2 History Taking of Common Pediatric Cases
2.14 Chronic Diarrhea
• Chronic diarrhea is the passage of loose and frequent stools for 2 weeks or more, usually secondary to significant malabsorption, as in celiac disease and tropical sprue (see Table 2.5) [34].
• In persistent diarrhea, the cutoff line for the duration is ≥2 weeks, but diarrhea invariably starts as an acute gastroenteritis in an infant.
• Chronic nonspecific diarrhea (toddler’s diarrhea) is the most common cause of chronic diarrhea in children aged 6 months to 3 years who have no failure to thrive [35].
• Acute diarrhea associated with blood, mucus, and fever may suggest an enteroinvasive agent, such as enteroinvasive Escherichia coli, Salmonella spp. Shigella spp., or Cryptosporidium.
• Acute diarrhea due to viral infections is commonly seen during the winter, while that due to bacterial infections is more common during the summer [32, 33].
• Diarrhea that occurs abruptly, with no preceding vomiting, is suggestive of bacterial enteritis [33].
• Acute diarrhea with fever may point to either an enteroinvasive pathogen or systemic illness (e.g., meningitis, septicemia, or pneumonia, which can be associated with nonspecific diarrhea) [34].
• Acute diarrhea can be associated with extraintestinal infections (e.g., otitis media and pyelonephritis).
• Contact with animals can transmit certain pathogens (e.g., Campylobacter, Salmonella, and Giardia lamblia) [33].
• Swimming in dirty water can transmit many bacterial and parasitic agents, especially Shigella, Giardia lamblia, Cryptosporidium, E. coli 0157:H7, and Entamoeba spp.
• Children who use proton-pump inhibitors or H2 blockers are more susceptible to bacterial enteritis [33].
• Children who have recently received antibiotics (e.g., ampicillin) may present with either nonbloody diarrhea (which suggests C. Difficile infection without colitis or antibiotic-induced gastroenteritis) or bloody diarrhea (which sug-gests antibiotic-associated pseudomembranous colitis).
• Acute diarrhea associated with petechial, purpuric rash is suggestive of Henoch–Schönlein purpura (anaphylactoid purpura). In an unwell child, that should raise the concern for sepsis [34].
• A child with bloody diarrhea, fatigue, easy bruising, and poor urine output may have a hemolytic-uremic syndrome (HUS).
Key Points 2.12
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Table 2.5 Short case scenarios of important cases of chronic diarrhea in children [26, 32, 35, 36, 90]
Short case scenarios Diagnosis and special point(s) in favor A 2-year-old child presents with a passage
of loose stools containing undigested food particles 5 times per day for a duration of 2 months. The symptoms occur during waking hours and become less frequent in the evening. The child is well and has a good appetite and normal growth
Toddler diarrhea
– Chronic diarrhea commonly occurs in children aged 6 months to 3 years – It involves passage of stools containing
undigested food particles about 3–10 times per day
An adolescent male child presents with a 7-month history of passing bloody, mucoid stools associated with fever, tenesmus, weight loss, arthralgia, anorexia, and abdominal pain; the last is exacerbated by defecation
Inflammatory bowel disease (IBD) – IBD is more common in older children
and adolescents
– Crohn’s disease is associated with extraintestinal manifestations (e.g., arthralgia and oral or perianal lesions) – Growth failure may occur with or prior to
other symptoms A 1-year-old child presents with a 2-month
history of passing loose, mushy, bulky, and smelly stools associated with lethargy, pallor, abdominal distension, and failure to thrive
Celiac disease
– Symptoms of celiac disease usually appear between 8 and 24 months of age, after gluten introduction
An adolescent male presents with a passage of three to ten stools per day in daytime (not at night). Stooling often occurs after each meal and is associated with a feeling of incomplete evacuation. The child’s growth is normal
Irritable bowel syndrome (IBS)
– The first stool in the morning is usually partially formed and becomes more frequent during the daytime
– A feeling of incomplete evacuation is characteristic
– Diarrhea may be alternated with constipation
A 9-month-old child presents with a 3-month history of frequent bowel motion associated with vomiting, discomfort on feeding, and squirming. The mother noticed that diarrhea stops when feeding is discontinued. There is a history of acute gastroenteritis preceding the appearance of the symptoms
Lactose intolerance
– This commonly occurs after acute infection
– Diarrhea stops when feeding is discontinued or lactose is restricted – Watery and acidic stools may lead to
severe perianal excoriation A 2-month-old infant presents with a
1-month history of blood-tinged, mucoid diarrhea, starting gradually and associated with vomiting, irritability, poor feeding, and skin rashes. There is a family history of atopy
Cow’s milk protein intolerance – Symptoms start before the age of
3 months
– Diarrhea is chronic and watery or blood-tinged mucoid
A 3-month-old male infant presents with a passage of large, bulky stools with a foul smell for a 1-month duration, associated with failure to thrive. The child has a history of a delayed passage of meconium for >24 h in the neonatal period, and recurrent chest infections over the past 2 months
Cystic fibrosis
– Newborns may present with meconium ileus
– Children may have failure to thrive coupled with voracious appetite, rectal prolapse, and chest infections – There may also be a passage of large,
bulky stools with a foul smell secondary to the steatorrhea
2.14 Chronic Diarrhea
• Identity: Age, sex, address, ethnicity/race
• Chief complaint: Diarrhea, passage of frequent and loose stools for 2 weeks or more
• History of present illness:
1. Age of onset and duration: When did diarrhea first start? (Immediately at birth? At weaning or after the first exposure to particular foods?)
2. Frequency and volume of stool output: Number of stools per 24 h. It is important to ask about the normal stool-passing pattern for the child 3. Ask whether the loose stools are interspersed withnormal ones
4. Timing of diarrheal episodes: Daytime vs. nocturnal diarrhea (awakening at night to pass stool suggests an organic cause of diarrhea)
5. Character and consistency of stool: Color, odor, presence of blood (sug-gests colitis), mucus, or undigested food, greasy, difficult to wash
6. Aggravating and relieving factors: Stress, effect of eating and fasting on diarrhea
7. Associated symptoms: Fever, abdominal pain, flatulence, tenesmus, anorexia, nausea, vomiting, hematemesis, melena, hematochezia
• Past history:
A—Birth history: Maternal polyhydramnios (suggests sodium/chloride transporter defect or microvillus inclusion disease), prematurity, necrotiz-ing enterocolitis, pattern of stoolnecrotiz-ing from birth, delayed passage of meconium
B—Past medical and surgical history: Inflammatory bowel disease (IBD), celiac disease, irritable bowel disease (IBS), constipation, diabetes, hyper-thyroidism, a history of gastroenteritis, recurrent pneumonia, intestinal surgery
• Medication history: Laxative abuse, recent use of antibiotics, use of magnesium- containing antacids, cholinergic drugs
• Developmental history: Developmental delay and growth retardation
• Feeding/dietary history: Type of feeding, formula changes, meal prepara-tion, dietary changes and their effect on stool pattern, milk intolerance, (4
“Fs”: fiber, fluid, fat, fruit juice), gum (sorbitol), timing and details of weaning
• Family history: Family history of chronic diarrhea, consanguinity, celiac disease, IBD, IBS, family history of allergy, milk intolerance
• Social history: Travel history, ill contacts, sexual exposure, water supply, and sanitation
• Review of systems: Malaise, myalgia, arthralgia, rashes (eczema, perianal irritation are associated with immunodeficiency syndromes), oliguria or anuria, weight loss, or failure to thrive
History Station 2.13: Chronic Diarrhea
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• A history of chronic diarrhea associated with failure to thrive suggests mal-absorptive conditions (e.g., cystic fibrosis, celiac disease, and cow’s milk protein intolerance) [34].
• Acute exacerbations of chronic diarrhea, especially if associated with fever, is highly suggestive of inflammatory bowel disease [34].
• Nocturnal diarrhea should raise the concern for inflammatory bowel disease [36].
• Toddler diarrhea usually diminishes in frequency in the evening.
• Diarrhea that occurs immediately after birth, with a history of maternal poly-hydramnios, is suggestive of congenital diarrhea (such as congenital chlo-ride-losing diarrhea) [36].
• Chronic diarrhea that follows an acute gastroenteritis is suggestive of acquired lactase deficiency, particularly in certain racial groups (e.g., African Americans and Asians) [26, 32, 36].
• Osmotic diarrhea is characterized by a large number of soft stools that are related to eating and that stop after discontinuation of feeding. Secretory diarrhea is characterized by a large volume of watery stools that occur even with fasting [32, 37].