Investigation of Chronic Diarrhoea

Investigation of Chronic Diarrhoea : 

Investigation of Chronic Diarrhoea Dr S Sen SpR Paediatric Gastroenterology Booth Hall Hospital

Definitions : 

18/10/2009 Dr Sen/Paediatric Gastroenterology/Booth Hall Hospital 2 Definitions Diarrhoea may be defined in terms of stool frequency, consistency, volume, or weight. Chronic diarrhoea is defined as stool volume of more than 10 grams/kg/day in infants and toddlers, or more than 200 grams/day in older children for more than 14 days This typically translates to persistent loose or watery stools occurring at least three times a day, where the change in stool consistency is more important than stool frequency

History : 

18/10/2009 Dr Sen/Paediatric Gastroenterology/Booth Hall Hospital 3 History Aims (a) To establish the likelihood that the symptoms are organic (as opposed to functional) (b) To distinguish malabsorptive from colonic/inflammatory forms of diarrhoea, and (c) To assess for specific causes of diarrhoea

Organic Causes : 

18/10/2009 Dr Sen/Paediatric Gastroenterology/Booth Hall Hospital 4 Organic Causes Symptoms suggestive of an organic disease include a history of diarrhoea of less than three months’ duration, predominantly nocturnal or continuous (as opposed to intermittent) diarrhoea, and significant weight loss

Causes of chronic diarrhoea : 

18/10/2009 Dr Sen/Paediatric Gastroenterology/Booth Hall Hospital 5 Causes of chronic diarrhoea Infectious Causes Immune Deficiency Abnormal Immune response Malabsorption of Fat Gastrointestinal Protein Loss Bowel Obstruction and dysmotility Congenital diarrhoeas Neuroendocrine tumours Factitious Diarrhoea Non specific diarrhoea

Specific risk factors : 

18/10/2009 Dr Sen/Paediatric Gastroenterology/Booth Hall Hospital 6 Specific risk factors (1) Family history (2) Previous surgery (3) Previous pancreatic disease (4) Systemic disease-Thyrotoxicosis and parathyroid disease, diabetes mellitus, adrenal disease (5) Drugs- 4% Laxatives, antihypertensive and non-steroidal anti-inflammatory drugs,theophyllines, antibiotics, antiarrhythmics, and antineoplastic agents. (6) Food additives such as sorbitol and fructose. (8) Recent overseas travel or other potential sources of infectious gastrointestinal pathogens (9) Recent antibiotic therapy and Clostridium difficile infection (10) Alcohol.

Initial investigations : 

18/10/2009 Dr Sen/Paediatric Gastroenterology/Booth Hall Hospital 7 Initial investigations Blood tests-Full blood count, urea and electrolytes, liver function tests, vitamin B12, folate, calcium, ESR and CRP,Fe status,coeliac serology and thyroid function Stool tests-Specific and nonspecific Stool microscopy and culture Stools for ova, cysts, and parasites Measurement of stool (faecal fluid) osmolality and calculation of the osmotic gap - Osmotic gap should be large (>125 mosmol/kg) in osmotic diarrhoea and small (<50 mosmol/kg) in secretory diarrhoea Faecal elastase, Stool analysis for fat Faecal occult blood

Further Investigations : 

18/10/2009 Dr Sen/Paediatric Gastroenterology/Booth Hall Hospital 8 Further Investigations Endoscopic and histological assessment Flexible sigmoidoscopy Colonoscopy Upper gastrointestinal endoscopy Small bowel imaging

Endoscopy:Detection of inflammatory lesionsin the small intestine : 

18/10/2009 Dr Sen/Paediatric Gastroenterology/Booth Hall Hospital 9 Endoscopy:Detection of inflammatory lesionsin the small intestine Thickened infiltrated folds (Jejunum) Villous erosion Linear ulcerations Apthous ulcerations (ileum)

Endoscopic diagnosis of Crohn’s Disease : 

18/10/2009 Dr Sen/Paediatric Gastroenterology/Booth Hall Hospital 10 Endoscopic diagnosis of Crohn’s Disease Jejunal Crohn's Disease

Coeliac Disease : 

18/10/2009 Dr Sen/Paediatric Gastroenterology/Booth Hall Hospital 11 Coeliac Disease

NON-INVASIVE TESTS FOR MALABSORPTION : 

18/10/2009 Dr Sen/Paediatric Gastroenterology/Booth Hall Hospital 12 NON-INVASIVE TESTS FOR MALABSORPTION Tests for fat Malabsorption-Stool fat, Breath tests-breath CO2 Tests for protein loss- faecal clearance of α1-antitrypsin or radiolabelled albumin Test for exocrine function-Faecal chymotrypsin,elastase & lipase,serum enzymes

INVESTIGATION OF CHRONIC DIARRHOEA DUE TO SPECIFIC CONDITIONS : 

18/10/2009 Dr Sen/Paediatric Gastroenterology/Booth Hall Hospital 13 INVESTIGATION OF CHRONIC DIARRHOEA DUE TO SPECIFIC CONDITIONS Small bowel bacterial overgrowth-Hydrogen breath Test Lactose malabsorption(i) assay of mucosal lactase, (ii) breath tests (hydrogen, 14C-lactose and 13C-lactose), and (iii)lactose tolerance tests measuring either serum glucose or galactose in response to an oral lactose load. Bile acid malabsorption (BAM)-75Se homotaurocholate (75Se-HCAT) testing

INVESTIGATION OF CHRONIC DIARRHOEA DUE TO SPECIFIC CONDITIONS : 

18/10/2009 Dr Sen/Paediatric Gastroenterology/Booth Hall Hospital 14 INVESTIGATION OF CHRONIC DIARRHOEA DUE TO SPECIFIC CONDITIONS Increased intestinal transit- Orocaecal transit time (OCTT) include barium studies, radionucleotide scintigraphy, and the lactulose hydrogen breath test. Hormone secreting tumours-Vasoactive intestinal peptide, gastrin, or glucagon

Thank you : 

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