湘雅儿科精品-Infantile-Diarrhea课件

小儿腹泻

中南大学儿科学教研室郭青第十一章第八节Vocabulary

hypochlorhydria－胃酸过少

normalflora－正常菌丛colibacillus－大肠杆菌

campylobacter－弯曲菌Yersinia－耶尔松菌adenylcyclase－腺苷酸环化酶guanyliccyclase－鸟苷酸环化酶microvillares－微绒毛Staphylocaccusaureus－金黄色葡萄球菌pseudomembranousenterocolitis－伪膜性小肠结肠炎

小儿腹泻InfantileDiarrhea目的要求

Objective概述

Summary病因

Etiology发病机制

Pathogenesis临床表现

Clinicalmenifestations诊断、鉴别诊断

Diagnosis&DifferentialDiagnosis

治疗原则

PrincipleofTreatment概述

Summary

小儿腹泻(腹泻病)，是由多病原、多因素引起以腹泻为主的一组疾病，容易并发水、电解质、酸碱平衡紊乱。根据病因可分为感染性（较多见）和非感染性两类，发病年龄多在2岁以下，1岁以内者约占半数。近30年来本病发病率和病死率已明显降低，但仍是小儿的常见病和死亡原因。

Infantilediarrheaiscausedbymulti-pathogeny&multifactor.Themainsymptomisdiarrhea.Itiseasilycomplicatedbydisturbancesofwater,electrolyteandacid-basebalance.Accordingaspathogeny,itcanbeclassifiedbytheinfected(most)andthenon-infected.Itoccursusuallylessthan2yearsold,about50%lessthan1year.Althoughtheincidenceandthemortalityofthediseasehaveevidentlydecreasedbylate30years,itoftenoccursininfantsandresultsininfants’death.病因

Etiology一、易感因素Predisposingfactors

1.

消化系统特点(胃酸↓,消化酶↓,酶活性↓,生长发育快)

Characteristicofdigestivesystem(hypochlorhydria,digestenzyme↓,enzymaticactivity↓,fastdevelopingandgrowth)

2.机体防御功能较差(胃酸↓,免疫球蛋白↓,SIgA↓,正常菌丛)

Organismdefensehypofunction(hypochlorhydria,immuneglobulin↓,SIgA↓,normalflora)

3.

人工喂养Non-human-milkfeed病因

Etiology二感染因素Infectedfactors

1.肠道内感染(细菌、真菌、病毒、寄生虫)

Intestinaltractinfection(bacteria,fungus,virus,parasite)2.肠道外感染(中耳炎、上感、肺炎、皮肤感染等)

Extraintestinaltractinfection(tympanitis,upperrespiratorytractinfection,pneumonia,skininfectionetc)三非感染因素Noninfectiousfactors

1.饮食因素Food2.气候因素Climate病因

Etiology肠内感染常见病原Pathogenyofinfectioninsideintestinaltract

1.

大肠杆菌

Colibacillus(EPECETECEIECEHECEAEC）

2.弯曲菌Campylobacter1972Belgium

－1981Shanghai3.

耶尔松菌Yersinia1973USA

－1980Fujian4.

抗生素诱发的肠炎Enteritisresultedfromantibiotics

5.轮状病毒Rotavirus1973Australia

－1978BeijingEnterotoxinHeat-intolerantenterotoxinHeat-resistantenterotoxinAdenylcyclase

Guanyliccyclase

cGMP↑cAMP↑Na+

Cl-

H2O↑Smallintestinejuicesecrete↑Diarrhea

BacteriainvasiveoralmucosaCongest,dropsy,ulcerStool(blood,mucusshreds,pus)PathogenesisBacterialenteritisCarbohydratedecomposition&absorptiondisorderSheddingofepithelialcellsonintestinemucousmembrane,intestinalvillusshorteningIntestinal

lacticacid↑IntestinalNa+&glucose↑Disaccharidaseactivity↓WaterydiarrheaNa+,glucosecouplingtransporterdisorderNa+,glucoseabsorptiondisorderReabsorbedwater-electrolyte↓PathogenesisofViralEnteritisIntestinesosmoticpressure↑VirusparticlesMicrovillaresepithelialcellsonSmallintestinemucousmembrane

胃内食物积滞，胃酸少，肠道下段细菌上移繁殖肠内渗透压↑肠蠕动↑细菌、毒性产物渗透性腹泻分解产生短链有机酸胺类↑门脉系统进入血循环非感染性腹泻发病机制中毒症状(内源性感染)饮食不当Gastric

stanatedfood，lessgastricacid,lowerintestinalbacteriaup-moving&propagationIntestinalosmoticpressure↑Enterokinesia↑Bacteria&toxicityproductsOsmoticdiarrheaDecompositionproducingshoutchainorganicacidAmines↑PortalveinsystementeringbloodcirculationPathogenesisofNoninfectiousDiarrheaToxicosissymptom(endogenousinfection)Improperdiet临床表现

ClinicalMenifestations一根据病程分类Classifiedbycourse

急性小儿腹泻（<2周）Acuteinfantilediarrhea（<2weeks） 迁延性小儿腹泻（2周~2月）Persisting

infantilediarrhea

（2weeks~2months）慢性小儿腹泻（>2月）Chronicinfantilediarrhea（

>2months）二根据病情分类Classifiedbypatient’scondition

轻型腹泻

无明显脱水及全身中毒症状MilddiarrheaDehydration&toxicosissymptomarelessevidently

重型腹泻有较明显的脱水,电解质紊乱,全身中毒症状SeverediarrheaDehydration,disturbancesofelectrolyteandacid-basebalanceandtoxicosissymptomareevidently三

根据病因分类

Classifiedbypathogeny

轮状病毒肠炎Rotavirusenteritis，大肠杆菌肠炎

Escherichiacolienteritis

空肠弯曲菌肠炎Campylobacterjejunienteritis,耶尔森菌小肠结炎Yersiniaenterocolitis四

抗生素诱发的肠炎

Antibioticprovocativeenteritis

金黄色葡萄球菌肠炎Staphylocaccusaureusenterocolitis,伪膜性小肠结肠炎 pseudomembranousenterocolitis,真菌性结肠炎fungalcolonitis临床表现

ClinicalMenifestations诊断和鉴别诊断Diagnosis&DifferentialDiagnosis

非侵袭性肠炎：生理性腹泻、小肠吸收功能障碍Non-invasiveenteritis

Physiologicdiarrhea，Intestinalmalabsorption侵袭性肠炎：菌痢、坏死性肠炎Invasiveenteritis

Bacillarydysentery，Enteritisnecroticcans小儿液体疗法

InfantileLiquidTherapy

目的要求Objective概述

Summary小儿体液平衡的特点

CharacteristicofInfantileBodyFluidBalance水电解质和酸碱平衡紊乱DisturbancesofWater,Electrolyte,&Acid-basebalance液体疗法时常用的溶液CommonSolutionofLiquidTherapy小儿腹泻液体疗法InfantileDiarrheaLiquidTherapy目的要求Objective了解小儿体液平衡的特点

Realized:CharacteristicofInfantileBodyFluidBalance熟悉小儿水、电解质和酸碱失衡的病理生理

Befamiliarwith:

PathophysiologyofInfantileFluid,Electrolyte&Acid-baseImbalance掌握小儿电解质和酸碱平衡紊乱的临床表现

Mastered:

ClinicalmenifestationsofInfantileDisturbancesofWater,Electrolyte&Acid-baseBalance熟悉液体疗法常用溶液的组成及临床应用

Befamiliarwith:CommonSolutionComponentofLiquidTherapy掌握小儿腹泻的液体疗法

Mastered:

LiquidTherapyofInfantileDiarrhea小儿体液平衡的特点一体液的总量和分布不同年龄的体液分布（占体重的％）

年龄

总量

细胞外液

细胞内液血浆间质液足月新生儿78637351岁70525402～14岁6652040成人55～66510～1540～45Characteristic

ofInfantileBodyFluidBalanceA.

Totalbodywater&itsdistributionBodywatercompartmentsrelatedtoage(totalbodymass%)

Age

TBWECF

ICFPlasmaISFNewborninfant78637351year70525402～14years6652040Adult55～66510～1540～45TBW:

totalbodywaterECF:extracellularfluidICF:intracellularfluidISF:interestitialfluid三水代谢的特点Watermetabolism

1.水的需要量大，交换率快，不显性失水多（为成人2倍）。婴儿每日水交换量为细胞外液量的1/2，成人仅为1/7。

Largewaterrequirements,swiftwaterexchange,unobvious

waterloss(doubleadult’samount).Infant’swaterexchangeamountis1/2ofECF,theadult’sisjust1/7.体液调节功能不成熟，小儿肾脏的浓缩和稀释功能不成熟。

Immaturebodyliquidregulatingfunction,immatureconcentrationanddilutionfunctionofinfantile.小儿体液平衡的特点Characteristic

of

Infantile

Body

Fluid

Balance水电解质酸碱平衡紊乱一脱水程度表现程度失水量神态眼眶、前囟皮肤弹性口唇粘膜眼泪尿量休克轻度脱水5％（50ml/kg）精神稍差，略有烦躁不安稍凹陷稍差略干燥有稍少无中度脱水5～10％（50～100ml/kg）精神萎靡，烦躁不安明显凹陷差干燥少明显减少无重度脱水>10％（100～120ml/kg）昏睡，昏迷深陷极差极干燥无极少或无有DisturbancesofWater,Electrolyte&Acid-baseBalanceA.DegreeofdehydrationDehydrationMildModerateSevereDecreaseinbodyweight5％(50ml/kg)5～10％(50～100ml/kg)>10％(100～120ml/kg)PsycheDepressed,hyperirritableDepressed,hyperirritableLethargic,comaOrbit,FontanelSunken±SunkenSeverelysunkenSkinturgorNormal±DecreaseMarkedlydecreaseMucousmembranesDry±DrySeverelydryTearsDecrease±DecreaseAbsentUrineMildoliguriaoliguriaAnuriaBloodpressureNormalNormalLowTypeofdehydrationPathogenySerumsodiumPathophysiology&clinicalcharacteristicIsosmoticAcutegastrointestinalfluidlose130～150mmol/LECF:decrease,Osmoticpressure(intracellular=extracellular)DehydrantvolumeaccordwithdehydrantphysicalsignHypotonicChronicgastrointestinalfluidlose<130mmol/LECF:severelydecrease,Easilyshock，SevererdehydrantsignthantheothertwokindsHyperosmoticHighgradefever,Infection>150mmol/LICF:severelydecrease,MilderdehydrantsignthantheothertwokindsDisturbancesofWater,Electrolyte&Acid-baseBalanceB.Propertyofdehydration水电解质酸碱平衡紊乱DisturbancesofWater,Electrolyte&Acid-baseBalance三代谢性酸中毒Metabolicacidosis（一）发生原因Pathogeny1.体内碱性物质丢失过多（消化道、肾脏丢失）Theloseoflargeamountofbasicsubstances（gastrointestinaltract,kidneys）2.酸性代谢产物产生过多（饥饿、糖尿病、肾衰、缺氧）ToomuchAcidmetabolite（hungriness,diabetes,renalfailure,hypoxia）3.摄入酸性物质过多（长期服氯化钙、氯化镁、静滴盐酸精氨酸或盐酸赖氨酸、复合氨基酸、水杨酸等）Toomuchacidsubstanceintake（longtimetotakecalciumchloride,ammoniumchloride,aminoacidetc.）（二）分度Degree轻度Mild HCO3-

18~13mmol/

L中度ModerateHCO3-

13~9mmol/

L重度Severe HCO3-

<9mmol/

L

水电解质酸碱平衡紊乱DisturbancesofWater,Electrolyte&Acid-baseBalance水电解质酸碱平衡紊乱DisturbancesofWater,Electrolyte&Acid-baseBalance四低钾血症Hypokalemia（一）病因Pathogeny1.摄入不足Lackofintake2.丢失过多（消化液丢失、利尿从肾脏丢失）

Lossofkaliumfromkidneysorgastrointestinaltract3.其他途径（烧伤、透析治疗不当）Burn,dialysisetc.4.钾在细胞内外分布异常（碱中毒、胰岛素治疗、周期性麻痹）

Abnormalkaliumdistributioninsideoroutsidecells

（alkalosis,insulintherapy、periodicanesthesia）（二）临床表现Clinicalmenifetation1.神经——精神萎靡

Nervoussystem——depressed2.肌肉骨骼肌——四肢肌乏力，肌张力↓，严重迟缓性瘫痪，呼吸肌麻痹

Muscle——inertiaoflimbs，musculartensiondown，severelyretardantparalysis，respiratorymuscleparalysis水电解质酸碱平衡紊乱DisturbancesofWater,Electrolyte&Acid-baseBalance3.心脏心率↑，心律失常，阿－期综合症，房室传导阻滞，

心肌纤维变性，局限性坏死，心肌收缩乏力，心音低钝

心电图，出现U波，U≥T，T波增宽、低平、倒置

Heart——heartrateincreasing,arrhythmia,Adams－Stokessyndrome,heartratedecreasing，atrioventricularblock,heartsoundlowering,cardiogram:Uwaveappearing，U≥T，flattenedTwave水电解质酸碱平衡紊乱DisturbancesofWater,Electrolyte&Acid-baseBalance4.肾脏肾小管上皮细胞空泡变性，对ADH的反应低下，浓缩功能减低，尿量增多，肾小管泌H–

增加，回吸收HCO3-

增加，氯的回吸收减少，可发生低钾、低氯碱中毒，伴反常性酸性尿。

Kidney——concentratingfunctionlowering,urinevolumeincreasing水电解质酸碱平衡紊乱DisturbancesofWater,Electrolyte&Acid-baseBalance液体疗法时常用的溶液CommonSolutionofLiquidTherapy一非电解质溶液Nonelectrolyte

solution

5％、10％

glucose二电解质溶液Electrolytesolution

0.9％

NaCl、1.4％、5％

NaHCO3、10％

KCl三混合溶液Mixedsolutions

见下表refertothefollowingtable液体疗法时常用的溶液CommonSolutionofLiquidTherapy常用混合液Commonmixedsolution0.9%NaCl1.4%NaHCO35~10%G.S2:1(等张含钠液)2份1份3:2:1(1/2张含钠液)2份1份3份4:3:2(2/3张含钠液)4份2份3份1/3张含钠液2份1份6份小儿腹泻液体疗法InfantileDiarrheaLiquidTherapy一定量Volume总量Totalvolume累积损失量Cumulatedlosingvolume维持输入阶段（生理需要，继续损失）Keeptransfusingperiod（physiologicalneed,losingcontinuing）轻90～120ml/kg45～60ml/kg45～60ml/kg中120～150ml/kg60～75ml/kg60～75ml/kg重150～180ml/kg75～90ml/kg75～90ml/kg二定性

Quality脱水种类Dehydrantcategory累积损失量Cumulatedlosingvolume维持输入阶段（生理需要，继续损失）Keeptransfusingperiod（physiologicalneed,losingcontinuing）低渗性脱水Hypotonicdehydration4:3:21/3～1/4张含钠液Sodicsolution等渗性脱水Isosmoticdehydration3:2:11/3～1/4张含钠液Sodicsolution高渗性脱水HyperosmoticDehydration1/3张含钠液Sodicsolution1/3～1/4张含钠液Sodicsolution小儿腹泻液体疗法InfantileDiarrheaLiquidTherapy三定速Speed总量Totalvolume累积损失量Cumulatedlosingvolume维持输入阶段（生理需要，继续损失）Keeptransfusingperiod（physiologicalneed,losingcontinuing）24h8～12h12～16h8～10ml/kg/h5ml/kg/h小儿腹泻液体疗法InfantileDiarrheaLiquidTherapy四休克扩容Shockvolumeexpansion，定量、定性、定速扩容量Volume溶液名称Solution速度Speed20ml/kg2:1或1.4％NaHCO330～60min小儿腹泻液体疗法InfantileDiarrheaLiquidTherapy注：总量不超过300mlTotalvolume

≤

300ml五代谢性酸中毒的治疗Treatmentofmetabolicacidosis

轻、中度代谢性酸中毒不须另行处理。

Mildormoderatemetabolicacidosismetabolicacidosis:Nospecialtreatment

重度代谢性酸中毒Severemetabolicacidosis：

1.4%NaHCO33ml/kg，[HCO3-]levelcanincreaseabout1mmol.小儿腹泻液体疗法InfantileDiarrheaLiquidTherapy六低钾血症的治疗Treatmentofhypokalemia

见尿补钾（入院前6小时排尿，膀胱叩诊浊音），补钾浓度

0.2～0.3％（不能超过0.3％），每日补钾总量静滴时