藥妝行業(yè)“十二五”規(guī)劃調(diào)研與發(fā)展

交通大學(xué)醫(yī)學(xué)院附屬

仁濟(jì)醫(yī)院消化科

上海市消化疾病研究所范竹萍DiarrheaDefinitionincreaseinthe

frequencyofbowelmovementsincreasein

stoolliquidityinsomecasesincreaseindaily

stoolweight

(>200g/d)Pathophysiologicalmechanismssecretorydiarrhea(increasedintestinalsecretion)OsmoticdiarrheaDecreasedintestinalsurfaceareaand/orintestinalabsorptionInflammatarydiarrheaRapidtransitofintestinalcontents(shortenedtransittime)Pathophysiologicalmechanismssecretorydiarrhea(increasedintestinalsecretion)

infections(choleratoxin,E-col,salmonella,staphylococcal)Hormonal(GutHormones,ZES,VIP),cancer(calcitonin,Prostaglandins)miscellaneous(laxativesabuse,villousadenomaoftherectum)agentsAdenylatecyclasecAMPsystemsecretorydiarrheaactivateNaCl

secretorydiarrhoeainfectioncholerahormonalVerner-Morrisonsyndrome(VIPassociated)carcinoidsyndromegastrinomamedullarythyroidcancerphenolphthaleinabusebilesaltmalabsorptionCholera:thesimplifiedversion

Verner-Morrisonsyndrome(VIPassociated)aprofuse,waterydiarrhoeathatresultsinmassiveintestinallossofwater,potassium,sodiumandbicarbonate,leadingtohypovolaemia,hypokalaemiaandreducedtotalbodypotassium,andachlorhydria(metabolicacidosis).carcinoidsyndromeparoxysmalflushing-forexample,followingcoffee,alcohol,certainfoodsanddrugsbronchoconstrictiveepisodes,similartoasthmaright-sidedheartfailureepisodesofexplosivewaterydiarrhoeaabdominalpainpellagra-likelesionsoftheskinandoralmucosagastrinoma

TheZollinger-Ellisonsyndromedescribestheassociationof:gastrin-producingtumoursgastrichypersecretionseverepepticulcerdiseasegastrinomahighfastingplasmagastrinhighgastricacidsecretiondiminishedresponsetopentagastrindemonstrablepancreaticorgastrointestinaltumour-byCTorvenoussamplingforgastrinmorethan90%ofgastrinomashavesomatostatinreceptors,andsomatostatinreceptorscintigraphyhasbeenreportedtobeaespeciallysensitivemethodtoimagegastrinomasPathophysiologicalmechanismsOsmoticdiarrheaItcausedbyaccumulationofthefollowingsinthegutlumenwatersalts

poorlyabsorblesolutesmaldigestionofingestedfoodfailuretotransportanosmoticallyactivedietarynonelectrolyte(E:glucose)intestinalLumenbeingosmoticallyactivediarrheaosmoticdiarrhoeadisaccharidasedeficiencyprimarilylactasedeficiencylaxativeabuse(about20%ofpatients

CausesofdiarrheainenteralnutritionCalculationofosmoticgap

PathophysiologicalmechanismsDecreasedintestinalsurfaceareaand/orintestinalabsorptionE:surgicalremoval;malabsorptionsyndromePathophysiologicalmechanismsRapidtransitofintestinalcontents(shortenedtransittime)

E:irritablebowelsyndrome[Functionaldiarrhea]laxativesabusepostvagotomydiarrheapostgastrectomydumbingsyndromestoolvolumeliquiditycontacttime

increasesmallbowelmucosa

contentsincreaseinintestinalmotility(intestinalhurry)reduceEtiologyAcuteDiarrheainfectionFoodpoisoningSystematicdiseases(influenza,sepsis,etc)MiscellanousEtiologyAcuteDiarrheainfection1.viral2.bacterialcampylobacteriaShigellaE.ColiSalmoneilaetc3.fungal4.parasitic(amebicTrophozoites,Giardia)AcuteDiarrheaFoodpoisoningbacterial,plants,chemicalpoison(arsenic,...)Systematicdiseases(influenza,sepsis,measle,etc)MiscellanousAllergicdiseasesAllergicpurpura,enteropathy..endocronicdiseases(ZES,etc.)Drugs:laxatives,5-Fu,etc.foodpoisoningbacterialintrinsicallypoisonousfood,forexampledeadlynightshade,redkidneybeansparasitesinthemeat,forexampleTaenia,Trichinellachemicalsheavymetals,e.g.mercury,zincpesticides,e.g.rodenticides,insecticidesallergiesparalyticshellfishpoisoningscombrotoxinhistamineintoxicationviralfoodpoisoniningchineserestaurantsyndrome-monosodiumglutamatechineserestaurantsyndromeExcessingestionofmonosodiumglutamateresultsinasyndromethatincludesaburningsensationovertheneck,chestandarms,withtightnessoverthefaceandchest.Theremayalsobeheadache,flushing,weakness,nauseaandabdominalcramps.EtiologyChronicDiarrheaIntestinalGastric(chronicgastritis,subtotalgastrectomy,etc.)Pancreatic(ChronicPancreatitis,PancreaticCancer,etc.)Hepatobiliary(livercirrhosis,obstructivejaundice)functionalcausesEndocronic(Hyperthyroidscrisis,ZES,Carcinoids)Drugs(Reserpin,Ismelin,Laxatives,etc.)Others(uremia,hypogammaglobulemia,etc.)ChronicDiarrheaIntestinalinfections(T.B.,Chronicbacteriadysentery,etc.)parasitics(Amebiadysentery,Giardiasis,etc.)IBD(ulcerativecolitis,Chron’s,etc.)malabsorptionsynd.(lactasedeficiency,etc.)tumorsEndoscopicimage:infectiouscolitisin7-year-oldgirl

lowersmallboweldiseaseCrohn'sdiseasetuberculosisYersiniaenterocoliticaComplicationsoflowersmallboweldiseasecausingdiarrhoeainclude:B12deficiencybileacidwastinguppersmallboweldisease

coeliacdiseaseGiardiasisWhipple'sdiseaseTheremaybesteatorrhoeaorawaterystool.Othercomplicationsinclude:irondeficiencyfolatedeficiencycalciumdeficiencylargeintestinecausesdysenterywormsinflammatoryboweldiseasecoloniccarcinomairritablebowelsyndromefaecalimpactionwithoverflowradiationenteritisdiverticulardiseasemesentericischaemiagastriccauses

postgastrectomypostvagotomygastrocolicfistulapancreaticcauses

cysticfibrosischronicpancreatitispancreaticcarcinomaendocrinerelateduraemiathyrotoxicosiscarcinoidsyndromeZollinger-Ellisonsyndromemedullarycarcinomaofthethyroidhypoparathyroidismdiabetesmellitus,whichmaycauseautonomicdiabeticneuropathy,presentingwithnocturnaldiarrhoeaVerner-Morrisonsyndromefunctionalcauses

irritablebowelsyndromemorethanthreemotionsperdaylessthanthreemotionsperweekhardorlumpystoolslooseorwaterystoolsstrainingduringabowelmovementurgencyfeelingofincompleteemptyingpassingmucusduringabowelmovementabdominalfullness,bloatingorswellingclassificationofdiarrhoealdiseasebytime-course

acutechronic

SymptomsAcutediarrhea

durationlessthan

2weeksonset:Abruptfrequent,smallfecaldischargeCrampingabdominalpain,tenesmusestool:increasedRoutinExseverecases:dehydration,electrolytedisturbances,metabolicacidosis,collapsehypovolumia,tetany.Acutediarrhea

Symptomsvolumeliquidityflecksofblood,mucusWBC,RBC,pus,destroyedepitheliumSymptoms

Chronicdiarrhea

durationmorethan2monthsChronicdiarrhea

SymptomsOnset:gradual/insidiousDiarrheaofvariableseverityDiarrheaalternatewithconstipationColickyabdominalpain,distentionintestinalcausesinsmallbowelpathology:abdominalpain,whenpresent,isperiumbilicalorrightiliacfossathefrequencyofdefecationisoftenreducedthestoolmaybewellformedbutitisbulky,offensive,andmaybepaleincolourtheremaybesignsandsymptomsofmalabsorptionintestinalcausesinlargebowelpathology:thereisoftenadefectinthereabsorptionofwaterfromthefaecesstoolsmaybeprofuseandwateryand/ormixedwithbloodandmucustheremaybelowerabdominalpainwithtenesmusandurgencystoolwatery,bloody,steatorrheacontains:inflammatorycells/mucus/pus/indigestedfoodsevere/long-standingcases:

weightloss,malnutrition,edema,multyvitsdeficiency,malabsorption,wasting,edema,bonepainAccompaniedSymptomsseveredehydration

(cholera,pancreaticcholera-WDHA,etc.)fever(Acutebacillerydysentery,Typhoid,TBenteritis,etc.)tenesmus(Acutedysentery,proctitis,etc.)markedlyweightloss(cancerofgut,malabsorption,etc.)Arthralgia/Arthritis(IBD,connectivetissuediseases,etc.)masses(malignantcancerofGI,TB,peritonitis,etc.)DiagnosticProceduresInformationP.E.Findings

fever,dehydration,malnutrion,anemia,ulticaria,jaundice,arthralgia,abdominalmasses,Tenesmus,digitalrectalexamination.LabfindingsDiagnosticProceduresinformationinepidemics(Dysentery,v.Cholerae,Typhoid,foodpoisonning,enteritis)foodallergypastillness(antibioticrelateddiarrhea,etc.)medicationtake(corticosteroids,laxatives,etc.)predisposingconditions(surgicalresection,parasiticinfection,etc.)

LabfindingsBloodUrineStoolMicroscopyTolerancetestsBreathtestsCultureofJejunalaspirates5HIAA(urinaryexcretion)VitB12absorptiontestX-rayBariumEndoscopySuctionbiopsytechnique(Jejunalmucosahistologyinvestigationsofdiarrhoeadigitalrectalexamination,toexcludeoverflowdiarrhoeaduetoconstipationandalowrectalcarcinomabloodtestsincludefullbloodcount,ESRcreatinineandelectrolytes,glucoseCreactiveproteinclottingscreenB12andfolateTIBCthyroxineimmunoglobulinsfastingguthormones-ifothertests(-)LabfindingsUrineProteincastStoolappearance(watery,bloody,bulky,sticky,malodorous,steaterrhea,foul-smelling)LabfindingsMicroscopyRBC,WBC

polymorphonuclear(PMN):Shigella,solmonella,Ecolimononuclear(M)motileamebictrophozoitesGram’sstain(+)staphylococcalenteritisCulture:salmonolla,shigella,v.choleraFatdeterminationinvestigationsofdiarrhoearadiologyespeciallyimportantwhentheabdomenisdistendedortenderaplainabdominalfilmmayrevealfluidlevels,gas-filledloopsorlossofgasinpartswheretheloopsareinflamedbariumenemasigmoidoscopy+/-biopsycolonoscopy+/-biopsystoolmicrobiology,includingmicroscopy,cultureandantibioticsensitivitydeterminestoolforfaecalfatestimationtoexcludesteatorrhoeaLabfindingsTolerancetests(d-xylose;Glucose/lactose/sucrose)Breathtests14CGlycine-cholate,xyloseCultureofJejunalaspirates(Bacterialovergrowth)(increasedBileanddeconjugation)5HIAA(urinaryexcretion)VitB12absorptiontestdifferentialdiagnosisofdiarrhoea

copiouswaterydiarrhoeasuggestsanorganicaetiology

nocturnaldiarrh