小儿腹泻-英文课件

INFANTILEDIARRHEACHCUMSDIVISIONOFINFECTIOUSDISEASEANDGASTROENTEROLOGYINFANTILEDIARRHEA1小儿腹泻-英文Background

Diarrheaisaclinicalsyndromeofdiverseetiologyassociatedwithmanyinfluencingfactors.Itisthemostfrequentchildhooddiseasesecondonlytotherespiratoryinfection.Themajorcauseofdeathamongworld’schildrenandthenumberonekillerofchildrenunderfiveinmanydevelopingcountries.2小儿腹泻-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小儿腹泻-英文

FluidityVolumeNumberInpediatrics,diarrheaisdefinedasanincreaseintherelativetotheusualhabitsofeachindividualofstoolsDefinition4小儿腹泻-英文NormalStoolofChildrenBreastfedbabies:

passstools3-4timesadayyellowloose(softtorunny)buttexturedsweet-smellingBottlefedbabies:

onceadaypaleyelloworyellowish-brownbulkierandmoreformedprettypungentBabiesonsolids:

thickenanddarkenslightlyhaveastrongerodor5小儿腹泻-英文DehydrationMalnutritionMortalityWhydiarrheaismoredangerousforchildren?6小儿腹泻-英文MalnutritionandChildMortality7小儿腹泻-英文If:Diarrhea+MalnutritionThe

RISK

of

DEATH

is

4fold

higherthan

thatofwellnourishedchildren8小儿腹泻-英文Whychildrenarehighlyvulnerabletodiarrhea?

ImmaturedigestivesystemMorenutritiondemandWeaknessofdefensesystemThenormalintestinalflorahavenotbuiltupwell

Bottlefeeding9小儿腹泻-英文EtiologyofDiarrhea10小儿腹泻-英文EtiologyofDiarrheaInfectiveNoninfectiveVirusesBacteriaParasitesFungi

Allergic

Symptomatic

Inappropriate

feeding

Food

intolerance

Climate11小儿腹泻-英文ViralEnteropathogensViralenteropathogenscausemostillnessesinpediatricpopulation.

Rotavirus

(mornthan50%acutediarrhea)

AstrovirusNorwalkvirusCoronavirusCalicivirusEntericadenovirus(serotypes40and41)12小儿腹泻-英文Rotavirus13小儿腹泻-英文Themostcommoncauseofchildhooddiarrheasecondonlytotheviralenteropathogens

Escherichiacoli

EPEC;ETEC;EITC;EHEC;EAEC

Campylobacterjejuni

ShigellaspeciesSalmonellatyphimuriumYersiniaenterocoliticaStaphylococcusaureusClostridiumdifficileVibriocholeraeBacterialEnteropathogens14小儿腹泻-英文Rareetiologicpathogenofdiarrhea

CryptosporidiumparvumEntamoebahistolyticGiardialambliaParasitesPathogens15小儿腹泻-英文Rareetiologicpathogenofdiarrhea

CandidaalbicansAspergillusMucor

FungousPathogens16小儿腹泻-英文Themostimportantinfectivecausesofacutediarrheaindevelopingcountriesinchildrenare:RotavirusEnterotoxigenicescherichiacoliShigellaCampylobacterjejuniSalmonellatyphimurium17小儿腹泻-英文EtiologyofDiarrheaInfectiveNoninfectiveVirusesBacteriaParasitesFungi

Allergic

Symptomatic

Inappropriate

feeding

lactose

intolerance

Climate18小儿腹泻-英文OverfeedingIndigestibledietSuddenchangeofformula

Inappropriatefeedingforamilk-fedbabyshiftingintosolidfood(toomuch,tooearly,toorapid…)

DietaryDiarrheaInappropriatefeeding:19小儿腹泻-英文AllergicDiarrheaPrimaryfoodhypersensitivity:

3monthsafterbirth

Secondfoodhypersensitivity:

Infection→injuryandhyperpermeabilityofintestinalmucosa→

largemolecularproteinenteringbloodstream→

allergicstateCow'smilkproteinSoybeanproteinEggwhite

peanuts,meat,andfishetc.20小儿腹泻-英文

SymptomaticDiarrheaDiarrheaisonlyoneofthesymptomsofprimarydisease.Problemisnotoriginallylocatedinintestinaltract.RespiratorytractinfectionOtitismediaSomeinfectiousdiseases,etc.Alwaysbemild,andrecoverwiththeprimarydiseasegettingbetterTheyoungerthechildren,themorechancetogetasymptomaticdiarrheaaccompaniedbyotherdiseases.21小儿腹泻-英文

LackofDisaccharidaseLactose

IntolerancePrimaryDisaccharidaseDeficiencyisararedisease(congenitaldefectsofcarbohydratehydrolysis).SecondDiaccharidaseDeficiency

:Rotavirusinfection

→Injurestheenterocytesofvilli→Transientdisaccharidasedeficiency→Malabsorptionoflactoseinthemilk→

Typicallooseandwaterystools22小儿腹泻-英文

ClimateSeasonalvariation

affectsthedigestivefunctionofsmallchildren:incidenceofdiarrheaishighestduringtheearlyraninyseasonColdweather

causesincreasingofenterokinesiaHotweather

causesdecreasingofdigestiveenzymeandmalfunctionofdigestivetract

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

Diarrhea27小儿腹泻-英文PathogenesisofVirusDiarrhea

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

Waterystool28小儿腹泻-英文VirusDiarrhea-RotavirusEnterotoxigenicenteritis–

ETEC,VibrioCholeraeEntero-InvasiveOrganisms–ShigellaSpecies,EIECDietarydiarrheaPathophysiologicalMechanismsofDiarrhea29小儿腹泻-英文PathogenesisofEnterotoxigenic

Diarrhea

Pathogens:

Vibriocholerae(cholera)ETECStaphylococcusaureusClostridiumdifficile30小儿腹泻-英文

enterotoxigenicorganismsIngestionsmallbowelmucosaandproliferate

activatescellular

guanylatecyclase

Heat-stableenterotoxinpromotethenetsecretionofwaterandchlorideincreasedintracellularconcentrationsofcAMP

activatescellularadenylcyclasebindstoreceptorsofepithelialcellsHeat-labileenterotoxindecreaseabsorptionofsodiumandchloridebyvillouscellsincreasedintracellularconcentrationsofcGMP

Secretory

diarrheaPathogenesisofEnterotoxigenicDiarrhea(SecretoryDiarrhea)

31小儿腹泻-英文PathogenesisofEnterotoxigenicDiarrhea(SecretoryDiarrhea)

1-EnterotoxigenicBacteriasecreteEnterotoxins2-ToxinstimulatestheproductionofC-AMPIncreasedC-AMPleadsto:3-InhibitionofabsorptionofNaandClfromthecellsofvilli4-StimulationofsecretionofClfromcryptcells+++---1234123432小儿腹泻-英文PathogenesisofEnterotoxigenicDiarrhea(SecretoryDiarrhea)

Themucosaisnotdestroyedduringthisprocess33小儿腹泻-英文Animbalanceintheratioofintestinalfluidabsorptiontosecretion,sowaterystoolmayoccurinclinicalobservationPathogenesisofEnterotoxigenicDiarrhea(SecretoryDiarrhea)

34小儿腹泻-英文Enterotoxigenic

Diarrhea

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

ShigellaSpecies,EIECDietarydiarrheaPathophysiologicalMechanismsofDiarrhea36小儿腹泻-英文InvasiveDiarrheaEntero-InvasiveOrganisms:

ShigellaspeciesEIEC(enteroinvasiveE.coli)CampylobacterjejuniSalmonellatyphimuriumYersiniaenterocoliticaThecentraleventinpathogenesisisinvasionofcolonicmucosa37小儿腹泻-英文PathogenesisofInvasiveDiarrheaInvasiveenteropathogenIngestionGutlumenColonandrectummucousmembraneproper

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

inflammatorycellsandmucus38小儿腹泻-英文PathogenesisofInvasiveDiarrhea39小儿腹泻-英文InvasiveDiarrheaClinicalfinding:Stoolsthatarefrequentandscantyandthatcontainbloodinflammatorycells,andmucusStoolexamination:largeamountofWBC,puscell,andRBCDehydrationandelectrolytedisturbancesarelessfrequentbecauseoflesslossofdigestivefluid40小儿腹泻-英文VirusDiarrhea-RotavirusEnterotoxigenicenteritis–ETEC,VibrioCholeraeEntero-InvasiveOrganisms–ShigellaSpecies,EIECDietarydiarrheaPathophysiologicalMechanismsofDiarrhea41小儿腹泻-英文PathogenesisofDietaryDiarrheaInappropriatedietIrritatesthebowelPromotetheperistalsisWaterenteringthelumenDecomposedproductamineslacticacidaceticacid

AciditydecreasingGivethechancetothebacteriawhichlivedinlowerpartofbowelcomingupEndogenousinfectionAggravatetheintestinalfunctiondisturbanceIndigestedfoodaccumulateintheupperpartofintestineDyspepsia

Indigestedfood

fermentandputrescenceHyperosmosisDiarrhea42小儿腹泻-英文MorphologyofIntestinalMucosa43小儿腹泻-英文MorphologyofIntestinalMucosaVillicoveredmainly(90%)bytallcolumnarabsorptivecells

(Enterocytes)havingamicrevillarbrushborderCryptsoflieberkuhnCoveredmainlybyshortcolumnarsecretorycellsGobletcellswithoutbrushborder44小儿腹泻-英文DefenseBarriersoftheEnterocytes1.Physicalbarrier:mucus2.Bacteriological(flora)3.Immunological:SecretoryIgA12345小儿腹泻-英文NormalFloraBreast-fed:AGram-positivepopulation:BifidobacteriaandLactobacilli

Bottle-fed:AGram-negativeflora:Enterobacteriaceae46小儿腹泻-英文ClinicalManifestations47小儿腹泻-英文ClinicalmanifestationsGastrointestinalsymptomSystemicsymptomDehydrationandelectrolytedisturbances48小儿腹泻-英文Assessmentofachildwithdehydration&electrolytedisturbances

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

serumpotassium<3.5mmol/LEtiologyExcessiveoflossInsufficientintakeDistributionaldisturbanceofextracelluarandintracelluarpotassiumHypopotassaemia56小儿腹泻-英文(二)低钾血症Manifestations（1）lownervousandmuscularexcitability

nervousexcitability：downcast,lethargy

muscularexcitability：weakness、byporesalexiaoftendonjerk,paralysis

GIsmoothmuscleexcitability

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

serumpotassium<3.5mmol/L57小儿腹泻-英文

serumcalcium<1.88mmol/L

HighnervousandmuscularexcitabilityHypocalcemia58小儿腹泻-英文

1etiology

(1)lossofalkalinesubstancefromGItrack(2)acidsubstanceaccumulationinbodyH+排除↓

2manifestations:

hyperpnoea、increasedheartrate、seriselip、consciousdisturbancefortheseverecases

H+产生↑MetabolicAcidosis59小儿腹泻-英文ClassificationofDiarrheabasedon……SeverityDurationEtiology60小儿腹泻-英文ClassificationofDiarrhea1.Milddiarrhea:

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

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

PathogenesisisnotclearGreatdangerous:MalnutritionandgrowthretardationMortalityishighTroublesometobecontrolled:AdequatecaloriesReestablishthenormalflora

63小儿腹泻-英文RotavirusesInfection64小儿腹泻-英文RotavirusesinfectionHistory:Firstrecognizedinhumansin1973byAustralianScientistBishop,withahubbedwheelappearanceunderelectronmicroscope,givingtheirname

Virology:Double-strandedRNAvirusVP6:A-Ggroup,groupAisthemostimportantgroupinchildhoodinfection65小儿腹泻-英文RotavirusesinfectionPeakseason:Deepfallandwinter(October-February）Causingsharplyincreasingofoutdoorpatients

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

Vomiting,wateryorsoftstoolthatlackgrossbloodormucusSeveredehydrationthaninfectionbyotherviralpathogensComplicationsandfatalitiesarerelatedalmostexclusivelytotheadverseeffectsofdehydration,electrolyteimbalance,andacidosisMalnutritionisariskfactorforsevereconsequences

DisaccharidesIntolerance

Laboratoryfindings:SpecificantigensinstoolspecimenrecommendedbyWHO67小儿腹泻-英文Diagnosis68小儿腹泻-英文Diarrhea?

Watery,loosestoolswithoutoronlyaminuteamountofWBCEpidemicdataStoolcultureSerousassayStoolcultureSerousassayShigellaspeciesEIECCampylobacterjejuniSalmonellatyphimuriumYersiniaenterocoliticaVirusDiarrheaETEC,EPECLotsofWBCandRBC,mucusinstoolsAcutestagePersistingorchronicdiarrheaAntibioticassociatediarrheaInfectiveNon-infective

Allergicstate?

Symptomaticdiarrhea?Inappropriatefeeding?foodintoleranceLackofdisaccharidase?Immunodeficience?Malnutrition?Malabsorption?etc.Persistinginfection?EntamoebahistolyticGiardialambliaCryptosporidiumStaphylococcusClostridiumdifficileCandidaalbicans69小儿腹泻-英文Treatment70小儿腹泻-英文MainlinesofmanagementFeedingFluidtherapyDrugs71小儿腹泻-英文

1.Feedingduringdiarrhea

ContinuefeedingthechildGiveasmuchasthechildwantGivesmallfrequentfeedsEncourageanorexicchildtoeat72小儿腹泻-英文

Forbreast-fedContinuebreastfeedingasusualduringandafterdiarrheaandrehydrationtherapy.

1.Feedingduringdiarrhea

73小儿腹泻-英文

Forformula-fed

Lowlactoseoflactose-freeformulaonlyincaseoflactoseintolerancechildren(rotavirus)

1.Feedingduringdiarrhea

74小儿腹泻-英文

ChildrenonMixedDietContinuenormalfeedingasusualGiverepeatedsmallfrequentfeedsAvoidtoosweetenedoroilyfoodsAvoidfoodscontainingahighfibercontent

1.Feedingduringdiarrhea

75小儿腹泻-英文2.Fluidtherapy76小儿腹泻-英文3.Drugsinthe

managementof

Diarrhea77小儿腹泻-英文CommonlyuseddrugsindiarrheaAntimicrobialagentsAntiparasiticsProbiotics:lactobacilli,BifidobacteriaAntidiarrhealagents:adsorbantsandmucousmembraneprotectors:SMECTA78小儿腹泻-英文AntimicrobialagentsAntimicrobialagentsarenotrecommendedforviraldiarrheainvasivepathogenandtoxicpathogeninfectionshouldchooseeffectiveantimicrobialagentsantibioticsshouldbestoppedorchangedfortheantibioticassociatediarrhea79小儿腹泻-英文FunctionsofNormalFloraDigestionProductionofvitaminsStimulationofhostimmuneresponseInhibitionofpathogenattachmentProductionofpathogeninhibitorysubstances80小儿腹泻-英文FluidTherapy81小儿腹泻-英文ORSTherapyinmildtomoderatedehydrationORSisthepreferredtreatmentforfluidandelectrolytelossescausedbydiarrhoeainchildrenwhohavemildtomoderatedehydration50-100ml/kgORStobegivenovera4-hourperiodWHOrecommendedORS

Highsodiumcontent90mmol/l82小儿腹泻-英文Intravenous

fluid

therapySeverelydehydratedorwhoareinastateofshockmustreceiveimmediateandaggressiveintravenousfluidtherapy

CompletecorrectingofthedeficitReplacingongoinglossofwaterandelectrolytesSupplythephysiologicalmaintenance83小儿腹泻-英文PhaseI:Treatshock(0-30minutes)PhaseII:InitialRehydration(½-8hours)PhaseIII:ContinuedReplacement(8-24hours)10-20ml/kg0.9%NaClReassessImprovedNoChangeMeasureplasmaelectrolytesCalculatefluiddeficitandmaintenanceReviewplasmaelectrolytesandfluidstatus