Chronic diarrhea: four decades experience in resource-limited settings

Objective: In view of the paucity of information in the literature, this article aims at providing a simplified and yet state-of-the-art approach for the management of chronic diarrhea in children in resource-limited settings. Resource and Design: Systematic review of literature supported with our own experience spread over four decades. Salient Features: Etiology of chronic diarrhea, implying diarrhea of 2 weeks or more, usually secondary to a malabsorptive cause, is exhaustive. However, in clinical practice in resource-limited settings, only a few conditions such as malnutrition, intestinal infestations, cow’s milk protein allergy (CMPA), celiac disease, cystic fibrosis and endemic tropical sprue monopolize the situation. Diagnostic evaluation needs to be step-by-step with good history-taking and clinical examination followed by select investigations depending on the individual merits of the cases. High index of suspicion is a forerunner in detecting CMPA. Mild to moderate steatorrhea is usually indicative of malnutrition, iron-deficiency anemia or intestinal parasites (L. giardia, A. duodenale). Gross steatorrhea is due to celiac disease, cystic fibrosis or tropical sprue. In cystic fibrosis, despite significant steatorrhea, D-xylose test is usually normal. Conclusion: A good idea about the pattern of etiology of chronic diarrhea/ malabsorption in different regions together with an individualized approach and an adequate follow-up is likely to resolve a large majority of the diagnostic as well as therapeutic problems. Treatment depends on the etiology of chronic diarrhea.