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CHRONIC DIARRHEA WITH FAILURE TO THRIVE

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  • suggests malabsorption (with frequent bulky, foul smelling stools)

 

Investigation of malabsorption

 

  1. stool consistency, pH, reducing substances, microscopy, occult blood
  2. stool: O & P, C & S, C. difficile toxin, 3-day fecal fat
  3. chest x-ray
  4. urinalysis
  5. FBC, differential, ESR, smear, electrolytes, total protein, immunoglobulins
  6. absorptive and nutritional status: albumin, carotene, Ca, PO4,Mg, Zn, Fe, ferritin, folate, fat-soluble vitamins, PT, PTT
  7. sweat chloride
  8. if indicated, a-antitrypsin level, thyroid function tests, urine Vanillylmandelic Acid (VMA) & Homovanillic Acid (HVA), HIV test, lead levels
  9. upper GI series + follow-through
  10. specialized tests: small bowel biopsy, endoscopy and biopsy

 


1. Intestinal Causes


Celiac Disease (Gluten-sensitive enteropathy)

 

  • defect at the mucosal level (BROW: barley, rye, oats, wheat)
  • toxic or immunologic reaction 

 

Clinical features

  1. presents at any age, usually 6-18 months
  2. FTT with poor appetite, irritability, apathy
  3. anorexia, nausea, vomiting, edema
  4. wasted muscles, distended abdomen and flat buttocks
  5. anemia, bleeding
  6. rickets
  7. clubbing of fingers 

 

Diagnosis

  1. fat malabsorption studies
  2. small bowel biopsy: flat atrophic mucosa with resolution
  3. after trial of gluten-free diet (villous atrophy)
  4. antigliadin, antiendomysial antibodies, low D-xylose absorption

 

Treatment

  1. gluten-free diet for life
  2. avoid BROW 

 

Complications if untreated

  1. small bowel lymphoma
  2. malnutrition


Milk Protein Allergy

 

  1. immune-mediated mucosal injury
  2. can be associated with soy protein, anemia, hypoalbuminemia
  3. often atopic individuals

 

Inflammatory Bowel Disease 

 

  1. see Gastroenterology lectures
  2. incidence: increasing in North America, mostly older children, teenagers

Other

 

  1. specific enzyme deficiencies
  2. liver disease,
  3. biliary atresia
  4. a-Beta-lipoproteinemia
  5. short gut syndrome
  6. blind loop syndrome
  7. protein-losing enteropathy (Celiac, IBD, Giardia)

 


2. Pancreatic Insufficiency


Cystic Fibrosis (see Cystic Fibrosis lecture)

 

  • loss of exocrine pancreatic function

 

Clinical features

  1. meconium ileus in the newborn
  2. FTT with good appetite
  3. rectal prolapse
  4. steatorrhea
  5. respiratory symptoms, nasal polyps 

Diagnosis: elevated sweat chloride (> 60 mEq/L), increased fecal fat,DNA mutation

 

Management (GI)

  • pancreatic enzyme replacement
  • fat soluble vitamins (A,D,E,K)

Shwachman Syndrome

 

  1. pancreatic insufficiency (autosomal recessive)
  2. cyclic neutropenia
  3. skeletal abnormalities (metaphyseal dystosis leading to short stature)
  4. Dry skin, eczematous, chthyosiform lesions

 

3. Diet-Induced

  • food allergy


4. Other

 

  1. diets rich in sorbitol, fructose (poorly absorbed CHO)
  2. metabolic/endocrine
    • thyrotoxicosis
    • Addison's disease
    • galactosemia 
  3. immune defects
    • IgA deficiency, hypogammaglobulinemia
    • SCID
    • AIDS 
  4. neoplastic
    • pheochromocytoma
    • lymphoma of small bowel
CHRONIC DIARRHEA WITH FAILURE TO THRIVE CHRONIC DIARRHEA WITH FAILURE TO THRIVE Reviewed by Radiology Madeeasy on August 27, 2010 Rating: 5
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