diarrhea(嬰兒腹瀉英文)后修.ppt

DiarrheaDisease ThefirstaffiliatedhospitalSUNYAT SENuniversityProf WangHuishen王慧深 Majorcauseofchildren s 5y deathindevelopingcountriesin2002 ARI diarrhea Malaria measles AIDS Diseaseinperinatalstage others 18 25 23 4 5 10 15 WHO UNICEF Clinicalmanagementofacutediarrhea Sources Theworldhealthreport2003 WHO Geneva GeneralintroductionClassificationPredisposingfactorEtiologyPathogenesisClinicalmanifestationsClinicalfeaturesofseveralcommonenteritisPersistentdiarrheaDiagnosisDifferentialDiagnosisTreatment Content Generalintroduction ConceptcommondiseaseinchildhoodfrequencyandcharactersofstoolAges6m 2y50 1ySeasonsviralorigins lateautumnandspringbeginningbacterialorigins summernoninfectiousdiarrhea everyseason Multiplesourcesandfactors GeneralintroductionClassificationPredisposingfactorEtiologyPathogenesisClinicalmanifestationsClinicalfeaturesofseveralcommonenteritisPersistentdiarrheaDiagnosisDifferentialDiagnosisTreatment Content Causes Course Degree Infectiousdiarrhea virus bacterium fungi parasites Noninfectiousdiarrhea diet weather others Acute 2m Mild thetimesofstoolandcharacterchange Severe accompanydehydration electrolytesabnormalityandgeneraltoxicitysymptoms Classification GeneralintroductionClassificationPredisposingfactorEtiologyPathogenesisClinicalmanifestationsClinicalfeaturesofseveralcommonenteritisPersistentdiarrheaDiagnosisDifferentialDiagnosisTreatment Content Gastricacidsecretion secretionandactivityofenzyme qualityandquantityofdietchangequickly Watermetabolism toleranceofhydropenia easytobodyfluiddisorder Nerves endocrine circulation liverandrenalfunction notmature easytodigestivetractfunctiondisorder Predisposingfactor 1 Developmentofinfancydigestivesystem notmature Predisposingfactor 2 Defensesystem notmature Threedefensesystem microflora epithelium immunity Growanddevelop demandfornutrients burdenofthestomachandintestines easytoindigestion Artificalfeeding enteritismorbility10timeshigherthanbreastfeeding milk nutritionalingredientdestroyedmilktool disinfection Predisposingfactor 3 4 3 4 Thelowerlevelofserumimmunoglobulin especiallyserumIgAlocatedingastrointestinaltractissmallerthanothers Disordermicrobialpopulationofdigestivetractresultingfromusingantibacterialdrugsforalongtimeornormalmicrobialpopulationhavenotbeenestablishedinneonates Relationbetweenfeedingandinfectionininfants 3m Howieetal1990 Artificialfeeding easytointestinalinfection Breastfeeding Days oftotalfaecalmicro organisms Artificialfeeding Days oftotalfaecalmicro organisms Bacillusbifidus Bacilluscoli Bacillusfaecalis 5 10 15 20 0 10 15 20 25 5 0 10 15 20 25 AccordingtoHarmsenetal 2000 Artificialfeeding easytodisordermicrobialpopulation GeneralintroductionClassificationPredisposingfactorEtiologyPathogenesisClinicalmanifestationsClinicalfeaturesofseveralcommonenteritisPersistentdiarrheaDiagnosisDifferentialDiagnosisTreatment Content Infectiousanimal Infectioushuman water Susceptiblepopulation food fecal oralway Etiology 1 intraentericinfection FromKapikianAZ ChanockRM Rotaviruses In FieldsVirology3rded Philadelphia PA Lippincott Raven 1996 1659 Developedcountry Bacterium Uncertainreason Rotavirus Calicivirus Rotavirus Bacilluscoli Parasite Otherbacterium Adenovirus Calicivirus Astrovirus Adenovirus Astrovirus Uncertainreason Developingcountry Distributionofetiologicalagent Intraentericinfection RotavirusAstrovirusCalicivirus Norwalkvirus sapovirusEnterovirus Coxsackievirus echovirus entericadenovirusCoronavirus torovirus Intraentericinfection virus Virus80 infantilediarrheaincoldmonths Deathforrotavirusinfectioninchildren 5y Intraentericinfection rotavirus Intraentericinfection rotavirus 20 sidebody 65 75nm Nucleus 45 50nmShape wheelLife 7mBearacid 20 keeplong PhotoCredit F P Williams U S EnvironmentalProtectionAgency AdaptedfromParasharetal EmergInftDis199814 4 561 570 Rotavirusinstoolbyelectronmicroscop Intraentericinfection rotavirus BacilluscolienteropathogenicE coli EPECenterotoxigenicE coli ETECenteroinvasiveE coli EIECenterhemorrhagicE coli EHECenteroadherentaggregativeE coli EAECCampylobacterjejuni Yersiniaenterocolitica othersFungi blastomycesalbicansProtozoa parasite giardialamblia amebicprotozoa Intraentericinfection bacteriumetc DisorderintestinalfunctionInfectintestinaltractdirectlyIrritationofrectum eg bladderinfection alterationofintestinalfloraMuchantibioticsusedtransportofcarbohydratelactase Etiology 2 extraentericinfection Pneumonia URI USI otitismedia skininfection etc Dietaryfactorsqualityandquantityoffood feedingstarchandfattooearly Allergicdiarrhea milkorbeanPrimaryandsecondarydisaccharidasedeficiency Etiology 3 noninfectiouscauses WeatherfactorsCoolenterokinesiaHotsecretionofdigestivejuiceandgastrictakemilkbecauseofthirsty GeneralintroductionClassificationPredisposingfactorEtiologyPathogenesisClinicalmanifestationsClinicalfeaturesofseveralcommonenteritisPersistentdiarrheaDiagnosisDifferentialDiagnosisTreatment Content Osmoticdiarrhea muchpoorlyabsorbedandhyperosmoticsoluteSecretorydiarrhea electrolyteshypersecretionExudativediarrhea inflammatorystatescausingliquorexudationMotilitydisturbance dynamicabnormalityofintestineNoninfectiousdiarrhea feedingfactors Pathogenesis Usuallycombinationofseveralmechanisms Pathogenesis 1 enterotoxin Adenylatecyclase Intestinaljuicesecretion Labiletoxin LT CAMP H2O Na Cl transferintoentericcavity Stabletoxin ST Guanylatecyclase GTP CGMP ATP activate activate Volumeofintestinaljuice diarrhea Pathogenesis 2 bacteriuminvadesenteron invade Smallintestinecolon Enteronwall mucosa congestion edema effusion ulserandhemorrhage PoorlyabsorptionofH2Oandelectrolyte diarrhea 侵襲性細(xì)菌在腸粘膜侵襲和繁殖炎癥改變 充血 腫脹 炎性細(xì)胞浸潤(rùn) 滲出和潰瘍 水和電解質(zhì)不能完全吸收腹瀉便中WBC RBC大量增加嚴(yán)重中毒癥狀侵襲性腸炎發(fā)病機(jī)制 Virusinvasion Pathogenesis 3 virusinfection recrement DisacchridePoorlydecomposed lactose Osmoticdiarrhea Na transportblock H2O electrolyte disaccharidase 病毒性腸炎發(fā)病機(jī)理 Pathogenesis 4 noninfectiousdiarrhea Foodfermnmydesis Entericosmoticpressure Digestivefunctiondisorder Osmoticdiarrhea Over feeding Noproperdietary 飲食不當(dāng)引起腹瀉發(fā)生機(jī)理 TheRViscomposedby11gemesegments NSP4 非結(jié)構(gòu)蛋白4 istheclosenessofPathogenesis ThestudyprogressionbyRVcausediarrhea A組RV病毒基因組功能 基因片段 123469編碼結(jié)構(gòu)蛋白 VP1VP2VP3VP4VP6VP7 核心 核心 核心 外殼 內(nèi)殼 外殼區(qū)分G血清型1 14 裂解抗原區(qū)分 A G組 VP5VP8A組為 亞群 P血清型1 44 基因片段 5781011編碼非結(jié)構(gòu)蛋白 NS53NS34NS35NS28NS26 NSP1NSP2NSP3NSP4NSP5 GeneralintroductionclassificationPredisposingfactorEtiologyPathogenesisClinicalmanifestationsClinicalfeaturesofseveralcommonenteritisPersistentdiarrheaDiagnosisDifferentialDiagnosisTreatment Content Digestivetractsymptom Water electrolytesandacid basedisorder DehydrationMetabolicacidosisElectrolytesdisorder DiarrheavomitAbdominalpain Clinicalmanifestation Mildandseverediarrhea Mild thetimesofstoolandcharacterchange stool frequency loose liquid color yelloworgreenyellow smell sourflavor shape eggsoup vomiting seldom generalpoisoningsymptom without dehydration electrolytesabnormalityandgeneraltoxicitysymptoms none Severe accompanydehydration electrolytesabnormalityandgeneraltoxicitysymptoms digestivetractsymptom diarrheaserious mucusbloodsamplestool anorexia nausea abdominalpainandabdominaldistention generalpoisoningsymptom lethargy dysphoria unconsciousnessandcoma dehydration electrolytesabnormality acidbaseimbalance Mildandseverediarrhea Degree Quality mild moderate Hypotonicdehydration Na 130mmol L Hypertonicdehydration Na 150mmol L Clinicalmanifestation 1 dehydration severe Isotonicdehydration Na 130 150mmol L Severityclinicalsignsofdehydration Dehydration Anuria tachypnea AnteriorfontanelandeyeballDepressed NoTear Cool weakpulse shock Dry pale Graymottled apathy dispirited SkinandMocousdry Weightdecrease Eyesocketdepressed rimaoculinotclosed Xerocheilia chap Dehydration Sameproportionloss P IF C P IF C Electrolytelossmore Phypotonic IF Chypertonic CellexpansionSevereEasytoshock P plasma IF interstitialfluid C cell Isotonic P IF C Waterlossmore PhypertonicIF Chypotonic CellhydrationMildThirsty Acutediarrheaaftervomitinggreatly Hypotonic Hypertonic Vomitinganddiarrhea AlkalinityintestinaljuicelostEat calorie malabsorption lipoclasis keto bodiesHypovolemia pachemia bloodflowslowly hypoxia anaerobicglycolysis lacticaciddehydration bloodflow excludingacid acidmetabolicproduct Clinicalmanifestation 2 metabolicacidosis Causes Dispirited dysphoria drowsiness comaHypernea Kussmaulsbreathing exhalationcoolExpiratorygassmellsketoneCherrylipsNausea vomit Metabolicacidosis clinicalmanifestation Mild breathfrequencyslightlySevere occur K potassium 3 5mmol L normal 3 5 5 5mmol L causes Excessivelosses vomit diarrhea Inadequateintake Renalfunctionofkeepingkalium itcontinuesexcludingkaliumwhenwithhypokalemia Clinicalmanifestation 3 electrolytedisorderHypokalemia depressedTensionofskeletalmuscle tendonreflex evenrespiratorymuscleweaknessTensionofsmoothmuscle abdominaldistentionintestinalsoundordisappearMyocardiumexcitability arrhythmia ECG T waveisloworinversion U waveoccurs prolongedP RintervalandQ Tinterval STsectiondescending Baseosis hypokalemia Clinicalmanifestation nerveandmuscularexcitability Ca2 1 75mmol L 7mg dl Mg2 0 6mmol L 1 5mg dl Symptomsusuallyoccurafterdehydrationandacidosisresolved orfluidreplacement Clinicalmanifestation thrill tetany convulsion Ifconvulsionhasn trelievedaftersupplementcalcium payattentiontohypomagnesemia hypocalcemia hypomagnesemia GeneralintroductionClassificationPredisposingfactorEtiologyPathogenesisClinicalmanifestationsClinicalfeaturesofseveralcommonenteritisPersistentdiarrheaDiagnosisDifferentialDiagnosisTreatment Content Severalcommonenteritis 1 Season coolmonths autumnandwinter Age 6m 2ySymptom fever vomit mildgeneraltoxicitysymptoms Stool frequency amount water yellow wateroreggsoup like asmallamountofmucus Dehydration mild moderate isotonic hypertonicComplication convulsion myocardiumdamaged Prognosis self limited course 3 8d Viralantigendetection fromstool Rotavirusenteritis humanrotavirus HRV Severalcommonenteritis 2 ETECenteritis產(chǎn)毒性細(xì)菌 Season summerSymptom vomitanddiarrhea noobviousgeneraltoxicitysymptoms Stool water likeoreggsoup like withoutmucus bloodorpus noWBC testundermicroscope Dehydration dehydration electrolyteandacid basedisorderusuallyoccur Prognosis self limited course 3 7d ETECenteritis Severalcommonenteritis 3 EIECenteritis侵襲性細(xì)菌 Similarwithbacillarydysentery Symptom diarrheawithfever nausea vomit abdominalpain tenesmus Severegeneraltoxicitysymptoms e g ardentfever consciousnesschange evensepticshock Stool withmucus bloodandpus smelloffish withWBC testundermicroscope Stoolculture pathogenicbacterium EIECenteritis Severalcommonenteritis 4 fungalenteritis Pathogen usuallyBlastomycesalbicans Age 2y Complicationbyotherinfection orafterusingantibioticsforlongtime Persistentcourse usuallythrushcompanion Stool yellowthinstool morefoamwithmucus sometimestofukasu like testundermicroscope fungalsporeandhypha fungalenteritis GeneralintroductionClassificationPredisposingfactorEtiologyPathogenesisClinicalmanifestationsClinicalfeaturesofseveralcommonenteritisPersistentdiarrheaDiagnosisDifferentialDiagnosisTreatment Content Gastricmucosaanalosis bacteriumandyeastfungusIntestinalmucosathinner indigestionandmalabsorptionBacteriuminuppersmallintestine enterocytedamagedDynamicabnormalityofintestine Usingantibioticsforlongtime Immunefunctiondefect liabilitytoagents Persistentdiarrhea acutediarrheawithoutproperorthoroughtreatment Causes malnutrition diarrhea viciouscycle Diarrhea malnutrition mortality4timeshigherthannormalchildren GeneralintroductionClassificationPredisposingfactorEtiologyPathogenesisClinicalmanifestationsClinicalfeaturesofseveralcommonenteritisPersistentdiarrheaDiagnosisDifferentialDiagnosisTreatment Content Diagnosis NotdifficultAccordingtoclinicalmanifestation laboratorytestsandcharacterofstool InfectiousOrNoninfectious DehydrationDegreeandquality ElectrolytedisturbancesAndDisturbanceofacid basebalance GeneralintroductionClassificationPredisposingfactorEtiologyPathogenesisClinicalmanifestationsClinicalfeaturesofseveralcommonenteritisPersistentdiarrheaDiagnosisDifferentialDiagnosisTreatment Content Differentialdiagnosis 1 physiologicaldiarrhea Usually 6m bloating breast feeding Usuallywitheczema Normalappetite growthanddeveloped Aftercofoodaddition stoolturnstonormal Aspecialtypeoflactoseintolerance Differentialdiagnosis 2 dysentery EpidemiologycharacterStoolculture adysenterybacillusdiscovered Bacillarydysentery Amebicdysentery Madderredjam likestoolStool amebatrophozoitediscovered Differentialdiagnosis 3 nec