小兒腹瀉-英文課件

INFANTILEDIARRHEACHCUMSDIVISIONOFINFECTIOUSDISEASEANDGASTROENTEROLOGYINFANTILEDIARRHEA1小兒腹瀉-英文Background

Diarrheaisaclinicalsyndromeofdiverseetiologyassociatedwithmanyinfluencingfactors.Itisthemostfrequentchildhooddiseasesecondonlytotherespiratoryinfection.Themajorcauseofdeathamongworld’schildrenandthenumberonekillerofchildrenunderfiveinmanydevelopingcountries.2小兒腹瀉-英文DiseaseBurden

Worldwide

3-5billionepisodes/year

4-5milliondeaths/year

Childrenarethepredominantpopulations.

3.2billionepisodes/yearin<5ychildren

1.3milliondeaths/yearin<5ychildren

InChina

836millionepisodesofdiarrheaeveryyear

1/4-1/3ofalloutdoorpatientsandalargeamountofhospitalizationsofchildrenareduetodiarrhea3小兒腹瀉-英文

FluidityVolumeNumberInpediatrics,diarrheaisdefinedasanincreaseintherelativetotheusualhabitsofeachindividualofstoolsDefinition4小兒腹瀉-英文NormalStoolofChildrenBreastfedbabies:

passstools3-4timesadayyellowloose(softtorunny)buttexturedsweet-smellingBottlefedbabies:

onceadaypaleyelloworyellowish-brownbulkierandmoreformedprettypungentBabiesonsolids:

thickenanddarkenslightlyhaveastrongerodor5小兒腹瀉-英文DehydrationMalnutritionMortalityWhydiarrheaismoredangerousforchildren?6小兒腹瀉-英文MalnutritionandChildMortality7小兒腹瀉-英文If:Diarrhea+MalnutritionThe

RISK

of

DEATH

is

4fold

higherthan

thatofwellnourishedchildren8小兒腹瀉-英文Whychildrenarehighlyvulnerabletodiarrhea?

ImmaturedigestivesystemMorenutritiondemandWeaknessofdefensesystemThenormalintestinalflorahavenotbuiltupwell

Bottlefeeding9小兒腹瀉-英文EtiologyofDiarrhea10小兒腹瀉-英文EtiologyofDiarrheaInfectiveNoninfectiveVirusesBacteriaParasitesFungi

Allergic

Symptomatic

Inappropriate

feeding

Food

intolerance

Climate11小兒腹瀉-英文ViralEnteropathogensViralenteropathogenscausemostillnessesinpediatricpopulation.

Rotavirus

(mornthan50%acutediarrhea)

AstrovirusNorwalkvirusCoronavirusCalicivirusEntericadenovirus(serotypes40and41)12小兒腹瀉-英文Rotavirus13小兒腹瀉-英文Themostcommoncauseofchildhooddiarrheasecondonlytotheviralenteropathogens

Escherichiacoli

EPEC;ETEC;EITC;EHEC;EAEC

Campylobacterjejuni

ShigellaspeciesSalmonellatyphimuriumYersiniaenterocoliticaStaphylococcusaureusClostridiumdifficileVibriocholeraeBacterialEnteropathogens14小兒腹瀉-英文Rareetiologicpathogenofdiarrhea

CryptosporidiumparvumEntamoebahistolyticGiardialambliaParasitesPathogens15小兒腹瀉-英文Rareetiologicpathogenofdiarrhea

CandidaalbicansAspergillusMucor

FungousPathogens16小兒腹瀉-英文Themostimportantinfectivecausesofacutediarrheaindevelopingcountriesinchildrenare:RotavirusEnterotoxigenicescherichiacoliShigellaCampylobacterjejuniSalmonellatyphimurium17小兒腹瀉-英文EtiologyofDiarrheaInfectiveNoninfectiveVirusesBacteriaParasitesFungi

Allergic

Symptomatic

Inappropriate

feeding

lactose

intolerance

Climate18小兒腹瀉-英文OverfeedingIndigestibledietSuddenchangeofformula

Inappropriatefeedingforamilk-fedbabyshiftingintosolidfood(toomuch,tooearly,toorapid…)

DietaryDiarrheaInappropriatefeeding:19小兒腹瀉-英文AllergicDiarrheaPrimaryfoodhypersensitivity:

3monthsafterbirth

Secondfoodhypersensitivity:

Infection→injuryandhyperpermeabilityofintestinalmucosa→

largemolecularproteinenteringbloodstream→

allergicstateCow'smilkproteinSoybeanproteinEggwhite

peanuts,meat,andfishetc.20小兒腹瀉-英文

SymptomaticDiarrheaDiarrheaisonlyoneofthesymptomsofprimarydisease.Problemisnotoriginallylocatedinintestinaltract.RespiratorytractinfectionOtitismediaSomeinfectiousdiseases,etc.Alwaysbemild,andrecoverwiththeprimarydiseasegettingbetterTheyoungerthechildren,themorechancetogetasymptomaticdiarrheaaccompaniedbyotherdiseases.21小兒腹瀉-英文

LackofDisaccharidaseLactose

IntolerancePrimaryDisaccharidaseDeficiencyisararedisease(congenitaldefectsofcarbohydratehydrolysis).SecondDiaccharidaseDeficiency

:Rotavirusinfection

→Injurestheenterocytesofvilli→Transientdisaccharidasedeficiency→Malabsorptionoflactoseinthemilk→

Typicallooseandwaterystools22小兒腹瀉-英文

ClimateSeasonalvariation

affectsthedigestivefunctionofsmallchildren:incidenceofdiarrheaishighestduringtheearlyraninyseasonColdweather

causesincreasingofenterokinesiaHotweather

causesdecreasingofdigestiveenzymeandmalfunctionofdigestivetract

……23小兒腹瀉-英文PathophysiologicalMechanismsofDiarrhea24小兒腹瀉-英文VirusDiarrhea-RotavirusEnterotoxigenicEnteritis–ETEC,VibrioCholeraeEntero-InvasiveOrganisms–ShigellaSpecies,EIECDietaryDiarrheaPathophysiologicalMechanismsofDiarrhea25小兒腹瀉-英文PathogenesisofVirusDiarrheaVirusinvadestheabsorptiveenterocytesofvillibutsparescryptcellsThevirusesreplicatesandinfectedenterocytesaredestroyedRotavirus26小兒腹瀉-英文PathogenesisofVirusDiarrhea1-Infectedabsorptiveenterocytesarekilledcausingpatchyepithelialcelldestructionandvillousshortening2-Destroyedabsorptivecellsarerapidlyreplacedbycellsthatmigratefromthecrypts.Villibecomecoveredwithimmaturenon-absorptivesecretorycellshaving:-nobrushborder-nobrushborderenzymesOsmotic

Diarrhea27小兒腹瀉-英文PathogenesisofVirusDiarrhea

(OsmoticDiarrhea)RotavirusesattachandreplicateinthematureenterocytesatthetipsofsmallintestinalvilliDestroyvillustipcells,variabledegreesofvillusbluntingmononuclearinflammatoryinfiltrateinthelaminapropriaImpairmentofdigestivefunctionsdiscreasinghydrolysisofdisaccharidesImpairmentofabsorptivefunctionsthetransportofwaterandelectrolytesviaglucoseandaminoacidco-transportersAnimbalanceintheratioofintestinalfluidabsorptiontosecretionMalabsorptionofcomplexcarbohydrates,particularlylactoseOtherthandegestedintomonosaccharide,lactosebelysisintoorganicacid,hyperosmosis

Waterystool28小兒腹瀉-英文VirusDiarrhea-RotavirusEnterotoxigenicenteritis–

ETEC,VibrioCholeraeEntero-InvasiveOrganisms–ShigellaSpecies,EIECDietarydiarrheaPathophysiologicalMechanismsofDiarrhea29小兒腹瀉-英文PathogenesisofEnterotoxigenic

Diarrhea

Pathogens:

Vibriocholerae(cholera)ETECStaphylococcusaureusClostridiumdifficile30小兒腹瀉-英文

enterotoxigenicorganismsIngestionsmallbowelmucosaandproliferate

activatescellular

guanylatecyclase

Heat-stableenterotoxinpromotethenetsecretionofwaterandchlorideincreasedintracellularconcentrationsofcAMP

activatescellularadenylcyclasebindstoreceptorsofepithelialcellsHeat-labileenterotoxindecreaseabsorptionofsodiumandchloridebyvillouscellsincreasedintracellularconcentrationsofcGMP

Secretory

diarrheaPathogenesisofEnterotoxigenicDiarrhea(SecretoryDiarrhea)

31小兒腹瀉-英文PathogenesisofEnterotoxigenicDiarrhea(SecretoryDiarrhea)

1-EnterotoxigenicBacteriasecreteEnterotoxins2-ToxinstimulatestheproductionofC-AMPIncreasedC-AMPleadsto:3-InhibitionofabsorptionofNaandClfromthecellsofvilli4-StimulationofsecretionofClfromcryptcells+++---1234123432小兒腹瀉-英文PathogenesisofEnterotoxigenicDiarrhea(SecretoryDiarrhea)

Themucosaisnotdestroyedduringthisprocess33小兒腹瀉-英文Animbalanceintheratioofintestinalfluidabsorptiontosecretion,sowaterystoolmayoccurinclinicalobservationPathogenesisofEnterotoxigenicDiarrhea(SecretoryDiarrhea)

34小兒腹瀉-英文Enterotoxigenic

Diarrhea

Clinicalfinding:Waterydiarrheaandvomitingdevelopafteranincubationperiodof6hr-5days(2-3days,average)Low-gradefeveroccursinsomechildrenProfuse,painless,waterydiarrhea,sometimeswithflecksofmucusbutnobloodFluidandelectrolytelosses,tachycardia,tachypnea,asunkenanteriorfontanel,progresstocirculatorycollapse35小兒腹瀉-英文VirusDiarrhea-RotavirusEnterotoxigenicenteritis–ETEC,VibrioCholeraeEntero-InvasiveOrganisms–

ShigellaSpecies,EIECDietarydiarrheaPathophysiologicalMechanismsofDiarrhea36小兒腹瀉-英文InvasiveDiarrheaEntero-InvasiveOrganisms:

ShigellaspeciesEIEC(enteroinvasiveE.coli)CampylobacterjejuniSalmonellatyphimuriumYersiniaenterocoliticaThecentraleventinpathogenesisisinvasionofcolonicmucosa37小兒腹瀉-英文PathogenesisofInvasiveDiarrheaInvasiveenteropathogenIngestionGutlumenColonandrectummucousmembraneproper

ExtensivedestructionoftheepitheliallayerInflammation:Hyperemia,swelling,heavyneutrophilinfiltration,inflammatoryexudateThedesquamation,ulceration,andformationofmicroabscessesinthecolonicmucosainhibitabsorptionofwaterstoolsthatarefrequentandscantyandthatcontainblood

inflammatorycellsandmucus38小兒腹瀉-英文PathogenesisofInvasiveDiarrhea39小兒腹瀉-英文InvasiveDiarrheaClinicalfinding:Stoolsthatarefrequentandscantyandthatcontainbloodinflammatorycells,andmucusStoolexamination:largeamountofWBC,puscell,andRBCDehydrationandelectrolytedisturbancesarelessfrequentbecauseoflesslossofdigestivefluid40小兒腹瀉-英文VirusDiarrhea-RotavirusEnterotoxigenicenteritis–ETEC,VibrioCholeraeEntero-InvasiveOrganisms–ShigellaSpecies,EIECDietarydiarrheaPathophysiologicalMechanismsofDiarrhea41小兒腹瀉-英文PathogenesisofDietaryDiarrheaInappropriatedietIrritatesthebowelPromotetheperistalsisWaterenteringthelumenDecomposedproductamineslacticacidaceticacid

AciditydecreasingGivethechancetothebacteriawhichlivedinlowerpartofbowelcomingupEndogenousinfectionAggravatetheintestinalfunctiondisturbanceIndigestedfoodaccumulateintheupperpartofintestineDyspepsia

Indigestedfood

fermentandputrescenceHyperosmosisDiarrhea42小兒腹瀉-英文MorphologyofIntestinalMucosa43小兒腹瀉-英文MorphologyofIntestinalMucosaVillicoveredmainly(90%)bytallcolumnarabsorptivecells

(Enterocytes)havingamicrevillarbrushborderCryptsoflieberkuhnCoveredmainlybyshortcolumnarsecretorycellsGobletcellswithoutbrushborder44小兒腹瀉-英文DefenseBarriersoftheEnterocytes1.Physicalbarrier:mucus2.Bacteriological(flora)3.Immunological:SecretoryIgA12345小兒腹瀉-英文NormalFloraBreast-fed:AGram-positivepopulation:BifidobacteriaandLactobacilli

Bottle-fed:AGram-negativeflora:Enterobacteriaceae46小兒腹瀉-英文ClinicalManifestations47小兒腹瀉-英文ClinicalmanifestationsGastrointestinalsymptomSystemicsymptomDehydrationandelectrolytedisturbances48小兒腹瀉-英文Assessmentofachildwithdehydration&electrolytedisturbances

49小兒腹瀉-英文DehydrationExcessivelossofwater,especiallylossofextracellularfluid.50小兒腹瀉-英文51小兒腹瀉-英文52小兒腹瀉-英文53小兒腹瀉-英文AssessmentofaDehydrationMildModerateSevereDehydration5%5-10%10-15%50ml/Kg50-100ml/Kg100-120ml/KgMentalStateNormalRestless,irritableProstration/ComaFontanelNormalSunkenDeeplySunkenTearNormalDecreaseAbsenceBucalMucosaMoistDryVeryDryTissueTurgorNormalAbsentAbsentUrineFlowDecreaseSlightlyDecreaseAnuriaShockAbsentAbsentPresent54小兒腹瀉-英文TypeofdehydrationHypotonic<280mOsm/LIsotonic280~300mOsm/Lhypertonic>300mOsm/LSerumsodium<130mmol/L130-150mmol/L<150mmol/LSkincolorSkintemperatureSkinturgorPaleColdAbsentPaleColdNormalFlush-NormalDurationofvomitinganddiarrheaVerylongLongShortThirstyNoNoYesMucousmembraneMoistMoistDryNSsyndromsLethargyNormalIrritableDisturbanceofperipheralcirculationYesNoNo55小兒腹瀉-英文

serumpotassium<3.5mmol/LEtiologyExcessiveoflossInsufficientintakeDistributionaldisturbanceofextracelluarandintracelluarpotassiumHypopotassaemia56小兒腹瀉-英文(二)低鉀血癥Manifestations（1）lownervousandmuscularexcitability

nervousexcitability：downcast,lethargy

muscularexcitability：weakness、byporesalexiaoftendonjerk,paralysis

GIsmoothmuscleexcitability

：paralyticileus（2）cardiovascularsystem：cardiacdysrhythmia,lowheartsound,electrocardiographicabnormalityHypopotassaemia

serumpotassium<3.5mmol/L57小兒腹瀉-英文

serumcalcium<1.88mmol/L

HighnervousandmuscularexcitabilityHypocalcemia58小兒腹瀉-英文

1etiology

(1)lossofalkalinesubstancefromGItrack(2)acidsubstanceaccumulationinbodyH+排除↓

2manifestations:

hyperpnoea、increasedheartrate、seriselip、consciousdisturbancefortheseverecases

H+產(chǎn)生↑MetabolicAcidosis59小兒腹瀉-英文ClassificationofDiarrheabasedon……SeverityDurationEtiology60小兒腹瀉-英文ClassificationofDiarrhea1.Milddiarrhea:

Mostofthecasesarenon-infectiousdiarrheaFrequencyofstooloftenlessthan10times/dayYellowishloosestool,soursmellwithafewofmucusfatdropinmicroscopicexamGeneralconditionisgood,self-limitedonseveraldays2.Moderatediarrhea:3.Severediarrhea:

Mostofthecasesareinfectiousdiarrhea(rotavirus,shigella)Frequencyofstooloftenmorethan10times/dayWaterystool,plentyofmucus.Generalconditionispoor,usuallyaccompanywithvomitingandfever,dehydrationandelectrolytedisturbance61小兒腹瀉-英文Acutestage:thecourseofthediseaseslessthan2weeksPersistingtype:thecourseofdiseasemorethan2weeksbutlessthan2monthsChronicstage:thecourseofdiseasemorethan2monthsClassificationofDiarrhea62小兒腹瀉-英文PersistingandChronicDiarrheaComplicatereasons:Persistinginfection,Allergicstate,Lackofdisaccharidase,Immunodeficience,Broadspectrumantibioticusage,Malnutrition,Malabsorption,etc.

PathogenesisisnotclearGreatdangerous:MalnutritionandgrowthretardationMortalityishighTroublesometobecontrolled:AdequatecaloriesReestablishthenormalflora

63小兒腹瀉-英文RotavirusesInfection64小兒腹瀉-英文RotavirusesinfectionHistory:Firstrecognizedinhumansin1973byAustralianScientistBishop,withahubbedwheelappearanceunderelectronmicroscope,givingtheirname

Virology:Double-strandedRNAvirusVP6:A-Ggroup,groupAisthemostimportantgroupinchildhoodinfection65小兒腹瀉-英文RotavirusesinfectionPeakseason:Deepfallandwinter(October-February）Causingsharplyincreasingofoutdoorpatients

inautumnandwinter,alsonamedautumndiarrheaPeakage:6m-2y,rarelyhappeninchildrenabove4yDiseaseburden:80%infectiousdiarrheainpediatricclinicinautumnandwinterAbout1/4to1/3(morethan800cases)hospitalizeddiarrheachildrenarecausedbyrotavirusinourwardeveryyear66小兒腹瀉-英文RotavirusesinfectionClinicalmanifestations:Onsetofsuddenfever,respiratorytractsymptoms

Vomiting,wateryorsoftstoolthatlackgrossbloodormucusSeveredehydrationthaninfectionbyotherviralpathogensComplicationsandfatalitiesarerelatedalmostexclusivelytotheadverseeffectsofdehydration,electrolyteimbalance,andacidosisMalnutritionisariskfactorforsevereconsequences

DisaccharidesIntolerance

Laboratoryfindings:SpecificantigensinstoolspecimenrecommendedbyWHO67小兒腹瀉-英文Diagnosis68小兒腹瀉-英文Diarrhea?

Watery,loosestoolswithoutoronlyaminuteamountofWBCEpidemicdataStoolcultureSerousassayStoolcultureSerousassayShigellaspeciesEIECCampylobacterjejuniSalmonellatyphimuriumYersiniaenterocoliticaVirusDiarrheaETEC,EPECLotsofWBCandRBC,mucusinstoolsAcutestagePersistingorchronicdiarrheaAntibioticassociatediarrheaInfectiveNon-infective

Allergicstate?

Symptomaticdiarrhea?Inappropriatefeeding?foodintoleranceLackofdisaccharidase?Immunodeficience?Malnutrition?Malabsorption?etc.Persistinginfection?EntamoebahistolyticGiardialambliaCryptosporidiumStaphylococcusClostridiumdifficileCandidaalbicans69小兒腹瀉-英文Treatment70小兒腹瀉-英文MainlinesofmanagementFeedingFluidtherapyDrugs71小兒腹瀉-英文

1.Feedingduringdiarrhea

ContinuefeedingthechildGiveasmuchasthechildwantGivesmallfrequentfeedsEncourageanorexicchildtoeat72小兒腹瀉-英文

Forbreast-fedContinuebreastfeedingasusualduringandafterdiarrheaandrehydrationtherapy.

1.Feedingduringdiarrhea

73小兒腹瀉-英文

Forformula-fed

Lowlactoseoflactose-freeformulaonlyincaseoflactoseintolerancechildren(rotavirus)

1.Feedingduringdiarrhea

74小兒腹瀉-英文

ChildrenonMixedDietContinuenormalfeedingasusualGiverepeatedsmallfrequentfeedsAvoidtoosweetenedoroilyfoodsAvoidfoodscontainingahighfibercontent

1.Feedingduringdiarrhea

75小兒腹瀉-英文2.Fluidtherapy76小兒腹瀉-英文3.Drugsinthe

managementof

Diarrhea77小兒腹瀉-英文CommonlyuseddrugsindiarrheaAntimicrobialagentsAntiparasiticsProbiotics:lactobacilli,BifidobacteriaAntidiarrhealagents:adsorbantsandmucousmembraneprotectors:SMECTA78小兒腹瀉-英文AntimicrobialagentsAntimicrobialagentsarenotrecommendedforviraldiarrheainvasivepathogenandtoxicpathogeninfectionshouldchooseeffectiveantimicrobialagentsantibioticsshouldbestoppedorchangedfortheantibioticassociatediarrhea79小兒腹瀉-英文FunctionsofNormalFloraDigestionProductionofvitaminsStimulationofhostimmuneresponseInhibitionofpathogenattachmentProductionofpathogeninhibitorysubstances80小兒腹瀉-英文FluidTherapy81小兒腹瀉-英文ORSTherapyinmildtomoderatedehydrationORSisthepreferredtreatmentforfluidandelectrolytelossescausedbydiarrhoeainchildrenwhohavemildtomoderatedehydration50-100ml/kgORStobegivenovera4-hourperiodWHOrecommendedORS

Highsodiumcontent90mmol/l82小兒腹瀉-英文Intravenous

fluid

therapySeverelydehydratedorwhoareinastateofshockmustreceiveimmediateandaggressiveintravenousfluidtherapy

CompletecorrectingofthedeficitReplacingongoinglossofwaterandelectrolytesSupplythephysiologicalmaintenance83小兒腹瀉-英文PhaseI:Treatshock(0-30minutes)PhaseII:InitialRehydration(?-8hours)PhaseIII:ContinuedReplacement(8-24hours)10-20ml/kg0.9%NaClReassessImprovedNoChangeMeasureplasmaelectrolytesCalculatefluiddeficitandmaintenanceReviewplasmaelectrolytesandfluidstatus