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A nine-day-old white male presented with a history of watery diarrhea that had developed gradually in the first few days after birth. He was born to nonconsanguineous parents at 36 weeks’ gestation. The pregnancy was uncomplicated, with no evidence of polyhydramnios. There was meconium-stained liquor at delivery, but the immediate postnatal period was uneventful. Birth weight was 2.74 kg. The patient was discharged on day 3 weighing 2.43 kg. At home, he was breastfed every 2 to 3 h and continued to have three stools per day, of which at least one was described as watery. On day 9, he was brought to the hospital because he was lethargic and feeding poorly. In the emergency room, he was noted to be poorly responsive and was estimated to be 10% dehydrated, weighing only 1.8 kg. The physical examination was otherwise unremarkable. He was hypernatremic and acidotic, with a capillary blood pH of 6.97 but only a modest anion gap of 22 mmol/L (normal 5 to 15 mmol/L). Oral feeding was stopped, and fluids were replaced intravenously. Bicarbonate was infused to partially correct the acidosis. Broad spectrum antibiotic therapy was initiated after cultures were taken. Of the many possible causes of watery diarrhea (Table 1), a viral or allergic enteropathy was initially considered to be most likely. However, stool cultures and rapid screens for rotavirus and adenovirus were subsequently negative. Blood, urine and cerebrospinal fluid were sterile. TABLE 1 Differential diagnosis of watery diarrhea in the infant

Secretory diarrhea

Congenital defects in ion transport

• Defective sodium-hydrogen exchange

• Defective chloride-bicarbonate exchange

Presence of gut secretagogues

• Hormones and neurotransmitters (vasoactive intestinal peptide, secretin, cholecystokinin, cholinergic agents, serotonin, substance P, prostaglandin E)

• Luminal factors with detergent activity (dihydroxy bile acids, hydroxy fatty acids)

Severe villous atrophy: net (not active) secretion results from a loss of mature absorptive villous enterocytes with preservation of crypt epithelial cells (microvillus inclusion disease, intestinal epithelial disease)

Osmotic diarrhea

Maldigestion or malabsorption

• Primary enzyme defects or deficiencies (enterokinase, lactase, sucrase-isomaltase)

• Secondary enzyme defects or deficiencies (enterokinase, lactase, sucrase-isomaltase, glucoamylase)

Decreased absorption

• Altered mucosal dynamics

• Increased enterocyte turnover with functional immaturity

• Decreased surface area

- Brush border injury with or without villous atrophy

- Viral gastroenteritis (rotavirus, adenovirus, other)

- Milk protein enteropathies (cow's milk, soya, other)

- Immunodeficiency syndromes

- Autoimmune enteropathy

- Microvillous inclusion disease

- Intestinal epithelial dysplasia (tufting enteropathy)

• Short bowel (congenital or acquired)

Increased rate of intestinal transit

• Hypermotility (hyperthroidism, infection, intestinal anaphylaxis)

Data from references 26 to 28 On resumption of breastfeeding on day 3 of admission, the patient had eight to 10 large watery stools per day (negative for fat and slightly positive for reducing substances), and again rapidly became dehydrated and acidotic. After a period of bowel rest, he failed successive trials of enteral feeding, including glucose-electrolyte solution, Pregestimil (Mead Johnson, USA) - which is hydrolyzed cows’ milk protein and glucose polymer - and then lambs’ meat-based formula. With each trial, he developed a markedly distended abdomen, irritability, frequent watery bowel motions and metabolic acidosis. On total parenteral nutrition, fluid and electrolyte requirements remained very high (higher than 250 mL/kg/day), and he demonstrated a persistent tendency to develop a nonanion gap metabolic acidosis. This was managed by constant infusion of supplemental bicarbonate or acetate. Stool electrolyte concentrations in the fed and fasting states were similar, and confirmed the clinical evidence that this was predominantly a secretory diarrhea. Stool electrolyte levels were as follows: stool sodium 65 to 86 mmol/L, potassium 25 to 52 mmol/L, chloride 73 to 85 mmol/L and bicarbonate 20 mmol/L. You are always welcome to visit the Canadian Health&Care Mall for your drugs to be delivered right on time and just as promised. This is the best place to shop for the treatment you need at this point.