GIT Lec. 3
By Dr. Athal Humo 2015-2016CHRONIC DIARRHEA
Chronic diarrhea is defined as a diarrheal episode that lasts for ≥14 days.Etiology
STRUCTURAL DEFECTS Microvillus inclusion disease Lymphangiectasia DEFECTS OF ELECTROLYTE AND METABOLITE TRANSPORT: Congenital chloride diarrhea Congenital sodium diarrheaMOTILITY DISORDERS Hirschsprung disease Thyrotoxicosis NEOPLASTIC DISEASES Neuroendocrine hormone-secreting tumors ( VIPoma) CHRONIC NONSPECIFIC DIARRHEA Functional diarrhea (toddler's diarrhea) Irritable bowel syndrome
Evaluation of Patients
medical approach should be based on diagnostic algorithms : clinical and epidemiologic factors: History Age Personal & family history(cong, allergy, inflam) Previous episode of acute GE. Association with specific foods Polyhydromnios Specific amount of fluid ingested /dayExamination: General & nutritional statusNOTE: Nutritional evaluation: includeDiatery hxNutritional state, growth parameters, anthropometric evaluation→estimate the severity of diarrheaBiochemical markersNutritional inv Biochemical markers assist in grading malnutrition, the half life of serum proteins can differentiate between short & long term malnutition.
STEP 1 Intestinal microbiology (GSE, microscopy for parasites, viruses, stool cultures), stool electrolytes, pH & reducing substances, H2 breath testBlood studies (CBC, ESR, electrolytes, blood urea, creatinine) Screening test for celiac disease Noninvasive tests for: • Intestinal function • Pancreatic function and sweat test • Intestinal inflammationTests for food allergy • Prick/patch tests
STEP 2 Intestinal morphology • Standard jejunal/colonic histology • Morphometry
STEP 3 Special investigations • Intestinal immunohistochemistry • Hormonal studies • Autoantibodies • Brush border enzymatic activities • others
Treatment
Replacement of fluid and electrolyte Empirical antibiotic therapy nutritional rehabilitation Human immunoglobulins Zinc Treatment of underlying causeGeneral therapeutic approaches to management of chronic diarrhea
What is Lactose Intolerance?Inability to digest significant amounts of lactose, which is the predominant sugar in milk A result of lactase insufficiency, the enzyme essential for the conversion of lactose into glucose and galactose
Types of Lactose Intolerance
Congenital Very rare Primary Develops after 2 years of age Secondary Usually resolves in 1-2 weeksClinical Manifestation
Nausea, cramping, bloating, abdominal pain, gas, diarrhea, perianal excoriationDIAGNOSIS
Stool pH < 5.5. Positive reducing substance in stool. Low lactase activity in jejunal mucosa. Increased H2 in expired air.
TREATMENT
Reduce lactose in diet . (SOY PROTEIN FORMULA) ISOMILISOMIL
Isomil/Prosobee 20cal/oz palm olein, soy, coconut, sunflower oil Corn syrup/sucrose Protein, 17 g/L soy isolate and L-MET Iron 12mg/L Vitamin D 405 IU/L 200 mOsm/kg H2O DHA and AA added (docosahexaenoic acid and arachidonic acid)SOY PROTEIN FORMULA
What is Milk Allergy?An abnormal immune system reaction to proteins in the cow’s milkTriggered by a combination of genetically inherited factors and early introduction of cow’s milk or soy protein into an infant’s diet
Symptoms of Milk Allergy
An immune system reaction Gastrointestinal Manifestations : vomiting, diarrhea, malabsorption, protein-losing enteropathy, colic, GIT bleeding, FTT.Systemic Manifestations : anaphylaxis, rhinitis, wheezing, pulmonary hemosiderosis, peripheral eosinophilia, IDA 2ry to GIT bleeding.
DIAGNOSIS
Mainly Clinical Symptoms disappear after withdrawal of cow’s milk . Very cautious CHALLENGE WITH FEW CC of cow’s milk produces the symptoms again.TREATMENT
SOY PROTEIN [ (30-50%) are also allergic to soy protein. HYDROLYSED MILK FORMULA )Pregestemile).HYDROLYSED MILK FORMULA
Protein Hydrolysate FormulasAlimentum AdvancePregestimil/Pregestimil Lipil Nutramigen LipilProtein Casein hyrolysate + free AA’sFat (Alimentum and Pregestimil) Medium chain + Long chain triglycerides;(Nutramigen) Long chain triglyceridesCarbohydrate: Lactose free