of Causes, Clinical Features and Outcome
Felix Olukayode Akinbami, FMC
(Paed), FWACP*
Poothirikovil Venugopalan, MRCP(UK),
FRCPCH**
Ibtisam Babiker ElNour, MRCP(UK),
FRCP**
Vatakepat Nirmala, MD***
Objective: To evaluate the aetiology, clinical features and outcome of chronic diarrhoea in hospitalised children from an Arab Population of the Sultanate of Oman.
Design: Prospective study.
Setting: Tertiary care facility at the Sultan Qaboos University Hospital, Muscat, Oman.
Subjects: All hospitalised patients
aged <13 years with chronic diarrhoea (diarrhoea persisting for >4 weeks)
from November 1994 to October 1999.
Results: Among the 41 children
studied, the major aetiological factors were post gastroenteritis syndrome
20(49%), enteric infections and infestations 11(27%), Coeliac disease 6
(14.4%), immunodeficiency states 2 (4.8%), cystic fibrosis 1 (2.4%), and
abetalipoproteinaemia 1(2.4%). Twenty five patients (61%) were
malnourished and 12 (29%) were anaemic and 16 (39%) were dehydrated on
presentation. The duration of hospital stay ranged from 10 days to 3 months
(mean 40 days; median 25 days). Majority of the patients 30 (73%) responded
to initial therapy with oral rehydration solution, followed by careful
nutritional supplementation. Specific therapy was required only in 11 (27%).
Parenteral nutrition was required only in 2 patients. One patient with
immunodeficiency died from gram-negative septicaemia.
Conclusion: Post gastroenteritis syndrome was the commonest cause of chronic diarrhoea, unlike some of the studies from other Arabian countries, and could be managed successfully with simple measures. Malnutrition was a major complication but early and energetic nutritional rehabilitation played a pivotal role in management.
Bahrain Med Bull 2001;23(4):166-68.
-
Diarrhoeal disease is an important
health problem accounting for significant morbidity and mortality in young
children, especially in the developing countries of the world1. Diarrhoea
is usually self-limiting, however it may progress to a chronic illness
in 3 to 20% of patients2, and chronic or intermittent diarrhoea has a significant
impact on the nutritional status and development of children3. The disease
poses major difficulties in diagnosis and management. In this prospective
study, we looked at the causes, clinical features and outcome of chronic
diarrhoea in children in Oman.
METHODS
The study involved all children admitted to Sultan Qaboos University Hospital, Muscat, Oman, between November 1994 and October 1999 (5 years) with a diagnosis of chronic diarrheoa, defined as diarrhoea persisting for more than 4 weeks4. On admission, a detailed history was taken and physical examination carried out on all the patients. Nutritional status was assessed using weight and height centiles of the National Center for Health Statistics Standards5. Stool examinations for ova, cysts and parasites, for pH and reducing substances and culture for bacterial and viral pathogens were performed on all patients, in addition to a full blood count, serum electrolytes and blood urea. Other investigations performed as clinically indicated, included serum proteins, serum ferritin, folate, immunoglobulins, anti endomysial antibodies, flow cytometry, sweat chloride, stool chromatography, jejunal aspirate for Giardia lamblia trophozoites and jejunal biopsy. Data entry and analysis were performed using Statistical Package for Social Sciences (SPSS) 9 for Windows 98.
RESULTS
During the 5-year period, 41 children
(26 boys, 15 girls, M: F=1.7:1) with chronic diarrhoea were studied and
this accounted for 0.34% of hospital admissions to Paediatric Wards during
the above period. Their ages ranged from 3 months to 12 years (mean 1.8
years) and 15 (37%) were below the age of 1 year.
The mean duration of diarrhoea
at the time of presentation was 3.5months (5weeks to 7 months). Table 1
shows the associated symptoms and signs at presentation in the 41 children.
Twenty five children were malnourished with their weights below the 3rd
percentile. Twelve were anaemic with a mean haemoglobin of 9.4g/dl and
6 had iron deficiency. Sixteen children were dehydrated, 11 mildly and
5 moderately. Twelve children had also vomiting.
The identified aetiologies for the chronic diarrhoea are shown in figure 1. Post gastro-enteritis syndrome was responsible for almost half (20) the cases. Seven of them had secondary lactose intolerance diagnosed by positive stool for reducing substances, and confirmed by stool chromatography and clinical response to elimination of lactose from diet. Two other children had cow’s milk protein intolerance. They responded to cow’s milk protein exclusion and exhibited a positive response to cow’s milk challenge.
Enteric pathogens were identified in 11 children. Giardia lamblia was isolated in the stool and or jejunal aspirate/mucosa of 6 children, cryptosporidium in 3 and enteropathogenic Escherichia coli (Esch. coli) in 2. The patients with Esch. coli had other pathogens in their stools, one of them had shigella and the other had rota virus.
Six (14.4%) children had flat mucosa
on jejunal biopsy, positive anti endomysial antibodies, and clinical and
histological response to gluten free diet. Two children (4.8%) had congenital
immune deficiency states, one had severe combined immunodeficiency and
the other common variable immuno-deficiency. Sweat chloride estimation
was consistently high (>80mmol/l) in one child with cystic fibrosis. Abetalipoproteinaemia
was diagnosed in a girl who presented with oily stool and severe malnutrition.
Her blood film showed marked acanthocytosis and her small intestinal biopsy
revealed accumulation of fat droplets in the enterocytes with otherwise
relatively normal villi.
The duration of hospital stay ranged
from 10 days to 3 months (mean 40 days; median 25 days). Thirty children
were managed with oral rehydration and careful nutritional support jointly
with the dietician and remained well on follow up. The diarrhoea decreased
in frequency in about a week and normal stools were recorded in majority
in 3 weeks. Additional measures required for the child with cystic fibrosis
included enzyme supplements, prophylactic antibiotics and regular chest
physiotherapy. Six children with enteric pathogens required specific therapy,
while 3 with cryptosproidium and 2 with enteropathogenic Esch. coli isolated
from the stool responded to nutritional supplements alone. The child with
abetalipoprotenaemia responded to a low fat diet with supplementary medium-chain
triglycerides and fat soluble vitamins including a high dose of vitamin
E. Two children with severe malnutrition and persistent diarrhoea despite
dietary manipulation required total parenteral nutrition for a period of
3 weeks. The child with severe combined immunodeficiency died of gram-negative
septicaemia.
DISCUSSION
The outcome of acute diarrhoea has improved significantly with worldwide use of oral rehydration solutions,. However, chronic diarrhoea is still harmful, especially for the growth and development status of children and continues to occur in up to 20% of children with gastroenteritis2.
Post gastroenteritis syndrome was the commonest cause of chronic diarrhoea in our study, accounting for almost half of the patients. This is similar to the findings of Shaltout et al6 from Kuwait who found 66% of their patients had post gastroenteritis syndrome, whereas Abdullah7 from Saudi Arabia reported it only in 33% and Altuntas et al3 from Turkey in 10% of their patients. Acute injury to the gut when inadequately or improperly managed results in continued small intestinal mucosal injury. Associated factors such as protein malnutrition, deficient enzymes, infection, increased absorption of native foreign protein, ineffective villous repair and malabsorption of nutrients result in a chronic enteropathy3,8,9. Malabsorption of nutrients leads to further malnutrition setting up a vicious cycle, that renders the management of these children a real challenge.
Secondary lactose intolerance was documented in about one third of our patients with post gastroenteritis syndrome. Lactase is a brush border enzyme in the small intestine and any injury to the gut mucosa leads to a loss of this enzyme activity. Furthermore, the regenerating mucosal cells that migrate up from the crypts do not mature fast enough to provide the enzyme in adequate concentrations. This problem is usually self-limiting and all our patients did well on conservative management with a lactose exclusion diet for periods ranging from 2 to 6 months. All of them could be restarted on milk feeds subsequently.
Enteric pathogens are well recognized causes of chronic diarrhoea6,7. These were the second commonest causes of chronic diarrhoea in our patients. Enteric pathogens alter the morphology of the intestinal mucosa leading to malabsorption. Giardia lamblia and cryptosporidium reported to be commonly associated with intestinal mucosal enteropathy and chronic diarrhoea10,11 were isolated from 9 of our patients. Patients with giardiasis responded to metronidazole therapy and those with cryptosporadiasis resolved spontaneously.
Coeliac disease was diagnosed in 14.4% of our patients and all of them demonstrated flat intestinal mucosa with positive anti-endomysial antibodies. Exclusion diet commenced under supervision in hospital did bring about a rapid improvement of the diarrhoea, however continuing compliance at home was very difficult. The social custom of all family members sharing food from a common bowl, low level of parental awareness and restricted availability of gluten free diet could have contributed to this. It is interesting to note that coeliac disease was equally prevalent in the studies of Shaltout et6 and Abdullah7 although the disease was the second commonest cause in their patients. Both these reports also have emphasized the difficulty in enforcing dietary modifications in this group of patients.
Malnutrition is a common sequel of chronic diarrhoea. Sixty one percent of our patients were malnourished and 29% anaemic. Early nutritional rehabilitation can break the vicious cycle of malnutrition, intestinal mucosal damage and depressed immunity and helps to re-establish gut function and integrity. It should therefore always play a major role in the management of children with chronic diarrhoea. Supervised careful nutritional rehabilitation without any other specific therapy was effective in the treatment of 11 of our patients with post gastroenteritis syndrome in whom a treatable cause could not be found.
CONCLUSION
The common causes of chronic diarrhoea
in children include post gastroenteritis syndrome, enteric pathogens and
celiac disease. Malnutrition is a major complication of chronic diarrhoea
and therefore early and adequate nutritional rehabilitation plays a pivotal
role in the management of these children.
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* Paediatric Gastroenterologist
** Consultant Paediatrician
*** Consultant Pathologist
Sultan Qaboos University Hosptial
Muscat, Sultanate of Oman
