malapsorption, diarrhea

[Corine__0__0]

  My 3 year old son has had chronic diarrhea for several months. He is currently undergoing testing for parasites, CF, etc. However, he also suffers from anemia, frequent canker sores and dry scaly skin. As an R.N., I feel he has a malapsorption problem going on. I'm wondering is is because of the diarrhea or is the diarrhea an effect of something related to a malapsorption syndrome. Any views on what might be going on with him?  Thanks.
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April 13, 1998
Dear Corinne:
In response to your letter of March 24, 1998, many children of the ages of one to four years can experience diarrhea or loose stools for prolonged periods of time.  Of these many children, a few do in fact have chronic intestinal malabsorption, or the inability to absorb the nutrients from meals such as protein, fat, vitamins, and minerals.  Rarely, a severely affected child may have lost the ability to absorb water and salts and easily becomes dehydrated and salt deficient.  There are several ways in which one may decide which of the many children with loose stools actually has malabsorption, or the inability to absorb food.  The first question is the child either losing weight or showing the failure to gain weight?  Since young children should be growing at a steady pace, diarrhea and malabsorption will quickly result in a weight loss and later in a failure to grow taller.  These children, like your 3 year old son, commonly show other problems such as anemia, which is usually due to iron deficiency with or without other mineral or vitamin deficiencies.  Specialized fats that the body cannot make and must be absorbed from the diet, i.e. essential fatty acids, can also be lost in malabsorption and their defiancy may cause a skin rash such as you describe.  The actual disorders causing the malabsorption may originate in the pancreas, a digestive gland connected to the intestine or may reside in the intestine itself.  The disorders of the pancreas usually are present from birth and quickly become apparent in early infancy as poor growth.  The specific conditions of the pancreas include cystic fibrosis (present in 1 in 1500 newborns) and Schwachman's Syndrome (the blood count is also abnormal).  The disorders of the intestine causing malabsorption are rarely present at birth; they include the congenital absence of an intestinal lining, the lacking of salt transporters, the lack of digestive enzymes, or an undeveloped system to absorb fats through the intestine.  The abrupt onset of diarrhea at ages one to four years is usually due to an infection.   As you mentioned, parasites such as giardia may take up residence in the small intestine and cause diarrhea and malabsorption.  Certain conditions cause the immune system of a given child to be more susceptible to giardia and its persistence such as IgA deficiency with minor IgG deficiency, two conditions of  low antibodies.  If infection is ruled out, one must also consider Celiac disease which is a sensitivity to wheat, barley, and oats.  The nutrients contain gluten, a protein complex, that the affected individual reacts to and causes a loss in the lining of the small intestine and malabsorption.  Individuals with Celiac disease may also have a rash in addition to rashes from malabsorption, called dermatitis herpetiformis.  Lastly, chronic diarrhea may result from a overactive allergy immune system called eosinophilic gastroentritis, which may be associated with eczema or the allergic skin rash.  Rarely, chronic eczema may be present as a sign of a deficient immune system.  
Each child with chronic diarrhea must be evaluated in an individual fashion.   Once common and benign causes such as excess intake of juice or other dietary imbalances are excluded, a proper and judicious work up is in order.  In some cases, extensive stool and blood test are required and may lead to a rapid diagnosis and on such example is Celiac disease where a sensitive screening blood test is available.  Internal tests such as endoscopy and intestinal biopsy are necessary to confirm the diagnosis, such as the case of celiac disease.  Rarely, early onset of inflammatory bowel diseases such as chronic colitis or Crohn's disease may be diagnosed this way.
This response is being provided for general informational purposes only and should not be considered medical advice or consultation.  Always check with your personal physician when you have a question pertaining to your health.
If you would like to be seen at our institution please call 1-800, our expert in the treatment of Pediatric gastrointestinal disease.  He would be happy to meet you and your family and to work with you regarding the cause of the symptoms and the best therapeutic approaches.
HFHSM.D.-bb
*keywords: diarrhea, malabsorption, pediatrics, cystic fibrosis,
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