diarrhea婴儿腹泻英文后修课件

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页，共70页。第2页，共70页。General introductionClassification Pre

2、disposing factorEtiologyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrheaDiagnosisDifferential DiagnosisTreatmentContent第3页，共70页。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页，共70页。General introductionClassificationPredisposing factorEtiologyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrheaDiagno

4、sisDifferential DiagnosisTreatmentContent第5页，共70页。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页，共70页。General introductionClassificationPredisposing factorEtiologyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrheaDiagnosisDifferential DiagnosisTreatmentContent第7页，共70页。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页，共70页。Predisposing factor-2Defense system: not matureThree defense system ( ): microflora, epithelium, immunity第9页，共70页。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页，共70页。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页，共70页。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页，共70页。General introductionClassificationPredisposing factorEtiologyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrheaDiagnosisDifferential Diagnosi

12、sTreatmentContent第13页，共70页。Infectious animalInfectious humanwaterSusceptible populationfoodfecal - oral way Etiology-1: intraenteric infection第14页，共70页。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页，共70页。RotavirusAstrovirusCalicivirus: Norwalk virus, sapovirusEnterovir

14、us: Coxsackie virus, echovirus, enteric adenovirus Coronavirus: torovirus Intraenteric infection-virusVirus 80% infantile diarrhea in cold months.第16页，共70页。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页，共70页。 Intraenteric infec

15、tion-rotavirus 20-side body(65-75nm)Nucleus: 45-50nmShape: wheelLife: 7mBear acid-20: keep long第18页，共70页。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页，共70页。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页，共70页。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页，共70页。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页，共70页。General introductionClassificationPredisposing factorEtiologyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrheaDiagnosisDifferential DiagnosisTreatment Content第23页，共70页。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页，共70页。 Pathogenesis-1: enterotoxin AdenylatecyclaseIntestinal juice secretion Labile toxin（LT）CAMPH2O, Na+, Cl- transfer into enteric cavityStable toxin（ST）GuanylatecyclaseGTPCGMPATPactivateactivateVolume of intestinal juicediarrhea第25页，共70页。产毒性大肠杆菌 附着到小肠粘膜上进行繁殖 在小肠上部，通过菌毛上的粘附因子 肠毒素 不耐热肠毒素

22、Labile toxin, LT 耐热肠毒素 stable toxin, ST 腺苷酸环化酶 鸟苷酸环化酶 细胞内ATP cAMP GTP cGMP 抑制小肠绒毛上皮细胞吸收Na+、Cl-和水，并促进Cl-分泌 肠液中Na+、Cl-和水总量增多，超过结肠吸收限度 大量水样腹泻 激活激活肠毒素引起的肠炎发病机理以产毒性大肠杆菌为例 第26页，共70页。Pathogenesis-2: bacterium invades enteroninvadeSmall intestinecolonEnteronwall mucosa: congestion, edema, effusion, ulser an

23、d hemorrhagePoorly absorption of H2O and electrolytediarrhea第27页，共70页。侵袭性细菌 在肠粘膜侵袭和繁殖炎症改变 （充血、肿胀、炎性细胞浸润、渗出和溃疡） 水和电解质不能完全吸收 腹泻便中WBC, RBC大量增加 严重中毒症状侵袭性肠炎发病机制第28页，共70页。Virus invasionPathogenesis-3: virus infectionrecrementDisacchride Poorly decomposedlactoseOsmotic diarrheaNa+ transportblock H2Oelectro

24、lytedisaccharidase第29页，共70页。病毒性肠炎发病机理 病毒侵入小肠粘膜绒毛上皮细胞并复制粘膜受累，绒毛被破坏 绒毛缩短 微绒毛肿胀，紊乱并脱落 线粒体、内质网膨胀 双糖酶活性下降载体减少消化吸收面积减少双糖（乳糖）吸收减少 葡萄糖钠与载体结合偶联转运吸收障碍 营养物质吸收减少 部分乳糖分解为小分子的乳酸 渗透压增加水样腹泻 第30页，共70页。Pathogenesis-4: noninfectious diarrheaFood fermn mydesisEnteric osmotic pressureDigestive functiondisorderOsmotic di

25、arrheaOver-feeding,No proper dietary第31页，共70页。食物质、量不当 食物消化吸收障碍而积滞在上消化道 胃酸度下降 肠道下部细菌上移并繁殖 内源性感染 发酵、腐败 有机酸（乳酸、乙酸）胺类 肠腔内渗透压增高 肠蠕动增强 腹泻、脱水、电解质紊乱、酸中毒 分解食物 中毒症状 肝解毒功能不全 毒素进入血循环 饮食不当引起腹泻发生机理 第32页，共70页。The RV is composed by 11 geme segments ，NSP4(非结构蛋白4） is the closeness of PathogenesisThe study progression

26、 by RV cause diarrhea 第33页，共70页。A组RV病毒基因组功能基因片段: 1 2 3 4 6 9 编码结构蛋白: VP1 VP2 VP3 VP4 VP6 VP7 (核心) (核心) (核心) (外壳) (内壳) (外壳 区分G血清型1-14) 裂解 抗原区分(A-G组) VP5 VP8 A组为,亚群 （P血清型1-44）基因片段: 5 7 8 10 11 编码非结构蛋白: NS53 NS34 NS35 NS28 NS26 (NSP1 NSP2 NSP3 NSP4 NSP5)第34页，共70页。General introductionclassificationPredi

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

28、avomitAbdominal pain Clinical manifestation第36页，共70页。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页，共70页。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页，共70页。Degree Quality mildmoderateHypotonic dehydration.Na+130mmol/LHypertonic dehydration.Na+150mmol/L Clinical manifestation-1: dehydrationsevereIsotonic dehydratio

31、n.Na+:130150mmol/L第39页，共70页。 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页，共70页。AnuriatachypneaAn

33、terior fontanel and eye ball DepressedNo TearCool, weak pulse, shockDry, pale, Gray mottledapathy ,dispiritedSkin and Mocous dryWeight decrease 第41页，共70页。Eye socket depressed, rima oculi not closed第42页，共70页。Xerocheilia, chap第43页，共70页。 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页，共70页。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页，共70页。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页，共70页。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页，共70页。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页，共70页。 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页，共70页。General introductionClassificationPredisposing

40、 factorEtiologyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrheaDiagnosisDifferential DiagnosisTreatmentContent第50页，共70页。 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页，

42、共70页。 Several common enteritis-2: ETEC enteritis 产毒性细菌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页，共70页。 Several common enteritis-3: EIEC enteritis 侵袭性细菌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页，共70页。 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页，共70页。General introductionClassificationPredisposing factorEtiologyPathogenesisClinical manifestat

46、ionsClinical features of several common enteritisPersistent diarrheaDiagnosisDifferential DiagnosisTreatment Content第55页，共70页。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页，共70页。malnutritiondiarrheavicious cycleDiarrhea + malnutrition: mortality 4 times higher than normal children第57页，共70页。Genera

48、l introductionClassificationPredisposing factorEtiologyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrheaDiagnosisDifferential DiagnosisTreatmentContent第58页，共70页。 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页，共70页。General introductionClassificationPredisposing factorEtiologyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrhe

50、aDiagnosisDifferential DiagnosisTreatmentContent第60页，共70页。 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页，共70页。 Differential diagnosis-2: dysenteryEpidemiology characterStool culture: a dysentery bacillus discoveredBacillary dysenteryAmebic dysenteryMadder red jam-like stoolStool : am