Approach to the diagnosis of chronic diarrhea in children in resource-rich countries
- Richard Kellermayer, MD, PhD
Richard Kellermayer, MD, PhD
- Assistant Professor of Pediatrics
- Baylor College of Medicine
- Robert J Shulman, MD
Robert J Shulman, MD
- Professor of Pediatrics
- Baylor College of Medicine
In resource-rich ("developed") countries, a wide variety of disorders cause chronic diarrheas in children. The causes range from developmental and dietary factors (eg, excessive consumption of juice), to diseases causing malabsorption or maldigestion, disordered immune regulation, or enteric infections (particularly in immunocompromised patients) (table 1) [1,2].
In resource-limited countries, chronic diarrhea typically is associated with serial enteric infections and malnutrition [3,4]. This common pathophysiology calls for a distinct algorithmic approach to diagnosis and treatment, which is discussed separately. (See "Persistent diarrhea in children in resource-limited countries".)
The diagnostic approach to diarrheal diseases in resource-rich countries will be reviewed here. The causes of these diarrheal diseases are discussed separately. (See "Overview of the causes of chronic diarrhea in children in resource-rich countries".)
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. Age at presentation and the population setting (eg, the genetic predisposition of the population) are also important factors to consider. For children presenting with chronic diarrhea in resource-rich countries, the most likely cause in young children (typically one to four years of age) is functional diarrhea. In this young age group, functional diarrhea is also known as chronic nonspecific diarrhea or "toddler's diarrhea." In older children and adolescents, functional diarrhea is associated with irritable bowel syndrome (IBS) as defined by the pediatric Rome IV criteria [5-8]. Celiac disease is also relatively common, and can be evaluated with a simple serologic screening test. Therefore, it is appropriate to consider these entities early in the evaluation before embarking on extensive laboratory testing. If these steps do not establish a diagnosis, then further laboratory testing can be selected based on history, physical examination, and the stool type. This stepwise strategy is outlined below (algorithm 1A-B).
HISTORY AND EXAMINATION
A detailed history often provides clues to the diagnosis or diagnostic category (table 2).
- Binder HJ. Causes of chronic diarrhea. N Engl J Med 2006; 355:236.
- Bhutta ZA, Ghishan F, Lindley K, et al. Persistent and chronic diarrhea and malabsorption: Working Group report of the second World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 2004; 39 Suppl 2:S711.
- Gibbons T, Fuchs GJ. Chronic enteropathy: clinical aspects. Nestle Nutr Workshop Ser Pediatr Program 2007; 59:89.
- Bhandari N, Bhan MK, Sazawal S, et al. Association of antecedent malnutrition with persistent diarrhoea: a case-control study. BMJ 1989; 298:1284.
- Kleinman RE. Chronic nonspecific diarrhea of childhood. Nestle Nutr Workshop Ser Pediatr Program 2005; 56:73.
- Guarino A, Lo Vecchio A, Berni Canani R. Chronic diarrhoea in children. Best Pract Res Clin Gastroenterol 2012; 26:649.
- Benninga MA, Faure C, Hyman PE, et al. Childhood Functional Gastrointestinal Disorders: Neonate/Toddler. Gastroenterology 2016.
- Hyams JS, Di Lorenzo C, Saps M, et al. Functional Disorders: Children and Adolescents. Gastroenterology 2016.
- Elsherif Y, Alexakis C, Mendall M. Determinants of Weight Loss prior to Diagnosis in Inflammatory Bowel Disease: A Retrospective Observational Study. Gastroenterol Res Pract 2014; 2014:762191.
- Fine KD, Schiller LR. AGA technical review on the evaluation and management of chronic diarrhea. Gastroenterology 1999; 116:1464.
- Hyman PE, Milla PJ, Benninga MA, et al. Childhood functional gastrointestinal disorders: neonate/toddler. Gastroenterology 2006; 130:1519.
- Cohen SA, Hendricks KM, Mathis RK, et al. Chronic nonspecific diarrhea: dietary relationships. Pediatrics 1979; 64:402.
- Evaluation of an algorithm for the treatment of persistent diarrhoea: a multicentre study. International Working Group on Persistent Diarrhoea. Bull World Health Organ 1996; 74:479.
- Bhan MK, Bhandari N. The role of zinc and vitamin A in persistent diarrhea among infants and young children. J Pediatr Gastroenterol Nutr 1998; 26:446.
- Rahman MM, Vermund SH, Wahed MA, et al. Simultaneous zinc and vitamin A supplementation in Bangladeshi children: randomised double blind controlled trial. BMJ 2001; 323:314.
- Ochoa TJ, Salazar-Lindo E, Cleary TG. Management of children with infection-associated persistent diarrhea. Semin Pediatr Infect Dis 2004; 15:229.
- Bhan MK, Bhandari N, Bahl R. Management of the severely malnourished child: perspective from developing countries. BMJ 2003; 326:146.
- Goldenberg JZ, Ma SS, Saxton JD, et al. Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children. Cochrane Database Syst Rev 2013; 5:CD006095.
- Szajewska H, Guarino A, Hojsak I, et al. Use of probiotics for management of acute gastroenteritis: a position paper by the ESPGHAN Working Group for Probiotics and Prebiotics. J Pediatr Gastroenterol Nutr 2014; 58:531.
- Cruchet S, Furnes R, Maruy A, et al. The use of probiotics in pediatric gastroenterology: a review of the literature and recommendations by Latin-American experts. Paediatr Drugs 2015; 17:199.
- Bernaola Aponte G, Bada Mancilla CA, Carreazo NY, Rojas Galarza RA. Probiotics for treating persistent diarrhoea in children. Cochrane Database Syst Rev 2013; 8:CD007401.
- Bisset WM, Jenkins H, Booth I, et al. The effect of somatostatin on small intestinal transport in intractable diarrhoea of infancy. J Pediatr Gastroenterol Nutr 1993; 17:169.
- Guarino A, Berni Canani R, Spagnuolo MI, et al. In vivo and in vitro efficacy of octreotide for treatment of enteric cryptosporidiosis. Dig Dis Sci 1998; 43:436.
- HISTORY AND EXAMINATION
- LABORATORY EVALUATION
- Celiac serology
- Stool pH, electrolytes, and reducing substances
- Occult blood, fecal leukocytes, and leukocyte markers
- Stool fat
- Other tests
- DIAGNOSTIC APPROACH
- Exclude celiac disease
- Consider functional diarrhea
- Selective testing according to stool type
- - Watery (osmotic versus secretory)
- - Inflammatory
- - Fatty
- Specific testing
- TREATMENT CONSIDERATIONS
- - Probiotics
- - Antidiarrheal drugs
- - Somatostatin
- SUMMARY AND RECOMMENDATIONS