游洁玉-小儿腹泻病课件

小儿腹泻病

湖南省儿童医院消化科游洁玉一、概念

腹泻病（diarrhealdisease）是由多病原、多因素引起的一组疾病，主要是有大便性状改变与大便次数比平时增多，在未明确病因前，统称为腹泻病，是我国婴幼儿最常见的消化道综合征。6个月～2岁婴幼儿发病率高，1岁以内约占半数，是造成小儿营养不良、生长发育障碍和死亡的主要原因之一。1982年，石家庄会议把腹泻病分为感染性与非感染性腹泻.Definitiondiarrhealdiseaseisagroupofdiseasescausedbymultiplepathogens,mainlydefinedasanincreaseinthefrequencyandthewatercontentofstools.Diarrheaisthemostcommongastrointestinalsyndromeofinfantsinourcountry.For6monthsto2yearsoldinfantstheincidencerateishigh,1yearoldinfantsaccountedforabout50%,Diarrheaisoneofthemaincauseofinfantmalnutrition,growthretardationanddeath.In1982,theShijiazhuangconferenceclassifiedthediarrhealdiseaseintoinfectiousandnoninfectiousdiarrhea.classification1、感染性腹泻：infectiousdiarrhea.痢疾、霍乱、其他感染性腹泻.Dysentery,cholera,andotherinfectiousdiarrhea.2、非感染性腹泻：noninfectiousdiarrhea.食饵性（饮食性）腹泻病症状性腹泻病过敏性腹泻病等.allergicdiarrhea.四、流行病学epidemiology小儿腹泻病为第三世界国家小儿第一位常见多发病，死因在我国居第二位。1986年对广东等七省妇糼卫生示范县及北京市的流行病学调查，发现5岁以下小儿急性腹泻年发病率为201.46%，平均年发病次数为2.01±0.03次/人，平均死亡率为0.51‰。1988年21省入户调查发现5岁以下小儿发病率为每年0.86-3.9次/人，平均为每年2.5次/人。Infantilediarrheaisthemostcommondeseaseinthirdworldcountries,andisthesecondcausescausingdeathinChina.In1986,sevenprovinces,includingGuangdongprovince,madeanepidemiologicalinvestigation,foundthatchildren,under5yearsold,theannualincidencerateoftheacutediarrheawas201.46%,theaverageannualincidencerateis2.01±0.03/person,theaveragemortalityratewas0.51perthousand.In1988,investigationfoundthatchildrenunder5yearsoldtheincidencerateswasabout0.86-3.9times/person,anaveragerateof2.5timesperyear/person.发病两个高峰期。夏季腹泻：发生于6、7、8月，主要是致病性大肠杆菌与痢疾杆菌，秋季腹泻：发生于10、11、12月，为，主要致病菌为轮状病毒，危险因素：①1岁以内婴儿；②小儿照看人卫生差；③小儿饭前不用肥皂洗手；④既往经常患腹泻病；⑤饮用水不洁；⑥禽畜放养。Predisposingfactors1、婴幼儿消化系统发育尚未成熟：胃酸和消化酶分泌少，酶活力偏低；生长发育快，所需营养物质相对较多，胃肠道负担重，进入量较多，加重了胃肠道的负担；婴幼儿水分代谢旺盛，对缺水的耐受力差，易发生体液紊乱；婴儿时期神经、内分泌、循环、肝、肾功能发育不成熟，容易发生消化道功能紊乱。Infant’sdigestivesystemdevelopmentisnotyetmature:thegastricacidanddigestiveenzymessecretedlessthantheadult,enzymeactivityispoor,butthegrowthvelosityisrapid,itneedsrelativelymorenutrients,sotheburdenofthegastrointestinalfunctionisaheavy,themoretheinfanteat,themoreburdunitexists;Asthenerve,endocrine,circulatory,liver,renalfunctionareimmatureininfants,pronetohavegastrointestinaldysfunction.Predisposingfactors3、人工喂养：家畜乳中虽有母乳中某些成分，但在加热过程中被破坏，而且人工喂养的食物和食具极易受污染，故人工喂养儿肠道感染发生率明显高于母乳喂养儿Livestockmilkhassomeingredientsofhumanmilk,butitcanbedestroyedintheprocessofheating,andartificialfeedingfoodandtablewarearetooeasytobepolluted,sotheartificialfeedinginfantshasthesignificanthigherintestinalinfectionratecomparetothebreast-fedinfants.

七、非感染因素noneinfectiousfactors

1、饮食因素Dietaryfactors

1）喂养不当：多为人工喂养儿，原因为：喂养不定时；饮食量不当；突然改变食物品种，或过早喂给大量淀粉或脂肪类食品，果汁，特别是那些含高果糖或山梨醇的果汁，可产生高渗性腹泻；肠道刺激物（调料、富含纤维素的食物）也可引起腹泻。1)improperfeeding:forartificialfeedinginfants,themaincausesofdiarrhea:feedingimregularly;improperdiet;suddenchangesinavarietyoffoods,orfeedlargeamountsofstarchorfattyfoodsinanearlyage,juices,especiallythosecontaininghighfructosesorbitolorfruitjuice,canproduceosmoticdiarrhea;eatrichseasoningcellulosefoodcanalsocausediarrhea.

非感染因素2）过敏性腹泻：如对牛奶或大豆（豆浆）过敏而引起腹泻。对牛奶过敏者较多。3）原发性或继发性双糖酶（本要为乳糖酶）缺乏或活性降低．肠道对糖的消化吸收不良．使乳糖积滞引起腹泻。2、气候因素

气候突变、腹部受凉使肠蠕动增加；天气过热消化液分泌减少或由于口渴饮奶过多等都可能诱发消化功能紊乱致腹泻。2)allergicdiarrhea:suchasmilkorsoybean(soybean)allergy.ThemostAllergicfoodismilk.3)thedecreaseoftheamountoractivityoflactase.Thedigestionandabsorptionofthelactosebreakdown.Thestagnationoflactoseinbowelcauseddiarrhea.2.climatefactorAbruptclimatechange,thecoldincreasesintestinalmotility;drinkingtoomuchjuiceormilkmayinducefunctionaldigestivedisordersanddiarrhea.八、发病机制Pathogenesis

(一)消化道功能紊乱:

主要是饮食的量与质不恰当，使婴儿消化道功能发生障碍，食物不能充分消化和吸收．并积滞于肠道上部，同时酸度下降，有利于肠道下部细菌上移繁殖，使消化功能紊乱。肠道内产生大量的乳酸、乙酸等有机酸，使肠腔渗透压增高，加之腐败酸的毒性产物如胺类等刺激肠道，使肠蠕动增强，引起腹泻。Themainreasonistheimapproprioteofqualityandquantityofthediet,soastocausethegastrointestinaldisfunction.thefoodhaven’tgotfullydigestionandabsorption,andthenstagnateintheupperpartoftheintestinaltract,atthesametime,theacidityoftheboweldecreases,thebacteriainlowintestinaltractbreedingup,causedthedisorderofdigestivefunction.theIntestinalproducelargeamountsoflacticacid,aceticacidandotherorganicacids,theintestinalosmoticpressureincreased,togetherwithcorruptionacidtoxicproductssuchasamines,stimulationofintestinal,increasesintestinalmotility,eventuerlycausingdiarrhea.

(二)肠——全身液体循环障碍:

正常小儿消化道吸收与分泌保持平衡，它们主要是通过肠一全身体液循环进行的。整个肠道粘膜都具有吸收和分泌水和电解质的功能，吸收是小肠微绒毛上皮细胞和大肠表层细胞的功能，而分泌则是小肠隐窝处细胞的功能。水的转运主要通过渗透压差进行被动转运及逆渗透压差进行主动转运。被动转运主要在细胞膜顶侧被动弥散进入细胞内，主动转运主要通过葡萄糖、氨基酸等与钠偶联以及钠、氯等协同转运。Normalypediatricgastrointestinemaintainbalancebetweenabsorptionandsecretion,throughasystemiccirculationofbowel.Theintestinalmucosahasthefunctionofabsorptionandsecretionofwaterandelectrolyte,thesmallintestinalmicrovilliepithelialcellsandlargesurfacecellhasthefunctionofabsorption,whiletheintestinalcryptcellhasthefunctionofsecretion.Watertransportismainlythroughtheosmoticpressuredifferenceforpassivetransportandreverseosmosispressuredifferenceofactivetransport.Passivetransportmainlyincellmembranetopsidepassivediffusionintothecell,activetransportofglucose,aminoacids,andmainlythroughthecouplingaswellassodium,chloridecotransport.

肠——全身液体循环障碍:

不耐热肠毒素可与小肠上皮细胞上的受体神经节苷脂（GM：ganglio－sides）结合，激活腺苷酸环化酶，使肠上皮细胞内的ATP转成CAMP，使肠液中的水、电解质分泌增加，水和cl—的再吸收减少，总量增多，超过了结肠吸收限度，引起腹泻，并使体内水、电解质紊乱。耐热性肠毒素可通过激活鸟苷酸环化酶使三磷酸鸟苷（GTP）转变为CGMP，促使小肠分泌增加，导致水样腹泻。病毒以及不耐热肠毒素，还可影响小肠上皮细胞对葡萄糖与钠的偶联运转。Heat-labileenterotoxinandintestinalepithelialcellreceptorsontheganglioside(GM:Gangliosides)binding,activationofadenylatecyclase,theintestinalepithelialcellswithintheATPintoCAMP,sothatthewaterintheintestinalfluid,electrolytesecretionincreases,waterandCl-reabsorptiondecrease,grossincreases,morethancolonicabsorptionlimit,causediarrhea,andinthewater,electrolytedisturbance.Heat-stabletoxinmaybeviatheactivationofguanylatecyclasethreeguanosinemonophosphate(GTP)intoCGMP,induceintestinalsecretionincreased,leadingtoawaterydiarrhea.Virusandheat-labileenterotoxin,canalsoaffecttheintestinalepithelialcellsonglucoseandsodiumcouplingoperation.

(三)病原侵袭肠粘膜的作用各种细菌引起的肠炎其肠系膜淋巴结均肿大，引起肠系膜淋巴结炎。由于结肠炎症病变可导致吸收功能障碍。最新提出，细胞内信息——前列腺素（PG）与各型肠炎有关，当组织损伤和发炎时，激肽激活可形成前列腺素，它可激活环化酶，与所有促进分泌协同转运系统均有联系，故认为PG是肽类致泻激素之一。Variousbacterialenteritisofthemesentericlymphnodeswereswollen,causedbymesentericlymphadenitis.inflammatorylesionscanleadtomalabsorbtion.Thelatest,intracellularinformationfoundthat--prostaglandins(PG)isassociatedandwithvarioustypesofenteritis,whentissueinjuryandinflammation,kininprostaglandinactivationcanbeformed,itcanactivatethecyclase,andisassociatewithallthesecretioncotransportsystems,sothatPGisapeptidehormoneofpurgative.

(四)病毒致泻作用

病毒颗粒侵入小肠上部可累及全部小肠甚至结肠，使绒毛细胞受损，小肠绒毛变短，微绒毛膨胀、不规则，固有膜层有单核细胞浸润。电镜检查在上皮细胞内可发现许多病毒颗粒受累的小肠粘膜上皮细胞及微绒毛很快脱落，由于绒毛细胞在破坏后修复功能不全，隐窝部立方上皮细胞（分泌细胞）增多，向柱状上皮细胞移位，造成水、电解质吸收减少，肠液分泌增多，导致腹泻。(四)病毒致泻作用另外肠道粘膜细胞受损，其细胞的双糖酶活性减少，结果造成糖分解吸收障碍，不能完全水解的糖类物质被肠道细菌分解，产生有机酸，增加肠内渗透压，使水进入肠腔，导致腹泻加重。另外，葡萄糖和钠与绒毛内载体结合的偶联运转也发生了障碍，造成大量的水样腹泻。Inaddition,theintestinalmucosalcelldamage,thedoubleenzymeactivitydecreased,resultinginsugarmalabsorption,cannotcompletehydrolysisofthecarbohydratebybacterialdecomposition,produceorganicacids,increasedintestinalpermeabilitypressure,makewaterintotheintestinallumen,causediarrheaaggravation.Inaddition,glucoseandsodiumandfluffcarriercombinedcouplingoperationalsooccurredindisorder,causealotofwaterydiarrhea.

九、病理生理(一)脂肪、蛋白质和糖代谢紊乱

由于肠道消化吸收功能减低，肠蠕动亢进，使营养素的消化和吸收发生障碍。营养物质的丢失主要是酶功能紊乱引起同化功能障碍所致。蛋白质的同化功能减弱，但仍能消化吸收蛋白质。脂肪的同化与吸收也受到影响，在恢复期，数日至数周后脂肪平衡实验显示，脂肪的同化作用仍低下。碳水化合物的吸收也受到影响，患儿糖耐量试验曲线低，这与碳水化合物吸收障碍有关。但在急性腹泻时，患儿胃肠道的消化吸收功能未完全丧失，对营养素的吸收可达正常的60％～90％。

(二)水和电解质紊乱

由于溶质的转运障碍;吸收功能减低，分泌功能亢进，腹泻和反复呕吐，使水、电解质大量从消化道丢失，继而发生水、电解质紊乱，产生一系列的脱水及酸中毒症状。Becausethesolutetransportdisorders;absorptionfunctionreduces,secretionfunctionhyperfunction,diarrheaandvomiting,makewater,electrolytesfromthegastrointestinaltractismissing,thenwater,electrolytedisturbance,toproduceaseriessymptomofdehydrationandacidosis.

十、临床表现轻型:

常由饮食因素及肠道外感染引起。起病可急可缓，以胃肠道症状为主，食欲不振，偶有溢乳或呕吐，大便次数增多，稀薄或带水，呈黄色或黄绿色，有酸味．常见白色或黄白色奶瓣和泡沫。无脱水及全身中毒症状．多在数日内痊愈。Oftencausedbydietaryfactorsandextraintestinalinfection.Theonsetcanbeacuteorslow,withpredominantlygastrointestinalsymptoms,lossofappetite,occasionallygalactorrheaorvomiting,thestoolfrequencyincreases,thinorwatery,yelloworyellowishgreen,hasasourtaste.Commonlywithwhiteoryellow-whitemilkvalveandfoam.ChildrenWithoutdehydrationandsymptomsofsystemicpoisoningcanrecoveryinafewdays.

重型:

多由肠道内感染引起。常急性起病，也可由轻型逐渐加重、转变而来，除有较重的胃肠道症状外，还有较明显的脱水、电解质紊乱和全身中毒症状，如发热、精神烦躁或萎靡、嗜睡，甚至昏迷、休克.causedbyIntestinalinfection.Oftenacuteonset,butalsobythelightgraduallyincreased,withtheseveregastrointestinalsymptoms,therearedehydration,electrolytedisturbancesandsystemicpoisoningsymptoms,suchasfever,mentalirritabilityordepressed,sleepiness,orevencoma,shock.

几种常见腹泻的临床特点6）抗生素诱发的腹泻①金黄色葡萄球菌感染性腹泻②伪膜性小肠结肠炎③真菌性肠炎7）食饵性腹泻8）症状性腹泻9）生理性腹泻6)antibioticassociateddiarrheaTheStaphylococcusaureusinfectiondiarrheaOfpseudomembranousenterocolitisFungalenteritis7)preydiarrhea8)symptomaticdiarrhea9)physiologicaldiarrhea几种常见腹泻的临床特点10）小儿糖原性腹泻11)先天性失氯性腹泻病（congenitalchloridediarrheaCCD）12）肠吸收不良性腹泻13）脂肪泻性腹泻14）牛奶蛋白过敏性腹泻10)pediatricglycogendiarrhea11)congenitalchloridediarrhea(congenitalchloridediarrheaCCD)12)intestinalmalabsorptiondiarrhea13)fattydiarrhea14)milkproteinallergydiarrhea十一、实验室检查（一）常规检查1、血、尿、粪为最基本检查，在条件较差的基层医院也应开展此常规检查。Thebasicexaminationsarebloodroutine,urineroutineandstoolroutine,thesecanbeapproachedinprimaryhospital.1）血常规根据血红蛋白及红细胞的改变可以判断有无贫血，根据白细胞及分类，我们可以初步判断有无感染及感染的类型。wecanestimatewhetherthepatienthasanemiabytheexaminationofHbandRBC,andalsowecanestimatewhetherthepatienthasinfectionaccordingtotheresultofwhitebloodcellscountanditsclassification.2）小便常规有无蛋白及红细胞及白细胞、管型等whetherthereareprotein,redbloodcells,whitebloodcellsandtubetypeintheurine.3）大便常规根据大便常规有无白细胞将腹泻分为两组。weclassifythepatientsintotwogroupsbytheresultofwhetherthereisWBCinthestool.（二）基本的血生化检查

包括E4A、Ca2+、P3-、Mg2+等检查，根据E4A结果我们可以判断脱水的性质（主要是根据测得的测得的血清Na+结果分为低渗、高渗、等渗脱水及判断酸缄平衡。）因而基层医院也应尽量开展此项检查。wecarriedouttheexaminationincludingE4A,Ca2+,P3-andMg2+,judgethenatureofthedehydrationaccordingtowhethertheplasmasodiumconcentrationisnormal,loworhigh.十二、病源学检查

大便细菌、真菌等培养应该一式二份，培养出同一种细菌或真菌意义更大。

病毒分离采用适合于其生长复制的细胞培养体系，是诊断病毒性疾病的金标准。

stoolcultureisnecessarytoexcludeonunderlyinginfectivecause,likebacteriaandfungus.oftenhavetoculturetwice.

Virusisolation,suitableforgrowthandreplicationincellculturesystem,isthegoldstandardfordiagnosisofviraldiseases.

十三、特殊检查

1、大便检查1）大便轮状病毒抗原检测：取新鲜的大便经过抗原抗体结合检测轮状病毒抗原。Specificidentificationofrotavirusisneccecery.rotavirusantigenscanbeidentifiedinstool.2）clinitest试剂，糖吸收不良时，从粪便排出的糖增多，国际上常用的测糖方法是用clinitest试剂测定粪便中的还原糖。

Clinitestreagent,whenthechildhassugarmalabsorption,wecancommonlyusethemethodofClinitestreagenttodeterminethereducingsugarinfeces.

2、小便检查1）尿中还原糖的测定，尿中出现双糖表明肠黏膜受损较严重，尿中的乳糖大于50mg为过度发酵的指征

Determinationofreducingsugarintheurine,disaccharidesinurineshowedseriousintestinalmucosadamage,theurinarylactose＞50mgindicatean

excessivefermentation.3、X线检查钡餐透视检查结肠、胃、小肠对慢性腹泻的诊断有一定意义，有助于溃疡性结肠炎和克隆病诊断。forthediagnosisofchronicdiarrhea,thesubjectofSWALLOWBARIUMFORROENTGENOGRAPHYGASTROINTESTINALofthecolon,stomach,smallintestinehasthecertainsignificance,contributetothediagnosisofulcerativecolitisandCrohn'sdisease.4、内窥镜检查小儿内窥镜检查，目前在全国开展很普通，主要有小儿电子胃肠镜、小肠镜等，对克隆病、溃疡性结肠炎有诊断意义，并可用于其分泌物涂片检查及粘膜活检行病理检查或涂片找虫卵等。

Pediatricendoscopy,currentlycarriedoutinthecountrycommonly,mainlyincludingpediatricgastrointestinalendoscopeandendoscopy,usedindiagnosisofCrohn'sdisease,ulcerativecolitis,andcanbeusedintheaspiratesmearsandmucosalbiopsy.十四、诊断

根据病因、发病季节、年龄、大便的性状、排便的次数可作出初步诊断，必要时应进行细菌、病毒及寄生虫等病原学检查、对于脱水程度及性质，有无酸中毒及钾、钙等电解质缺乏的判定，可根据临床表现作出症状诊断。wecanmakeaninitialdiagnosisaccordingtotheetiology,incidence,age,stooltraits,thefrequencyofdefecation,takeexaminationsforbacteria,virusesandparasites,examinationforthedegreeofdehydration,andnature,whetherthereisacidosisandpotassium,calciumandotherelectrolytedeficiency,andcanmakesymptomsdiagnosisaccordingtoclinicalmanifestations.（一）临床诊断

1)诊断依据①大便性状有改变，呈水样便、糊状便、粘液便或脓血便。②大便次数增多。awatery,mushystool,mucousorpusandbloodseeninthestool.Thedefecateincreased.2）病程分类1、急性腹泻病（acutediarrhealdisease）：病程在2周以内(within2weeks)2、迁延性腹泻病(persistentdiarrhealdisease)：病程在2周-2个月(2weeks-2months)3、慢性腹泻(chronicdiarrhealdisease)：病程在2个月以上。(over2weeks)临床诊断

3）病情分类①轻型：无脱水、无中毒症状。②中型：轻至中度脱水或有轻度中毒症状。③重型：重度脱水或有明显中毒症状如烦躁、精神萎糜、嗜睡、面色苍白、高热或体温不升、白细胞计数明显增高等。4）临床分类

①感染性：肠炎、痢疾、霍乱②非感染性：饮食性、症状性、过敏性等

3)diseaseclassificationmild:nodehydration,nosymptomsofpoisoning.modreate:mildtomoderatedehydrationorhadmildsymptomsofpoisoning.severe:severedehydrationorobviouspoisoningsymptomssuchasirritability,lethargy,mentaldeclineisrotten,pale,heatortemperaturedoesnotrise,whitebloodcellcountwassignificantlyincreased.4)clinicalclassificationTheinfectionofenteritis,dysentery,cholera:Thenoninfectious:diet,symptoms,allergicandother（二）病因诊断

1）感染性腹泻

①有条件者应进行细菌、病毒及寄生虫、原虫等病原学检查。病原明确后应按病原学进行诊断，如细菌性痢疾、霍乱、鼠伤寒沙氏菌肠炎、致泻性大肠杆菌肠炎、空肠弯曲菌肠炎、轮状病毒肠炎、蓝氏贾第鞭毛虫肠炎、隐孢子虫肠炎、霉菌性肠炎等。

1)infectiousdiarrheaTheetiologicalexaminationshouldbecarriedouttodeterminethepathogensuchasbacterial,viralandparasiticprotozoaanddoanetiologydiagnosis,suchasbacillarydysentery,cholera,Salmonellatyphimuriumenteritis,diarrheagenicEscherichiacolienteritis,Campylobacterjejunienteritis,rotavirusenteritis,Giardialambliaenteritis,Cryptosporidiumenteritis,mycoticenteritis.

病因诊断

②无条件者，可根据大便外观、性状及流行季节估计最可能的病原，此时统称为急性肠炎。流行性腹泻水样便，多为轮状病毒或产毒素性细菌感染，小儿尤其是2岁以下发生在秋冬季节，以轮状病毒肠炎可能性大；发生在夏季以产毒性大肠杆菌（ETEC）肠炎可能性大，特殊情况下要考虑霍乱。如粪便为粘液或脓血便，多为侵袭性细菌感染，应考虑细菌性痢疾、侵袭性大肠杆菌肠炎、空肠弯曲菌肠炎或沙氏菌肠炎等。Wecanestimatethemostlikelypathogenbythestoolappearance,characteristicsandseasonalprevalence.Epidemicdiarrheaofwaterystools,mostlycausedbytherotavirusortoxinbacterialinfection,childrenespeciallyunder2yearsoccurredintheseasonofautumnandwinter,possibilyarerotavirusenteritis;whenoccurredinthesummer,arelikelybetheenterotoxigenicEscherichiacoli(ETEC)enteritis,especiallyconsidercholera.Whenstoolswithmucusorblood,morelikelybetheinvasivebacterialinfection,shouldconsiderthebacillarydysentery,enteritisandinvasiveEscherichiacoli,CampylobacterjejunienteritisorSalmonellaenteritis.

2）非感染性腹泻

根据病史、症状及检查分析，可诊断为食饵性腹泻、症状性腹泻、过敏性腹泻、非特异性溃疡性结肠炎、糖原性腹泻等。2)noninfectiousdiarrheaItcanbediagnosedaspreydiarrhea,symptomsofdiarrhea,allergicdiarrhea,nonspecificulcerativecolitis,glycogendiarrheaaccordingtothemedicalhistory,symptomsandexaminationanalysis.

脱水程度评估

轻度脱水中度脱水重度脱水望诊：一般情况良好*烦躁、易激惹 *嗜睡或昏迷，软弱无力眼窝 正常 下陷 明显下陷眼泪 有 少或无 无口舌 湿润 干燥 非常干燥口渴 饮水正常*口渴、想喝水 少量饮水或不能饮水无口渴触诊 捏起后回捏起后回缩慢 捏起后回缩很慢皮肤弹性 缩快 （<2秒） （>2秒）诊断 无脱水 轻至中度脱水： 重度脱水：患者有两个患者有两个或两个 或两个以上上述体征， 以上上述体征，其 其中至少包括一个*符 中至少包括一个* 号所示体征，丢失水分 符号所示的体征， 占体重的10%-12%。 丢失水份占体重的5%-10%ClinicalEstimationofDegreeofDehydration

mildmoderateSevereWeightloss＜5%5%-10%＞10%Spiritgood*agitateorirritabilily*comaandweakEyesappearancenormalsunkensunkenTearingnormal/absent

normalnormalMucousmembrancesnormal/drydrydryThirstynormal*

thirstyunabletodrinkordrinkalittleCapillaryrefill＜2s2s-3s＞3s

不同性质脱水的特点

类型血清钠（mmol/L）受影响部分主要症状等渗性脱水130-150细胞内外均等重者循环障碍高渗性脱水>150细胞内神经症状低渗性脱水<130细胞外循环障碍

ThenatureofthefluidlostTypeserumsodiumthedehydrationpartsymptomsIsotonicdehydration130-150mmol/lbothseveredysemiaHypotonicdehydration<130intra-cellularneuralsymHypertonicdehydration>150ecto-cellulardysemia

十五、治疗treatment原则:principle预防脱水preventdehydration纠正脱水rehydration继续饮食feedthroughthediarrhea合理用药rationaladministration

（一）液体疗法：oralrehydrationtherapy

治疗方案一：适用于无脱水征患者，可以家庭治疗。家庭治疗三原则如下。①给患者口服足够的液体以预防脱水。可选用以下液体。infantswhoarenotdehydrationmaybetreatedathome.theprincipleareasfollows:①choosethefollowingfluidstopreventdehydration.oralrehydrationtherapya米汤加盐溶液配制方法：米汤500ml（1斤装酒瓶）＋细盐（一平啤酒瓶盖的一半）或炒米粉25g（约两满瓷汤勺）十细盐1．75g（一平啤酒瓶盖的一半）十水500ml者2～3分钟。预防脱水；20～40ml／kg，4小时内服完，以后随时口服，能喝多少给多少。Ricesoupwithsaltsolution

Preparationmethod:rice500ml+finesaltorfriedrice25g+finesalt1.75g+water500mlin2~3minutes.Preventionofdehydration:20~40ml/kg,drinkwithin4hours,youcantakeitatanytimeafteroraladministration,asmuchaspossible.oralrehydrationtherapyB糖盐水Glucosesaline

配制方法：白开水500ml（1斤装酒瓶）十蔗糖10g（2小勺）十细盐1．75g（一平啤酒瓶盖的一半），剂量服方同上。Preparationmethod:water500ml+sucrose10g+finesalt1.75gC口服补液（ORS）溶液（新生儿慎用）ORShastousecautiouslywithneonates.ORS液服用量年龄（周岁）每次腹泻后服用ORS应提供ORS液的量液的量（ml）（ml／天）小于250～1005002至10100～2001000大于10能喝多少给多少2000ThetakingamountofORSAge(years)theamountofORStheamountofORStakenoncediarrhea

takenaday

＜250～1005002-10100～2001000＞10能喝多少给多少2000

②足够的食物以预防营养不良。

②eatadequatefoodtopreventmalnutritiona继续用母乳喂养。Continuationofbreastfeedingb不是母乳喂养，年龄在6个月以内，可用儿日常食用的奶或奶制品继续喂用。Infantswhoarefedwithmilk,below6months,canbefedthroughthediarrhea.若患儿年龄在6个月以上，给已经习惯的平常饮食，如粥、面条或烂饭、蔬菜、鱼或肉末等。可给一些新鲜水果汁或水果以补充钾。这些食物要很好烹调、研磨或捣碎使之容易消化。Ifthechildrenolderthan6months,accustomedtotheusualdrink,canbegivenfood,suchasporridge,noodlesorrottenrice,vegetable,fishormeat.Givesomefreshfruitjuiceorfruittosupplementpotassium.Foodmustbegoodcooking,grindingorpoundingfordigest.鼓励患者多进食，每日加餐1次，直到腹泻停止后1周。Patientsareencouragedtoeatmore,1timesdailywithmeals,until1weeksaftercessationofdiarrhea.

③如果3天患者病情不见好转或3天内出现下列任何一种症状，应找医生诊断。

Ifthepatientsdidnotimprovewithin3daysoronsetofanyoneofthefollowingsymptoms,shouldlookforadoctor.a腹泻次数和量增加。不能正常饮食Thefrequencyandtheamountofdiarrheaincreased.Cannoteat.

b频繁呕吐、发热vomitfrequently、feverc明显口渴,大便带血thurstyaparrently,bloodinthestool.治疗方案二适用于有些脱水（轻-中度脱水），此类脱水约占90%，完全可用ORS纠正，经济又方便，效果也很好。Applyforsomedehydration(mildormoderatedehydration),thetypeofdehydrationoccupiedabout90%ofalltypesofthedehydration,itcanbecorrectedonlybyORS,anditisalsoaneconomical,convenient,andeffectiveway.①最初4小时内ORS液用量见表:thevolumerequiredintheinitial4hours

表最初4小时内ORS液用量

年龄小于4月4月～1岁～2岁～4岁～14岁大于或等于15岁体重（kg）小于55～8～11～16～大于30用量（ml）200～400400～600600～800800～12001200～22002200～4000age＜4months4m-1y＜2y＜4y＜14y≥15yWeight＜5kg5-8kg8-11kg16kg＞30kgVolume200-400ml400-600600-800800-12001200-22002200-4000note：只有在不知道患儿体重时，才用年龄进行估计ORS液的用量。也可以用以下公式计算：体重（kg）×75ml=用量ml.如果患儿想喝比表中所示的量还多的ORS液，则可多给；鼓励母亲继续用母乳喂养患儿；对于6个月以下非母乳喂养的患儿，在这段时间内应额外给100～200毫升白开水Whenwedon’thavethepatients’bodyweight,wecanuseestimatethevolumebyage.Alsocanusethefollowingformula:Weight(kg)x75=thevolume.Ifthechildrendrinkmorethanthevolumeshowninthetable,youcangivemore;Encouragemotherstocontinuebreast-feeding;Fornonebreast-feedinginfants,theagebelow6m,inthistimemothershouldgiveadditional100~200milliliterswatertochildren.②密切观察患儿病情帮助母亲给患儿服用ORS液。告诉母亲给患儿服用ORS液，示范如何给患儿服用ORS液——2岁以内的患儿每1～2分钟喂1小勺，年龄大一点的患儿可以用杯子一点一点不断地喝。TeachthemotherhowtofeedORS.2yearsoldchildrenevery1~2minutestofeed1smallspoon,olderchildrencanuseonepointoneconstantlydrinkingcup.如果患儿呕吐，等10分钟后再慢慢喂服，每2～3分钟1小勺。如果患儿眼睑出现水肿，停止服用ORS液，改用白开水或母乳，水肿消除后按治疗方案一继续服用ORS液。Ifthechildrenvomiting,waitfor10minutesandthenfedslowlybythefrequencyof1smallspoonevery2to3minutes.Ifchildrenwitheyelidedema,stoptakingORSliquid,usewaterormilkinstead.continuetotakeORSafterrecovery.治疗方案三strategythree适用于中度以上脱水、吐泻严重或腹胀的患儿，输入溶液的成分、容量和滴注时间必须根据不同的脱水程度和性质决定，同时要注意个体化，结合年龄、营养情况、自身调节功能而灵活掌握。

suitforthemoderatetoseveredehydration,clinicalestimationofdegreeofdehydrationandserumeletrolytestudiestailorsubsequentmanagement.Payingattentiontotheage,nutritionalstatus,andtheselfadjustingfunction,soastomakeaflexibleandindividualtreatment.

①第一天补液thevolumerequiredinthefirst24hoursa总量:totalvolume

包括补充累积损失量、继续损失量和生理需要量，一般轻度脱水约为90-120ml/kg、中度脱水约为120-150ml/kg、重度脱水约为150-180ml/kg，对少数营养不良，肺炎、心、肾功能不全的患儿尚应根据具体病情分别做较详细的计算。

thevolumerequiredin24hoursiscalculatedfromestimateddeficit+maintenance+ddehydration90-120ml/kgmoderatedehydration120-150ml/kgseveredehydration150-180ml/kg

weshouldmakeadetailedcalculationforthechildrenwithmalnutrition,pneumonia,cardiac,renalinsufficiency.b溶液种类：solutiontypes

溶液中电解质与非电解质溶液的比例应根据脱水性质（等渗性、低渗性、高渗性）分别选用，一般等渗性脱水用1/2张含钠液、低渗性脱水用2/3张含钠液、高渗性脱水用1/3张含钠液。若临床判断脱水性质有困难时，可先按等渗性脱水处理。

clinicalestimationofserumeletrolytestudiestailorsubsequentusageofsolutions.(isotonic,hypotonic,hypertonic)usallyfortheisotonicdehydration,usethe1:2solution;thehyponatremia,usethe2:3solution;andthehypernatremia,usethe1:3solution.ifwecan’tevaluatethetypeofthedehydration,wecantreataccordingtotheisotonicdehydration.

c输液速度：

主要取决于脱水程度和继续损失的量和速度，对重度脱水有明显周围循环障碍者应先快速扩容，20ml/kg等渗含钠液30-60分钟内快速输入；累积损失量（扣初扩容液量）一般在8-12小时内补完，约每小时8-10ml/kg；脱水纠正后，补充继续损失量和生理需要量时速度宜减慢，于12-16小时内补完，约每小时5ml/kg；若吐泻缓解，可酌情减少补液量或改为口服补液。Transfusionspeed:Iftherearesignsofcirculatoryfailure,immediateresuscitationisachievedbyintravenousadministrationof20ml/kgof0.9%NaClor‘plasma’(humanalbumin5%)within30-60minutes.thevolumeofestimateddeficitshouldbeachievedin8-12h,withthespeedof8-10ml/kg.oncethedehydrationiscorrected,thevolumeofmaintenance+ongoinglossesshouldbeachievedin12-16h,withthespeedof5ml/kg.d纠正酸中毒：因输入的混合溶液中已含有一部分碱性溶液，输液后循环和肾功能改善，酸中毒即可纠正，根据临床症状结合血气测定结果，另加碱性溶液（如碳酸氢钠）纠正。对重度酸中毒可用1.4%碳酸氢钠扩容，兼有扩充血容量和纠正酸中毒的作用。Aftertheimportationofthemixedsolutioncontainingaportionofalkalinesolution,thecirculationandrenalfunctioncanbeimproved,acidosiscanbecorrected.Weshouldintravenousanalkalinesolution(suchassodiumbicarbonate)tocorrecttheacidosisaccordingtothebloodgasdeterminationresults.Forsevereacidosis,rehydrationwith1.4%sodiumbicarbonate,whichhastheeffectionofboththeexpansionofbloodvolumeandthecorrectionofacidosis.

e纠正低钠累积损失需用2/3张～等渗含钠液补充，开始用等张液，病情好转可改为2/3张液。低渗性脱水病儿如输入低渗溶液过多，常仍不能纠正细胞外液脱水症状，反可引起严重低钠，脑细胞水肿，颅压增高，出现脑症状；此时宜采用3%氯化钠溶液治疗，公式：3%氯化钠（ml）=[130-测得的血钠值（mmol）]×0.5×体重（kg）×2.0，一般先给计算量的1/2,再根据治疗反应酌情继续补充。thevolumeofestimateddeficitissupplimentbythe2/3,isotonicsolution,startingwithisotonicfluid,aftertheconditionimproved,canbechangedtothe2/3solution.Hypotonicdehydrationwheninputtoomuchh