios from the doctor and workup their differentials Case One\nMy baby whom I just deliver developed diarrhea from day 1 aXer birth, what is the cause?\nAlways remember early diarrhea = secondary infecAon or congenital \n\nDDx 1: Congenital Chloride Diarrhea Presenta?on An autosomal recessive disease, caused by a\ndefect in chloride transport Maternal polyhydrammics Prematurity Abdominal DistenAon Diarrhea Findings Hypokalemia hypochloremic Metabolic alkalosis Fecal chloride greater than fecal sodium and\npotassium hyperbilirubinemia in 90% Treatment Na + Kcl supplement Reference A Study in Arab Children J Clin Gastroenterol 1994\n\nDDx 2: Congenital Sodium Diarrhea \nFeatures An autosomal recessive disease, caused by a defect in a jejunal sodium/proton exchange that\nresults in severe watery diarrhea. SPINT2 gene located on 19q13.1 (a serine-protease inhibitor) Skipped \nPresenta?on Polyhydramnios (first manifestaAon of CSD) Findings Hyponatremia Metabolic Acidosis \n\nDDx 3: Microvillous Atrophy-Inclusion Disease (Familial Microvillous Atrophy) Presenta?on Watery diarrhea despite paAents NPO Clinical forms 1. Congenital: the onset of the diarrhea in the first week of life 2. Late onset: when diarrhea start aXer neonatal period 1-2 months Diagnosis Based on the finding of villus atrophy and intracytoplasmic inclusions lined by intact microvilli in intesAnal biopsy Treatment Total parenteral nutriAon IntesAnal transplantaAon\n\nDDx 4: Intes?nal Epithelial Dysplasia (TuQing Enteropathy) Presenta?on A congenital enteropathy presen?ng with early-onset severe\nintractable diarrhea Watery diarrhea within the first days aXer birth Growth is impaired No past history of hydramnios sugges?ng congenital chloride\ndiarrhea or sodium malabsorp?on Affected children are reported to have dysmorphic features Associated with choanal or esophageal atresia or imperforate anus Diagnosis Biopsy showing: Villous atrophy (persistent) AbnormaliAes are localized mainly in\nthe epithelium, includes\ndisorganizaAon of surface\nenterocytes with focal crowding. \n\n• Specific features include:\n- Focal enterocyte crowding observed in crypt epithelium.\nresembling tuXs\n- Crypts are dilated with features of pseudo cysts. Treatment Total parenteral nutriAon IntesAnal transplantaAon\n\nDDx 5: Autoimmune Enteropathy Presenta?on Severe protracted watery diarrhea during infancy or toddlerhood Diarrhea may be isolated or may occur in associaAon with diabetes mellitus as part of the\nIPEX syndrome (Immune dysregulaAon, Polyendocrinopathy and Enteropathy, X-linked),\nassociated with mutaAons in the FOXP3 gene CirculaAng anAbodies to enterocytes anA- smooth, anAthyroid and islet-cell anAbodies Treatment Total parenteral nutriAon Prednisone Cyclosporine Azathioprine IntesAnal transplant\n\nCase Two I delivered this baby and I start to feed him/ her my breast milk and/ or bomle milk, since I start\nfeeding the baby developed diarrhea. What is the cause?\nWhat are the contents of milk? 1. carbs in the form of lactose broken into glucose and\ngalactose 2. proteins 3. vitamins 4. Immunoglobulins 5. lipids 6. water 7. ashes\n\nDDx 1: Monosaccharide Malabsorp?on or glu