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Mohammad I.

El Mouzan, MD
Professor and Consultant
Department of Pediatrics (Gastroenterology)
College of Medicine and KKUH
King Saud University. Riyadh, Saudi Arabia.

Clinical Approach to Chronic Diarrhea



Etiology .

Pathophysiology .

Common Clinical Forms

Clinical approach


Clinical Approach to Chronic Diarrhea

Diarrhea is a symptom not a disease .

Arbitrary .
Duration of the acute episode .

Chronic : > 14 days-30 days duration .

 frequency .
Increased volume .

Increased fluidity ( consistency).

- Diarrhea :


Clinical Approach to Chronic Diarrhea


B. overgrowth ( pseudoobstruction, malrotation, etc) .

Transit time ( irritable bowel s, etc ) .

Exudative disorders : Inflammation (infection, IBD, etc) .


Motility disorders :

hormone/ VIP-secreting tumors ( neuroblastoma, G.neuroma, carcinoids ) .

Secretory : stimulation of enterocyte receptor by (B. toxin, B. acid, SCF.acid,

Osmotic : osmotically-active substance (CHO, Mg, P, PEG, lactose, sorbitol, )


Clinical Approach to Chronic Diarrhea

Chronic enteritis : E. coli , S. enteritidis. G. lamblia.

Prolonged diarrhea .
Follows acute gastroenteritis.
After clearance of the infection .

The postenteritis syndrome :


Clinical Approach to Chronic Diarrhea

CHO malabsorption (lactose, sucrose, glu-galact) .

Bile acid malabsorption, intest. lymphangiectasia.
Acrodermatitis enteropathica, abeta-lipoproteinemia .
Congenital chloride diarrhea .

Selective Malabsorption :

involves all nutrients (CHO, proteins, fat) .

Examples : celiac disease, cystic fibrosis .

Generalized malabsorption :

malabsorption syndromes

Clinical Approach to Chronic Diarrhea

V.I.P-secreting tumors .

Inflammatory bowel disease (UC, CD, IC)

Chronic nonspecific diarrhea (toddlers, IBS) .

Colitis (allergic) .
Gastroenteritis (allergic) .
Generalized malabsorption .

- Cows milk sensitivity (allergy , intolerance) .


Clinical Approach to Chronic Diarrhea


Anatomic ( structural ) : malrotation, short boweletc.

Idiopathic microvillus atrophy .
Eosinophilic gastroenteropathy .
Autoimmune enteropathy .
Immune deficiency ( T - B cell ) .


Miscellaneous etiologies

Clinical Approach to Chronic Diarrhea

Clinical Approach to Chronic Diarrhea

Growth and development .

Type of stool and associated symptoms .

Temporal relationship : food/ diarrhea.

Dietary history and appetite .

Age at onset .

Family history .

Clinical approach : the history

Clinical Approach to Chronic Diarrhea

Abdominal distension (malabsorption) .

Dermatitis (allergy , Acroderm. Enteropathica , vit. Def.) .
Edema (P C malnutrition , protein - losing enteropathy) ..
Arthritis (inflammatory bowel disease) .

Retinitis , ataxia (abetalipoproteinemia) .

Special signs :

Nutritional status : signs of malnutrition , wasting .

Growth parameters : weight , length , Wt for length (or BMI), HC .

Clinical approach: the physical examination

Clinical Approach to Chronic Diarrhea

Stool :
Microscopy (cells,fat, parasites) , and culture.
Occult blood ,
pH and reducing substances .

Urine : microscopy, and culture .

Blood : CBC diff., ESR, electrolytes, BUN, creatinine TSP, albumin .

Routine (first line)

Clinical approach: investigations

Clinical Approach to Chronic Diarrhea

Elimination/challenge tests .

Endoscopy and biopsies (upper, lower) for histopathology .

Sweat chloride. Barium meal with SBFT.

Stool : 72H. stool fat,alpha-1-antitrypsine level.

triglycerides, cholesterol, lipoprotein electrophoresis, Ca, P, alk.phos.

Enterocytes autoantibodies.

Blood : Antiendomysial or anti tissue trans glutaminase A antibodies,

Further (second line)

Clinical approach: investigations

Clinical Approach to Chronic Diarrhea

Clinical Approach to Chronic Diarrhea

Clinical Approach to Chronic Diarrhea

Celiac disease
The Postenteritis syndrome
Chronic enteritis (I.e Giardiasis)
Cows milk protein allergy
Autoimune enteropathy
Congenital microvillous atrophy
Eosinophilic gastroenteropathy

Differential Diagnosis of Villous Atrophy

Clinical Approach to Chronic Diarrhea

Gluten-sensitive enteropathy

The post enteritis syndrome

Chronic non specific diarrhea

Common Clinical Forms of chronic diarrhea

Clinical Approach to Chronic Diarrhea

No evidence of gastrointestinal pathology .

Normal growth: (FTT 2 . to dietary restrictions) .

3 - 6 BMs / day .
Contains undigested vegetables .
First BM (morning) may be firm and large .

The diarrhea is mild :

The onset is gradual .

Clinical profile

Chronic nonspecific diarrhea .

Boehm P, et al . Acta Pediatr 1998; 87 : 268 .

Role of ASA , Loperamide .

Medication generally not helpful .

Prescribe a normal diet for age with normal fat .

Avoid excessive fluid intake (fruit juice) .

Avoid exclusion diets .


Chronic nonspecific diarrhea .

Sandhu BK, et al . J Pediatr Gastroenterol Nutr 1997; 24 : 522 .

Age : < 3 months .

Nutrition : Lack of breastfeeding, malnutrition , nutrition during acute GE .
Severity of the preceding gastroenteritis .

Risk factors

5- 20% ,commonest cause of ch.D in DC .


Diarrhea >2wks, following acute GE, associated with F.T.T and no evidence
of other causes.


The postenteritis syndrome .

loperamide, antibiotics) .

Nutrition : provide sufficient calories as tolerated .

Drugs : Limited indication (cholestyramine, ASA , peptobisthmol,

The management is non specific

The diagnosis is clinical

Intestinal villous injury .

Secondary CHO intolerance, bacterial overgrowth .
Relative pancreatic insufficiency .

The etiology is multifactorial

The postenteritis syndrome .

are present in 95% of CD patients Vs 20-30% in Nl subjects .

are involved in binding gliadin and their presentation to T cells.

Multiple cases in families .

High prevalence in first degree relatives ( 10% ) .
High concordance rate in monozygotic twins ( 75% ) .
Association with DQ alleles on DRw17, DR7, and DR5.
These H.L.A (chr.6) molecules :

certain cereals (barely,oats, wheat, rye) .

Environmental = exposure to gluten (gliadin fraction) - a protein in

Genetic predisposition :


Gluten-sensitive enteropathy (CD) .

Conditions with  prevalence of CD


The classical presentation: Gastrointestinal

Clinical aspects of celiac disease

Gluten-sensitive enteropathy (CD)

Chronic diarrhea
abdominal distension ,
muscle wasting .
irritability, apathy .

The classical presentation: Gastrointestinal

Gluten-sensitive enteropathy (CD)

Short stature.
Enamel hypoplasia
Osteopenia, osteoporosis .
Unexplained anemia
Delayed puberty
ALT elevation .
Intractable seizures .

- Dermatitis herpetiformis

Non-gastrointestinal manifestations of CD

Gluten-sensitive enteropathy (CD)

Recommended screening after 3 years of age

First degree relatives of CD patients

Selective IgA deficiency

Williams Syndrome

Turner Syndrome

Down Syndrome

Autoimmune thyroiditis

Type 1 diabetes mellitus

Conditions with  prevalence of CD

Gluten-sensitive enteropathy (CD)

Anemia, hypocalcemia, hypoalbuminemia .

Antiendomysium/anti tissue transglutaminase A abs.
Histopathology: villous atrophy, crypt hyperplasia, and
inflammatory infiltrate .

Laboratory findings

Gluten-sensitive enteropathy (CD)




- IgG








Sensitivity and specificity of CD serology

Gluten-sensitive enteropathy (CD)

Guideline for the diagnosis and treatment of Celiac disease: recommendation of the
NASPGHAN. J PG N 2005; 40: 1-19.

The diagnosis is definitive only when there is complete response to GFD

 Small bowel biopsy is recommended in all cases for confirmation.

The others are no longer recommended. (limitation = IgA deficiency).

Measurement of IgA antibody to human recombinant tissue transglutaminase (TTG).

Diagnostic criteria :

Gluten-sensitive enteropathy (CD).

Del Rosario MA, et al . J pediatr Gastroenterol Nutr 1998 ; 27 : 191.

G.F.D for life (malignancy) . ? Transient GI(5%) .

sensitivity to other proteins or food .

Immune deficiency (IgA) .
Intestinal lymphoma .

Consider other diagnoses :

Nonresponse to GFD

Eliminate ALL sources of gluten in the diet .

Gluten-free diet (G.F.D)


Gluten-sensitive enteropathy (CD).