Chronic Diarrhea and

Malabsorption

Dr Malik Aboelhassan
 Learning objectives
By the end of this lecture the student should be able to:
• Define chronic diarrhea & malasorption
• Identify the causes of chronic diarrhea
• Discuss the diagnosis of chronic diarrhea &
malasorption disorders
• Describe the supportive treatment for disorders of
chronic diarrhea & malasorption
• Discuss the specific treatment for the common
disorders of chronic diarrhea & malasorption
 Definitions
• Excessive loss of fluid and electrolyte in the stool.
• Increased total daily stool output, is usually associated with
increased stool water content. For infants and children, this
would result in stool output >10 g/kg/24 hr, or more than
the adult limit of 200g/24hr.
• A gradual or sudden increase in the number and volume of
stools to more than 15 g/kg/d combined with an increase in
fluidity.

When diarrhea lasts more than 2weeks, it is considered

chronic.
 Malabsorption
• Malabsorption is defined as a state in which there
is disturbance of the digestive – absorptive
sequence of nutrients across the intestinal mucosa.

• Malabsorption syndromes are characterized by

association of chronic diarrhea and failure to
thrive. The disorders involve inadequate
absorption of one or more of the major nutrients
and primarily involve the small intestine or the
exocrine pancreas.
 Pathophysiology
Diarrhea may result from:
• Interruption of normal cell transport processes for water,
electrolytes, or nutrients
• Decrease in the surface area available for absorption
secondary to shortened bowel or mucosal disease
• Increase in intestinal motility
• Increase in unabsorbable osmotically active molecules in the
intestinal lumen
• Increase in intestinal permeability, leading to increased loss of
water and electrolytes
• Stimulation of enterocyte secretion by toxins or cytokines.
 Causes of chronic diarrhea
• Celiac disease
• Infections / Immunodeficiency
• Toddler diarrhea
• Cow's milk protein intolerance
• Carbohydrate malabsorption:
– Lactose intolerance
– Sucrase-isomaltase deficiency
– Glucose – galactose malabsorption
• Fat malabsorption:
– Cystic fibrosis
– Schwachmann – diamond
– A betalipoproteinemia
• Protein losing enteropathy
• Inflammatory bowel diseases
• Short gut syndrome
• Congenital chloride diarrhea
 Diagnostic approach

Selection of the appropriate strategy to diagnose the

cause of chronic diarrhea in a child depends on the
presentation of the patient. In most cases, a
thorough history and physical examination
narrows the range of possibilities.
 Diagnostic approach
Detailed history:
• Diarrhea: onset & age of onset, duration, frequency,
consistency, odor and relation to certain diet
• Associated symptoms: fever, vomiting, anorexia,
abdominal pain, abdominal distension growth faltering
• Past history: diarrhea, constipation, respiratory
illnesses, recurrent infections, bowel surgery
• Nutritional history
• Family history (Celiac, inflammatory bowel disease)
 Diagnostic approach
Physical examination:
• Anthropometric measurements
• Signs of dehydration
• Edema
• Clubbing
• Jaundice
• Abdominal examination: Surgical scars, distension,
tenderness, hepatosplenomegaly, ascites, anal excoriation
• Examination of other systems (Chest, CVS, CNS)
• Skin: malnutrition, acrodermatitis enteropathica
 Diagnostic approach
Investigations:
• CBC, peripheral smear, ESR
• Biochemestry: protein & albumin, urea &
electrolytes, calcium, phosphorus, alkaline
phosphatase, LFTs
• Urine analysis & culture
 Diagnostic approach
Investigations:
• Stool examination:
– Routine macroscopy & microscopy
– Special tests:
• Reducing substances
• Occult blood
• Fat content
• α 1 antitrypsin
• Fecal elastase
• Fecal calprotectin
 Diagnostic approach
Investigations:
• Celiac serology
• Hydrogen breath test
• Endoscopy & small intestine biopsy
• Sweat chloride test
 Celiac disease
• This is a disease of small intestine characterized by
abnormal small intestine mucosa, associated with a
permanent intolerance to gluten (found in wheat, rye,
barley and oat). Removal of gluten from the diet leads to
full clinical remission with restoration to normal of small
intestinal mucosa. The condition may present at any age
and diagnosis is for life.
• Celiac disease is due to T lymphocyte-mediated
enteropathy induced by gluten in a genetically predisposed
individual. There is increased incidence with HLA B8 and
DQ
• Associations include diabetes mellitus, thyroid disease and
IgA deficiency
 Celiac disease
Common clinical features:
• Chronic diarrhea
• Weight loss/failure to thrive
• Abdominal distension
• Anemia (IDA)
• Abdominal pain
 Celiac disease
Diagnosis:
• Screening:
– IgA anti gliadin
– IgG anti gliadin
– IgA anti endomysial
– IgA anti tissue transglutaminase (higher diagnostic
accuracy)
• Definitive: abnormal intestinal biopsy with
subtotal villous atrophy, crypt hyperplasia and
increased inflammatory cells in lamina propria
 Giardiasis
• Giardia is a protozoal parasites found in
contaminated food & water.
• Variable clinical manifestations:
– Asymptomatic
– Acute diarrheal disease
– Chronic diarrhea
– Partial villous atrophy is occasionally seen
• Diagnosis is by stool examination or examination
of the duodenal aspirate at small bowel biopsy.
• Treatment is with metronidazole.
 Carbohydrate malabsorption
Malabsorption of carbohydrate leads to osmotic
diarrhea. The undigested sugar is then
fermented in the colon, producing excessive
flatus and acidic stools
Characteristic stools of sugar malabsorption:
– Osmotic diarrhea (stops on fasting)
– Very watery
– Acidic (anal excoriation)
– Passed with excessive flatus (explosive)
 Lactose intolerance
• The most common form of carbohydrate
malabsorption.
• Lactose is hydrolysed by lactase into glucose and
galactose
• Lactase is found in the brush border in the small
bowel. Any mechanism causing damage to the
mucosa and villi of the small bowel (enteropathy)
will cause secondary lactase deficiency. This can be
managed with a lactose-free formula or diet, but
resolves spontaneously as the enteropathy resolves.
 Cow's milk protein intolerance
• This is due to an intolerance to cow's milk protein, which is
usually transient. The symptoms may be confined to the
gastrointestinal tract or there may be other manifestations of
atopy (cow's milk protein allergy).
• In children with gastrointestinal manifestations changes in the
small intestinal mucosa may vary from normal to patchy to
partial to subtotal villous atrophy.

Manifestations of cow's milk intolerance:

– Gastrointestinal manifestations: Diarrhea, vomiting, failure to thrive,
acute colitis, constipation
– Non-gastrointestinal manifestations: Migraine, eczema, asthma,
anaphylaxis
 steatorrhea
Steatorrhea results from the impaired digestion and absorption of fat
due to:
• Exocrine pancreatic insufficiency
– Cystic fibrosis
– Schwachmann – diamond
• Lack of bile salts
– Obstructive jaundice, ileal resection (impaired enterohepatic circulation)
• Damage to the intestinal mucosa
– Celiac disease
– cow's milk protein intolerance
– giardiasis
• Failure of chylomicron formation
– Abetalipoproteinemia
• Damage to intestinal lymphatics
– Intestinal lymphangiectasia
 Protein losing enteropathy
• Loss of protein across the gut mucosa may
occur because of :
– Abnormal or inflamed mucosal surface: celiac
disease, cow's milk protein enteropathy,
giardiasis
– Intestinal lymphangiectasia.
• Serum albumin is low
• Elevated alpha 1 antitrypsin in stool
 Intestinal lymphangiectasia
• Functional obstruction of flow of lymph through
the thoracic duct and into the inferior vena cava.
• Leads to fat malabsorption and Protein losing
enteropathy.
• Treatment is with Medium-chain triglycerides
(absorbed directly into the portal vein)
• Can be primary or secondary to other causes of
lymphatic obstruction (lymphoma, cardiac
disease)
 Toddler diarrhea
• Known also as chronic non specific diarrhea
• Common cause of diarrhea in children aged 6 month to 4
years
• Children are healthy and well thriving
• 3 – 6 loose stools/day, mostly during waking hours and
often containing undigested vegetable material.
• The diarrhea worsens with low residue, low fat or high
carbohydrate diet
• Management: reassurance & dietary advice (increase fat
and decrease fruit juice)
 Treatment
Supportive:
• Correction of fluid & electrolyte disturbances
• Correction of vitamin & mineral deficiencies
• Nutritional support
• Treatment with antidiarrheal agents is not
recommended
Specific:
• According to the cause