diarrhea嬰兒腹瀉英文后修課件

1、Major cause of childrens(5y) death in developing countries in 2002ARIdiarrheaMalariameaslesAIDSDisease inperinatal stageothers18%25%23%4%5%10%15%WHO/UNICEF. Clinical management of acute diarrheaSources: The world health report 2003, WHO,Geneva.第1頁，共70頁。第2頁，共70頁。General introductionClassification Pre

2、disposing factorEtiologyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrheaDiagnosisDifferential DiagnosisTreatmentContent第3頁，共70頁。General introductionConcept common disease in childhood frequency and characters of stoolAges 6m2y 50% 1ySeasons viral or

3、iginslate autumn and spring beginning bacterial originssummer noninfectious diarrhea every seasonMultiple sources and factors第4頁，共70頁。General introductionClassificationPredisposing factorEtiologyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrheaDiagno

4、sisDifferential DiagnosisTreatmentContent第5頁，共70頁。CausesCourseDegreeInfectious diarrhea: virus, bacterium, fungi, parasitesNoninfectious diarrhea: diet, weather, othersAcute：2mMild: the times of stool and character changeSevere: accompany dehydration, electrolytes abnormality and general toxicity sy

5、mptomsClassification第6頁，共70頁。General introductionClassificationPredisposing factorEtiologyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrheaDiagnosisDifferential DiagnosisTreatmentContent第7頁，共70頁。Gastric acid secretion , secretion and activity of enzy

6、me , quality and quantity of diet change quickly.Water metabolism ，tolerance of hydropenia ，easy to body fluid disorder.Nerves, endocrine, circulation, liver and renal function: not mature, easy to digestive tract function disorder. Predisposing factor-1Development of infancy digestive system : not

7、mature第8頁，共70頁。Predisposing factor-2Defense system: not matureThree defense system ( ): microflora, epithelium, immunity第9頁，共70頁。Grow and develop , demand for nutrients , burden of the stomach and intestines , easy to indigestion. Artifical feeding: enteritis morbility 10 times higher than breast fe

8、k: nutritional ingredient destroyedmilk tool: disinfection.Predisposing factor-3&4 3 4The lower level of serum immunoglobulin, especially serum IgA located in gastrointestinal tract is smaller than others. Disorder microbial population of digestive tract resulting from using antibacterial d

9、rugs for a long time or normal microbial population have not been established in neonates. 第10頁，共70頁。Relation between feeding and infection in infants(3m)Pure breast milkn=95 Partial breast milkn=126Laboratory milkn=257pGastrointestinal infection2.9 %5.1 %15.7 %0.001Respiratory infection25.6 %24.2 %

10、37.0 %0.05（Howie et al 1990） Artificial feeding: easy to intestinal infection第11頁，共70頁。Breast feedingDays% of total faecal micro-organismsArtificial feedingDays0102030405060708090100% of total faecal micro-organismsBacillus bifidusBacillus coliBacillus faecalis510152001020304050607080901000101520255

11、010152025According to Harmsen et al., 2000 Artificial feeding: easy to disorder microbial population第12頁，共70頁。General introductionClassificationPredisposing factorEtiologyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrheaDiagnosisDifferential Diagnosi

12、sTreatmentContent第13頁，共70頁。Infectious animalInfectious humanwaterSusceptible populationfoodfecal - oral way Etiology-1: intraenteric infection第14頁，共70頁。From Kapikian AZ, Chanock RM. Rotaviruses. In: Fields Virology 3rd ed. Philadelphia, PA: Lippincott-Raven; 1996:1659.Developed countryBacterium Unce

13、rtain reasonRotavirusCalicivirus Rotavirus Bacillus coliParasite Other bacteriumAdenovirus Calicivirus Astrovirus Adenovirus Astrovirus Uncertain reasonDeveloping countryDistribution of etiological agentIntraenteric infection第15頁，共70頁。RotavirusAstrovirusCalicivirus: Norwalk virus, sapovirusEnterovir

14、us: Coxsackie virus, echovirus, enteric adenovirus Coronavirus: torovirus Intraenteric infection-virusVirus 80% infantile diarrhea in cold months.第16頁，共70頁。Death for rotavirus infection in children 5y（）0.0-0.10.6-0.91.0-1.92.0-3.40.2-0.5 Intraenteric infection-rotavirus 第17頁，共70頁。 Intraenteric infec

15、tion-rotavirus 20-side body(65-75nm)Nucleus: 45-50nmShape: wheelLife: 7mBear acid-20: keep long第18頁，共70頁。Photo Credit : F.P. Williams, U.S. Environmental Protection Agency; Adapted from Parashar et al, Emerg Inft Dis 199814(4) 561570Rotavirus in stool by electronmicroscop Intraenteric infection-rota

16、virus 第19頁，共70頁。Bacillus coli enteropathogenic E. coli EPEC enterotoxigenic E. coli ETEC enteroinvasive E. coli .EIEC enterhemorrhagic E. coli EHEC enteroadherent aggregative E. coli EAECCampylobacter jejuni, Yersinia enterocolitica, othersFungi ：blastomyces albicansProtozoa (parasite) ：giardia lamb

17、lia, amebic protozoa Intraenteric infection-bacterium etc.第20頁，共70頁。Disorder intestinal functionInfect intestinal tract directlyIrritation of rectum (eg. bladder infection) alteration of intestinal floraMuch antibiotics used transport of carbohydrate lactase Etiology-2: extraenteric infectionPneumon

18、ia, URI, USI, otitis media, skin infection, etc.第21頁，共70頁。Dietary factorsquality and quantity of food (feeding starch and fat too early) Allergic diarrhea: milk or beanPrimary and secondary disaccharidase deficiency Etiology-3: noninfectious causesWeather factorsCool enterokinesia Hot secretion of d

19、igestive juice and gastric take milk because of thirsty 第22頁，共70頁。General introductionClassificationPredisposing factorEtiologyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrheaDiagnosisDifferential DiagnosisTreatment Content第23頁，共70頁。Osmotic diarrhea

20、: much poorly absorbed and hyperosmotic soluteSecretory diarrhea: electrolytes hypersecretionExudative diarrhea: inflammatory states causing liquor exudationMotility disturbance: dynamic abnormality of intestineNoninfectious diarrhea: feeding factors Pathogenesis Usually combination of several mecha

21、nisms第24頁，共70頁。 Pathogenesis-1: enterotoxin AdenylatecyclaseIntestinal juice secretion Labile toxin（LT）CAMPH2O, Na+, Cl- transfer into enteric cavityStable toxin（ST）GuanylatecyclaseGTPCGMPATPactivateactivateVolume of intestinal juicediarrhea第25頁，共70頁。產(chǎn)毒性大腸桿菌 附著到小腸粘膜上進行繁殖 在小腸上部，通過菌毛上的粘附因子 腸毒素 不耐熱腸毒素

22、Labile toxin, LT 耐熱腸毒素 stable toxin, ST 腺苷酸環(huán)化酶 鳥苷酸環(huán)化酶 細胞內(nèi)ATP cAMP GTP cGMP 抑制小腸絨毛上皮細胞吸收Na+、Cl-和水，并促進Cl-分泌 腸液中Na+、Cl-和水總量增多，超過結腸吸收限度 大量水樣腹瀉 激活激活腸毒素引起的腸炎發(fā)病機理以產(chǎn)毒性大腸桿菌為例 第26頁，共70頁。Pathogenesis-2: bacterium invades enteroninvadeSmall intestinecolonEnteronwall mucosa: congestion, edema, effusion, ulser an

23、d hemorrhagePoorly absorption of H2O and electrolytediarrhea第27頁，共70頁。侵襲性細菌 在腸粘膜侵襲和繁殖炎癥改變 （充血、腫脹、炎性細胞浸潤、滲出和潰瘍） 水和電解質(zhì)不能完全吸收 腹瀉便中WBC, RBC大量增加 嚴重中毒癥狀侵襲性腸炎發(fā)病機制第28頁，共70頁。Virus invasionPathogenesis-3: virus infectionrecrementDisacchride Poorly decomposedlactoseOsmotic diarrheaNa+ transportblock H2Oelectro

24、lytedisaccharidase第29頁，共70頁。病毒性腸炎發(fā)病機理 病毒侵入小腸粘膜絨毛上皮細胞并復制粘膜受累，絨毛被破壞 絨毛縮短 微絨毛腫脹，紊亂并脫落 線粒體、內(nèi)質(zhì)網(wǎng)膨脹 雙糖酶活性下降載體減少消化吸收面積減少雙糖（乳糖）吸收減少 葡萄糖鈉與載體結合偶聯(lián)轉運吸收障礙 營養(yǎng)物質(zhì)吸收減少 部分乳糖分解為小分子的乳酸 滲透壓增加水樣腹瀉 第30頁，共70頁。Pathogenesis-4: noninfectious diarrheaFood fermn mydesisEnteric osmotic pressureDigestive functiondisorderOsmotic di

25、arrheaOver-feeding,No proper dietary第31頁，共70頁。食物質(zhì)、量不當 食物消化吸收障礙而積滯在上消化道 胃酸度下降 腸道下部細菌上移并繁殖 內(nèi)源性感染 發(fā)酵、腐敗 有機酸（乳酸、乙酸）胺類 腸腔內(nèi)滲透壓增高 腸蠕動增強 腹瀉、脫水、電解質(zhì)紊亂、酸中毒 分解食物 中毒癥狀 肝解毒功能不全 毒素進入血循環(huán) 飲食不當引起腹瀉發(fā)生機理 第32頁，共70頁。The RV is composed by 11 geme segments ，NSP4(非結構蛋白4） is the closeness of PathogenesisThe study progression

26、 by RV cause diarrhea 第33頁，共70頁。A組RV病毒基因組功能基因片段: 1 2 3 4 6 9 編碼結構蛋白: VP1 VP2 VP3 VP4 VP6 VP7 (核心) (核心) (核心) (外殼) (內(nèi)殼) (外殼 區(qū)分G血清型1-14) 裂解 抗原區(qū)分(A-G組) VP5 VP8 A組為,亞群 （P血清型1-44）基因片段: 5 7 8 10 11 編碼非結構蛋白: NS53 NS34 NS35 NS28 NS26 (NSP1 NSP2 NSP3 NSP4 NSP5)第34頁，共70頁。General introductionclassificationPredi

27、sposing factorEtiologyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrheaDiagnosisDifferential DiagnosisTreatment Content第35頁，共70頁。Digestive tractsymptomWater, electrolytes and acid-base disorderDehydrationMetabolic acidosisElectrolytes disorderDiarrhe

28、avomitAbdominal pain Clinical manifestation第36頁，共70頁。Mild and severe diarrhea Mild: the times of stool and character change stool :frequency ,loose, liquid, color: yellow or greenyellow, smell: sour flavor, shape: egg soup vomiting: seldom general poisoning symptom: without dehydration, electrolytes

29、 abnormality and general toxicity symptoms: none第37頁，共70頁。Severe: accompany dehydration, electrolytes abnormality and general toxicity symptoms digestive tract symptom : diarrhea serious ,mucus blood sample stool, anorexia, nausea, abdominal pain and abdominal distention general poisoning symptom :

30、lethargy, dysphoria, unconsciousness and coma dehydration, electrolytes abnormality , acid base imbalance Mild and severe diarrhea 第38頁，共70頁。Degree Quality mildmoderateHypotonic dehydration.Na+130mmol/LHypertonic dehydration.Na+150mmol/L Clinical manifestation-1: dehydrationsevereIsotonic dehydratio

31、n.Na+:130150mmol/L第39頁，共70頁。 Severity clinical signs of dehydrationmildmoderatesevereWater lossBy weightSpirit SkinMucous Anterior fontanel and eye ballTearthirstUrine outputPeripheral circulation50ml/kg 5%Slightly dispiritedslightly agitatedSlightly drySlightly drySlightlydepressedNormalslightlydec

32、reasednormal50100ml/kg5%10%DispiritedAgitatedDry, paleVery dry depressedReducedincreasedLittle or noLittle cool100120ml/kg10%Extremely dispiritedapathy, hypnody, comaGray mottledParched depressed greatlyNoGreatly increasedNo urine outputCool, weak pulse, shock Dehydration 第40頁，共70頁。AnuriatachypneaAn

33、terior fontanel and eye ball DepressedNo TearCool, weak pulse, shockDry, pale, Gray mottledapathy ,dispiritedSkin and Mocous dryWeight decrease 第41頁，共70頁。Eye socket depressed, rima oculi not closed第42頁，共70頁。Xerocheilia, chap第43頁，共70頁。 Dehydration Same proportion lossPIFCPIFCElectrolyte lossmoreP hyp

34、otonic,IF+C hypertonicCell expansionSevereEasy to shockP: plasma, IF: interstitial fluid, C: cellIsotonic PIFCWater lossmoreP hypertonicIF+C hypotonicCell hydrationMildThirsty Acute diarrheaafter vomiting greatlyHypotonic Hypertonic 第44頁，共70頁。Vomiting and diarrhea :Alkalinity intestinal juice lostEa

35、t :calorie , malabsorptionlipoclasis keto-bodiesHypovolemiapachemiablood flow slowly hypoxia anaerobic glycolysis lactic aciddehydration blood flow excluding acid acid metabolic product Clinical manifestation-2: metabolic acidosisCauses:第45頁，共70頁。Dispirited, dysphoria, drowsiness, comaHypernea (Kuss

36、mauls breathing)，exhalation coolExpiratory gas smells ketoneCherry lipsNausea, vomit Metabolic acidosis-clinical manifestationMild: breath frequency slightlySevere: occur:第46頁，共70頁。K+ (potassium)3.5mmol/L (normal: 3.55.5 mmol/L)causes： Excessive losses: vomit, diarrhea.Inadequate intake.Renal functi

37、on of keeping kalium ,it continues excluding kalium when with hypokalemia. Clinical manifestation-3: electrolyte disorder Hypokalemia第47頁，共70頁。depressedTension of skeletal muscle ，tendon reflex， even respiratory muscle weakness Tension of smooth muscle , abdominal distention intestinal sound or disa

38、ppearMyocardium excitability , arrhythmia, ECG: T-wave is low or inversion, U-wave occurs, prolonged P-R interval and Q-T interval, ST section descending.Baseosis hypokalemiaClinical manifestation: nerve and muscular excitability第48頁，共70頁。 Ca2+1.75mmol/L (7mg/dl) ; Mg2+0.6mmol/L (1.5mg/dl).Symptoms

39、usually occur after dehydration and acidosis resolved, or fluid replacement.Clinical manifestation: thrill, tetany, convulsion.If convulsion hasnt relieved after supplement calcium, pay attention to hypomagnesemia. hypocalcemia & hypomagnesemia第49頁，共70頁。General introductionClassificationPredisposing

40、 factorEtiologyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrheaDiagnosisDifferential DiagnosisTreatmentContent第50頁，共70頁。 Several common enteritis-1:Season: cool months (autumn and winter) Age: 6m2ySymptom: fever, vomit, mild general toxicity symptom

41、s.Stool: frequency, amount, water; yellow-water or egg soup-like; a small amount of mucus.Dehydration: mild/moderate，isotonic/hypertonicComplication: convulsion, myocardium damaged.Prognosis: self-limited, course: 38d.Viral antigen detection: from stool.Rotavirus enteritis human rotavirus (HRV)第51頁，

42、共70頁。 Several common enteritis-2: ETEC enteritis 產(chǎn)毒性細菌Season: summer Symptom: vomit and diarrhea, no obvious general toxicity symptoms.Stool: water-like or egg soup-like, without mucus, blood or pus, no WBC (test under microscope).Dehydration: dehydration, electrolyte and acid-base disorder usually

43、occur.Prognosis: self-limited, course: 37d.ETECenteritis第52頁，共70頁。 Several common enteritis-3: EIEC enteritis 侵襲性細菌Similar with bacillary dysentery.Symptom: diarrhea with fever, nausea, vomit, abdominal pain, tenesmus. Severe general toxicity symptoms, e.g. ardent fever, consciousness change, even s

44、eptic shock. Stool: with mucus, blood and pus, smell of fish, with WBC (test under microscope).Stool culture: pathogenic bacterium.EIECenteritis第53頁，共70頁。 Several common enteritis-4: fungal enteritisPathogen: usually Blastomyces albicans.Age: 2y.Complication by other infection, or after using antibi

45、otics for long time.Persistent course, usually thrush companion.Stool: yellow thin stool, more foam with mucus, sometimes tofukasu-like. test under microscope: fungal spore and hypha.fungalenteritis第54頁，共70頁。General introductionClassificationPredisposing factorEtiologyPathogenesisClinical manifestat

46、ionsClinical features of several common enteritisPersistent diarrheaDiagnosisDifferential DiagnosisTreatment Content第55頁，共70頁。Gastric mucosa analosis bacterium and yeast fungusIntestinal mucosa thinnerindigestion and malabsorptionBacterium in upper small intestine enterocyte damagedDynamic abnormali

47、ty of intestine.Using antibiotics for long time.Immune function defect liability to agents Persistent diarrhea acute diarrhea without proper or thorough treatment. Causes:第56頁，共70頁。malnutritiondiarrheavicious cycleDiarrhea + malnutrition: mortality 4 times higher than normal children第57頁，共70頁。Genera

48、l introductionClassificationPredisposing factorEtiologyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrheaDiagnosisDifferential DiagnosisTreatmentContent第58頁，共70頁。 Diagnosis Not difficultAccording to clinical manifestation, laboratory tests and charact

49、er of stool. +Infectious OrNoninfectious Dehydration Degree and quality Electrolyte disturbancesAndDisturbance of acid-base balance第59頁，共70頁。General introductionClassificationPredisposing factorEtiologyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrhe

50、aDiagnosisDifferential DiagnosisTreatmentContent第60頁，共70頁。 Differential diagnosis-1: physiological diarrheaUsually 6m, bloating, breast-feeding.Usually with eczema.Normal appetite, growth and developed.After cofood addition, stool turns to normal.A special type of lactose intolerance第61頁，共70頁。 Differential diagnosis-2: dysenteryEpidemiology characterStool culture: a dysentery bacillus discoveredBacillary dysenteryAmebic dysenteryMadder red jam-like stoolStool : am