儿科腹泻病.ppt

腹泻病,武汉科技大学儿科学教研室 李圭华,第十一章第八节,Vocabulary,hypochlorhydria胃酸过少 normal flora正常菌丛 colibacillus大肠杆菌 campylobacter弯曲菌 Yersinia耶尔松菌 adenyl cyclase腺苷酸环化酶 guanylic cyclase 鸟苷酸环化酶 microvillares微绒毛 Staphylocaccus aureus金黄色葡萄球菌 pseudomembranous enterocolitis伪膜性小肠结肠炎,小 儿 腹 泻 Infantile Diarrhea,目的要求 Objective,概述 Summary,病因 Etiology,发病机制 Pathogenesis,临床表现 Clinical menifestations,诊断、鉴别诊断 Diagnosis & Differential Diagnosis,治疗原则 Principle of Treatment,目的要求 Objective,掌握本病的病因、发病机制与临床表现 Mastered：Etiology , Pathogenesis & Clinical menifetation 掌握本病的诊断与治疗 Mastered：Diagnosis & Treatment 熟悉本病的鉴别诊断 Be familiar with：Differential Diagnosis 了解本病的预防 Realized： Prevent,概述 Summary,小儿腹泻(腹泻病)，是由多病原、多因素引起以腹泻为主的一组疾病，容易并发水、电解质、酸碱平衡紊乱。根据病因可分为感染性（较多见）和非感染性两类，发病年龄多在 2 岁以下，1 岁以内者约占半数。近30年来本病发病率和病死率已明显降低，但仍是小儿的常见病和死亡原因。 Infantile diarrhea is caused by multi-pathogeny & multifactor. The main symptom is diarrhea. It is easily complicated by disturbances of water, electrolyte and acid-base balance. According as pathogeny, it can be classified by the infected (most) and the non-infected. It occurs usually less than 2 years old, about 50% less than 1 year. Although the incidence and the mortality of the disease have evidently decreased by late 30 years, it often occurs in infants and results in infants death.,病因 Etiology,一 、易感因素 Predisposing factors 1. 消化系统特点(胃酸,消化酶,酶活性,生长发育快) Characteristic of digestive system (hypochlorhydria, digest enzyme, enzymatic activity, fast developing and growth) 2. 机体防御功能较差(胃酸,免疫球蛋白,SIgA ,正常菌丛) Organism defense hypofunction (hypochlorhydria, immune globulin, SIgA , normal flora ) 3. 人工喂养 Non-human-milk feed,二 感染因素 Infected factors 1. 肠道内感染(细菌、真菌、病毒、寄生虫) Intestinal tract infection (bacteria, fungus, virus, parasite) 2. 肠道外感染(中耳炎、上感、肺炎、皮肤感染等) Extraintestinal tract infection (tympanitis, upper respiratory tract infection, pneumonia, skin infection etc) 三 非感染因素Noninfectious factors 1. 饮食因素 Food 2. 气候因素 Climate,肠内感染常见病原 Pathogeny of infection inside intestinal tract 1. 大肠杆菌 Colibacillus (EPEC ETEC EIEC EHEC EAEC） 2. 弯曲菌 Campylobacter 1972 Belgium 1981 Shanghai 3. 耶尔松菌 Yersinia 1973 USA 1980 Fujian 4. 抗生素诱发的肠炎 Enteritis resulted from antibiotics 5. 轮状病毒 Rotavirus 1973 Australia 1978 Beijing,肠毒素,不耐热肠毒素,耐热肠毒素,腺苷酸环化酶,鸟苷酸环化酶,CGMP,CAMP,Na+ Cl- H2O,小肠液分泌,腹泻,细菌侵袭肠粘膜,充血、水肿、溃疡,血或粘冻状便,发病机制,痢疾样改变,细菌性肠炎,Enterotoxin,Heat-intolerant enterotoxin,Heat-resistant enterotoxin,Adenyl cyclase,Guanylic cyclase,cGMP,cAMP,Na+ Cl- H2O,Small intestine juice secrete,Diarrhea,Bacteria invasive oral mucosa,Congest, dropsy, ulcer,Stool (blood, mucus shreds, pus),Pathogenesis,Bacterial enteritis,糖类分解吸收障碍,肠粘膜上皮细胞脱落，绒毛变短,肠道内乳酸,肠道内钠、葡萄糖,双糖酶活性,水样泻,钠葡萄糖载体的偶联转运障碍,钠、葡萄糖吸收障碍,回吸收水电解质能力,病毒性肠炎发病机制,肠渗透压,病毒颗粒,小肠粘膜带有微绒毛的上皮细胞,Carbohydrate decomposition & absorption disorder,Shedding of epithelial cells on intestine mucous membrane, intestinal villus shortening,Intestinal lactic acid,Intestinal Na + & glucose,Disaccharidase activity,Watery diarrhea,Na +, glucose coupling transporter disorder,Na +, glucose absorption disorder,Reabsorbed water-electrolyte,Pathogenesis of Viral Enteritis,Intestines osmotic pressure,Virus particles,Microvillares epithelial cells on Small intestine mucous membrane,胃内食物积滞，胃酸少，肠道下段细菌上移繁殖,肠内渗透压,肠蠕动,细菌、毒性产物,渗透性腹泻,分解产生短链有机酸,胺类,门脉系统进入血循环,非感染性腹泻发病机制,中毒症状(内源性感染),饮食不当,Gastric stanated food，less gastric acid, lower intestinal bacteria up-moving & propagation,Intestinal osmotic pressure,Enterokinesia,Bacteria & toxicity products,Osmotic diarrhea,Decomposition producing shout chain organic acid,Amines,Portal vein system entering blood circulation,Pathogenesis of Noninfectious Diarrhea,Toxicosis symptom (endogenous infection),Improper diet,临床表现 Clinical Menifestations,一 根据病程分类Classified by course 急性小儿腹泻（2月） Chronic infantile diarrhea（ 2 months ） 二 根据病情分类Classified by patients condition 轻型腹泻 无明显脱水及全身中毒症状 Mild diarrhea Dehydration & toxicosis symptom are less evidently 重型腹泻 有较明显的脱水,电解质紊乱,全身中毒症状 Severe diarrhea Dehydration, disturbances of electrolyte and acid-base balance and toxicosis symptom are evidently,水电解质酸碱平衡紊乱,一 脱水程度,Disturbances of Water, Electrolyte & Acid-base Balance,A. Degree of dehydration,水电解质酸碱平衡紊乱,二 脱水性质,Disturbances of Water, Electrolyte & Acid-base Balance,B. Property of dehydration,水电解质酸碱平衡紊乱 Disturbances of Water, Electrolyte & Acid-base Balance,三 代谢性酸中毒 Metabolic acidosis （一）发生原因 Pathogeny 1. 体内碱性物质丢失过多（消化道、肾脏丢失） The lose of large amount of basic substances（gastrointestinal tract, kidneys） 2. 酸性代谢产物产生过多（饥饿、糖尿病、肾衰、缺氧） Too much Acid metabolite （hungriness, diabetes, renal failure, hypoxia） 3. 摄入酸性物质过多（长期服氯化钙、氯化镁、静滴盐酸精氨酸或盐酸赖氨酸、复合氨基酸、水杨酸等）Too much acid substance intake （long time to take calcium chloride, ammonium chloride, amino acid etc.）,（二） 分度 Degree 轻度 Mild HCO3- 1813 mmol / L 中度 Moderate HCO3- 139 mmol / L 重度 Severe HCO3- 9 mmol / L,水电解质酸碱平衡紊乱 Disturbances of Water, Electrolyte & Acid-base Balance,水电解质酸碱平衡紊乱 Disturbances of Water, Electrolyte & Acid-base Balance,四 低钾血症 Hypokalemia （一） 病因 Pathogeny 1. 摄入不足 Lack of intake 2. 丢失过多（消化液丢失、利尿从肾脏丢失） Loss of kalium from kidneys or gastrointestinal tract 3. 其他途径（烧伤、透析治疗不当） Burn, dialysis etc. 4. 钾在细胞内外分布异常（碱中毒、胰岛素治疗、周期性麻痹） Abnormal kalium distribution inside or outside cells （alkalosis, insulin therapy、periodic anesthesia）,（二） 临床表现 Clinical menifetation 1. 神经精神萎靡 Nervous system depressed 2. 肌肉 骨骼肌四肢肌乏力，肌张力，严重迟缓性瘫痪，呼吸肌麻痹 Muscleinertia of limbs，muscular tension down，severely retardant paralysis，respiratory muscle paralysis,水电解质酸碱平衡紊乱 Disturbances of Water, Electrolyte & Acid-base Balance,3. 心脏 心率，心律失常，阿期综合症，房室传导阻滞， 心肌纤维变性，局限性坏死，心肌收缩乏力，心音低钝 心电图，出现U波，UT，T波增宽、低平、倒置 Heart heart rate increasing, arrhythmia, AdamsStokes syndrome, heart rate decreasing，atrioventricular block, heart sound lowering, cardiogram: U wave appearing，UT，flattened T wave,水电解质酸碱平衡紊乱 Disturbances of Water, Electrolyte & Acid-base Balance,4. 肾脏 肾小管上皮细胞空泡变性，对ADH的反应低下，浓 缩功能减低，尿量增多，肾小管泌H 增加，回吸收HCO3- 增加，氯的回吸收减少，可发生低钾、低氯碱中毒，伴反常 性酸性尿。 Kidney concentrating function lowering, urine volume increasing,水电解质酸碱平衡紊乱 Disturbances of Water, Electrolyte & Acid-base Balance,三 根据病因分类 Classified by pathogeny 轮状病毒肠炎 Rotavirus enteritis，大肠杆菌肠炎 Escherichia coli enteritis 空肠弯曲菌肠炎 Campylobacter jejuni enteritis, 耶尔森菌小肠结炎 Yersinia enterocolitis 四 抗生素诱发的肠炎 Antibiotic provocative enteritis 金黄色葡萄球菌肠炎 Staphylocaccus aureus enterocolitis , 伪膜性小肠结肠炎 pseudomembranous enterocolitis , 真菌性结肠炎 fungal colonitis,临床表现 Clinical Menifestations,诊断和鉴别诊断 Diagnosis & Differential Diagnosis,非侵袭性肠炎：生理性腹泻、小肠吸收功能障碍 Non-invasive enteritis Physiologic diarrhea，Intestinal malabsorption 侵袭性肠炎：菌痢、坏死性肠炎 Invasive enteritis Bacillary dysentery，Enteritis necroticcans,治疗原则 Principle of Treatment,一 合理饮食 Reasonable Diet 二 合理选择抗生素 Antibiotic treatment 三 加强护理 Intensive nursing care 四 液体疗法 Liquid therapy 口服补液 Oral rehydration salts, 静脉补液 Vein fluid replacement 五 慢性腹泻治疗原则 Principle of chronic diarrhea treatment 消除病因 Eliminating Etiology, 调整饮食 Adjusting diet, 慎用抗生素 Careful using antibiotics, 微生态疗法 Micro-ecological therapy,小 儿 液体疗法 Infantile Liquid Therapy,目的要求 Objective,概述 Summary,小儿体液平衡的特点 Characteristic of Infantile Body Fluid Balance,水电解质和酸碱平衡紊乱 Disturbances of Water, Electrolyte, & Acid-base balance,液体疗法时常用的溶液 Common Solution of Liquid Therapy,小儿腹泻液体疗法 Infantile Diarrhea Liquid Therapy,目的要求 Objective,了解小儿体液平衡的特点 Realized: Characteristic of Infantile Body Fluid Balance 熟悉小儿水、电解质和酸碱失衡的病理生理 Be familiar with: Pathophysiology of Infantile Fluid, Electrolyte & Acid-base Imbalance 掌握小儿电解质和酸碱平衡紊乱的临床表现 Mastered: Clinical menifestations of Infantile Disturbances of Water, Electrolyte & Acid-base Balance 熟悉液体疗法常用溶液的组成及临床应用 Be familiar with :Common Solution Component of Liquid Therapy 掌握小儿腹泻的液体疗法 Mastered: Liquid Therapy of Infantile Diarrhea,概述 Summary,体液是人体的重要组成部分，保持其生理平衡是维持生命的重要条件。体液中水、电解质、酸碱度、渗透压等的动态平衡依赖于神经、内分泌、肺，特别是肾脏等系统的正常调节功能，由于小儿的生理特点，这些系统的功能极易受疾病和外界环境的影响而失调，因此水、电解质和酸碱平衡紊乱在儿科临床中极为常见。 Body fluid is important component of human body and the physiological equilibrium of body fluid is an important factor for human living. The dynamic equilibrium of fluid, electrolyte, acid-base, osmotic pressure depends on normal regulating function of nerve, incretion, lung and kidney. Because of the infantile physiologic peculiarity, These systematic functions are easily affected by diseases and/or environment and are maladjusted. Therefore, the disturbances of water, electrolyte and acid-base balance is common in pediatric clinic.,小儿体液平衡的特点,一 体液的总量和分布 不同年龄的体液分布（占体重的）,Characteristic of Infantile Body Fluid Balance,A. Total body water & its distribution Body water compartments related to age (total body mass%),TBW: total body water ECF: extracellular fluid ICF: intracellular fluid ISF: interestitial fluid,小儿体液平衡的特点 Characteristic of Infantile Body Fluid Balance,二 体液的电解质组成 Electrolyte composition of body fluid 细胞外液 ECF: Na+ 、 Cl-，HCO3 - 细胞内液 ICF: K + 、Mg 2+ 、HPO4 2-、蛋白质 Protein,三 水代谢的特点 Water metabolism 1. 水的需要量大，交换率快，不显性失水多（为成人2倍）。婴儿每日水交换量为细胞外液量的1 / 2 ，成人仅为1 / 7。 Large water requirements, swift water exchange, unobvious water loss (double adults amount ). Infants water exchange amount is 1 / 2 of ECF , the adults is just 1 / 7. 体液调节功能不成熟，小儿肾脏的浓缩和稀释功能不成熟。 Immature body liquid regulating function , immature concentration and dilution function of infantile.,小儿体液平衡的特点 Characteristic of Infantile Body Fluid Balance,液体疗法时常用的溶液 Common Solution of Liquid Therapy,一 非电解质溶液 Nonelectrolyte solution 5、10 glucose 二 电解质溶液 Electrolyte solution 0.9 NaCl、1.4、5 NaHCO3、10 KCl 三 混合溶液 Mixed solutions 见下表 refer to the following table,液体疗法时常用的溶液 Common Solution of Liquid Therapy,小儿腹泻液体疗法 Infantile Diarrhea Liquid Therapy,一 定量 Volume,二 定性 Quality,小儿腹泻液体疗法 Infantile Diarrhea Liquid Therapy,三 定速 Speed,小儿腹泻液体疗法 Infantile Diarrhea Liquid Therapy,四 休克扩容 Shock volume expansion，定量、定性、定速,小儿腹泻液体疗法 Infantile Diarrhea Liquid Therapy,注：总量不超过300ml Total volume 300ml,五 代谢性酸中毒的治疗 Treatment of metabolic acidosis 轻、中度代谢性酸中毒不须另行处理。 Mild or moderate metabolic acidosis metabolic acidosis: No special treatment 重度代谢性酸中毒 Severe metabolic acidosis： 1.4%NaHCO3 3ml/kg， HCO3- level can increase about 1 mmol.,小儿腹泻液体疗法 Infantile Diarrhea Liquid Therapy,六 低钾血症的治疗 Treatment of hypokalemia 见尿补钾（入院前6小时排尿，膀胱叩诊浊音），补钾浓度 0.20.3（不能超过0.3 ），每日补钾总量静滴时间不应短于8小时。 Supply kalium after urination (urination