Normal Stool Pattern Research Articles

EVALUATION OF INTESTINAL FUNCTION IN AIDS

A longitudinal (9 to 14 months) evaluation of the intestinal function has been performed in 5 children with AIDS (age range 3 months - 9 years). Diarrhea was observed in two children. One showed 5 episodes of acute, self-limiting diarrhea. The other was diagnosed as having cow's milk protein intolerance and had 5 episodes of diarrhea, 4 of which as a consequence of cow's milk protein ingestion. All the tests were performed by published methods, while on a normal stool pattern. d-xylose and iron oral loads were positive in 2 out of 3 patients tested. The determination of steatocrit showed steatorrhea in 4/5 cases. Fecal leucocytes were present in 1/3 and increased fecalα1 antitrypsin was found in 2/4. Search for enteric pathogens, including Criptosporidia, was always negative. One child carried a Giardia in her stools. Determination of antigliadin IgG and IgA was positive in 4/4 and 2/4 patients respectively; 2 had intermediate levels of IgA. Although diarrhea was observed in only 2 children and was always mild, several tests indicated an impairment of intestinal function in all cases, suggesting a frequent involvment of upper intestinal function associated with AIDS. The increase in antigliadin IgG and IgA antibodiss night be related to alterations of the intestinal permeability and/or to the immunological derangement.

1009 SELECTIVITY OF THE IMMUNOLOGICAL DISTURBANCES IN A ZINC DEFICIENT INFANT

An infant born prematurely (25wk;720g) presented at six months with acrodermatitis enteropathica. Despite adequate dietary zinc (zn), good weight gain and a normal stooling pattern, the serum zn level was 15 ug/dl (nl range 50-150 ug/dl). Lymphocyte response to the T cell mitogen PHA was normal, but the patient was anergic, and had abnormally high numbers of circulating B cells (1,847 cells/ul;nl 115/cells/ul). The serum IgG level was 140 mg/dl and IgA level was 6 mg/dl. No significant antibody to Tetanus, and no detectable antibody to Pertussis developed after primary immunization. Zn sulphate (2mg/kg/day) rapidly reversed the clinical condition, but immunological abnormalities responded slowly. After three months of zn replacement therapy (with adequate serum zn levels), the infant remained hypogammaglobulinemic, B cells in circulation remained elevated, and the response to the B cell mitogen Pokewood (PWM) was depressed. B cells, however, did respond in vitro to the T cell independent B cell mitogen Staph aureus Cowan (SAC). Responses to allogenic lymphocytes have shown consistent improvement. Overall, the absence of antigen specific responses, the decreased expression of the T3 marker, with normal proliferative responses to PHA and SAC, but not PWM, suggests that prolonged zn deficiency produces chronic disturbances in antigen presentation and/or T cell interactions that respond only slowly to zn replacement therapy. The selectivity of these immunological defects points to those areas of the immune system that may be critically zn dependent.

String placement and progressive dilatations in the management of high membranous rectal atresia

A newborn with rectal atresia underwent a sigmoid colostomy followed by fluoroscopic placement of a string across the membrane. Progressive dilatations were done until normalization of the rectal canal occurred at 4 months. At 6 months, the colostomy was closed. Although moderate sigmoid dilatation persisted initially, the boy is now developing well and has a normal stooling pattern 3 years following the last procedure. The technique demonstrates the feasibility of high rectal-membrane management without excision.

Reversal of enterocolitis-associated combined immunodeficiency by plasma therapy

Two 6-month-old male infants with diarrhea, malabsorption, and hypoproteinemia, who were initially diagnosed as having combined immunodeficiency syndrome, recovered with intensive plasma therapy. Prior to the onset of diarrhea, they had normal serum protein and lymphocyte values. Immunologic features of combined immunodeficiency included lymphopenia, diminished B and T cells, cutaneous anergy, low immunoglobulin levels, and poor lymphocyte proliferative responses in vitro. Prior to therapy, both children had rectal ulcerations by proctosigmoidoscopy, colitis by rectal biopsy, and moderate to severe intestinal villus abnormalities by small bowel biopsy; plasma cells were absent Both had generalized malabsorption of all nutrients. Both infants were given irradiated fresh-frozen plasma for one to two months at 11 to 20 ml/kg/day to replace intestinal protein losses. During this time, diarrhea slowed, biopsy morphology improved, and immunoglobulin levels and T-cell function became normal. After discontinuance of plasma therapy, normal immune function and a normal stool pattern with reversal of malabsorption continued. Since intensive plasma therapy may have contributed to the reversal of the immunodeficiency state, a trial of such therapy is recommended in similar patients.

Pathologic childhood aerophagia: A recognizable clinical entity

Pathologic childhood aerophagia is a rarely recognized, often poorly treated entity that has remained almost undescribed in either the surgical or pediatric literature. In only 1 of 9 children the condition was recognized at presentation. The initial diagnosis of the others was Hirschsprung's disease (2), malabsorption syndrome (3), gastric outlet syndrome (1), constipation (1), and esophagitis (1). Five were hospitalized and two underwent surgical procedures. History disclosed a remarkably constant triad: previous normal stooling pattern, visible and often audible air swallowing and excessive flatus. Physical examination often demonstrated a markedly or intermittently distended and tympanitic abdomen. Abdominal musculature was thinned in children with chronic aerophagia. Roentgenographic evaluation showed massively distended loops of intestine throughout without associated air-fluid levels. There was marked compression of the diaphragm with limited excursion in some. Laboratory and malabsorption testing was normal. Treatment is limited to recognition of the problem, nasogastric decompression in severe cases and psychologic counseling when symptoms persist in the older child. The recognition of this condition may lead to a better understanding of its pathophysiology and will reduce the number of unnecessary admissions or surgical procedures.

474 MANAGEMENT OF ACUTE SECRETORY DIARRHEA SYNDROME

ASDS is a clinical syndrome characterized by frequent, watery stools, rapid onset of dehydration, and lack of response to dietary restriction. The stools are mainly yellowish water and are produced almost continuously. Stool electrolytes show sodium above 70 mEq/L, chloride above 60 mEq/L, and potassium below 30 mEq/L. Diarrhea responsive to dietary restriction usually has sodium, potassium and chloride under 40 mEq/L. Stool volumes in ASDA are over 60 cc/kg/day leading to rapid onset of dehydration, hyponatremia, and shock. Treatment with exclusively I.V. fluids for as long as 8 days has no effect on fecal losses in ASDS. In 1977, 28 cases of ASDS were recognized at Texas Children's Hospital. Oral colistin was of no value in ASDS. Parenteral aminoglycoside therapy was associated with recovery of normal stool patterns in 4 to 5 days. Oral gentamicin was associated with recovery of normal consistency, frequency, and electrolyte concentrations in 24 to 36 hours. Thus, ASDS is characterized by cholera-like stooling, dehydration during the first days of illness, and an elevated stool sodium. This syndrome responds rapidly to oral gentamicin therapy. Supported by Children's Clinical Research Center NIH RR-00188, Kelsey-Seybold Fellowship Fund and Venezuelan National Academy of Sciences.

Therapeutic approach to pancreatic extract-induced hyperuricosuria in cystic fibrosis

The relationship between the dosage of pancreatic extract and the excretion of uric acid was investigated in 29 patients with cystic fibrosis and exocrine pancreatic insufficiency. Urinary excretion of uric acid was normal in patients receiving small doses of pancreatic extracts and abnormally high in those receiving large amounts. In the latter group, normouricosuria was achieved by reducing the dose of pancreatic extract. Normal stool patterns and adequate weight gains were preserved by a diet modification that was well accepted by the patients. To eliminate the potential renal consequences of hyperuricosuria, it seems appropriate to control the need for increasing amounts of pancreatic enzymes by limiting the dietary intake of fat and maintaining a positive caloric and nitrogen balance with high intake of protein and carbohydrates and supplementation with medium-chain triglycerides.