Summary

Diarrhoea is a nutritional disease. In this part, Dr. YK Amdekar uses case studies to emphasise that…

• non-pathological causes should be ruled out before starting treatment
• patient/parent counselling should take precedence over medicine prescription to avoid recurrent episodes
• detailed history taking is more important than running lab tests

 

Before you begin, take the quiz below to test your knowledge.

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Case-based studies

Case 1

A two-month-old infant presented with loose stools over the last two weeks. He was on exclusive breastfeed since birth. Prior to the onset of diarrhoea, he used to pass stools 3-4 times a day which were golden yellow in colour. But since the last two weeks, he passed 8-10 stools per day. However, he has been feeding well and also gained weight despite diarrhoea.

Physical examination did not reveal any abnormality. There has been a change in stool pattern and so needs proper evaluation. However, the infant is not sick and feeds well with normal weight gain. This may suggest it may not be pathological.

What is then a probable cause of change in stool pattern?

Breast milk consists of foremilk– the first part of milk-feed which is watery and contains a large amount of sugar while hindmilk– the latter part of milk-feed– contains fat.

When an infant takes a full feed– both foremilk and hindmilk– stools are formed and are infrequent, but when the infant stops sucking after taking only foremilk and does so at every feed, stools get more watery and frequent.

So this infant must be getting distracted while feeding and so takes only the foremilk. As it is not sufficient for him, he feeds more frequently and takes foremilk again, each time.

This is the cause of the infant’s loose stools. There is no need for any tests or drug treatment but the mother must be counselled to feed for a longer period at each feeding time without distraction so that the infant consumes both foremilk and hindmilk.

An exclusively breastfed infant never suffers from infection or indigestion. A mere change in feeding pattern results in a change in stool pattern which may be misdiagnosed as pathological. However, a happy infant, feeding well and gaining weight should rule out any disease. Every diseased child appears sick, more so in infancy.

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Case 2

An eight-month-old infant presented with greenish loose stools since last one month. Prior to the onset of this problem, he used to pass stools 1 to 2 times a day in normal colour. There were no other complaints. On direct questioning, the mother informed that the infant would refuse semi-solid food even when she had been trying to introduce it since the last two months and he was only on breast feeds.

He had not gained weight over the last two months. However, he was happy and playful. Physical examination did not reveal any abnormality.

Similar to the previous case, there is change in stool pattern but the infant is happy and so, it must not be pathological.

What then must be cause of diarrhoea in this child?

Green stools suggest unused bile getting excreted in stools. It could result from intestinal hurry due to infection that does not allow enough time for the bile to mix withthe food, but this infant is not sick and so it is unlikely to be an infection. The other cause is inadequate food intake because of which unused bile is excreted in the stools. This infant is happy feeding on the breast and is not used to taking any semi-solid food. Few infants when exposed to semi-solid food reject to begin with but persistence makes the infant accept it.

However if the mother gives in to frequent demand of breastfeeding, the infant does not learn to eat semi-solid food. He gets breast addicted and looks satisfied just by sucking even an empty breast resulting in inadequate intake.

So this child does not need any tests or drug treatment for diarrhoea but just counselling to parents to offer semi-solid food while the mother eats. It is a stimulus for the infant to imitate and learn to eat as well. Children learn best by imitation.

This condition is often referred to as hunger diarrhoea. A hungry child should be demanding food more often but this infant is not used to eating semi-solid food and so keeps on demanding more breastfeeds. However, breast milk yield beyond 6 months of an infant’s age is not sufficient for his needs and complimentary feeds must be introduced. Thus, due to breast addiction, the infant learns to be satisfied despite of deficient food intake and passes green stools.

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Case 3

A two-year-old child was seen for frequent stools persisting over the last two weeks. Stools were of normal consistency and colour but frequent. He used to pass stools once or twice a day but the last two weeks, he had been passing stools 5 to 6 times a day. He continued to be happy and playful.

Physical examination did not reveal any abnormality. So, there is a change in stool pattern in terms of frequency but the colour is normal and the child is also happy and not sick. It indicates that the food is well digested and his food intake is normal but there is a intestinal hurry.

As there is no evidence of infection, the intestinal hurry is likely to be due to stress. Parents need counselling and no tests or drugs are required. Stress is the imbalance between demand and supply. If the child wants something that is denied or if he is forced to have something that he does not want, it would result in stress. Intestines react first to stress resulting in frequency of stooling. When you see something frightful, the intestines cramp much before the brain realises danger. Similarly when a student goes for an examination, there may be an urge to pass stools or urine. It is a manifestation of stress.

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Case 4

A one-year-old child presented with recurrent episodes of loose stools in the last 6 months. Each episode started with fever and loose stools with mucus and foul smell. Every time he was prescribed different antibiotics and only to get well enough for it to recur in a few days.

In between episodes, he would feed well, remain active and also gain weight, though over 6 months, he had gained only one kg of weight. Physical examination did not reveal any significant abnormality. It is likely to be repeated bacterial infections as suggested by fever and stools with mucus and foul smell.

Parasitic infection such as amoebiasis is rare in young children besides it rarely presents as an acute disease. At any age, repeated bacterial infections strongly suggest either abnormality in the host such as immune deficiency or cystic fibrosis or infection due to unhygienic conditions.

As this child remained well in between episodes and also gained weight, it rules out any significant host abnormality and his issue must be due to poor hygiene. Thus, treatment of each episode by antibiotics is not going to solve the problem unless parents are counselled about maintaining adequate hygiene. Bottle feeding is the main culprit for poor hygiene and also contaminated food.

Recurrent episodes of similar disease must be evaluated to answer whether the disease process is persistent or recurrent. Persistent disease such as immune deficiency also presents with recurrent symptoms but the child is not well in between episodes and loses weight continuously over time. On the other hand, when poor hygiene is the problem, the child remains well in between episodes if disease is recurrent, as was so in this case. Cause of recurrent disease often lies outside the body and needs to be kept in mind.

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Case 5

A two-year-old child presented with abdominal distension, loose stools off and on, and loss of weight and appetite over the last one year. Frequency of stools varied from 2 to 4 per day with changing consistency. There was no fever or vomiting. He was treated with antibiotics, anti-parasitic drugs and also enzymes and digestives.

Physical examination revealed a chronically sick child with gaseous abdominal distension but without any other signs. It is obviously a chronic progressive disease starting around one year of age. Absence of fever suggests non-infective aetiology. However, parasitic infections may present without fever but he had failed to get better in spite of being put on anti-parasitic therapy. Parasitic infections are not difficult to treat though, they may recur on and off due to poor food hygiene.

So, they are recurrent but this child has a persistent disease, as is evident by a progressive loss of weight. This may be due to chronic malabsorption due to deficient intestinal enzymes. However, such a child would have a normal or voracious appetite. As this child has a loss of appetite, this malabsorption must have resulted from chronic inflammation.

This inflammation is unlikely due to infection as it would have at least partially responded to antibiotics and so it is likely to be due to non-infective inflammation. As it has started around one year of age, on direct questioning to parents, it was revealed that it coincided with the introduction of wheat. This gives a clue that it may be coeliac disease due to gluten sensitivity or allergy.

A serum antibody test and intestinal biopsy can confirm the diagnosis and the condition can be managed by avoidance of wheat products as well as rye and barley. Coeliac disease is a common cause of non-infective inflammatory disease and can be well-managed by dietary restriction that is necessary for life. It is a genetic disorder but presents with a wide spectrum of severity and hence may manifest for the first time years after intake of wheat.

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Case 6

An eight-year-old child presented with loose stools with mucus, abdominal pain, and poor appetite for the last one month and on and off fever for the last three weeks. Stools vary in number from 2 to 5 times a day. Abdominal pain was dull and generalised all over. Fever was mild to moderate. He had lost 2 kgs of weight.

Physical examination revealed a sick looking child with abdominal distension and mild pallor. There was vague tenderness all over the abdomen. Other systems were normal. This child had subacute progressive intestinal inflammatory disease as was evident by mucus in stools but not so frequent suggesting probably both small and large intestine involvement.

It is unlikely to be infection as uncontrolled infection would have led to local or systemic complications. Thus, it is mostly non-infective inflammation such as Crohn’s disease. Neutrophilic leucocytosis with thrombocytosis and hypoalbuminemia are investigatory correlates of such a disease. An intestinal biopsy would prove the diagnosis and the disease can be treated with steroids and anti-inflammatory drugs. Inflammatory bowel disease resembles intestinal infection though subtle points and progress can differentiate one from the other. Aetiology remains obscure and role of heredity, stress and diet is considered in causation of this disease.

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Case 7

An eight-year-old child presented with loose stools and abdominal pain persisting on and off over the last 4 months. Stool frequency varied from 2 to 4 times a day and at times, stools contained mucus. However, appetite activity, play and sleep remained unaffected, He had gained 1 kg of weight over the last 4 months despite having loose stools.

Physical examination did not reveal any abnormality. Several tests were carried out without a clue to diagnosis and drugs were tried but failed. There was a change in the bowel pattern over the last 4 months but it had not affected the general well-being of the child. This fact is important to note and it excludes all pathological conditions.

A diagnosis of irritable bowel syndrome was made based on circumstantial evidence. Irritable bowel syndrome is related to stress in a susceptible child and one must find out by discussion what stress the child at this age must be undergoing. Stress may arise from school, home, or friends. Parents need to be counselled to observe common areas of stress with friends or at school and they should avoid undue stress at home.

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Case 8

A four-year-old child presented with soiling underwear with small volumes of loose stools a few times a day for the last one month. He was treated for loose stools without any benefit. Physical examination did not reveal any abnormality. On direct questioning, parents informed that besides frequent passing of stools with soiling, he would pass good volume of hard stools once in 2 to 3 days. So he was constipated as was evident by the passing of hard stools infrequently. But also he was passing small volumes of loose stools few times a day.

As parents were more concerned about loose stools and soiling underwear, a history of constipation did not come out as the main problem. This is typically seen in habitual constipation.

Habitual constipation results from a diet poor in roughage in a child who has irregular bowel habits. It is often compounded by a hurry to go to school in the morning and unhygienic toilet facilities at the school that makes a child hold back stools. Retained hard stool leads to stretching and weakness of the rectal muscles that makes it more difficult to pass stools. It becomes a vicious cycle. Loose stool proximal to retained hard stool leaks from the side of hard stool and keeps on soiling underwear. Diarrhoea is not the problem of this child and he needs management of constipation that is beyond the scope of the present article.

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1. The first three cases are examples of diarrhoea due to non-pathological causes. What is common to all these cases is that the child is not sick and happy. It is a clue to search for non-pathological causes.
2. The last case masquerades as diarrhoea but actually it is constipation due to poor habits.
3. The other four cases can be diagnosed by analysing the history though physical findings are mostly scarce.

These cases emphasise the importance of detailed history taking. Laboratory tests have limitations and should be reserved for specific diseases.

To read the first part in the series, click Which type of diarrhoea should be controlled, and how? Dr. YK Amdekar

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.