1、儿科学教研室儿科学教研室Infantile diarrheaPediatrics of Guangxi Medical UniversityQing Tang 儿科学教研室儿科学教研室Objectives,emphases,difficulty1.To master the pathogenesis and clinical manifestation of infant diarrhea2.To master the diagnosis and treatment of infant diarrhea儿科学教研室儿科学教研室儿科学教研室儿科学教研室 8个月婴儿，腹泻个月婴儿，腹泻3天，每天十
2、余次蛋花汤样便，天，每天十余次蛋花汤样便，12小时无尿，呼吸深长，前囟眼窝明显凹陷，皮小时无尿，呼吸深长，前囟眼窝明显凹陷，皮肤弹性很差，四肢厥冷，肤弹性很差，四肢厥冷，11月份就诊，血钠月份就诊，血钠125mmol/l，血钾，血钾3.2mmol/l，HCO3-10mmol/L,便便无臭味，镜检无臭味，镜检WBC0-2/HP,既往无营养不良既往无营养不良 Diagnosis?Treatment？儿科学教研室儿科学教研室Which is diarrhea?儿科学教研室儿科学教研室Types 12 indicate constipation with 3 and 4 being the ideal
3、 stools as they are easy to defecate while not containing any excess liquid 5,6 and 7 tending towards diarrhea儿科学教研室儿科学教研室Diarrhea is.A symptom characterized by an abnormal increase in stool frequency,liquidity or amountInfants:stool volume 10g/kg/day Children2:stool volume 200g/dayIn practice,this
4、typically means loose-to-watery stools passed 4 or more times per day.consistency of stools is the more important feature儿科学教研室儿科学教研室IS just a little case of diarrhea?儿科学教研室儿科学教研室-1.2-1.9episodes per person annually in the general population-2.4 episodes per child 3 years old annuallyEPidemiologyDia
5、rrhea disease mainly affects children under two years old.儿科学教研室儿科学教研室-全世界：150万；-我国：5岁儿童每年患腹泻病估计有1.7亿人次，死亡4万多；平均2.01次/人，婴儿为4次左右；Diarrhea is a leading cause of malnutrition in children under five years old.儿科学教研室儿科学教研室儿科学教研室儿科学教研室儿科学教研室儿科学教研室EPidemiologyWorldwide,around 1 billion people lack access t
6、o improved water and 2.5 billion have no access to basic sanitation.Diarrhea due to infection is widespread throughout developing countries.儿科学教研室儿科学教研室感染的动感染的动物物感染的感染的人人水水易感人群易感人群食物食物fecal-oral route ingestion of contaminated food or waterperson to person contactHow are diarrhea pathogens transmitt
7、ed?儿科学教研室儿科学教研室Prevalent seasonsBacterial enteritis is most prevalent in summerViral enteritis is in autumn and winter months,but they may be occur all year roundNoninfectious diarrhea may occur at any seasonEPIDEMIOLOGY儿科学教研室儿科学教研室EPIDEMIOLOGYFactors that increase susceptibility to infection with e
8、nteropathogens include:-young age -immune deficiency -measles malnutrition -travel to an endemic area -lack of breast feeding -exposure to unsanitary conditions -ingestion of contaminated food or water -level of maternal education -child care center attendance儿科学教研室儿科学教研室Predisposing factors 1.Chara
9、cteristic of digestive system (hypochlorhydria,digest enzyme,enzymatic activity)2.Fast developing and growth 3.Organism defense hypofunction (hypochlorhydria,immune globulin,SIgA,IgM,normal flora )4.Non-human-milk feedWhat Causes Diarrhea?儿科学教研室儿科学教研室Etiology of diarrheaInfectious factors1.Intestina
10、l infection Bacterial infections:Escherichia coli:Enteropathogenic E.coli(EPEC)Enterotoxigenic E.coli(ETEC)Enteroinvasive E.coli(EIEC)Enterohemorrhagic E.coli(EHEC)Enteroaggregative(EAEC)Campylobacter jejuni yersinia,Salmonella儿科学教研室儿科学教研室Viral infections:rotavirus,Norwalk virus,astrovirus,echo riru
11、s,enteric adenovirusParasites:Giardia lamblia,Entamoeba histolytica,and Cryptosporidium.Fungus:candida albicans儿科学教研室儿科学教研室2.Extraintestinal infections：Otitis media,upper respiratory infection,meningitis,pneumonia,urinary infection,cutaneous infection or other acute infectious diseases may associate
12、 with diarrhea and vomiting.-cause a temporary upset of gastrointestinal function (toxin,fever).-Pathogens infect intestine directly.-Local irritation of the rectum(bladder infection).儿科学教研室儿科学教研室3.Antibiotic-associated diarrhea,AAD Some antibiotics decrease carbohydrate transport and intestinal lac
13、tase levels.Eradication of normal gut flora and overgrowth of other organisms may cause diarrhea.Etiology of diarrhea儿科学教研室儿科学教研室 Excess or irregular feeding Allergic diarrhea Climatic factorcoldHotNoninfectious factorsFood intolerance:lactoseDietary factor儿科学教研室儿科学教研室Viral:70-80%of infectious diarr
14、hea in developed countriesBacterial:10-20%of infectious diarrhea but responsible for most cases of severe diarrheaProtozoan:less than 10%Etiology of diarrhea儿科学教研室儿科学教研室Secretory Diarrhea：Excess secretion of electrolytes,fluid across mucosa Exudative diarrheaIncrease in intestinal permeability,leadi
15、ng to increased loss of water and electrolytesAbnormal intestinal motility：Increase in intestinal motilityOsmotic diarrhea Increase in unabsorbable osmotically active molecules in the intestinal lumen 儿科学教研室儿科学教研室Disaccharidase Glucose-Na+transporterSecretory cellundifferentiated cell Intestinal cry
16、ptGoblet cellAbsorptive cell儿科学教研室儿科学教研室Viral infective enteritis rotavirus invade the epithelial cells of small intestine microvilli are irregular villi destroy swollen and shortened activity of disaccharidase Glucose-Na+transporter Area of absorption lactose can not be Absorption of Absorption of
17、digested and absorbed Glucose and Na+carbohydrate and lipid Organic acid osmolarity Watery diarrhea PathogenesisFigure 1.Pathogenesis of rotaviral enteritis 儿科学教研室儿科学教研室儿科学教研室儿科学教研室轮状病毒非结构蛋白轮状病毒非结构蛋白4 4的作用的作用u作用固有层细胞，激活cl-的分泌和水的外流u改变上皮细胞的完整性，影响细胞膜的通透性u形成通道或激活钙激活通道，导致分泌增加u通过旁分泌效应作用于未感染的细胞。u直接作用于肠道神经系
18、统，产生类似霍乱毒素引起的腹泻New！儿科学教研室儿科学教研室儿科学教研室儿科学教研室Invasive pathogens invade and multiply within intestinal mucosa inflammatory changes(congestion,swollen,inflammatory cell infiltration,effusion and ulcer)water and electrolyte are not absorbed entirely diarrhea WBC,RBC increase severe general in stools toxi
19、c symptoms Figure 3.Pathogenesis of invasive enteritis 儿科学教研室儿科学教研室（四）非感（四）非感染性腹泻染性腹泻儿科学教研室儿科学教研室Diarrhea ClassificationDurationAcute diarrhea：2mPersistent diarrhea:2w 2mpathogenyInfectedNon infectedPathophysiologyOsmoticSecretoryExudationAbnormal motilityPathogenetic condition Mild diarrhea Severe
20、diarrhea儿科学教研室儿科学教研室Clinical ManifestationsGastrointestinal symptomsDisturbance of water,electrolyte,and acid-base balance-Diarrhea-Vomiting-Abdominal pain-Dehydration-Metabolic acidosis-Hyponatremia,Hypokalemia,Hypocalcemia,Hypomagnesemia儿科学教研室儿科学教研室MILDSEVERECausedietary factors or extraintestinal
21、 infections intestinal infectionsStool10/daywatery stoolyellow or greenish yellow,sometimes with mucus,pus and bloodVomitingmildsevere even blood in vomitusabdominal painmildabdominal painOther symptoms noneanorexia,nausea,and abdominal distentionSystemic symptoms temperatureNo,May be restless or ir
22、ritableis normal or slight highObvious systemic toxic symptoms,may be very irritable,lethargy even coma;may be high or lowdehydration,electrolyte and acid-base disturbances.nomoderate even severe儿科学教研室儿科学教研室When a person loses more than 10%of their body fluids they can die.儿科学教研室儿科学教研室Dehydration 由于
23、呕吐、腹泻丢失体液和摄入量不足,使体液总量尤其细胞外液减少，导致不同程度的脱水。由于腹泻时水和电解质二者丢失比例不同，造成体液渗透压变化，导致不同性质脱水。按脱水程度程度分：轻、中、重度脱水 按脱水性质性质分：低渗、等渗、高渗性脱水。儿科学教研室儿科学教研室The most precise method of assessing fluid deficit is based on pre-illness weight,calculated as follows:fluid deficit(L)=Pre-illness weight(kg)-illness weight(kg)%Dehydrat
24、ion=Pre-illness weight(kg)-illness weight(kg)Pre-illness weight(kg)if this is not available,clinical observation may be used,as described below100%儿科学教研室儿科学教研室儿科学教研室儿科学教研室Clinical Observations in DehydrationDEHYDRATION MILDMODERATESEVEREBody weight lossEstimated fluid deficit 3-5%(30-50 ml/kg)5-10%(
25、50-100ml/kg)10%or more (100120ml/kg)Skin turgorNormaldecreasedMarkedly deceasedSkin(touch)NormalDryClammyBuccal mucosa/lipsMoistDryParched/crackedCNSConsolableIrritableLethargicObtundedFontanelleFlatsunkenVery SunkenEyesNormal SunkenGrossly Sunken儿科学教研室儿科学教研室DEHYDRATIONMILDMODERATE SEVERETearsPresen
26、tReducedNoneSystolic blood pressureNormalNormal or low,orthostatic hypotensionLow,may be unrecordablerespirationNormalDeep,may be rapidDeep and rapidPulse RateNormalSlightlyIncreasedIncreasedPulse qualityNormalWeakFeebleImpalpableCapillary refillNormal2 seconds3 secondsUrine outputNormalDecreasedAnu
27、ric儿科学教研室儿科学教研室Early dehydration no signs or symptoms.Moderate dehydration:thirst restless or irritable behaviour decreased skin elasticity sunken eyes Severe dehydration:symptoms become more severe shock,with diminished consciousness,lack of urine output,cool,moist extremities,a rapid and feeble pu
28、lse,low or undetectable blood pressure,pale skin.儿科学教研室儿科学教研室脱水程度脱水程度临床表现 轻 中 重神志 精神稍差 烦躁不安或萎靡昏睡或昏迷皮肤 稍干、弹性可 干、弹性差 灰白冰冷、弹性极差前囟眼窝 稍凹 凹陷明显 极度凹陷、眼闭不合唇粘膜 稍干 干燥 干裂尿量 稍减 显著减少 几乎无尿末梢循环 好 差、四肢稍凉 休克、肢厥冷失水量 10估计累积损失 50ml/kg 50-100ml/kg 100-120ml/kg儿科学教研室儿科学教研室 Dehydration-Eyes Sunkun儿科学教研室儿科学教研室Skin elasticit
29、y Pinch儿科学教研室儿科学教研室Skin elasticity Pinch retracts slowly儿科学教研室儿科学教研室儿科学教研室儿科学教研室儿科学教研室儿科学教研室儿科学教研室儿科学教研室The type of dehydrationType of dehydration electrolyte statusHypotonic or hyponatremia serum Na150mEq/L A reflection of the relative net losses of water and electrolytes Based on serum sodium conc
30、entration or plasma osmolality儿科学教研室儿科学教研室In isotonic dehydration no osmotic gradient across cell walls exists,ICF volume unchanged.ICFECF儿科学教研室儿科学教研室脱水症状严重，容易脱水症状严重，容易发生休克；发生休克；脑细胞水肿出现神经脑细胞水肿出现神经系统症状系统症状 儿科学教研室儿科学教研室ECFICF在失水量相同情况下，脱水症在失水量相同情况下，脱水症较轻；较轻；细胞内脱水：皮肤黏膜干燥、烦细胞内脱水：皮肤黏膜干燥、烦渴、高热、烦躁不安、肌张力渴、高热
31、、烦躁不安、肌张力增高、惊厥；增高、惊厥；神经细胞脱水：脑脊液压力降低，神经细胞脱水：脑脊液压力降低，脑血管破裂出血，脑血栓；脑血管破裂出血，脑血栓；儿科学教研室儿科学教研室Hypertonic and hypotonic dehydration each occur in 10-15%,but approximately 70-80%of pediatric dehydration is isotonicl A child with diarrhea for several days who has ingested adequate water but little sodium may
32、have hypotonic.l An infant with a high fever for several days and little access to water may have hypertonic儿科学教研室儿科学教研室 低渗脱水低渗脱水 等渗脱水等渗脱水 高渗脱水高渗脱水血钠血钠 130130mmol/Lmmol/L 130-150 150 130-150 150病因病因 慢泻营养不良慢泻营养不良 腹泻、胃肠腹泻、胃肠 高热、高热、大汗大汗 低盐并利尿低盐并利尿 引流引流 泻输高张液泻输高张液精神精神 极度萎靡极度萎靡 萎靡烦躁萎靡烦躁 兴奋激惹兴奋激惹昏迷昏迷口渴口渴
33、早期不明显早期不明显 一般一般 早期即有、早期即有、烦渴烦渴尿量尿量 减少减少 减少减少 减少减少皮肤皮肤 弹性极差湿冷弹性极差湿冷 燥弹性差燥弹性差 燥弹性正常燥弹性正常循环循环 衰竭早严重衰竭早严重 重症有衰竭重症有衰竭 一般无衰竭一般无衰竭各型脱水临床特点各型脱水临床特点儿科学教研室儿科学教研室HypokalemiaSerum K+3.5mEq/LCauses:1.Increased potassium losses.2.Decreased stores.3.Shift into intracellular compartment.Alkalosis,hyperinsulinemia儿科
34、学教研室儿科学教研室HypokalemiaClinical manifestations 1.Causes skeletal muscle weakness or paralysis,ileus 2.ECG changes include ST segment depression,T waves flattening or inversion,appearance of U waves and arrhythmias.3.Long standing hypokalemia causes a typical vacuolar nephropathy and polyuria.儿科学教研室儿科学
35、教研室u为什么脱水早期，钾离子总量减少，而血清为什么脱水早期，钾离子总量减少，而血清钾多数正常？钾多数正常？u为什么随着脱水的纠正，低血钾的症状反而为什么随着脱水的纠正，低血钾的症状反而会出现呢？会出现呢？儿科学教研室儿科学教研室低钾血症的临床表低钾血症的临床表现不仅取决于血现不仅取决于血K K的浓度，更取决于的浓度，更取决于缺钾的速度。缺钾的速度。儿科学教研室儿科学教研室Metabolic acidosiscauses:-Stool bicarbonate losses-Starvation ketosis due to poor intake and malabsorption-Hypop
36、erfusion and hypotension lead to tissue hypoxia and accumulation of lactic acid-Decreased excretion of fixed acid due to oliguriaAcidosis is most commonly associated with severe diarrhea儿科学教研室儿科学教研室Clinic manifestationsMild:asymptomaticModerate:deep and rapid breathingSevere:confusion,drowsiness,myo
37、cardial depression and shock儿科学教研室儿科学教研室PH7.35,CO2cp -BE HCO3-HCO3-mEq/L Normal 18-27Mild acidosis 13-18 Moderate 9-13 Severe 9儿科学教研室儿科学教研室儿科学教研室儿科学教研室Hypocalcemia and hypomagnesemiaHypocalcemia Total calcium1.75mmol/l Ionized calcium1.0mmol/lHypomagnesemiamagnesium0.6mmol/l儿科学教研室儿科学教研室Clinic manife
38、stationTetany and convulsion.if patient has been given calcium,the tetany or convulsion are not relieved,Hypomagnesemia should be considered儿科学教研室儿科学教研室脱水纠正前，可不出现症状脱水纠正前，可不出现症状脱水酸中毒纠正后，易出现症状？脱水酸中毒纠正后，易出现症状？脱水、酸中毒未纠正：血液浓缩，血脱水、酸中毒未纠正：血液浓缩，血Ca+Ca+浓浓 度相对增高度相对增高脱水、酸中毒纠正后：血液稀释，血清结合脱水、酸中毒纠正后：血液稀释，血清结合 钙增多，
39、离子钙钙增多，离子钙 儿科学教研室儿科学教研室几种常见类型肠炎几种常见类型肠炎儿科学教研室儿科学教研室Viral gastroenteritisvViruses are the most common cause of acute gastroenteritis in developing and developed countriesv80-85%of episodes of acute diarrhea are caused by viruses儿科学教研室儿科学教研室Magnitude of the ProblemDeveloping countries2.6 episodes/chil
40、d/year in children 7PH7儿科学教研室儿科学教研室Antimicrobial Agentu大肠杆菌：大肠杆菌：庆大、庆大、FPAFPA、三代头孢三代头孢u空肠弯曲菌：红霉素、空肠弯曲菌：红霉素、庆大、氯霉素、庆大、氯霉素、FPAFPAu鼠伤寒：氨苄、鼠伤寒：氨苄、庆大、庆大、FPAFPA、三代头孢三代头孢u金葡菌：金葡菌：万古霉素、万古霉素、邻氯青霉素邻氯青霉素u伪膜肠炎：伪膜肠炎：万古霉素、万古霉素、灭滴灵灭滴灵u真菌：制霉菌素真菌：制霉菌素儿科学教研室儿科学教研室Nonantimicrobial AgentuAntidiarrheal medications（洛哌丁胺）
41、（洛哌丁胺）前前3 3天避免用止泻药天避免用止泻药uantisecretory drugs （消旋卡多曲）（消旋卡多曲）uIntestinal mucosa protector Smectite PowderuMicrocological therapy Bifidobacterium儿科学教研室儿科学教研室 Zinc has been identified to play a critical role in metalloenzymes,polyribosomes,the cell membrane,and cellular function,leading to the belief t
42、hat it also plays a central role in cellular growth and in the function of the immune system.Intestinal zinc losses during diarrhea aggravate preexisting zinc deficiency.锌制剂锌制剂儿科学教研室儿科学教研室uA reduction in the duration of acute diarrhea episodesuReduction in stool outputuReduction in stool frequencyuR
43、eduction in incidence of diarrhoea in the 2 to 6months following the end of the short course of supplementation 儿科学教研室儿科学教研室 WHO supplemental zinc 20 mg per day for 6 months 10 mg per day for 6 months for 14 days儿科学教研室儿科学教研室l access to safe drinking-water l improved sanitation l exclusive breastfeed
44、ing for the first six months of life l good personal and food hygiene l health education about how infections spread l rotavirus vaccination.Prevention儿科学教研室儿科学教研室儿科学教研室儿科学教研室思考题 6月男孩，因发热、腹泻3天于12月18日急诊入院，入院前三天清晨突起发热，下午呕吐2次，继而泻水样便5-6次，量少，次日吐止，泻频增至10余次/天，尿量减少，体温：38.5，神萎，前囟眼窝凹陷，泪少，咽稍充血，心肺检查正常，皮肤弹性减退。腹泻
45、的病因是什么？应如何治疗？(是否用抗生素？液体疗法)儿科学教研室儿科学教研室参考文献参考文献1.81.8年制及年制及7 7年制儿科学年制儿科学 人民卫生出版社人民卫生出版社2.2.医学英文原版改编双语教材儿科学医学英文原版改编双语教材儿科学 科学出科学出版社版社儿科学教研室儿科学教研室The end Thank you!儿科学教研室儿科学教研室Stool CharacteristicsSmall BowelLarge BowelAppearanceWateryMucoid and/or bloodyVolumeLargeSmallFrequencyIncreasedHighly increas
46、edBloodPossibly positive but never gross bloodCommonly grossly bloodypHPossibly 5.5Reducing substancesPossibly positiveNegativeWBCs10/high power fieldSerum WBCsNormalPossible leukocytosis,bandemiaOrganismsViralRotavirusAdenovirusCalicivirusAstrovirusNorwalk virusInvasive bacteriaE Coli(enteroinvasiv
47、e,enterohemorrhagic)Shigella speciesSalmonella speciesCampylobacter speciesYersinia speciesAeromonas speciesPlesiomonas species Enterotoxigenic bacteriaE coliClostridium perfringensCholera speciesVibrio speciesToxic bacteriaClostridium difficile儿科学教研室儿科学教研室Table 2.Organisms and Frequency of Symptoms
48、 OrganismIncubationDurationVomitingFeverAbdominal PainRotavirus1-7 days4-8 daysYesLowNoAdenovirus8-10 days5-12 daysDelayedLowNoNorwalk virus1-2 days2 daysYesNoNoAstrovirus1-2 days4-8 days+/-+/-NoCalicivirus1-4 days4-8 daysYes+/-NoAeromonas speciesNone0-2 weeks+/-+/-NoCampylobacter species2-4 days5-7
49、 daysNoYesYesC difficileVariableVariableNoFewFewC perfringensMinimal1 dayMildNoYes儿科学教研室儿科学教研室FLUID THERAPY儿科学教研室儿科学教研室“In the year 2002,about 2.2 million children will die of dehydration caused by diarrhoea.80%of them in the first two years of their life;42,000 a week,6,000 a day,four every minute,
50、one every fourteen seconds.”(Rehydration program)儿科学教研室儿科学教研室The goal is to normalize the intracellular and extracellular chemical environments that optimize cell and organ function 儿科学教研室儿科学教研室1 1、小儿体液平衡的特点：、小儿体液平衡的特点：（1）Total body water and fluid compartment：TBW as a percentage of body weight decr
