Diarrhea
Diarrhea: Excerpt from The Diagnostic Approach to Symptoms and Signs in Pediatrics
Definedas stools that are more fluid and frequent than normal.Can be acute or chronic (>2–3wks in duration). Acute diarrhea is discussed in first section ofthis chapter, and chronic diarrhea is discussed in second section. Principle Causes of Acute Diarrhea
- Infection
- Gastroenteritis
- Viral
- Rotavirus
- Other viruses
- Bacterial
- Salmonella
- Shigella
- Campylobacter jejuni
- Escherichia coli
- Other bacterial pathogens
- Parasitic
- Giardia lamblia
- Entamoeba histolytica
- Cryptosporidium parvum
- Strongyloides stercoralis
- Ascaris lumbricoides
- Hookworm infection
- Trichuris trichiura
- Fungal
- Candida species
- Other infections
- Food poisoning
- Antibiotic-associated diarrhea
- Allergic disorders
- Cow milkprotein sensitivity
- Soy protein sensitivity
- Other food allergy
- Congenital aganglionic megacolon (Hirschsprungdisease)
- Hemolytic-uremic syndrome
- Intussusception
Clinical Features and Diagnosis: Acute Diarrhea
Infection
Gastroenteritis
Viral
Rotavirus
Most commoncause of viral gastroenteritis in North America.Usually occurs between 3 mos and 3yrs of age.Although most common during wintermonths, it may occur year round.Diarrhea may be accompanied by feverand vomiting. Blood is not usually found in stools. Usually lastsfor few days and up to 1 wk.Detection of rotavirus antigen in stoolby enzyme immunoassay is diagnostic. Other Viruses
Adenovirusesmay be associated with acute gastroenteritis, especially in children <2 yrsof age.Illnessusually occurs during summer.Stool viral culture is diagnostic. Caliciviruses, which include Norwalkand Norwalk-like viruses, usually cause epidemics in school-agedchildren or adults.Infection usually comes from contaminated wateror food.Cramping abdominal pain, vomiting,and low-grade fever may be associated with diarrhea. Illness usuallylasts several days.Diagnostic tests include enzyme immunoassayfor detection of viral antigen in stool or antibody in serum, reverse-transcriptasepolymerase chain reaction for detection of viral RNA in stool, and electronmicroscopy for detection of viral antigen in stool. Astrovirus infection usually occursduring winter.Vomitingand fever are variable findings.Stool viral culture is diagnostic. Role of enteroviruses in GI diseaseis still unsettled.Although diarrhea may occur, incidence is probablyvery low.Stool viral culture is diagnostic. Bacterial
Most commoncauses of bacterial diarrhea include Salmonella species, Shigellaspecies, C. jejuni, and E. coli. Less common are Y. enterocolitica,A. hydrophila, C. difficile, V. parahaemolyticus, non-O1 Vibrioserogroups, S. aureus, and C. perfringens.Positive bacterial stool culture isdiagnostic. Salmonella
Most commoncause of bacterial diarrhea in children.Presentation is variable.Uncomplicatedacute gastroenteritis is associated with diarrhea, vomiting, cramping abdominalpain, and fever, with resolution usually within 1 wk. Blood in stoolis variable finding.Salmonella food poisoning occurs 12–24hrs after ingestion of contaminated food or milk products. Vomiting,diarrhea, and abdominal cramping pain usually occur for 2–3days. History and positive culture of stool or contaminated foodproduct are diagnostic.Enteric or typhoid fever causes abdominalpain and diarrhea. During second week of illness, fine pink macularor papular rash with typical rose spots occurs, and S. typhi maybe isolated from stool and blood. Shigella
Usual clinicalpresentation of intestinal shigellosis is watery diarrhea and fever. Bloodin stool is variable finding. Occasionally, seizure occurs.Another presentation is dysentery,which is characterized by severe diarrhea, tenesmus, and fever.Stools contain mixture of blood, mucus, and pus. Campylobacter jejuni
Peak incidenceof illness due to C. jejuni is between 1 and 5 yrs of age.Clinical findings include fever, vomiting,abdominal pain, and watery, foul-smelling diarrhea. Stools may containblood and mucus. Escherichia coli
5 groupsof pathogenic E. coli are recognized: enteropathogenic, enterotoxigenic,enteroinvasive, enteroaggregative, and enterohemorrhagic. In theU.S., disease caused by first 4 groups is uncommon, whereas enterohemorrhagicform is often associated with diarrheal illness seen with hemolytic-uremicsyndrome (HUS).Although stool culture can identifyE. coli, serotyping must be performed to identify specific strains.Enteropathogenic strains cause diarrheaand low-grade fever, primarily in infants.Enterotoxigenic strains produce toxinsthat cause watery diarrhea, vomiting, abdominal cramping pain, andlow-grade fever. Major cause of traveler's diarrhea, butdefinitive diagnosis requires enterotoxin identification, whichis not widely available.Enteroinvasive strains produce illnesscharacterized by watery diarrhea, abdominal cramps, and high feverwith or without blood in stool. Outbreaks usually occur secondaryto food contamination.Enteroaggregative strains usually producemild chronic diarrhea.Enterohemorrhagic strains produce toxinsthat cause watery diarrhea mixed with streaks of blood, hemorrhagiccolitis, or HUS. Serotype 0157:H7 is most common strain associatedwith HUS. Other Bacterial Pathogens
Infectionwith Y. enterocolitica is most common in children <5 yrsof age.Clinical findings include fever, vomiting,diarrhea with occasional blood in stool, and right lower quadrantabdominal pain, which may mimic pain of acute appendicitis. Associatedreactive arthritis also may occur. Diarrhea usually lasts 1–2wks.Usual presentation of A. hydrophilainfection is self-limited, watery diarrhea that usually occurs inchildren <3 yrs of age. Vomiting, fever, and occasionalblood in stools also may occur.Transmission of V. cholerae, rare infectionin the U.S., occurs by contaminated food or water. Ingested bacteriarelease toxin in intestinal lumen that causes explosive diarrheawith rice water–like stools and massive fluid losses. Parasitic
Giardia lamblia
G. lamblia,flagellate protozoan, is most common intestinal parasite in the U.S.Can cause acute self-limited illnesswith diarrhea and crampy abdominal pain or chronic diarrhea withmalabsorption and poor weight gain. Fever is unusual, and bloodin stool is rare. Eosinophilia occurs in minority of cases.Presence of either trophozoites orcysts in stool or detection of G. lamblia antigens in stool by enzymeimmunoassay is diagnostic. Entamoeba histolytica
Althoughmany species of amebae exist, only E. histolytica is clearly pathogenic.Transmission occurs by fecal contaminationof food or water.Infection is endemic throughout theworld, especially where poor sanitation exists.Clinical manifestations include diarrheaand abdominal pain or acute colitis with abdominal cramps, tenesmus,and diarrhea containing blood and mucus.Diagnosis is usually made by identificationof cysts or trophozoites in stool. Serology also may be helpful,particularly with diagnosis of extraintestinal amebiasis and liverinvolvement. Cryptosporidium parvum
Infectionhas been described in normal persons, individuals with drug-inducedimmunosuppression, and those with HIV.Normal individuals usually have self-limitedillness, which consists of crampy epigastric pain, nausea, vomiting,and watery, nonbloody diarrhea.Chronic diarrhea may occur with HIVinfection.Identification of oocysts in stoolis diagnostic. Strongyloides stercoralis
This roundworm,2.5 mm in length, is endemic in southern U.S. and common in tropicsand Asia.Skin becomes red and pruritic afterpenetration by larvae, which usually occurs on feet. Diarrhea, vomiting,and abdominal pain may follow. Migration of larvae through lungscan cause cough and pneumonia. Peripheral eosinophilia also mayoccur.Identification of larvae in stool isdiagnostic. Ascaris lumbricoides
Infectioncan be asymptomatic or cause mild diarrhea, intermittent epigastricpain, anorexia, and vomiting.Identifying whitish-brown Ascaris worm,20–40 cm in length, or finding Ascaris eggs on microscopicexam of stool is diagnostic. Hookworm Infection
Adult hookwormsN. americanus and A. duodenale can cause red, pruritic lesions on feetor between toes where larvae penetrate. Other manifestations includediarrhea, vomiting, abdominal pain, anemia from GI blood loss, andperipheral eosinophilia.Detecting hookworm eggs on stool smearis diagnostic. Trichuris trichiura
T. trichiura,4-cm long whipworm, occurs most commonly in tropical areas but isalso found in subtropical areas (e.g., southern U.S.).Most individuals are asymptomatic,but diarrhea, tenesmus, weight loss, anemia, and peripheral eosinophiliamay occur.Seeing eggs on microscopic stool examis diagnostic. Fungal
Candida Species
C. albicansis most common cause of Candida enteritis, which is characterizedby watery diarrhea and abdominal pain.Predisposing factors include prolongedantibiotic or immunosuppressive therapy.Because yeast forms are ubiquitousand occur in fecal flora of normal persons, their presence aloneis not diagnostic. Definitive diagnosis requires demonstration ofintestinal mucosal invasion by Candida on biopsy or isolation ofCandida from ulcerative lesions. Other Infections
Diarrhea also may be associated with otitismedia, urinary tract infection, meningitis, and septicemia (seefurther discussion of these disorders in other chapters).
Food Poisoning
Occurs becauseof food contaminated with bacterial toxins. Most common bacteria areS. aureus, C. perfringens, and V. parahaemolyticus.Children usually have acute onset ofcrampy abdominal pain, vomiting, and profuse watery diarrhea.Resolution usually occurs in 2–3days.Positive stool culture or culture ofsuspected contaminated food is confirmatory. Antibiotic-Associated Diarrhea
Oral antibiotictherapy may produce mild, self-limited diarrhea, nausea, vomiting, andabdominal pain.Frequently implicated antibiotics includeamoxicillin, erythromycin, and tetracycline. Discontinuing drugleads to resolution of diarrhea.C. difficile–associated diseasepresumably occurs because of antibiotic alteration of colonic floraallowing spores to form vegetative forms that produce toxins. Almostany antibiotic can be implicated, but most frequent ones are amoxicillin,ampicillin, cephalosporins, and clindamycin. Spectrum of illnessvaries from self-limited diarrhea to severe colitis.Confirm diagnosis with assay specificfor C. difficile toxin because nontoxigenic strains can be isolatedfrom anaerobic cultures. Sigmoidoscopy with biopsy can show typicalmultiple plaquelike lesions (pseudomembranes) in colon. Allergic Disorders
Developmentof diarrhea after formula feeding may indicate cow milk proteinor soy protein sensitivity.Clinical picture is variable, rangingfrom acute enterocolitis to chronic diarrhea with or without bloodin stools. Cow Milk Protein Sensitivity
Although >25known proteins in cow milk are immunogenic, casein and beta-lactoglobulinare of most clinical importance.Besides diarrhea, other manifestationsof cow milk protein sensitivity are urticaria and anaphylaxis.Positive skin tests are useful butmay be negative in children <3 yrs. There also may be false-positiveresults with radioallergosorbent test to cow milk protein.Elimination of cow milk with subsequentchallenge can confirm diagnosis, but if symptoms have been severe,most physicians would not rechallenge. Soy Protein Sensitivity
Many infantswith cow milk protein sensitivity also have soy protein sensitivity.Most common presentation is persistentdiarrhea.History of soy protein formula intakefollowed by clearance of symptoms on hypoallergenic formula [Alimentum(Abbott Laboratories, Abbott Park, IL), Nutramigen (Mead JohnsonNutritionals, Evansville, IN), Neocate (SHS North America, Gaithersburg,MD)], and if necessary, rechallenge with soy formula confirmsdiagnosis. Other Food Allergy
Common causesbesides milk and soy include eggs, chocolate, shellfish, citrusfruits, and nuts.Clinical manifestations include diarrhea,urticaria, rhinitis, wheezing, eczema, and anaphylaxis.History is often diagnostic. Double-blindfood challenges are also diagnostic but can be dangerous if severeallergic reactions have previously occurred. Congenital Aganglionic Megacolon (Hirschsprung Disease)
Characterizedby absence of enteric ganglia along variable length of intestine.May present in many ways, including delayed passage of meconium;constipation; intestinal obstruction with vomiting and abdominaldistension; or enterocolitis with explosive diarrhea, abdominaldistension, vomiting, and fever.Suction rectal biopsy with acetylcholinesterasestaining is usually diagnostic. Hemolytic-Uremic Syndrome
E. coli0157:H7 is most common pathogen associated with HUS.Onset often begins with fever, vomiting,abdominal pain, and diarrhea, which may contain blood, followedin 5–10 days by hemolytic anemia, hematuria, thrombocytopenia,and often oliguria or anuria. Intussusception
Most commonage of presentation is 6–12 mos. Usual clinical manifestationsare crampy abdominal pain, vomiting, and blood in stool. Abdominalmass may be palpable, and diarrhea may occasionally occur.Abdominal radiographs that show leadingedge of intussusceptum outlined by air are diagnostic. Otherwise,radiographs may be normal or show evidence of bowel obstruction.If intussusception is suspected, air-contrastenema should be performed. If bowel obstruction is suspected, surgicalconsultation should be obtained before proceeding with air-contrastenema. Diagnostic Approach: Acute Diarrhea
Most commoncause of acute diarrhea is infection with rotavirus. Common bacterial pathogensinclude Salmonella species, Shigella species, and C. jejuni.Presence of fever and blood or pusin stool suggests bacterial infection, and bacterial stool cultureshould be performed.Stool toxin assay for C. difficileshould be considered whenever diarrhea persists during or followingantibiotic therapy.Cow milk or soy protein sensitivityis likely when diarrhea occurs after ingestion of these productsand no evidence of infection or antibiotic usage exists.Intussusception and HUS also shouldbe considered in children with bloody diarrhea. Principle Causes of Chronic Diarrhea
- Infection
- Drug-induced
- Constipation with overflow
- Allergic disorders
- Chronic nonspecific diarrhea of infancy
- Lactose intolerance
- Irritable bowel syndrome
- Inflammatory bowel disease
- Ulcerativecolitis
- Crohn disease
- Celiac disease
- Protein calorie malnutrition
- Short-bowel syndrome
- Immunodeficiency disorders
- Cystic fibrosis
- Shwachman disease
- Eosinophilic gastroenteritis
- Sucrase-isomaltase deficiency
- Glucose-galactose malabsorption
- Intestinal lymphangiectasia
- Acrodermatitis enteropathica
- Abetalipoproteinemia
Clinical Features and Diagnosis: Chronic Diarrhea
Chronic diarrhea, associated with varietyof disorders, may lead to decreased weight gain and linear growth,if not treated successfully.
Infection
In mostcases, enteric viral infections are uncomplicated and self-limited;however, severe enteritis can produce chronic diarrhea. Parasiticinfection (G. lamblia, E. histolytica, Cryptosporidium) also mayproduce chronic diarrhea. Infection with bacteria (Salmonella, Shigella,Campylobacter, Yersinia, Aeromonas) usually causes acute diarrheaand rarely chronic diarrhea.Stool cultures for viruses and bacteriaand stool exam for ova and parasites should be performed. Drug-Induced
Diarrhea may be side effect of many drugs.Antibiotics, in particular, can alter bowel flora and produce loose,watery stools.C. difficile–associated diseasesecondary to antibiotic usage may cause prolonged diarrhea.Laxative abuse, particularly in adolescentgirls who wish to lose weight, is another cause of chronic diarrhea.Cancer chemotherapeutic agents may causeprolonged diarrhea.
Constipation with Overflow
Sometimeschildren with constipation have loose stools that leak around chronicimpacted stool.Rectal exam may reveal impacted stool.Otherwise, abdominal radiograph will show bowel filled with stool. Allergic Disorders
Cow milk protein sensitivity, soy proteinsensitivity, and allergy to other foods may cause chronic diarrheaif offending substances are not identified and eliminated from diet.These disorders are discussed in first part of this chapter.
Chronic Nonspecific Diarrhea of Infancy
Unexplaineddiarrhea that typically occurs in children 1–3 yrs of age.Although 5–10 loose waterystools occur each day, these children appear well and grow normally.Diarrhea also may occur in cycles—normal stools for a fewweeks followed by weeks of diarrhea.In some cases, high intake of sorbitol-containingfoods (pears, prunes, plums, cherries), juices with high ratiosof fructose/glucose ± sorbitol, and high-carbohydratelow-fat intake may contribute to diarrhea.Resolution usually occurs by 4 yrsof age. Lactose Intolerance
May be dueto primary or secondary lactase deficiency.Primary lactase deficiency that presentsin newborn with watery diarrhea is rare. Most common cause is geneticlate-onset disease, which appears after 5 yrs of age from declinein intestinal specific lactase activity.Secondary lactase deficiency may bedue to several disorders, including gastroenteritis, giardiasis,antibiotic-induced diarrhea, protein-calorie malnutrition, necrotizingenterocolitis, celiac disease, cystic fibrosis, and extensive smallbowel resection.Clinical manifestations include diarrhea,flatulence, and abdominal pain when large amounts of lactose-containingproducts are ingested. Acidic stool (pH <5.5) and positivereducing substances (Clinitest, Bayer Corp., Elkhart, IN) suggestits presence.For children ≥5 yrs, breath hydrogentest can be performed. After ingestion of lactose load, breath hydrogencontent is measured q30mins for 2–3 hrs.Increase in expired hydrogen of >20ppm indicates lactose intolerance.If these tests are inconclusive orchild is younger, intestinal biopsy with measurement of lactaseactivity can be performed. Irritable Bowel Syndrome
Etiologyis unknown but may be related to environmental or emotional stress.Characteristic findings in irritablebowel syndrome are intermittent diarrhea, abdominal discomfort,flatulence, and occasional constipation.No specific diagnostic test. Historyand normal physical exam help confirm diagnosis. Inflammatory Bowel Disease
Ulcerative Colitis
Ulcerativecolitis, a disease of unknown cause, is most common type of IBDand involves colon and rectum.Although it can occur at any time inchildhood, it is rare in children <2 yrs.Diarrhea usually contains mixture ofblood, pus, and mucus. Associated findings include fever, abdominalpain, weight loss, anemia, and arthritis of large joints.Proctosigmoidoscopy and colonoscopywith mucosal biopsy confirm diagnosis. Crohn Disease
Can affectany portion of GI tract but usually involves terminal ileum andcolon. Cause is unknown.Rare in children <6 yrs.Characteristic findings include diarrheawith or without blood, anorexia, crampy abdominal pain, recurrentfever, weight loss, impaired linear growth, arthritis, erythemanodosum, clubbing, perianal abscesses and fistulae, and delayedsexual maturation. Growth failure usually is more severe in Crohndisease than in ulcerative colitis and may precede diarrhea andabdominal pain by months or years.Lab tests commonly reveal anemia, hypoalbuminemia,and increased sedimentation rate.Radiographic contrast studies of largeand small intestine and colonoscopy with biopsy should be performed.Diagnosis usually is made by combinationof clinical, radiologic, and histologic findings. Celiac Disease
Characterizedby gluten intolerance, recurrent diarrhea, and malabsorption. Glutenis found in wheat, rye, and barley.Antiendomysial or tissue transglutaminaseantibodies are useful for screening, but disease is diagnosed bysmall-bowel biopsy that shows flat villous lesion which respondsto elimination of gluten in diet. Protein-Calorie Malnutrition
Both marasmusand kwashiorkor can produce chronic diarrhea and poor growth. Marasmicchild is small, wasted, and chronically ill.Abdominal distension, diarrhea, stomatitis,and skin changes (scaling, ulceration, infection) can occur. Clinicalpicture of marasmus may overlap that of kwashiorkor in which hypoproteinemia,edema, and ascites are characteristic findings.Children with protein-calorie malnutritionalso have frequent bacterial and parasitic GI infections. Short-Bowel Syndrome
Extensivesurgical resection of intestine causes various disturbances in absorptiondepending on location and length of resected bowel. Bile acid deficiencyand small bowel bacterial overgrowth also may play role.Lesions that may require extensiveresection include necrotizing enterocolitis, enteric atresias, volvulus,complicated intussusception, and mesenteric vascular thrombosiswith infarction.Clinical features include diarrhea,malabsorption, and diminished growth. Immunodeficiency Disorders
Chronicdiarrhea may occur with number of immunodeficiency disorders, including isolatedIg A deficiency, combined immunodeficiency disease, and HIV infection.Recurrent GI infections are common.Stool should be sent for rotavirusantigen, bacterial culture, and exam for ova and parasites to begininvestigation. Cystic Fibrosis
Chronicdiarrhea or steatorrhea, recurrent cough, pulmonary infiltrates,and impaired growth are common manifestations of cystic fibrosis.Meconium ileus or delayed passage of meconium may have occurredin newborn period.Abnormal sweat chloride >60mEq/L is diagnostic. Shwachman Disease
Disorderof exocrine pancreatic insufficiency characterized by steatorrheawith pale, greasy stools; cyclic or chronic neutropenia; recurrentinfections (otitis media, sinusitis); bone findings of metaphysealdysostosis; and impaired growth.Analysis of duodenal fluid revealsdecreased concentrations of pancreatic lipase, trypsin, and amylase.Sweat chloride levels are normal.Clinical and lab findings confirm diagnosis. Eosinophilic Gastroenteritis
Disorderof unknown cause.Characteristic findings include abdominalpain, vomiting, diarrhea, hypoalbuminemia, edema, peripheral eosinophilia,and poor growth.Diagnosis is based on clinical findingsand eosinophilic infiltration on intestinal biopsy. Sucrase-Isomaltase Deficiency
Autosomal-recessivedisorder characterized by chronic diarrhea and poor growth. Genelocus has been mapped to chromosome 3q25-26.Onset depends on when sucrose-containingjuices and foods are introduced in diet.Stools are usually watery, frothy,and acidic (pH <5.5) but negative for reducing substances becausesucrose is not a reducing sugar. By adding 0.1 N hydrochloric acidto stool supernatant, sucrose can be converted to reducing sugar.In older children, breath hydrogentest is abnormal.Diagnosis can be confirmed by smallbowel biopsy with enzyme assay. Glucose-Galactose Malabsorption
Autosomal-recessivedisorder caused by mutations in SGLT1 gene that codes for intestinalsodium-glucose cotransporter. Gene locus has been mapped to chromosome 22q13.1.Causes failure of absorption of glucoseand galactose from intestine and results in severe diarrhea in neonatalperiod.Stools are acidic (pH<5.5)and positive for reducing substances (Clinitest, Bayer Corp., Elkhart,IN). Diarrhea resolves after elimination of glucose, galactose,and lactose from diet.Small bowel biopsy with enzyme analysisis normal. Molecular genetic analysis is definitive. Intestinal Lymphangiectasia
Autosomal-dominantdisorder characterized by diarrhea, intestinal protein loss, edema,ascites, and poor growth.Increase in alpha1-antitrypsinconcentration in spot stool sample indicates increased intestinalprotein loss.Small-bowel biopsy that shows dilatedvillous lymphatic spaces confirms diagnosis. Acrodermatitis Enteropathica
Impairedintestinal absorption of zinc causes this autosomal-recessive disorder.Characteristic findings include intermittentdiarrhea, bullous dermatitis with plaquelike scaly lesions, alopeciawith absent eyebrows and eyelashes, nail dystrophy, and impaired growth.Low plasma zinc concentration confirmsdiagnosis. Abetalipoproteinemia
Autosomal-recessivedisorder caused by mutations in microsomal triglyceride transferprotein gene, whose locus is on chromosome 4q22-q24.Alteration in transport of triglyceridefrom intestine and liver results in absence of chylomicrons, very-low-densitylipoproteins, and low-density lipoproteins in plasma.Characteristic findings are fat malabsorptionwith diarrhea, retinitis pigmentosa, cerebellar ataxia, and acanthocytosis. Diagnostic Approach: Chronic Diarrhea
Age of child,characteristics of diarrhea, dietary history, travel history, andassociated findings narrow diagnostic possibilities.Duration and severity of diarrhea,especially presence of dehydration or malnutrition, dictate guidelinesand speed of investigations. Age
Common causesof chronic diarrhea in infants <3 mos are postinfectiousgastroenteritis, cow milk protein sensitivity, soy protein sensitivity,cystic fibrosis, and short-bowel syndrome.Between 3 mos and 3 yrs of age, commoncauses of chronic diarrhea are postinfectious gastroenteritis, chronicnonspecific diarrhea, cow milk protein sensitivity, giardiasis,cystic fibrosis, and celiac disease.Irritable bowel syndrome, late-onsetlactose intolerance, giardiasis, celiac disease, and inflammatorybowel disease are common causes in childhood and adolescence. Stool Characteristics
Stool shouldbe visually examined for color; consistency; and presence of mucus, blood,and fat droplets.Mucus with or without blood suggestscolonic irritation from infectious, allergic, and immunologic disorders,or inflammatory bowel disease.Watery, frothy, acidic stools suggestcarbohydrate malabsorption.Foul-smelling, pale, greasy stoolssuggest steatorrhea and fat malabsorption.Oil droplets usually occur with pancreaticinsufficiency disorders.Blood in stool is seen commonly withinfectious disorders, allergic disorders, and inflammatory boweldisease. Investigations
Completehistory and physical exam must be performed in any child with chronicdiarrhea.Growth parameters, including weight,height, weight for height, and head circumference, should be plottedon growth charts developed for girls and boys by CDC (2001).Initial investigations should includestool exam for blood, pH, reducing sugars (Clinitest), ova, andparasites; CBC with differential; sedimentation rate; stool culturefor bacteria; and stool for C. difficile toxin.Acidic stool pH of <5.5 indicatescarbohydrate malabsorption. Stool positive for reducing substancesusing Clinitest tablets indicates lactose or glucose malabsorption.Because sucrose is not a reducing substance, hydrochloric acid shouldbe added to stool supernatant, which should be heated for 30 secsbefore using Clinitest tablets to test for sucrose. If these investigationsare normal and growth and development are normal, chronic nonspecificdiarrhea or postinfectious diarrhea are likely diagnoses.With suspected malabsorption syndromesand impaired weight gain or weight loss, additional tests shouldbe considered: serum electrolytes, creatinine, total protein, albumin,calcium, phosphorus, magnesium, alanine and aspartate aminotransferases,alkaline phosphatase, fractionated bilirubin, cholesterol, triglycerides,and bile acids; blood urea nitrogen; sweat test; antiendomysialor tissue transglutaminase antibodies; stool osmolality and electrolytes;72-hr stool collection for fat; breath hydrogen test; serum quantitativeimmunoglobulins; skin tests for delayed hypersensitivity; fecal alpha1-antitrypsin;small bowel biopsy and enzyme assay; duodenal drainage for measurementof pancreatic enzymes and exam for ova and parasites; radiographiccontrast studies as indicated by clinical findings; and proctosigmoidoscopywith or without rectal biopsy. References
- Altschuler SM, Liacouras CA. Clinicalpediatric gastroenterology. Philadelphia: Churchill Livingstone,1998.
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- Burks AW, Sampson H. Food allergies in children. CurrProbl Pediatr 1993;23:230–252.
- CDC Growth Charts: United States. U.S. Department ofHealth and Human Services, Centers for Disease Control and Prevention,National Center for Health Statistics, Division of Data Services. Hyattsville,MD, 2001. World Wide Web URL: http://www.cdc.gov/growthcharts.
- Cohen MB. Etiology and mechanisms of acute infectiousdiarrhea in infants in the United States. Pediatrics 1991;118(suppl):34–39.
- Feigin RD, Cherry JD, eds. Textbook of pediatric infectiousdiseases, 4th ed. Philadelphia: WB Saunders, 1998.
- Fleisher GR. Diarrhea. In: Fleisher GR, Ludwig S, eds.Textbook of pediatric emergency medicine, 4th ed. Philadelphia:Lippincott Williams & Wilkins, 2000:203–207.
- Gorbach SL. Antibiotics and Clostridium difficile.N Engl J Med 1999;341:1690–1691.
- Long SS, et al., eds. Principles and practice of pediatricinfectious diseases. New York: Churchill Livingstone, 1997.
- Online Mendelian Inheritance in Man (OMIM). McKusick-NathansInstitute for Genetic Medicine, Johns Hopkins University (Baltimore,MD) and National Center for Biotechnology Information, NationalLibrary of Medicine (Bethesda, MD), 2000. World Wide Web URL: http://www.ncbi.nlm.nih.gov/omim.
- Pickering LK, ed. 2000 Red book: report of the Committeeon Infectious Diseases, 25th ed. Elk Grove Village, IL: AmericanAcademy of Pediatrics, 2000.
- Rudolph AM, ed. Rudolph's pediatrics, 20thed. Stamford, CT: Appleton & Lange, 1996.
- Schwartz MW, ed. Pediatric primary care: a problem-orientedapproach, 2nd ed. Chicago: Year Book Medical Publishers, 1990.
- Scriver CR, et al., eds. The metabolic and molecularbases of inherited disease, 8th ed. New York: McGraw-Hill, 2001.
- Stern M, for the Working Group on Serologic Screeningfor Celiac Disease. Comparative evaluation of serologic tests forceliac disease: a European initiative toward standardization. JPediatr Gastroenterol Nutr 2000;31:513–519.
- Walker WA, et al., eds. Pediatric gastrointestinaldisease, 3rd ed. Hamilton, Ontario, Canada: BC Decker, 2000.
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Book Source Details
- Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
- Author(s): Paul S. Bellet
- Year of Publication: 2006
- Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.
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