diarrhea婴儿腹泻英文后修.pptx

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1、Major cause of childrens(Major cause of childrens(5y)death5y)death in developing countries in 2002 in developing countries in 2002ARIARIdiarrheadiarrheaMalariaMalariameaslesmeaslesAIDSAIDSDisease inDisease inperinatal stageperinatal stageothersothers18%25%23%4%5%10%15%WHO/UNICEF.Clinical management

2、of acute WHO/UNICEF.Clinical management of acute diarrheadiarrheaSources:The world health report 2003,WHO,Geneva.第1页/共71页第2页/共71页General introductionClassification Predisposing factorEtiologyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrheaDiagnosisD

3、ifferential DiagnosisTreatmentContent第3页/共71页GeneralintroductionConcept common disease in childhood frequency and characters of stoolAges 6m2y 50%1ySeasons viral originslate autumn and spring beginning bacterial originssummer noninfectious diarrhea every seasonMultiple sources and factorsMultiple so

4、urces and factors第4页/共71页General introductionClassificationClassificationPredisposing factorEtiologyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrheaDiagnosisDifferential DiagnosisTreatmentContent第5页/共71页CausesCourseDegreeInfectious diarrhea:virus,ba

5、cterium,fungi,parasitesNoninfectious diarrhea:diet,weather,othersAcute：2mMild:the times of stool and character changeSevere:accompany dehydration,electrolytes abnormality and general toxicity symptomsClassification第6页/共71页General introductionClassificationPredisposing factorPredisposing factorEtiolo

6、gyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrheaDiagnosisDifferential DiagnosisTreatmentContent第7页/共71页Gastric acid secretion ,secretion and activity of enzyme ,quality and quantity of diet change quickly.Water metabolism ，tolerance of hydropenia

7、，easy to body fluid disorder.Nerves,endocrine,circulation,liver and renal function:not mature,easy to digestive tract function disorder.Predisposingfactor-1Development of infancy digestive system:not Development of infancy digestive system:not maturemature第8页/共71页Predisposing factor-2Defense system:

8、not matureThree defense system():microflora,epithelium,immunity第9页/共71页Growanddevelop,demandfornutrients,burdenofthestomachandintestines,easytoindigestion.Artificalfeeding:enteritismorbility10timeshigherthanbreastfeeding.milk:nutritionalingredientdestroyedmilktool:disinfection.Predisposing factor-3&

9、4 3 4n nThe lower level of serum immunoglobulin,especially serum IgA located in The lower level of serum immunoglobulin,especially serum IgA located in gastrointestinal tract is smaller than others.Disorder microbial population gastrointestinal tract is smaller than others.Disorder microbial populat

10、ion of digestive tract resulting from using antibacterial drugs for a long time or of digestive tract resulting from using antibacterial drugs for a long time or normal microbial population have not been established in neonates.normal microbial population have not been established in neonates.第10页/共

11、71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%37.0%0.05（Howie et al 1990）Artificial feeding:easy to intestinal infection第11页/共71页Breast feedingDays%o

12、f total faecal micro-organismsArtificial feedingDays0102030405060708090100%of total faecal micro-organismsBacillus bifidusBacillus coliBacillus faecalis510152001020304050607080901000101520255010152025According to Harmsen et al.,2000 Artificial feeding:easy to disorder microbial population第12页/共71页Ge

13、neral introductionClassificationPredisposing factorEtiologyEtiologyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrheaDiagnosisDifferential DiagnosisTreatmentContent第13页/共71页Infectious animalInfectious humanwaterSusceptible populationfoodfecalfecal-ora

14、loral wayway Etiology-1:intraenteric infection第14页/共71页From Kapikian AZ,Chanock RM.Rotaviruses.In:Fields Virology 3rd From Kapikian AZ,Chanock RM.Rotaviruses.In:Fields Virology 3rd ed.Philadelphia,PA:Lippincott-Raven;1996:1659.ed.Philadelphia,PA:Lippincott-Raven;1996:1659.Developed countryBacteriuBa

15、cterium m Uncertain Uncertain reasonreasonRotavirusRotavirusCalicivirus Calicivirus Rotavirus Rotavirus Bacillus Bacillus colicoliParasite Parasite Other Other bacteriubacteriummAdenoviruAdenovirus s CaliciviruCalicivirus s AstrovirusAstrovirus Adenovirus Adenovirus Astrovirus Astrovirus Uncertain U

16、ncertain reasonreasonDeveloping Developing countrycountryDistribution of etiological agentIntraenteric infection第15页/共71页RotavirusAstrovirusCalicivirus:Norwalkvirus,sapovirusEnterovirus:Coxsackievirus,echovirus,entericadenovirusCoronavirus:torovirus Intraenteric infection-virusVirus 80%infantile dia

17、rrhea in cold months.第16页/共71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71页 Intraenteric infection-rotavirus 20-side body(65-75nm)Nucleus:45-50nmShape:wheelLife:7mBear acid-20:keep long第18页/共71页Photo Credit:F.P.Williams,U

18、.S.Environmental Protection Agency;Adapted from Parashar et al,Emerg Inft Dis 199814(4)561570Rotavirus in stool by electronmicroscop Intraenteric infection-rotavirus 第19页/共71页Bacilluscoli enteropathogenicE.coliEPECenterotoxigenicE.coliETECenteroinvasiveE.coli.EIECenterhemorrhagicE.coliEHECenteroadhe

19、rentaggregativeE.coliEAECCampylobacterjejuni,Yersiniaenterocolitica,othersFungi：blastomycesalbicansProtozoa(parasite)：giardialamblia,amebicprotozoa Intraenteric infection-bacterium etc.第20页/共71页DisorderintestinalfunctionInfectintestinaltractdirectlyIrritationofrectum(eg.bladderinfection)alterationof

20、intestinalfloraMuchantibioticsusedtransportofcarbohydratelactase Etiology-2:extraenteric infectionPneumonia,URI,USI,otitis media,skin infection,etc.第21页/共71页Dietaryfactorsnqualityandquantityoffood(feedingstarchandfattooearly)nAllergicdiarrhea:milkorbeannPrimaryandsecondarydisaccharidasedeficiency Et

21、iology-3:noninfectious causesoWeather factorsCool enterokinesia Hot secretion of digestive juice and gastric take milk because of thirsty 第22页/共71页General introductionClassificationPredisposing factorEtiologyPathogenesisPathogenesisClinical manifestationsClinical features of several common enteritis

22、Persistent diarrheaDiagnosisDifferential DiagnosisTreatment Content第23页/共71页Osmoticdiarrhea:muchpoorlyabsorbedandhyperosmoticsoluteSecretorydiarrhea:electrolyteshypersecretionExudativediarrhea:inflammatorystatescausingliquorexudationMotilitydisturbance:dynamicabnormalityofintestineNoninfectiousdiarr

23、hea:feedingfactors Pathogenesis Usually combination of several mechanisms第24页/共71页 Pathogenesis-1:enterotoxin AdenylatecyclaseIntestinal juice secretion Labile toxin（LT）CAMP H2O,Na+,Cl-transfer into enteric cavityStable toxin（ST）GuanylatecyclaseGTPCGMP ATPactivateactivateVolume of intestinal juicedi

24、arrhea第25页/共71页产毒性大肠杆菌产毒性大肠杆菌 附着到小肠粘膜上进行繁殖附着到小肠粘膜上进行繁殖 在小肠上部，通过在小肠上部，通过菌毛上的粘附因子菌毛上的粘附因子 肠毒素肠毒素 不耐热肠毒素不耐热肠毒素不耐热肠毒素不耐热肠毒素 Labile toxin,LTLabile toxin,LT 耐热肠毒素耐热肠毒素 stable toxin,ST 腺苷酸环化酶腺苷酸环化酶 鸟苷酸环化酶鸟苷酸环化酶 细胞内细胞内ATP cAMPATP cAMP GTP cGMPGTP cGMP 抑制小肠绒毛上皮细胞吸收抑制小肠绒毛上皮细胞吸收NaNa+、ClCl-和水，并促进和水，并促进ClCl-分泌分泌

25、 肠液中肠液中NaNa+、ClCl-和水总量增多，超过结肠吸收限度和水总量增多，超过结肠吸收限度 大量水样腹泻大量水样腹泻 激活激活激活激活肠毒素引起的肠炎发病机理肠毒素引起的肠炎发病机理以产毒性大肠杆菌为例以产毒性大肠杆菌为例 第26页/共71页Pathogenesis-2:bacterium invades enteroninvadeSmall intestinecolonEnteronwall mucosa:congestion,edema,effusion,ulser and hemorrhagePoorly absorption of H2O and electrolytediarr

26、hea第27页/共71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,RBCWBC,RBC大量增加 严重中毒症状侵袭性肠炎发病机制第28页/共71页Virus invasionPathogenesis-3:virus infectionrecrement Disacchride Poorly decomposedlactose Osmotic diarrheaNa+transportblock H2O electrolyte disaccharidase第29页/共71页病毒性肠炎发病机理病毒性肠炎发病机理 病毒侵入小肠

27、粘膜绒毛上皮细胞并复制病毒侵入小肠粘膜绒毛上皮细胞并复制粘膜受累，绒毛被破坏粘膜受累，绒毛被破坏 绒毛缩短绒毛缩短 微绒毛肿胀，紊乱并脱落微绒毛肿胀，紊乱并脱落 线粒体、内质网膨胀线粒体、内质网膨胀 双糖酶活性下双糖酶活性下降降载体减少载体减少消化吸收面积减少消化吸收面积减少双糖（乳糖）吸收减少双糖（乳糖）吸收减少 葡萄糖钠与载体结合葡萄糖钠与载体结合偶联转运吸收障碍偶联转运吸收障碍 营养物质吸收减少营养物质吸收减少 部分乳糖分解为小分子的乳酸部分乳糖分解为小分子的乳酸 渗透压增加渗透压增加水样腹泻水样腹泻 第30页/共71页Pathogenesis-4:noninfectious diarr

28、heaFood fermn mydesisEnteric osmotic pressure Digestive functiondisorderOsmotic diarrheaOver-feeding,No proper dietary第31页/共71页食物质、量不当食物质、量不当食物质、量不当食物质、量不当 食物消化吸收障碍而积滞在上消化道食物消化吸收障碍而积滞在上消化道 胃酸度下降胃酸度下降 肠道下部细菌上移并繁殖肠道下部细菌上移并繁殖 内源性感染内源性感染 发酵、腐败发酵、腐败 有机酸（乳酸、乙酸）有机酸（乳酸、乙酸）胺类胺类 肠腔内渗透压增高肠腔内渗透压增高肠腔内渗透压增高肠腔内渗透压

29、增高 肠蠕动增强肠蠕动增强 腹泻、脱水、电解质紊乱、酸中毒腹泻、脱水、电解质紊乱、酸中毒 分解食物分解食物 中毒症状中毒症状 肝解毒功能不全肝解毒功能不全肝解毒功能不全肝解毒功能不全 毒素进入血循环毒素进入血循环毒素进入血循环毒素进入血循环 饮食不当引起腹泻发生机理饮食不当引起腹泻发生机理 第32页/共71页TheRViscomposedby11gemesegments，NSP4(非结构蛋白4）istheclosenessofPathogenesisThe study progression by RV cause The study progression by RV cause diarr

30、headiarrhea 第33页/共71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71页General introductionclassificationPredisposing factorEtiologyP

31、athogenesisClinical manifestationsClinical manifestationsClinical features of several common enteritisPersistent diarrheaDiagnosisDifferential DiagnosisTreatment Content第35页/共71页Digestive tractsymptomWater,electrolytes and acid-base disorderDehydrationMetabolic acidosisElectrolytes disorderoDiarrhea

32、ovomitoAbdominal pain Clinical manifestation第36页/共71页MildandseverediarrheaMild:thetimesofstoolandcharacterchangestool:frequency,loose,liquid,color:yelloworgreenyellow,smell:sourflavor,shape:eggsoupvomiting:seldomgeneralpoisoningsymptom:withoutdehydration,electrolytesabnormalityandgeneraltoxicitysymp

33、toms:none第37页/共71页Severe:accompanydehydration,electrolytesabnormalityandgeneraltoxicitysymptomsdigestivetractsymptom:diarrheaserious,mucusbloodsamplestool,anorexia,nausea,abdominalpainandabdominaldistentiongeneral poisoningsymptom:lethargy,dysphoria,unconsciousnessandcomadehydration,electrolytesabno

34、rmality,acidbaseimbalanceMildandseverediarrhea第38页/共71页Degree Quality mildmoderateHypotonic+130mmol/L+150mmol/L Clinical manifestation-1:dehydrationsevere+:130150mmol/L第39页/共71页SeverityclinicalsignsofdehydrationmildmoderatesevereWater lossBy weightSpirit SkinMucous Anterior fontanel and eye ballTear

35、thirstUrine outputPeripheral circulation50ml/kg 5%Slightly dispiritedslightly agitatedSlightly drySlightly drySlightlydepressedNormalslightlydecreasednormal50100ml/kg5%10%DispiritedAgitatedDry,paleVery dry depressedReducedincreasedLittle or noLittle cool100120ml/kg10%Extremely dispiritedapathy,hypno

36、dy,comaGray mottledParched depressed greatlyNoGreatly increasedNo urine outputCool,weak pulse,shock Dehydration 第40页/共71页AnuriatachypneaAnterior fontanel and eye ball DepressedNo TearCool,weak pulse,shockDry,pale,Gray mottledapathy,dispiritedSkin and Mocous dryWeight decrease 第41页/共71页Eye socket dep

37、ressed,rima oculi not closed第42页/共71页Xerocheilia,chap第43页/共71页 Dehydration Same proportion lossP IFCPIFCElectrolyte lossmoreP hypotonic,IF+C hypertonicCell expansionSevereEasy to shockP:plasma,IF:interstitial fluid,C:cellIsotonic PIFCWater lossmoreP hypertonicIF+C hypotonicCell hydrationMildThirsty

38、Acute diarrheaafter vomiting greatlyHypotonic Hypertonic 第44页/共71页Vomitinganddiarrhea:AlkalinityintestinaljuicelostEat:calorie,malabsorptionlipoclasisketo-bodiesHypovolemiapachemiabloodflowslowlyhypoxiaanaerobicglycolysislacticaciddehydrationbloodflowexcludingacidacidmetabolicproduct Clinical manife

39、station-2:metabolic acidosisCauses:第45页/共71页Dispirited,dysphoria,drowsiness,comaHypernea(Kussmaulsbreathing)，exhalationcoolExpiratorygassmellsketoneCherrylipsNausea,vomit Metabolic acidosis-clinical manifestationMild:breath frequency slightlySevere:occur:第46页/共71页K+5.5mmol/L)causes：Excessivelosses:v

40、omit,diarrhea.Inadequateintake.Renalfunctionofkeepingkalium,itcontinuesexcludingkaliumwhenwithhypokalemia.Clinical manifestation-3:electrolyte disorder Hypokalemia第47页/共71页depressedTensionofskeletalmuscle，tendonreflex，evenrespiratorymuscleweaknessTensionofsmoothmuscle,abdominaldistention intestinals

41、oundordisappearMyocardiumexcitability,arrhythmia,ECG:T-waveisloworinversion,U-waveoccurs,prolongedP-RintervalandQ-Tinterval,STsectiondescending.Baseosis hypokalemiaClinical manifestation:nerve and muscular excitability第48页/共71页Ca2+1.75mmol/L(7mg/dl);Mg2+0.6mmol/L(1.5mg/dl).Symptomsusuallyoccurafterd

42、ehydrationandacidosisresolved,orfluidreplacement.Clinicalmanifestation:thrill,tetany,convulsion.Ifconvulsionhasntrelievedaftersupplementcalcium,payattentiontohypomagnesemia.hypocalcemia&hypomagnesemia第49页/共71页General introductionClassificationPredisposing factorEtiologyPathogenesisClinical manifesta

43、tionsClinical features of several common enteritisClinical features of several common enteritisPersistent diarrheaDiagnosisDifferential DiagnosisTreatmentContent第50页/共71页 Several common enteritis-1:Season:coolmonths(autumnandwinter)Age:6m2ySymptom:fever,vomit,mildgeneraltoxicitysymptoms.Stool:freque

44、ncy,amount,water;yellow-wateroreggsoup-like;asmallamountofmucus.Dehydration:mild/moderate，isotonic/hypertonicComplication:convulsion,myocardiumdamaged.Prognosis:self-limited,course:38d.Viralantigendetection:fromstool.Rotavirus enteritis human rotavirus(HRV)第51页/共71页 Several common enteritis-2:ETEC e

45、nteritis 产毒性细菌Season:summerSymptom:vomitanddiarrhea,noobviousgeneraltoxicitysymptoms.Stool:water-likeoreggsoup-like,withoutmucus,bloodorpus,noWBC(testundermicroscope).Dehydration:dehydration,electrolyteandacid-basedisorderusuallyoccur.Prognosis:self-limited,course:37d.ETECenteritis第52页/共71页 Several

46、common enteritis-3:EIEC enteritis 侵袭性细菌侵袭性细菌Similarwithbacillarydysentery.Symptom:diarrheawithfever,nausea,vomit,abdominalpain,tenesmus.Severegeneraltoxicitysymptoms,e.g.ardentfever,consciousnesschange,evensepticshock.Stool:withmucus,bloodandpus,smelloffish,withWBC(testundermicroscope).Stoolculture:

47、pathogenicbacterium.EIECenteritis第53页/共71页 Several common enteritis-4:fungal enteritisPathogen:usuallyBlastomycesalbicans.Age:2y.Complicationbyotherinfection,orafterusingantibioticsforlongtime.Persistentcourse,usuallythrushcompanion.Stool:yellowthinstool,morefoamwithmucus,sometimestofukasu-like.test

48、undermicroscope:fungalsporeandhypha.fungalenteritis第54页/共71页General introductionClassificationPredisposing factorEtiologyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrheaPersistent diarrheaDiagnosisDifferential DiagnosisTreatment Content第55页/共71页Gast

49、ricmucosaanalosisbacteriumandyeastfungusIntestinalmucosathinnerindigestionandmalabsorptionBacteriuminuppersmallintestineenterocytedamagedDynamicabnormalityofintestine.Usingantibioticsforlongtime.Immunefunctiondefectliabilitytoagents Persistent diarrhea acute diarrhea without proper or thorough treat

50、ment.Causes:第56页/共71页malnutritiondiarrheavicious cycleDiarrhea+malnutrition:mortality 4 times higher than normal children第57页/共71页General introductionClassificationPredisposing factorEtiologyPathogenesisClinical manifestationsClinical features of several common enteritisPersistent diarrheaDiagnosisD