CHRONIC DIARRHEA

The persistent diarrhea and chronic

Persistent diarrhea when it comes to the issue of loose stools lasts more than two weeks, and chronic diarrhea when the duration exceeds four settimane.Nei industrialized countries the most common causes of persistent diarrhea or chronic and are basically four to them, in the daily practice of the pediatrician, reference should be delegating to specialized structures gastroenterological the rare cases that respond to other reasons and that do not resolve outpatient follow the practical rules of conduct which are subsequently outlined.
It 's always the fault of the food?
Not always, but it is of frequent observation, almost daily, to see children with persistent diarrhea or chronic treated only with diets: without cow's milk protein, lactose free, gluten free, many different foods, sometimes with diets containing very few foods ( as the so-called diet Rezza based cream of rice, olive oil, lamb), sometimes with milk containing only the so-called primary amino acid mixtures. In reality, only a fraction of persistent diarrhea is caused by food intolerance and also it is very unlikely that a persistent diarrhea is caused by food intolerance foods other than milk and gluten. E 'therefore unjustified and unnecessary scramble desperately seeking food manager, subtracting from feeding the baby a food after another in an attempt to solve a diarrhea that is not resolved by suspending the milk and gluten: the reasons are obviously other . Among other things, it is not justified removing gluten from the diet of a child to "test" it is an intolerance can be diagnosed by laboratory tests. Gluten intolerance (celiac) disease if present would be a "life-long" and would require, for life, food deprivation, in addition to its associate and to achieve it, if you do not follow a strict diet, other diseases including cancer: you should not, therefore, make a gluten-free diet "test" but the diagnosis of celiac disease and diet should be done only after a subsequent diagnostic process rigorous.

What are the main causes of
the four causes of persistent diarrhea or chronic, responsible for the vast majority of these cases in industrialized countries, and to which reference must be made ??in addressing these issues are:

1. the irritable bowel syndrome (diarrhea or healthy child),
2. postenteritica syndrome (or infected bowel syndrome or high colonization of the small intestine),
3. chronic diarrhea from cow's milk,
4. celiac disease (gluten intolerance).

Of these four forms of chronic diarrhea only the last two, of course, are due to specific foods; postenteritica syndrome is due to an infection by microbes while the so-called irritable colon at the end is not a real disease.
irritable bowel syndrome or diarrhea healthy child, the most trivial and harmless of the four, is the most common cause of chronic diarrhea in current practice and is the main cause of the pilgrimage of parents of medical doctors, increasing anxiety, repeated examinations of unnecessary and often expensive, increasingly restrictive diets and often obsessive.
Apart from these, other causes of chronic diarrhea are much less frequent and have a different connotation.

Orienting

The key criteria to navigate through these four forms of diarrhea are two: 1) the age of the child, 2) its growth.
Chronic diarrhea from milk intolerance is a disease of the young child, under two years, and especially first year of life. The majority of cases begins in the first six months of life. It 'great that a child may have diarrhea from milk intolerance than two years of age. Moreover, even the children who had chronic diarrhea from milk intolerance in the first months of life is usually two years have regained tolerance and can be summarized milk without problems.
postenteritica's syndrome, diarrhea from milk protein intolerance in celiac disease c 'is impairment of the weight (malnutrition-malabsorption): the growth curve of the child appears compromised with reduction of the speed of growth arrest or accretion or even loss of weight. On the contrary in the irritable bowel syndrome child, unless it has been plagued with too strict diets, growing adequately.

In addition to these two basic elements are there other practical items that can be useful.

In irritable bowel syndrome (diarrhea healthy baby or toddlers diarrhea syndrome or accelerated intestinal transit or chronic nonspecific diarrhea), which as I said is the most common cause of chronic diarrhea in current practice:

- Age 6 months-5 years, there is irritable bowel outside of this age
- There is alternating constipation and diarrhea that feces are capriciously variables and this happens independently of the type of power supply and the food suspended, and this variability is present in the course of several days (one day many discharges, a few days, a few days even no evacuation), but also in the same day (in the morning stools formed, the more decomposed afternoon) or even in the same evacuation (a part formed and a part undone, with mucus and plant residues);
- are present in feces undigested plant residue that often lead mothers to believe that precisely those foods are responsible for diarrhea and to make further deletions, it is instead of fibrous residue (diarrhea peas and carrots), due to the accelerated transit of food through the intestine
- E 'this mucus in the stool
- are frequent abdominal pain.
However, fundamentally,
- the children have good appetite and
- grow well.

The diagnosis then emerges from the fact that the child is well, has a good appetite, grows well. Never, by definition, there is malnutrition.
E 'is therefore incorrect, although it is very common to observe in practice, keep your baby on a diet of two to three years with chronic diarrhea in feces variables, good condition, good appetite and good growth.
The problem is that sometimes its diagnosis and improper diets, growth is not adequate. And in this case, the recognition can be a bit 'more complicated.

1. Abdominal pain which disappears after defecation is a sign of functional pathology, irritable bowel, pain that persists after the evacuation suggests an organic disease;

2. The slowdown in growth (malnutrition) is, as mentioned, the first element that raises suspicions of organic pathology. But it should be suspected even
- in the case of abdominal pain at night, away from the umbilical region, and disabling conditions
- in the case of diarrhea at night: nocturnal diarrhea is always organic
- in the presence of mucus and blood in the stool.
In the latter If the prime suspect is the so-called inflammatory bowel disease. That is, in the presence of mucus and blood in the stool in a child> 2-3 years, if malnutrition coexists, the first diagnostic hypothesis is inflammatory bowel disease (ulcerative colitis and Crohn's disease) disease that must be managed by structures specialist.

3. Important is also the history of diarrhea. The primary cause chronic diarrhea postenteritica or infected bowel syndrome or post-infectious diarrhea is a first episode of acute enteritico. The acute enteritis prepares the way for the so-called high colonization of the small intestine, ie the part of the intestine immediately downstream with respect to the stomach. The proximal small intestine of man, although not sterile, usually contains a low charge of microbes; after an episode enteritico herein can, vice versa, implant and develop colonies of microbes, mainly so-called anaerobic germs which may be responsible for the persistence of diarrhea.
So if after an episode gastroenteritico feces are soft and frequent:
_ if the baby is fine and growing well think of irritable bowel syndrome,
_ if the child is sick and does not grow to think of the colonization of the small intestine. Less likely intolerance to milk proteins acquired during the acute episode.

Faced with a chronic diarrhea with malabsorption, ie, poor growth, can therefore be permissible to place the child on a diet, but if the diarrhea does not improve with the elemental diet suggests a bacterial cause of diarrhea continued: it is justified in this case, the treatment antibiotic as evidence.

Regarding food intolerances may be of utility some considerations:

- If the diarrhea persists fasting is likely that there is a food intolerance;
- If the diarrhea is caused by intolerance to a certain food to disappear in the short term (even within 24 hours) after discontinuation. In other words, if the suspicion of intolerance to cow's milk is permitted, it is useful in the first year of life test elimination test. But in case of failure diet should be promptly abandoned;
- may be important in guiding the diagnosis also the coexistence of other diseases, such as diarrhea continued in a child with atopic dermatitis suggests the presence of food intolerance, primarily milk , and dermatitis herpetiformis, a disease not frequent, very itchy, suggests the diagnosis of celiac disease.

They are useful exams?

Not in the first instance, that the first approach to the problem. A practical behavior, empirical, without the aid of examinations, is decisive in most casi.D 'other hand if you consider those that are the main causes of chronic diarrhea in daily practice and will take into consideration the examinations possible if they can be deduced as follows:

- The irritable bowel does not provide tests that allow their diagnosis: the clinical diagnostic element is the child who is doing well and has grown steadily;
- in chronic diarrhea postenteritica exams to be proposed, the Breath test and survey duodenal culture of duodenal , can be performed only in specialized centers. In everyday practice, then they are not available and can be replaced by the administration of antibiotics whose effectiveness would value also of diagnostic test;
- intolerance to cow's milk proteins prick test and the RAST generally are not useful for the diagnosis because normally not there is "IgE-mediated sensitization", ie it is not operating mechanism that can be investigated with these diagnostic tools. The immunologic mechanism is different, generally "cell-mediated", ie not involving a particular type of antibody called IgE, but cellular elements called T lymphocytes. An exception is allergic colitis, typical of the small infant, often breastfed, which is characterized by the presence of blood in stools, but unlike other diseases such as inflammatory bowel disease, the general condition is good and the baby is growing well.
E 'therefore useless to expect by skin tests or blood tests to answer the question whether it is appropriate or not to put the little child with chronic diarrhea on a diet without cow's milk protein, in fact any negative response of the test could induce error to exclude liability for food even when it it was truly the cause.
- The only form of chronic diarrhea that can be diagnosed by laboratory tests is celiac disease. Are available on the blood tests (antibodies antitransglutaminase, endomysial antibodies, antigliadin antibodies) which allow to orientate the diagnosis. In current practice of pediatric ambulatory, however, may postpone the execution of these tests to a second phase, that is when you do not get the resolution of the problem with empirical behavior to evaluate other possibilities for chronic diarrhea, frequent diarrhea celiac .

What to do?

In fact, if a child has diarrhea lasting more than usual time of acute diarrhea, the first thing to consider is the growth curve and the age of the child. If the growth is adequate, the baby is fine and age is compatible the problem is closed: this is an irritable bowel syndrome and the child should not do any investigation, no pharmacological treatment, no diet. It 'important that parents are reassured and advised not to check the more I do not take account of shocks but how the child is, how it grows, its good appetite.
then in the irritable bowel syndrome:
- Reassure the parents
- not give importance to stool;
- But give importance to the weight and growth curve;
- free diet, rich in fat, whether or not cooked, even fried. The high-fat diet resulted in an improvement because fats slow intestinal transit and also giving a lot of fat because they give less carbohydrate. Can be used without problems french fries.
To increase the proportion of fat in the diet is often sufficient to simply feed these children normally and according to the usual eating patterns.

- Indispensable eliminate fruit juices that contain sorbitol and fructose
- Sorbitol is a polyalcohol which determines fermentation and then call water in the intestine;
- Fructose is particularly low in pear juice (+ + +) and apple (+ +).
The "white diet" has no rational and is the opposite of what is needed because it is rich in carbohydrates and low in fat.
vice versa If the growth is compromised should be taken into account the other common causes of chronic diarrhea, that intolerance milk, post-infectious diarrhea, celiac disease.
history of diarrhea, the characters of the stool, the temporal relationship between the onset of diarrhea and the intake of food, accompanying symptoms, the age of the child, may in such cases help the diagnosis. But above all, the practical approach to the problem will make it possible in both its resolution and clarification of its causes (so-called "ex juvantibus criterion").
Empirical therapy, valid as a criterion juvantibus former is represented by:

1. Diet without milk and dairy products (alternatives are, in some cases, the elemental diet with amino acids or homemade diet, the so-called diet Rezza) caloricamente adequate;
2. Antibiotics "aminoglycoside" orally or co-trimoxazole for an appropriate period of time (up to 15 days).
3. Ion exchange resins such as cholestyramine, usually used in the treatment of hypercholesterolemia, which binds bile salts that due to these germs colonizing the small intestine have an irritating effect on the colonic mucosa.
In this way it acts on two of the three cases of persistent diarrhea, intolerance to milk and infected bowel syndrome.

The evolution of diarrhea may be at this point twofold:

A. The diarrhea disappears. The problem will then state or that of a milk intolerance or that of a post-infectious diarrhea (diarrhea postenteritica). The reintroduction in feeding the baby milk and dairy products help you distinguish between the two cases and in the case of diarrhea reappear after reintroduction of the food you will be required to keep the child on a diet without cow's milk protein for a few months;
B. The diarrhea persists. At this point will be crucial to assess the growth of the child
- if the child is adequately increased in the period despite the diarrhea means that it is an irritable bowel where, previously, the lack of growth was due to diets incongruous;
- if the growth was deficient must consider the diagnosis of celiac disease and should be performed as relevant laboratory positive if the child will require a gluten-free diet for life.

Vice versa if these findings were not positive, then in front of a diarrhea with malnutrition, unresponsive to diet without dairy products and an appropriate antibiotic treatment, with negative tests for celiac disease, it is necessary that the child is assessed in a specialized environment of pediatric gastroenterology.
This pattern of behavior has shown practical in daily office practice to be very effective and only in an exceptional occasion, in my experience, there has been no resolution of the problem and the need for in specialized structures in higher-level , it was in the case of a child with celiac disease showed that over a rare cancer producing substance (VIP) responsible for diarrhea and malnutrition of the child.

Common Mistakes

1. Diet B: It has no rational is exactly the opposite of what is needed in the irritable bowel syndrome (it is rich in carbohydrates and low in fat).
2. Keep your child on a diet of two to three years with chronic diarrhea in feces variables, good condition, good appetite and good growth (irritable bowel syndrome).
3. Put your child on a diet without gluten if there was a diagnosis of celiac disease (endomysial, transglutaminase).
4. Consider diarrhea, and put on a diet for the mother this, evacuations sometimes explosive, liquid, sometimes frothy, sometimes greenish, often very frequent in the early weeks of life, the breastfed baby. The breastfed baby potentially suffering from diarrhea.
5. Consider manifestation of intolerance to milk feces green. The stools more or less intensely green are not pathological. The green color is due to oxidation of bilirubin (which turns into biliverdin) contained in the stool and the iron content of the milk of formula.
6. Put on a diet toddler sensitized, ie with positive tests to milk or other foods, but tolerant, ie no demonstrations or disturbances to his appointment, may expose you to much more severe reactions to subsequent exposure random. The child who takes sensitized milk (if tolerant) essentially makes a desensitization continues.