Chronic Nonspecific Diarrhea Research Articles

P-BN05 Solitary jejunal diverticulum: a rare unexpected cause of chronic pneumoperitoneum

Abstract Background Jejunal diverticula are rare acquired herniation of the mucosa and submucosa through the muscularis propria. They are asymptomatic in the majority of cases, however, they can present with non-specific abdominal symptoms and rarely complicate leading to acute abdomen. Perforation usually results in symptoms and signs of acute peritonitis and it is not an identifiable aetiology of chronic pneumoperitoneum. Computed tomography scan may identify intestinal wall oedema, air bubbles travelling through the mesentery, free intra-abdominal air and/or fluid . Radiological diagnosis requires high index of suspicion of such pathology. We report a case of an isolated jejunal diverticulum as a cause for aseptic chronic pneumoperitoneum . Methods A 77-year-old female was referred to the ambulatory emergency surgical unit (AESU) with a 4-month history of nonspecific abdominal pain, considerable weight loss, diarrhea, nausea and a few episodes of vomiting.Physical examination revealed no constitutional signs of sepsis and her abdomen was mildly distended but soft and nontender to palpation. Laboratory investigations were unremarkable. CT scan of her abdomen and pelvis on her first visit showed pneumoperitoneum with associated low volume ascites, which raised the possibility of sealed gastrointestinal perforation. In the absence of any clear signs of sepsis, a strategy of ambulatory, conservative management and follow up was chosen. Four months after her initial presentation our patient presented with ongoing vague abdominal symptoms with weight loss and failure to thrive. A CT colonogram described pneumoperitoneum and larger volume of ascites is in comparison to the previous CT scan. There was an unusual pattern of mural gas in some loops of small bowel in the left side of the abdomen that suggested pneumatosis. MDT decided to proceed with diagnostic laparoscopy. Results Laparoscopy exploration revealed odorless pneumoperitoneum, moderate amount of non-turbid bile stained serous ascites and thin fibrinous covering. We identified a jejunal diverticulum associated with mesenteric air bubbles and moderately enlarged reactive feeling lymph nodes in the diverticular segment . A small bowel resection with a primary side-to-side anastomosis, washout of the abdomen and cholecystectomy were done through a Kocher’s subcostal incision. She made an uneventful post-operative recovery and was discharged home well on day 4. Histopathological examination of the resected specimens confirmed the presence of a ruptured isolated jejunal diverticulum with a breach in muscularis propria and chronic cholecystitis in the gallbladder. Conclusions In summary, our case report highlights the importance of being aware of the possibility of perforated jejunal diverticula as a possible source of chronic pneumoperitoneum causing chronic nonspecific abdominal pain, diarrhea and unexplained weight loss. The surgical option of segmental resection and primary anastomosis was beneficial in this patient. However, calculating the risk benefit ratio remains the mainstay of the management plan, which, as ever, should be tailored to each patient’s general condition and fitness with appropriate counselling and consent.

Food Offer, Chronic Diarrhea and Preparedness to Alimentary Diabetes from the Second Year of Life Onwards

<p class="Standard"><strong>Background: </strong>We have worked out an alimentary behaviour based on a meal- after -meal individual limit of energy intake (IHMP). We have then studied the energy intake, the pre-prandial blood glucose concentration (blood glucose, BG) and the body weight of a group of children with chronic not specific diarrhea. Finally we have added BG tolerance tests to clinically healthy adults in order to ascertain a possible association between IHMP and insulin sensitivity, should functional disorders or overweight problems arise.</p><p class="Standard"><strong>Objective:</strong> With the present study we want to verify if mothers are capable of maintaining the IHMP and low pre-prandial BG levels in the eight years following the initial training, also in absence of diarrhea relapses. In adults the IHMP is associated to a good insulin sensitivity and this fact should be taken into consideration in order to reduce the increase of non - trasmissible deseases in the Western World.</p><p class="Standard"><strong>Methods:</strong> We recruited children with not specific chronic diarrhea (bowel functional disorders) and selected randomly 53 mother-child pairs as the control group and 100 to be trained. Mothers were taught both how to recognise the correspondence between the individual manifestations of hunger and the BG concentration (Initial Hunger Meal Pattern, IHMP). The aim was to get low BG levels before each meal, and, thanks to the skill acquired, to stop the insulin resistance. The energy intake and the pre-prandial BG levels were reported in weekly diaries while the symptoms were recorded through structured interviews after 3 and 6 months and after 2,4,6,8 years.</p><p class="Standard"><strong>Results: </strong>Energy intake reductions were significantly larger in trained than in control subjects at all 6 surveys after recruitment (P < 0.04 to < 0.0001) although growth was similar, Diarrhea and vomiting significantly dropped both in the trained group and in the control one compared to the beginning of the research. Larger reductions from base values in days with diarrhea in trained children (compared with controls) were found for the three initial months and in drug administration at the surveys after 2 years and after 8 years</p><strong>Conclusion: </strong>Chronic non-specific diarrhea of the second year of life is associated<strong> </strong>with high energy intake<strong> </strong>and high pre-prandial BG for incomplete exhaustion of previous energy intake. In adults, this habit is associated with fattening/insulin resistance.

Growth Assessment in Egyptian Infants and Children with Chronic Diarrhea

This study evaluated the various growth parameters among patients presenting with chronic diarrhea and highlight the most common causes of chronic diarrhea among a sample of Egyptian infants and children. This cross-sectional study included 146 patients with chronic diarrhea. They were 87 males and 59 females, with age ranging between 2 and 198 months and a mean age of 27.3 +/- 34.5 months. Each patient was subjected to medical history taking including age of onset and duration of diarrhea, consistency of stools, presence of blood and mucus, vomiting with or without hematemesis, fever, allergic manifestations and family history of atopy. Dietetic history included milk feeding during the first 6 months and age of weaning and age of introduction of cow's milk products. Anthropometric measurements included weight and height and weight for height were assessed and z-scores were calculated using software WHO anthro v3.2.2. Laboratory investigations included stool analysis and culture, CBC and all other investigations necessary for diagnosis of the definite cause including RAST for specific IgE against cow's milk proteins, serology for celiac disease (anti-gliadin and anti tTG), Breath hydrogen test, endoscopy (colonoscopy or esophago-gastrodudenoscopy) and histopathologic assessment of endoscopic biopsies. CMA was diagnosed on basis of withdrawal and open re-challenge technique. Causes included chronic infections (40.4%), CMA (34.9%), celiac disease (10.3%), inflammatory bowel disease (6.8%) and lactose intolerance (3.4%). Rare causes were chronic non-specific diarrhea (1.3%), cystic fibrosis (0.7%), post-surgery short bowel syndrome (0.7%), neuroblastoma (0.7%) and IBS (0.7%).78.7% of patients enrolled in the study had a low WFA z-score (< -2), 75% had low length for age z-score (<-2) and 50.7% showed wasting with low weight for height z-scores (< -2). Patients with IBD had the lowest mean value of WFA and HFA z-scores (-4.03 +/- 3.23, -6.31 +/- 3.74 respectively). Infants with CMA had the lowest mean value of WFH z-score (-2.26 +/- 1.78).

Chronic Diarrhea in Children

Chronic Diarrhea in Children

Chronic nonspecific diarrhea of children

Chronic nonspecific diarrhea (CNSD) or toddler’s diarrhea is the most frequent cause of chronic diarrhea in young children of developed countries. The pathogenesis of CNSD remains unclear. It has been associated with drinking large amounts of fluids and fruit juices that contain large amounts of fructose and sorbitol. Reduction in the intake of fat and fiber can also be the cause of CNSD. Children with CNSD do not show signs of malnutrition or growth retardation. They experience watery stools four to more than ten times daily. Stools are foul smelling, occasionally with undigested food remnants because of the short transit time. The patients do not normally suffer from their ailment; however, diarrhea may cause parents to be extremely worried. Pediatricians and primary physicians have to diagnose CNSD with clinical symptoms and exclusion of specific illness. Proper dietary manipulation improves the condition of most patients.

Small intestinal bacterial overgrowth and lactose intolerance contribute to irritable bowel syndrome symptomatology in Pakistan

Background /Aim:The symptoms of irritable bowel syndrome resemble those of small intestinal bacterial overgrowth (SIBO). The aim of this study was to determine the frequency of SIBO and lactose intolerance (LI) occurrence in patients with diarrhea-predominant irritable bowel syndrome (IBS-D) according to Rome III criteria.Patients and Methods:In this retrospective case-control study, patients over 18 years of age with altered bowel habit, bloating, and patients who had lactose Hydrogen breath test (H2BT) done were included. The “cases” were defined as patients who fulfill Rome III criteria for IBS-D, while “controls” were those having chronic nonspecific diarrhea (CNSD) who did not fulfill Rome III criteria for IBS-D. Demographic data, predominant bowel habit pattern, concurrent use of medications, etc., were noted.Results:Patients with IBS-D were 119 (51%) with a mean age of 35 ± 13 years, while those with CNSD were 115 (49%) with mean age 36 ± 15 years. Patients in both IBS-D and CNSD were comparable in gender, with male 87 (74%) and female 77 (64%). SIBO was documented by lactose H2BT in 32/234 (14%) cases. It was positive in 22/119 (19%) cases with IBS-D, while 10/115 (9%) cases had CNSD (P = 0.03). LI was positive in 43/234 (18%) cases. Of these, 25/119 (21%) cases had IBS-D and 18/115 (16%) cases had CNSD (P = 0.29).Conclusion:SIBO was seen in a significant number of our patients with IBS-D. There was no significant age or gender difference in patients with or without SIBO.

Do Patients With Irritable Bowel Syndrome Exhale More Hydrogen Than Healthy Subjects in Fasting State?: Author's Reply

TO THE EDITOR: We appreciate the interest of Dr. Choi on our paper and for their critical appraisal of our results. As seen in the figure provided in our previous study, healthy subject (HS) had lowest value of hydrogen excretion in fasting state compared to patients with chronic non-specific diarrhea (CNSD) and irritable bowel syndrome (IBS).1 Though the difference between fasting breath hydrogen excretion in HS and patients with IBS was not significant in that study,1 it is worthwhile to realize that most of those who had diarrhea in absence of malabsorption might be patients with diarrheal IBS. Therefore, it is important to club patients with CNSD and IBS in the perspective of our second study.1 Such an analysis showed that fasting breath hydrogen level in 50 HS tended to be lower than that in 204 patients with IBS and CNSD (4.9 ± 5.4 vs 6.5 ± 6.3 ppm, p = 0.08).1 Dr. Choi suggested that the results of the present study comparing fasting breath hydrogen between constipation and diarrhea predominant IBS might have changed if we classified the IBS subtypes by Rome III criteria.2 We beg to differ on this issue. There are several reports, which showed that sub-typing IBS using Rome III criteria may not be appropriate in Asia in general and in India in particular.3-5 Though 95% patients in our study reported looser stools at onset of pain, this symptom is not the only determinant to subtype IBS.2 We reiterate that another study done previously, had limitations as they included non comparable patients with IBS and HS.6 However, we fully agree with Dr. Choi that further studies with a larger sample size are needed on this issue. In fact, we believe that many of the gastrointestinal diseases which were once thought to be psychogenic, later turned out to be related to structural or functional defect in the gastrointestinal system.5 Similarly, bloating in patients with IBS might be related to distension of the gut with gas such as hydrogen.3,5 Since 96% of patients in our study had bloating and only 4% did not report it, we could not study the relationship between bloating and fasting breath hydrogen.2 Future studies should be planned to evaluate the relationship between patient-perceived bloating, and that measured using playthismography and fasting breath hydrogen on an adequate number of patients. We agree with Dr. Choi that repeated toilet visit by the patients with constipation predominant IBS may result in spuriously increased stool frequency. Hence, we reanalyzed our data using Bristol Stool Form as suggested; we found that there was correlation between fasting breath hydrogen excretion and number of stools per week among patients with IBS who were passing Bristol Stool Form 5 and 6 (r = 0.35, p = 0.02). However, there was no correlation between fasting breath hydrogen excretion and number of stool per week among the patients passing Bristol Stool Form 1 to 4. We appreciate the interest of Dr. Choi on this subject in general and on our paper in particular. We believe that inspite of the limitation of our study, it attempted to explore a new issue of whether excess hydrogen production in the gut even in fasting state by the patients with IBS may explain their symptom at least partly. We hope this may give a new insight on this disease which is left in the realm of psychogenic nature rather than an abnormal primary gastrointestinal abnormality.

Frequency of Small Intestinal Bacterial Overgrowth in Patients with Irritable Bowel Syndrome and Chronic Non-Specific Diarrhea

IntroductionSmall intestinal bacterial overgrowth (SIBO) occurs in varying frequency in irritable bowel syndrome (IBS). We studied the frequency of SIBO in IBS and chronic non-specific diarrhea (CNSD).Methods129 patients with IBS (Manning's criteria), 73 with CNSD (≥ 4 weeks diarrhea with two of these tests normal [urine D-xylose, fecal fat and duodenal biopsy]) and 51 healthy controls (HC) were evaluated for SIBO using glucose hydrogen breath test (GHBT). Diarrhea-predominant IBS (D-IBS) was grouped into CNSD. Rise in breath hydrogen 12 ppm above basal following 100 g glucose was diagnostic of SIBO.ResultsOf 129 patients with IBS, 7 were constipation (C-IBS), and 122 were of indeterminate type (I-IBS). Patients with IBS were younger than HC and CNSD (IBS vs. HC: 36.6 yr ± 11.4 vs. 44.1 yr ± 13.6, p = 0.001; IBS vs. CNSD: 36.6 yr ± 11.4 vs. 42 yr ± 14.5, p = 0.003). Patients with CNSD were comparable to HC in age (42 yr ± 14.5 vs. 44.1 yr ± 13.6, p = ns). Patients with IBS were more often male than HC [108/129 (83.7%) vs. 34/51 (66.7%) p = 0.02]; gender of CNSD and HC was comparable [male 39/73 (53.4%) vs. 34/51 (66.7%) p = ns]. SIBO was commoner in CNSD than HC [16 (21.9%) vs. 1 (2%), p = 0.003], but was comparable in IBS and HC [11 (8.5%) vs. 1 (2%), p = 0.18]. Patients with CNSD more often had SIBO than IBS [16 (21.9%) vs. 11 (8.5%), p = 0.007].ConclusionsSIBO was more common in CNSD including D-IBS than other types of IBS and HC.

The Role of Small Intestinal Bacterial Overgrowth in the Pathophysiology of Irritable Bowel Syndrome

Small intestinal bacterial overgrowth (SIBO) is a clinical condition caused by excessive number of bacteria in the small bowel. SIBO is characterized by symptoms of diarrhea, abdominal pain, or bloating which may be associated with excessive gas of small intestine due to increased production by bacterial fermentation in the gut. In the last decade, SIBO has been occupied as a hot topic of interests by a group of researchers because of its potential role in the development of irritable bowel syndrome (IBS).1 In the diagnosis of SIBO, a bacterial count greater than 105 colony-forming units/mL by small bowel culture is believed to be the gold standard.2 But small bowel culture through jejunal aspirate is time-consuming, invasive, and potential for contamination. Due to several flaws of small bowel culture, a number of non-invasive and indirect tests for diagnosing SIBO have been developed. Breath test, the most common indirect method for evaluating SIBO, utilizes the metabolism of carbohydrates by bacterial enzymes, in turn indirectly measures bacterial activity of small bowel. Different carbohydrates have different properties. As lactulose is a non-absorbable carbohydrate, it easily reaches the site of potential overgrowth in the small bowel, although non-absorbed carbohydrate has limitations by the intestinal transit time. In patients with rapid transit, lactulose may produce an early hydrogen peak which makes it difficult to discriminate the true SIBO from a phenomenon by rapid intestinal transit, therefore specificity of lactulose hydrogen breath test (LHBT) is relatively low.3 Pimentel and colleagues4 suggested a concept that SIBO is a major pathogenic mechanism underlying IBS in 2000. They have found 78% of 202 IBS subjects to be positive for LHBT which is suggestive of SIBO. They also demonstrated a significant improvement in symptoms including abdominal pain, bloating, and diarrhea by treating SIBO with antibiotics and converted many IBS patients from Rome criteria positive to negative. Since then, SIBO has been proposed as an etiologic factor in IBS, but also the potential role of SIBO in IBS has been strongly debated about the methods used in diagnosing SIBO. A prevalence of SIBO in subjects meeting diagnostic criteria for IBS varies from 4% to 64%, depending on the kind of test and criteria used to define a positive result.5 In addition, a recent well-designed study from the US6 using LHBT to diagnose SIBO could not discriminate patients with IBS from healthy subjects, which was a consistent finding the authors demonstrated previously.7 Therefore, the proposed etiologic role of SIBO diagnosed by LHBT in IBS patients is controversial and the correlation between the normalization of the LHBT following antibiotic treatment and symptom improvement has become less clear. Glucose, on the other hand, is rapidly absorbed in the proximal small bowel. Thereby detecting hydrogen in this test means SIBO in a proximal location. Glucose hydrogen breath test (GHBT) is the most commonly used test in the diagnosis of SIBO, although GHBT may be less sensitive for the diagnosis of SIBO since it is absorbed in the proximal small bowel. GHBT has been reported to have a overall sensitivity between 25% to 93% and a specificity from 34% to 96% in detecting SIBO.3,5 In this issue of the Journal of Neurogastroenterology and Motility, Ghoshal et al. reported the frequency of SIBO in patients with IBS and chronic non-specific diarrhea (CNSD) with comparison to healthy controls by using GHBT. The authors found that SIBO was more common in patients with CNSD (21.9%) than those with IBS (8.5%) and healthy controls (2%). Since CNSD including diarrhea predominant IBS (D-IBS) had higher frequency of SIBO, the authors suggested clinicians to consider testing for SIBO among them. However, since false positive GHBT could result from rapid intestinal transit in patients with diarrhea, the frequency of SIBO in patients with CNSD and D-IBS demonstrated in the author's study might have been overestimated in part.

Gaps between Infant Diarrheal Disease and Frequent Loose Stool

Chronic diarrhea in children has a long differential diagnosis, but the clinician can usually distinguish disease from functional diarrhea. A careful history will provide information on medical and dietary problem, growth disturbance, associated symptoms and signs. The extent of laboratory evaluation should be guided by common sense. In the absence of the worrisome historical items noted, or abnormal findings on examination or growth history, reassurance may be all that is required. This article reviewed the diagnostic approach and differential diagnosis of chronic diarrhea, and summarized common non pathologic conditions of chronic diarrhea such as chronic nonspecific diarrhea (toddler’s diarrhea) and secondary lactase deficiency. [Korean J Pediatr Gastroenterol Nutr 2010; 13(Suppl 1): 44∼50]

Role of dietary fat in chronic non-specific diarrhea in childhood.

Role of Dietary Fat in Chronic Non-Specific Diarrhea in Childhood Get access Nutrition Reviews, Volume 38, Issue 7, July 1980, Pages 240–242, https://doi.org/10.1111/j.1753-4887.1980.tb05913.x Published: 01 July 1980

Dietary fructose intolerance in children and adolescents

Children’s diets contain increased amounts of sweeteners such as fructose. Fructose is present in fruit, honey and some vegetables, and fructose corn syrup is increasingly being consumed as a sweetener...

Sacrosidase Trial in Chronic Nonspecific Diarrhea in Children

Chronic nonspecific diarrhea in children, or toddler's diarrhea, is a frequently encountered entity in pediatric clinical practice. This disorder remains poorly understood. Suggested etiologies include malabsorption, dietary intake and motility abnormalities. We investigated the use of sacrosidase (a yeast sucrase supplement) in children with toddler's diar- rhea. The study outcome was clinical response to sacrosidase supplementation. Children, 1-6 years of age, with toddler's diarrhea were enrolled in an open prospective trial. Stooling patterns were obtained at baseline and while on supplementa- tion. Twelve patients were enrolled out of 40 patients who presented with chronic diarrhea. Eight patients did not respond to standard diet changes and were entered into the trial. With supplementation, 4 out of the 8 patients responded clinically with a decrease in mean daily stool frequency and an improvement in the mean daily stool consistency. Sacrosidase sup- plementation demonstrated a potential benefit in a subset of children with toddler's diarrhea. Response to sacrosidase may suggest excessive sucrose intake or unrecognized partial or complete sucrase deficiency in some children with toddler's diarrhea.

43 Sacrosidase in the Treatment of Chronic Nonspecific Diarrhea in Children.

Context: Chronic nonspecific diarrhea in children, also known as toddler's diarrhea, is a frequently encountered disorder in clinical practice. It tends to cause significant parental anxiety and frustration leading to frequent health care visits.Objective: We investigated the usefulness of sacrosidase (Sucraid®) in children with toddler's diarrhea. The primary outcome was the proportion of patients who responded to sacrosidase supplementation. Secondary outcome measures included safety and potential adverse effects.Population: Children 1 to 6 years of age with a current history of toddler's diarrhea (≥ 3 loose stools per day for ≥ 3 months) were enrolled in a prospective trial from our outpatient specialty clinic. Exclusion criteria included a history consistent with infection, inflammation, malnutrition or the use of motility altering agents. Patients were also excluded if they had abnormal screening tests including the presence of anemia, elevated inflammatory markers, positive celiac disease antibodies or infectious stool studies.Design: Baseline defecation patterns (stool frequency and consistency) were obtained using daily diaries filled by caregivers over 1 week prior to any intervention. Patients with baseline defecation patterns that satisfied the definition of toddler's diarrhea (≥ 3 stools daily) were placed on sacrosidase supplementation with all snacks and meals. Caregivers filled similar daily diaries for 2 weeks. We defined clinical response as a decrease in daily stool frequency by 50% and/or a decrease of ≥ 2 points on the stool consistency scale while on sacrosidase supplementation.Results: Between September 2005 and July 2006, 37 children presented for evaluation of diarrhea, of which 20 were eligible for the study. Of those eligible, 12 were enrolled (average age 31.6 months, range 41 to 23 months). One subject was excluded from analysis for noncompliance and three subjects were not kept in the study due to normal defecation patterns in the baseline period. Four of the remaining eight patients (50%) who finished the study were clinical responders. In the responder group, the average daily stool frequency decreased from 5.2 to 1.9 and the stool consistency scale decreased from a mean of 4.5 to 2.5 points. In the non-responder group, the average daily stool frequency and stool consistency remained unchanged. There were no complications reported.Conclusions: Sacrosidase supplementation demonstrated a potential benefit in children with toddler's diarrhea by decreasing defecation frequency and improving stool consistency. This may be due to excessive sucrose in children's diet or to unrecognized partial sucrase deficiency. A larger scale study with longer patient follow up is needed to further assess the benefit of such an intervention.

DIETARY FRUCTOSE INTOLERANCE IN CHILDREN AND ADOLESCENTS

Children’s diets contain increased amounts of sweeteners such as fructose. Fructose is present in fruit, honey and some vegetables, and fructose corn syrup is increasingly being consumed as a sweetener in various products including soda-pop.1 Unabsorbed fructose may be fermented in the colon and creates an osmotic load, drawing fluid into the gut lumen and is the basis for recommendations that toddlers with chronic non-specific diarrhoea reduce their intake of apple juice. The abdominal pain, bloating and alteration of bowel habits associated with dietary fructose intolerance are under-recognised in adult patients diagnosed with irritable bowel syndrome.2 3 However, the production of …

Diet and gastrointestinal disease.

Dietary manipulation can be an important part of therapy for several common gastrointestinal disorders. In Crohn disease, the provision of adequate protein and calories may not only improve symptoms but may be associated with acceleration of growth. In celiac disease, the dietary restriction of gluten is curative of the intestinal inflammation. In chronic nonspecific diarrhea and functional constipation, the provision of appropriate amounts of fiber and fluids may ameliorate symptoms. A thorough understanding of the role of diet is essential to the management of these disorders.

Motility disorders in childhood: Working Group Report of the First World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition.

Motility disorders in childhood: Working Group Report of the First World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition.

Irritable bowel syndrome and nonspecific diarrhea in infancy and childhood--relationship with juice carbohydrate malabsorption.

Lactose intolerance and malabsorbed carbohydrate present in some fruitjuice may trigger symptoms commonly seen in irritable bowel syndrome. In a two-site study, 28 subjects 9 months to 18 years old (mean 6.9 +/- 5.9 years) with significant intake of apple juice or pear nectar (> 6 oz a day) with the diagnoses of irritable bowel syndrome, functional abdominal pain, or chronic nonspecific diarrhea were recruited. Breath hydrogen tolerance tests utilizing lactose, sucrose, and apple juice in the amount they typically consumed were positive in 32%, 0%, and 50%, respectively. Subjects were asked to refrain from the ingestion ofjuice for 1 month: 13 of the 28 (46%) subjects improved while 15 (54%) showed no change in their symptoms. In fact, none consuming 6 to 12 oz of apple or pear juice daily improved, 27% of those consuming 12 to 16 oz improved, and 91% of those consuming > 16 oz improved (P < 0.02). Subjects were then given comparable amounts of white grape juice for 1 year. The initial symptoms did not recur in any of the subjects who initially responded to the juice-free diet. Of the 15 subjects who did not respond to the juice-free diet, seven became asymptomatic. Overall, 20 subjects (71%) were asymptomatic, and eight (29%) had no change in their symptoms. Some individuals with irritable bowel syndrome have their symptoms based on their malabsorption of carbohydrates present in apple juice and pear nectar and may improve with adequate choices of fruit juice such as changing to white grape juice.

Irritable bowel syndrome

OBJECTIVE: To review the pathophysiology in order to explain the clinical manifestation and treatment of this syndrome, which has not been completely explained yet. METHODS: References were searched on recent review articles, personal files, and Medline. RESULTS: Irritable bowel syndrome in children or chronic nonspecific diarrhea is a very frequent reason for pediatric gastroenterology visits. It is a benign disease and disappears with age, but may cause extreme worry to parents. The pathophysiology is still unclear, and there is not laboratory corroboration. Thus, it is frequently diagnosed incorrectly, although it has proper clinical manifestation (if there is no diet or medicine manipulation). Dietary advice is usually efficient, and is based on pathophysiologic data. The use of drug is still discussed. CONCLUSIONS: Irritable bowel syndrome must be always considered in oligosymptomatic children without signs of malnutrition, with diarrhea, between 6 months and 5 years of age. Drugs are not necessary, and their action is still unclear. Food manipulation based on pathophysiology is enough.

Functional gastrointestinal disorders.

When clinicians label a child as having a functional disorder, there is often a pejorative connotation that the symptoms are psychological, imagined, or faked. These symptoms range from chronic abdominal pain to recurrent headaches to fatigue. We say the complaints are functional because we are unable to demonstrate any structural or biochemical abnormality causing them. The degree to which we go searching for these abnormalities varies from case to case and often depends on our own clinical experience, insecurities, and demands of the patient's family. Labeling a child as having a functional complaint can put a tremendous burden on the child and family, because if this concept is presented improperly (as implied above), it can suggest that it is their fault there are symptoms and that if they "got their act together" the symptoms would melt away. Functional gastrointestinal disorders are defined as conditions in which a variable combination of chronic or recurrent gastrointestinal symptoms are present in the absence of demonstrable disease. There may indeed be physiologic abnormalities underlying the symptoms, but at the present time we are unable to detect them. We make a diagnosis based on symptoms, not on demonstrable abnormalities in physical examination or laboratory tests. A number of common pediatric diagnoses fall into this category, including infant regurgitation, chronic nonspecific diarrhea, irritable bowel syndrome, non-ulcer dyspepsia, infant dyschezia, and functional constipation. This paper presents a brief review of our current understanding of each diagnosis and gives suggestions for management.