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Thursday, April 16, 2009

Diarrhoea

Diarrhoea is variously described as

  1. Increase in stool frequency
  2. Increase in stool fluidity
  3. Increase in total daily stool out put

Increase in total daily stool output (water + electrolytes) is the best scientific definition. For infants and young children this accounts to a stool out put of greater than 10gm/kg/day or more than the adult limit of 200gm/day. Diarrhoea is a symptom which can be caused by several causes. Diarrhoea is classified into

1.Acute
2.Persistent
3.Chronic

Acute diarrhoea is usually caused by infection by a bacteria virus or protozoa. It usually resolve in 4-6 days. Main concern in acute diarrhoea is prevention /treatment of dehydration.

For prevention of dehydration, one should use ORS / oral rehydrating solution and if patient is not accepting well orally or having excessive vomting, or excessive dehydration or non responsive to ORS – IV fluids are required.

Persistent diarrhoea usually begins as an acute diarrhoea but persistent beyond 2 weeks.

Chronic diarrhoea : diarrhoea lasting >3-4 weeks is called as chronic diarrhoea. Chronic diarrhoea if not treated leads to loss / failure to gain weight and malnutrition, which can have serious consequences. Common causes of chronic diarrhoea are

• Giardiasis
• Secondary diasaccharidase deficiency / lactose intolerance
• Malabsorption after acute diarrhoea
• Celiac disease (wheat Hyper sensitivity)
• Tropical enteropathy
• Irritable bowel syndrome
• Inflammatory bowel disease
• Milk protein allergy
• Cystic fibrosis, etc.

Chronic diarrhoea needs careful and meticulous evaluation of child's symptoms, stool test and blood tests. Endoscopy and biopsy may be required to arrive at a diagnosis. In addition to treatment of underlying causes, the child needs nutritional rehabilitation.

Celiac disease ( also called gluten sensitive enteropathy, celiac sprue) is a disorder in which the lining of small intestine is damaged as a result of exposure to gluten. Gluten is a protein which is present in wheat, rye, barley and oat's. This leads to defective digestion and absorption of nutrients. There is a substantial lack of awareness in general public and few doctors leading to a delay in diagnosis and the condition is much more common in Indian than thought of.

Typically the child presents with failure to thrive, diarrhoea, irritability, vomiting, anorexia, large bulky foul smelling stools, abdominal pain, abdominal distention. Atypically, children may present just with anaemia, constipation, short stature, rickets or diabetes.

The diagnosis of this condition requires specific blood tests and endoscopy with biopsy of small intestine. The sibling of a child with celiac disease may have to be screened for the disease as there is a likelihood of them also being affected.

Apart from immediate complications if not treated / in appropriately treated there is a high risk of developing intestinal lymphoma (cancer) later in life.

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