_diarrhea weebly慢性腹泻课件

DiarrheaDiarrhea Ricardo A. Caicedo, MD Pediatric Gastroenterology University of Florida Diarrhea Increase in frequency and water content of stools MECHANISMExamples MALABSORPTIONCeliac disease, Rotavirus OSMOTICLactase deficiency SECRETORYCholera, C. difficile toxin HYPERMOTILITYIBS INFLAMMATORYIBD, Shigella Acute Diarrhea Infection Viral gastroenteritis Rotavirus Enterovirus, adenovirus Norwalk virus Bacterial enterocolitis Shigella, Salmonella Yersinia, Campylobacter E.coli enteroinvasive C. difficile Foodborne S.aureus, Bacillus cereus E. coli enterotoxigenic Other: UTI, OM Inflammatory Hemolytic Uremic Syndrome (HUS) Henoch-Schonlein Purpura (HSP) Anatomic Intussusception Appendicitis Toxic Ingestion Iron, mercury, lead Other Antibiotic-induced Hyperconcentrated infant formula Overfeeding infants Chronic Diarrhea Infection parasitic Giardia lamblia Entamoeba histolytica Cryptosporidium parvum Inflammatory Milk protein intolerance Food allergy IBD Malabsorption Celiac disease Cystic fibrosis Bacterial overgrowth Osmotic Lactase deficiency Primary Secondary post-infectious Excessive fructose intake Laxative overuse Duration 2 weeks Parasitic OrganismSourcesDuration Giardia Fecal-oral, water supplies2 wks years Entamoeba SameWeeks Cryptosporidium Same, plus petting zoos, swimming pools 2 wks Cyclospora Water, unpasteurized apple cider 1wk-1month Isospora Fecal-oral, water 2 wks Strongyloides Fecal-oral Appalachia same Blastocystis hominis Pathogenic? Keating J (2005) Pediatr Rev 26: 5-13. Tan KS et al (2002) Int J Parasitol 32: 789-804 Giardiasis Presentation Watery, foul stools Abdominal distention Bloating, flatulence Crampy abdominal pain Malaise, weakness Nausea/vomiting Anorexia, wt loss Risk factors Well water Daycare Public pools, summer camp Immunodeficiency Diagnosis Stool antigen test Greater sensitivity than O+P Simpler than duodenal bx Often overlooked Fever, WBC, eosinophilia rare Natural history Most become asx by 6 wks Frequent re-infx (up to 35%) Few develop prolonged diarrhea with wt loss and growth failure Treatment Flagyl 15 mg/kg/d X 10 d Albendazole, furazolidone Asx carriers usually not treated Prolonged Viral/Bacterial Diarrheas AgentSourcesDuration Adenovirus, Rotavirus, CMV Avg. 11 d Months in immunodeficient C. difficile Abx, nosocomialRelapses in 10% of cases Campylobacter Raw poultry, unpasteurized milk, contaminated water 5 d - weeks Salmonella Poultry, fecal-oralMonths in infants Yersinia Raw pig intestines, fecal- oral 3 wks -3 months Aeromonas Untreated water1 wk 1 yr Prolonged Diarrhea in Infants Prolonged/recurrent diarrhea Failure to gain weight Intractable diarrhea of infancy, postenteritis enteropathy Metabolic acidosis Treatment Initial lactose-free, sucrose- free formula Elemental formula TPN “Slick Gut” Syndrome OTHER: Immunodeficiency CF VIPoma Abetalipoproteinemia Celiac disease Congenital intestinal lymphangiectasia due to malrotation Sucrase-isomaltase deficiency = diagnosable by SB bx Small bowel biopsy Tufting enteropathy No effective tx Microvillus inclusion disease Neonatal Apical membrane autophagocytosis Consanguinity TPN-dependence, SB Transplant Congenital lymphangiectasia Protein losing enteropathy Villous clubbing Subepithelial bleb MCT and high protein diet Toddlers diarrhea Chronic nonspecific diarrhea of childhood Symptoms Explosive loose stools Contain food particles Frequent stools, decline as day goes on Management Verify normal growth and absence of red flags Blood in stool, persistent fever, anemia Exclude celiac disease (tTG) and Giardia Trial of dietary modification Restrict fructose and/or lactose Diarrhea in older children OSMOTIC Lactase deficiency Primary African, Asian, Hispanic Secondary Postenteritis Laxative overuse/Poisoning INFLAMMATORY Infectious IBD FUNCTIONAL/hypermotility IBS CNSD (Toddlers) MALABSORPTIVE Celiac disease CF Pancreatic insufficiency Chronic cholestasis Bacterial overgrowth Zinc deficiency Intestinal lymphangiectasia Cong. Heart Dz (Fontan physiol) Tumor or radiation SECRETORY steatorrhea Secretory diarrheas Voluminous watery Persists despite bowel rest Massive efflux of fluid/salt Stool electrolyte content similar to serum WDHA syndrome Watery diarrhea Hypokalemia Alkalosis DIFFERENTIAL DX Cholera C. difficile Severe mucosal injury Short bowel syndrome Secretory tumors Carcinoid Gastrinoma Ganglioneuroma Neuroblastoma Pheochromocytoma VIPoma Zinc deficiency Acrodermatitis enteropathica Perineal and perioral rash Chronic diarrhea & undernutrition Low serum Zn and alk phos Primary Rare, recessive, mutation in Zn transporter Secondary CF Crohns Anorexia nervosa Dialysis Chronic TPN Exclusively breastfed preterms Tx = longterm Zn supplementation Immunodeficiency CONDITIONDIARRHEA Immunosuppression CMV colitis, Cryptosporidium, Isospora, Entamoeba, Microspora, Cyclospora HIV Cryptosporidium, Giardia, +/- VIP-oma SCID 50% have protracted diarrhea in infancy CGD Crohn-like colitis early in life Wiskott IBD-like early in life CVID Campy, Giardia Hyper IgM 50% have chronic diarrhea Selective IgA deficiency Increased risk of chronic giardiasis MHC II deficiency Death in infancy due to severe malabsorption Approach Impact of diarrhea How is the infant/child growing? How is symptom affecting childs life? Mechanism of diarrhea Description of stool Blood? Oily? Food particles? Frequency Diet and exposures Complete physical exam Attention to skin, LN, spleen Screening and diagnostic tests Screening tests BLOOD Electrolytes Total protein/albumin Liver tests CBC ESR Celiac serology (tTG) Vitamin levels