1、Diarrhea,Ricardo A. Caicedo, MD Pediatric Gastroenterology University of Florida,Chronic,Diarrhea,Increase in frequency and water content of stools,Acute Diarrhea,Infection Viral gastroenteritis Rotavirus Enterovirus, adenovirus Norwalk virus Bacterial enterocolitis Shigella, Salmonella Yersinia, Ca
2、mpylobacter E.coli enteroinvasive C. difficile Foodborne S.aureus, Bacillus cereus E. coli enterotoxigenic Other: UTI, OM,Inflammatory Hemolytic Uremic Syndrome (HUS) Henoch-Schonlein Purpura (HSP) Anatomic Intussusception Appendicitis Toxic Ingestion Iron, mercury, lead Other Antibiotic-induced Hyp
3、erconcentrated infant formula Overfeeding infants,Chronic Diarrhea,Infection parasitic Giardia lamblia Entamoeba histolytica Cryptosporidium parvum Inflammatory Milk protein intolerance Food allergy IBD,Malabsorption Celiac disease Cystic fibrosis Bacterial overgrowth Osmotic Lactase deficiency Prim
4、ary Secondary post-infectious Excessive fructose intake Laxative overuse,Duration 2 weeks,Parasitic,Keating J (2005) Pediatr Rev 26: 5-13.,Tan KS et al (2002) Int J Parasitol 32: 789-804,Giardiasis,Presentation Watery, foul stools Abdominal distention Bloating, flatulence Crampy abdominal pain Malai
5、se, weakness Nausea/vomiting Anorexia, wt loss Risk factors Well water Daycare Public pools, summer camp Immunodeficiency,Diagnosis Stool antigen test Greater sensitivity than O+P Simpler than duodenal bx Often overlooked Fever, WBC, eosinophilia rare Natural history Most become asx by 6 wks Frequen
6、t re-infx (up to 35%) Few develop prolonged diarrhea with wt loss and growth failure Treatment Flagyl 15 mg/kg/d X 10 d Albendazole, furazolidone Asx carriers usually not treated,Prolonged Viral/Bacterial Diarrheas,Prolonged Diarrhea in Infants,Prolonged/recurrent diarrhea Failure to gain weightIntr
7、actable diarrhea of infancy, postenteritis enteropathy Metabolic acidosis Treatment Initial lactose-free, sucrose-free formula Elemental formula TPN,“Slick Gut” Syndrome,OTHER: Immunodeficiency CF VIPoma Abetalipoproteinemia Celiac disease Congenital intestinal lymphangiectasia,due to malrotation,Su
8、crase-isomaltase deficiency,= diagnosable by SB bx,Small bowel biopsy,Tufting enteropathy No effective tx,Microvillus inclusion disease Neonatal Apical membrane autophagocytosis Consanguinity TPN-dependence, SB Transplant,Congenital lymphangiectasia Protein losing enteropathy Villous clubbing Subepi
9、thelial bleb MCT and high protein diet,Toddlers diarrhea,Chronic nonspecific diarrhea of childhood Symptoms Explosive loose stools Contain food particles Frequent stools, decline as day goes on Management Verify normal growth and absence of red flags Blood in stool, persistent fever, anemia Exclude
10、celiac disease (tTG) and Giardia Trial of dietary modification Restrict fructose and/or lactose,Diarrhea in older children,OSMOTIC Lactase deficiency Primary African, Asian, Hispanic Secondary Postenteritis Laxative overuse/Poisoning INFLAMMATORY Infectious IBD FUNCTIONAL/hypermotility IBS CNSD (Tod
11、dlers),MALABSORPTIVE Celiac disease CF Pancreatic insufficiency Chronic cholestasis Bacterial overgrowth Zinc deficiency Intestinal lymphangiectasia Cong. Heart Dz (Fontan physiol) Tumor or radiation SECRETORY,steatorrhea,Secretory diarrheas,Voluminous watery Persists despite bowel rest Massive effl
12、ux of fluid/salt Stool electrolyte content similar to serum WDHA syndrome Watery diarrhea Hypokalemia Alkalosis,DIFFERENTIAL DX Cholera C. difficile Severe mucosal injury Short bowel syndrome Secretory tumors Carcinoid Gastrinoma Ganglioneuroma Neuroblastoma Pheochromocytoma VIPoma,Zinc deficiency,A
13、crodermatitis enteropathica Perineal and perioral rash Chronic diarrhea & undernutrition Low serum Zn and alk phos Primary Rare, recessive, mutation in Zn transporter Secondary CF Crohns Anorexia nervosa Dialysis Chronic TPN Exclusively breastfed preterms Tx = longterm Zn supplementation,Immunodefic
14、iency,Approach,Impact of diarrhea How is the infant/child growing? How is symptom affecting childs life? Mechanism of diarrhea Description of stool Blood? Oily? Food particles? Frequency Diet and exposures Complete physical exam Attention to skin, LN, spleen Screening and diagnostic tests,Screening
15、tests,BLOOD Electrolytes Total protein/albumin Liver tests CBC ESR Celiac serology (tTG) Vitamin levels B12, FA, Fe A, D, E,STOOL Guaiac pH and reducing substances Spot fat stain Gram stain/Culture Giardia Ag O+P C. diff toxin Osmolarity Electrolytes,Secretory vs. Osmotic,Osmotic Gap: 290 2 (Na+ + K
16、+),Stool Na 70 Osmotic Gap 100,Stool Na 100,Persists while NPO,Decreases when NPO,Malabsorption studies,FAT Spot fecal fat stain Quantitative 72 hr Total excretion 5g fat/24 h Coefficient of absorption = (fat ingested excreted)/ingested X 100% PROTEIN Fecal alpha-1-antitrypsin (A1AT) Suggests mucosal disorder such as celiac disease,CARBOHYDRATE Stool pH 20 ppm above baseline: malabs. Elevated baseline or 20 ppm w/in 30 min: overgrowth,
