Paeds Vivas · gastroenterology-hepatology-and-nutrition
Persistent and chronic diarrhoea — branching viva
Branching viva from the duration definitions and mechanism classification of chronic diarrhoea through the thriving toddler, the infant with cow's milk protein allergy, the school-age child with coeliac disease, and the adolescent with inflammatory bowel disease, testing the osmotic-versus-secretory distinction and the stool-directed workup.
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RACP General PaediatricsRACP DCEMRCPCH ClinicalRCPSC Pediatrics
Prompt
You are the paediatric registrar in a general clinic. The consultant asks you to talk through four children referred with diarrhoea that will not settle: a thriving two-year-old with loose stools containing undigested food, a six-month-old with blood and mucus in the stool, a nine-year-old with faltering growth and a distended abdomen, and a fifteen-year-old with bloody diarrhoea and weight loss.
Station opening
Examiner: "Define persistent and chronic diarrhoea, and explain how you would frame your approach to a child referred with diarrhoea that will not settle." [1]
Strong candidate (must-hit)
- Defines persistent diarrhoea as an episode lasting fourteen days or more and chronic diarrhoea as loose or frequent stools continuing for four weeks or more; explains that the duration shifts the differential away from self-limiting infection towards an underlying cause; frames the approach around three lines — the duration, the stool type (watery osmotic or secretory, fatty, inflammatory) and the age — and states that the first decision is whether the child is thriving, which points to a functional or dietary cause, or failing to grow or passing blood, which points to an organic enteropathy. [1]
Weak candidate
- "Diarrhoea is chronic if it goes on a long time, and I would send off some stool tests." [1]
References6ShowHide
- [1]Zella GC; Israel EJ Chronic diarrhea in children. Pediatr Rev, 2012.PMID 22550264
- [3]Field M Intestinal ion transport and the pathophysiology of diarrhea. J Clin Invest, 2003.PMID 12671039
- [4]Kneepkens CM; Hoekstra JH Chronic nonspecific diarrhea of childhood: pathophysiology and management. Pediatr Clin North Am, 1996.PMID 8614606
- [6]Husby S; Koletzko S; Korponay-Szabó I; Kurppa K; Mearin ML; Ribes-Koninckx C European Society Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for Diagnosing Coeliac Disease 2020. J Pediatr Gastroenterol Nutr, 2020.PMID 31568151
- [7]Levine A; Koletzko S; Turner D; Escher JC; Cucchiara S; de Ridder L ESPGHAN revised porto criteria for the diagnosis of inflammatory bowel disease in children and adolescents. J Pediatr Gastroenterol Nutr, 2014.PMID 24231644
- [8]Luyt D; Ball H; Makwana N; Green MR; Bravin K; Nasser SM BSACI guideline for the diagnosis and management of cow's milk allergy. Clin Exp Allergy, 2014.PMID 24588904