游洁玉—小儿腹泻病

小儿腹泻病,湖南省儿童医院消化科 游洁玉,一、概念,腹泻病（diarrheal disease）是由多病原、多因素引起的一组疾病，主要是有大便性状改变与大便次数比平时增多，在未明确病因前，统称为腹泻病，是我国婴幼儿最常见的消化道综合征。6个月2岁婴幼儿发病率高，1岁以内约占半数，是造成小儿营养不良、生长发育障碍和死亡的主要原因之一。1982年，石家庄会议把腹泻病分为感染性与非感染性腹泻.,Definition,diarrheal disease is a group of diseases caused by multiple pathogens,mainly defined as an increase in the frequency and the water content of stools. Diarrhea is the most common gastrointestinal syndrome of infants in our country. For 6 months to 2 years old infants the incidence rate is high, 1 year old infants accounted for about 50%,Diarrhea is one of the main cause of infant malnutrition, growth retardation and death. In 1982, the Shijiazhuang conference classified the diarrheal disease into infectious and non infectious diarrhea.,二、病程分类classification,1、急性腹泻病（acute diarrheal disease）： 病程在2周以内 (within 2 weeks) 2、迁延性腹泻病(persistent diarrheal disease)： 病程在2周-2个月 (2 weeks-2 months)3、慢性腹泻(chronic diarrheal disease)： 病程在2个月以上。 (over 2 weeks),classification,1、感染性腹泻：infectious diarrhea. 痢疾、霍乱、其他感染性腹泻. Dysentery, cholera, and other infectious diarrhea.2、非感染性腹泻：non infectious diarrhea. 食饵性（饮食性）腹泻病 症状性腹泻病 过敏性腹泻病等. allergic diarrhea.,四、流行病学epidemiology,小儿腹泻病为第三世界国家小儿第一位常见多发病，死因在我国居第二位。1986年对广东等七省妇糼卫生示范县及北京市的流行病学调查，发现5岁以下小儿急性腹泻年发病率为201.46%，平均年发病次数为2.010.03次/人，平均死亡率为0.51。1988年21省入户调查发现5岁以下小儿发病率为每年0.86-3.9次/人，平均为每年2.5次/人。,Infantile diarrhea is the most common desease in third world countries,and is the second causes causing death in China. In 1986, seven provinces,including Guangdong province, made an epidemiological investigation, found that children ,under 5 years old,the annual incidence rate of the acute diarrhea was 201.46%, the average annual incidence rate is 2.010.03 / person, the average mortality rate was 0.51 per thousand. In 1988, investigation found that children under 5 years old the incidence rates was about 0.86-3.9 times/ person, an average rate of 2.5 times per year / person.,发病两个高峰期。夏季腹泻：发生于6、7、8月，主要是致病性大肠杆 菌与痢疾杆菌，秋季腹泻：发生于10、11、12月，为，主要致病菌为 轮状病毒，危险因素：1岁以内婴儿；小儿照看人卫生差； 小儿饭前不用肥皂洗手； 既往经常患腹泻病；饮用水不洁； 禽畜放养。,Summer diarrhea: peak incidence is in June,July, August, the main pathogens are pathogenic Escherichia coli and Bacteria associated with Shigella.Autumn diarrhea: peak incidence is in October,November, December, the main pathogen is Rotavirus.Risk factors : 1. infants under the age of 1 year; 2.poor health of baby sitter; 3.The children dont have the habit washing hands before meals;4.Have a history of diarrhea disease; 5.the drinking water is unclean;6.Livestock grazing,Predisposing factors,1、婴幼儿消化系统发育尚未成熟：胃酸和消化酶分泌少，酶活力偏低；生长发育快，所需营养物质相对较多，胃肠道负担重，进入量较多，加重了胃肠道的负担；婴幼儿水分代谢旺盛，对缺水的耐受力差，易发生体液紊乱；婴儿时期神经、内分泌、循环、肝、肾功能发育不成熟，容易发生消化道功能紊乱。Infants digestive system development is not yet mature: the gastric acid and digestive enzymes secreted less than the adult, enzyme activity is poor,but the growth velosity is rapid, it needs relatively more nutrients, so the burden of the gastrointestinal function is a heavy,the more the infant eat,the more burdun it exists; As the nerve, endocrine, circulatory, liver, renal function are immature in infants, prone to have gastrointestinal dysfunction.,Predisposing factors,2、机体防御功能差：婴儿胃酸偏低，胃排空较快，对进人胃内的细菌杀灭能力较弱；血清免疫球蛋白（尤其是 lgM、lgA）和胃肠道分泌型 IgA均较低;新生儿生后尚未建立正常肠道菌群时，或由于使用抗生素等引起肠道菌群失调时，均易患肠道感染。2.infants defence function is poor:the ability of killing of intragastric bacterial is poor.the secretion of serum globulin ( especially lgM, lgA ) and gastrointestinal IgA Is poor too.the Newborns normal intestinal flora has not been established, or the imbalance of intestinal flora caused by the abuse of antibiotics, are susceptible to enteric infection.,Predisposing factors,3、人工喂养： 家畜乳中虽有母乳中某些成分，但在加热过程中被破坏，而且人工喂养的食物和食具极易受污染，故人工喂养儿肠道感染发生率明显高于母乳喂养儿 Livestock milk has some ingredients of human milk, but it can be destroyed in the process of heating, and artificial feeding food and tableware are too easy to be polluted, so the artificial feeding infants has the significant higher intestinal infection rate compare to the breast-fed infants.,六、感染因素Infectious factors,1、 肠道内感染：由病毒、细菌、真菌、寄生虫引起，以前两者多见，尤其是病毒。2、肠道外感染：如患中耳炎、上呼吸道感染、肺炎、肾盂肾炎、皮肤感染或急性传染病时，可由于发热、感染原释放的毒素、抗生素治疗、直肠局部激惹（膀胱感染）作用而并发腹泻。有时病原体（主要是病毒）可同时感染肠道。3、滥用抗生素引起的肠道菌群紊乱。Intestinal infection: virus, bacteria, fungi, parasite can cause diarhea, the former two are the most common reasons, especially the virus.Other infection: when suffering from otitis media, upper respiratory tract infection, pneumonia, pyelonephritis, skin infection or acute infectious diseases, patients may appear diarrhea for reasons of fever, infection, antibiotic therapy, the toxins released partial rectal bowel ( bladder infection ). Sometimes the pathogen (mainly virus ) in the same time cause the gut infection.The abuse abuse of antibiotics causes intestinal flora disturbance.,七、非感染因素none infectious factors,1、饮食因素 Dietary factors 1）喂养不当：多为人工喂养儿，原因为：喂养不定时；饮食量不当；突然改变食物品种，或过早喂给大量淀粉或脂肪类食品，果汁，特别是那些含高果糖或山梨醇的果汁，可产生高渗性腹泻；肠道刺激物（调料、富含纤维素的食物）也可引起腹泻。1) improper feeding: for artificial feeding infants, the main causes of diarrhea: feeding imregularly; improper diet; sudden changes in a variety of foods, or feed large amounts of starch or fatty foods in an early age, juices, especially those containing high fructose sorbitol or fruit juice, can produce osmotic diarrhea; eat rich seasoning cellulose food can also cause diarrhea.,非感染因素,2）过敏性腹泻：如对牛奶或大豆（豆浆）过敏而引起腹泻。对牛奶过敏者较多。3）原发性或继发性双糖酶（本要为乳糖酶）缺乏或活性降低肠道对糖的消化吸收不良使乳糖积滞引起腹泻。2、气候因素 气候突变、腹部受凉使肠蠕动增加；天气过热消化液分泌减少或由于口渴饮奶过多等都可能诱发消化功能紊乱致腹泻。2) allergic diarrhea: such as milk or soybean ( soybean ) allergy. The most Allergic food is milk. 3) the decrease of the amount or activity of lactase. The digestion and absorption of the lactose break down. The stagnation of lactose in bowel caused diarrhea.2. climate factorAbrupt climate change, the cold increases intestinal motility; drinking too much juice or milk may induce functional digestive disorders and diarrhea.,八、发病机制Pathogenesis,(一)消化道功能紊乱: 主要是饮食的量与质不恰当，使婴儿消化道功能发生障碍，食物不能充分消化和吸收并积滞于肠道上部，同时酸度下降，有利于肠道下部细菌上移繁殖，使消化功能紊乱。肠道内产生大量的乳酸、乙酸等有机酸，使肠腔渗透压增高，加之腐败酸的毒性产物如胺类等刺激肠道，使肠蠕动增强，引起腹泻。 The main reason is the imappropriote of quality and quantity of the diet, so as to cause the gastrointestinal disfunction.the food havent got fully digestion and absorption ,and then stagnate in the upper part of the intestinal tract, at the same time, the acidity of the bowel decreases, the bacteria in low intestinal tract breeding up, caused the disorder of digestive function.the Intestinal produce large amounts of lactic acid, acetic acid and other organic acids, the intestinal osmotic pressure increased, together with corruption acid toxic products such as amines, stimulation of intestinal, increases intestinal motility, eventuerly causing diarrhea.,(二)肠全身液体循环障碍: 正常小儿消化道吸收与分泌保持平衡，它们主要是通过肠一全身体液循环进行的。整个肠道粘膜都具有吸收和分泌水和电解质的功能，吸收是小肠微绒毛上皮细胞和大肠表层细胞的功能，而分泌则是小肠隐窝处细胞的功能。水的转运主要通过渗透压差进行被动转运及逆渗透压差进行主动转运。被动转运主要在细胞膜顶侧被动弥散进入细胞内，主动转运主要通过葡萄糖、氨基酸等与钠偶联以及钠、氯等协同转运。 Normaly pediatric gastrointestine maintain balance between absorption and secretion, through a systemic circulation of bowel. The intestinal mucosa has the function of absorption and secretion of water and electrolyte, the small intestinal microvilli epithelial cells and large surface cell has the function of absorption, while the intestinal crypt cell has the function of secretion. Water transport is mainly through the osmotic pressure difference for passive transport and reverse osmosis pressure difference of active transport. Passive transport mainly in cell membrane top side passive diffusion into the cell, active transport of glucose, amino acids, and mainly through the coupling as well as sodium, chloride cotransport.,肠全身液体循环障碍:,不耐热肠毒素可与小肠上皮细胞上的受体神经节苷脂（GM：gangliosides）结合，激活腺苷酸环化酶，使肠上皮细胞内的ATP转成CAMP，使肠液中的水、电解质分泌增加，水和cl 的再吸收减少，总量增多，超过了结肠吸收限度，引起腹泻，并使体内水、电解质紊乱。耐热性肠毒素可通过激活鸟苷酸环化酶使三磷酸鸟苷（GTP）转变为CGMP，促使小肠分泌增加，导致水样腹泻。病毒以及不耐热肠毒素，还可影响小肠上皮细胞对葡萄糖与钠的偶联运转。 Heat-labile enterotoxin and intestinal epithelial cell receptors on the ganglioside ( GM: Gangliosides ) binding, activation of adenylate cyclase, the intestinal epithelial cells within the ATP into CAMP, so that the water in the intestinal fluid, electrolyte secretion increases, water and Cl - reabsorption decrease, gross increases, more than colonic absorption limit, cause diarrhea, and in the water, electrolyte disturbance. Heat-stable toxin may be via the activation of guanylate cyclase three guanosine monophosphate ( GTP ) into CGMP, induce intestinal secretion increased, leading to a watery diarrhea. Virus and heat-labile enterotoxin, can also affect the intestinal epithelial cells on glucose and sodium coupling operation.,(三)病原侵袭肠粘膜的作用 病原可侵入肠粘膜固有层，引起充血、水肿、炎症细胞浸润以及溃疡和渗出性炎症病变，造成吸收不良，引起腹泻。侵入性大肠杆菌肠炎主要累及结肠；空肠弯曲菌肠炎主要病变在空肠和回肠；耶尔森菌肠炎主要病变在回肠；细菌性痢疾累及结肠及回肠末端；伤寒与副伤寒主要侵入小肠；阿米巴痢疾主要侵袭盲肠。The pathogen can invade the intestinal mucosa lamina propria, cause congestion, edema, inflammatory cell infiltration and ulcers and exudative inflammatory lesions, resulting in malabsorption, diarrhea caused by Invasive Escherichia coli enteritis primarily affects the colon; Campylobacter jejuni enteritis with primary lesions in the jejunum and ileum; Yersinia enterocolitis primary lesions in the ileum; bacterial dysentery involving the colon and terminal ileum; typhoid fever and paratyphoid fever mainly invade the small intestine; amoebic dysentery attack cecum.,(三)病原侵袭肠粘膜的作用各种细菌引起的肠炎其肠系膜淋巴结均肿大，引起肠系膜淋巴结炎。由于结肠炎症病变可导致吸收功能障碍。最新提出，细胞内信息前列腺素（PG）与各型肠炎有关，当组织损伤和发炎时，激肽激活可形成前列腺素，它可激活环化酶，与所有促进分泌协同转运系统均有联系，故认为PG是肽类致泻激素之一。Various bacterial enteritis of the mesenteric lymph nodes were swollen, caused by mesenteric lymphadenitis. inflammatory lesions can lead to malabsorbtion. The latest, intracellular information found that- prostaglandins (PG ) is associatedand with various types of enteritis, when tissue injury and inflammation, kinin prostaglandin activation can be formed, it can activate the cyclase, and is associate with all the secretion cotransport systems, so that PG is a peptide hormone of purgative.,(四)病毒致泻作用 病毒颗粒侵入小肠上部可累及全部小肠甚至结肠，使绒毛细胞受损，小肠绒毛变短，微绒毛膨胀、不规则，固有膜层有单核细胞浸润。电镜检查在上皮细胞内可发现许多病毒颗粒受累的小肠粘膜上皮细胞及微绒毛很快脱落，由于绒毛细胞在破坏后修复功能不全，隐窝部立方上皮细胞（分泌细胞）增多，向柱状上皮细胞移位，造成水、电解质吸收减少，肠液分泌增多，导致腹泻。,Virus particles irrupting the upper intestine will implicate all the small intestinal and even the colon as well, damaging the hair cells, shortening the small intestinal villi, making the microvilli expanding and irregular. As a result, mononuclear cells infiltrate the inherent membrane layer. Electron microscopy examination in the epithelial cells shows that small intestine epithelium cells and microvilli immediately fall off where many virus particles are involved. As the recovering function of damaged chorionic villus cells is not so good, the cuboidal recess epithelium cells (secretory cells) keep increasing and shift toward the columnar epithelial cells. Consequently, water and electrolyte absorption decrease, the bowel liquid secretion increases and subsequently diarrhea starts.,(四)病毒致泻作用另外肠道粘膜细胞受损，其细胞的双糖酶活性减少，结果造成糖分解吸收障碍，不能完全水解的糖类物质被肠道细菌分解，产生有机酸，增加肠内渗透压，使水进入肠腔，导致腹泻加重。另外，葡萄糖和钠与绒毛内载体结合的偶联运转也发生了障碍，造成大量的水样腹泻。In addition ,the intestinal mucosal cell damage, the double enzyme activity decreased, resulting in sugar malabsorption, cannot complete hydrolysis of the carbohydrate by bacterial decomposition, produce organic acids, increased intestinal permeability pressure, make water into the intestinal lumen, cause diarrhea aggravation. In addition, glucose and sodium and fluff carrier combined coupling operation also occurred in disorder, cause a lot of watery diarrhea.,九、病理生理,(一)脂肪、蛋白质和糖代谢紊乱 由于肠道消化吸收功能减低，肠蠕动亢进，使营养素的消化和吸收发生障碍。营养物质的丢失主要是酶功能紊乱引起同化功能障碍所致。蛋白质的同化功能减弱，但仍能消化吸收蛋白质。脂肪的同化与吸收也受到影响，在恢复期，数日至数周后脂肪平衡实验显示，脂肪的同化作用仍低下。碳水化合物的吸收也受到影响，患儿糖耐量试验曲线低，这与碳水化合物吸收障碍有关。但在急性腹泻时，患儿胃肠道的消化吸收功能未完全丧失，对营养素的吸收可达正常的6090。,Due to intestinal digestion and absorption function to reduce the risk of bowel peristalsis, hyperthyroidism, the nutrient digestion and absorption disorders. Nutrients loss is the main enzyme dysfunction induced by anabolic dysfunction induced by. Protein assimilation function is weakened, but still the digestion and absorption of protein. Fat assimilation and absorption is also affected, during the recovery period, a few days to a few weeks after fat balance experiment shows, fat assimilation is still low. Carbohydrate absorption is also affected, with glucose tolerance test curve is low, this and carbohydrate absorption barriers related to. But in children with acute diarrhea, gastrointestinal digestion and absorption function is not completely lost, the absorption of nutrients in up to 60% of normal 90%.,(二)水和电解质紊乱 由于溶质的转运障碍; 吸收功能减低，分泌功能亢进，腹泻和反复呕吐，使水、电解质大量从消化道丢失，继而发生水、电解质紊乱，产生一系列的脱水及酸中毒症状。 Because the solute transport disorders; absorption function reduces, secretion function hyperfunction, diarrhea and vomiting, make water, electrolytes from the gastrointestinal tract is missing, then water, electrolyte disturbance, to produce a series symptom of dehydration and acidosis.,十、临床表现,轻型: 常由饮食因素及肠道外感染引起。起病可急可缓，以胃肠道症状为主，食欲不振，偶有溢乳或呕吐，大便次数增多，稀薄或带水，呈黄色或黄绿色，有酸味常见白色或黄白色奶瓣和泡沫。无脱水及全身中毒症状多在数日内痊愈。Often caused by dietary factors and extraintestinal infection. The onset can be acute or slow, with predominantly gastrointestinal symptoms, loss of appetite, occasionally galactorrhea or vomiting, the stool frequency increases, thin or watery, yellow or yellowish green, has a sour taste. Commonly with white or yellow-white milk valve and foam. Children Without dehydration and symptoms of systemic poisoning can recovery in a few days.,重 型: 多由肠道内感染引起。常急性起病，也可由轻型逐渐加重、转变而来，除有较重的胃肠道症状外，还有较明显的脱水、电解质紊乱和全身中毒症状，如发热、精神烦躁或萎靡、嗜睡，甚至昏迷、休克.caused by Intestinal infection. Often acute onset, but also by the light gradually increased, with the severe gastrointestinal symptoms, there are dehydration, electrolyte disturbances and systemic poisoning symptoms, such as fever, mental irritability or depressed, sleepiness, or even coma, shock.,几种常见腹泻的临床特点,1）轮状病毒感染性腹泻2）诺沃克（NORWALK）病毒感染性腹泻 3）产毒性细菌性腹泻 4）侵袭性细菌性腹泻5）出血性大肠杆菌感染性腹泻 6）抗生素诱发的腹泻 1) rotavirus infection diarrhea2) the Norwalk virus ( NORWALK ) infection diarrhea3) enterotoxigenic bacterial diarrhea4) invasive bacterial diarrhea5) hemorrhagic Escherichia coli infection diarrhea6) antibiotic associated diarrhea,几种常见腹泻的临床特点,6）抗生素诱发的腹泻 金黄色葡萄球菌感染性腹泻 伪膜性小肠结肠炎 真菌性肠炎 7）食饵性腹泻8）症状性腹泻9）生理性腹泻6) antibiotic associated diarrheaThe Staphylococcus aureus infection diarrheaOf pseudomembranous enterocolitisFungal enteritis7) prey diarrhea8) symptomatic diarrhea9) physiological diarrhea,几种常见腹泻的临床特点,10） 小儿糖原性腹泻11) 先天性失氯性腹泻病（congenital chloride diarrhea CCD）12） 肠吸收不良性腹泻13） 脂肪泻性腹泻14） 牛奶蛋白过敏性腹泻10) pediatric glycogen diarrhea11) congenital chloride diarrhea ( congenital chloride diarrhea CCD )12) intestinal malabsorption diarrhea13) fatty diarrhea14) milk protein allergy diarrhea,十一、实验室检查,（一）常规检查1、血、尿、粪为最基本检查，在条件较差的基层医院也应开展此常规检查。The basic examinations are blood routine,urine routine and stool routine,these can be approached in primary hospital.1）血常规 根据血红蛋白及红细胞的改变可以判断有无贫血，根据白细胞及分类，我们可以初步判断有无感染及感染的类型。 we can estimate whether the patient has anemia by the examination of Hb and RBC,and also we can estimate whether the patient has infection according to the result of white blood cells count and its classification.2）小便常规 有无蛋白及红细胞及白细胞、管型等 whether there are protein ,red blood cells,white blood cells and tube type in the urine. 3）大便常规 根据大便常规有无白细胞将腹泻分为 两组。 we classify the patients into two groups by the result of whether there is WBC in the stool.,（二）基本的血生化检查 包括E4A 、Ca2+ 、 P3- 、Mg2+等检查，根据E4A结果我们可以判断脱水的性质（主要是根据测得的测得的血清Na+结果分为低渗、高渗、等渗脱水及判断酸缄平衡。）因而基层医院也应尽量开展此项检查。 we carried out the examination including E4A ,Ca2+ , P3- and Mg2+,judge the nature of the dehydration according to whether the plasma sodium concentration is normal,low or high.,十二、病源学检查,大便细菌、真菌等培养应该一式二份，培养出同一种细菌或真菌意义更大。 病毒分离 采用适合于其生长复制的细胞培养体系，是诊断病毒性疾病的金标准。 stool culture is necessary to exclude on underlying infective cause,like bacteria and fungus.often have to culture twice. Virus isolation ,suitable for growth and replication in cell culture system, is the gold standard for diagnosis of viral diseases.,十三、特殊检查,1、大便检查1） 大便轮状病毒抗原检测：取新鲜的大便经过抗原抗体结合检测轮状病毒抗原。Specific identification of rotavirus is neccecery.rotavirus antigens can be identified in stool.2） clinitest试剂，糖吸收不良时，从粪便排出的糖增多，国际上常用的测糖方法是用clinitest试剂测定粪便中的还原糖。 Clinitest reagent, when the child has sugar malabsorption, we can commonly use the method of Clinitest reagent to determine the reducing sugar in feces. 2、小便检查1）尿中还原糖的测定，尿中出现双糖表明肠黏膜受损较严重，尿中的乳糖大于50mg为过度发酵的指征 Determination of reducing sugar in the urine, disaccharides in urine showed serious intestinal mucosa damage, the urinary lactose 50mg indicate an excessive fermentation.,3、X线检查 钡餐透视检查结肠、胃、小肠对慢性腹泻的诊断有一定意义，有助于溃疡性结肠炎和克隆病诊断。 for the diagnosis of chronic diarrhea,the subject of SWALLOW BARIUM FOR ROENTGENOGRAPHY GASTROINTESTINAL of the colon, stomach, small intestine has the certain significance, contribute to the diagnosis of ulcerative colitis and Crohns disease. 4、内窥镜检查 小儿内窥镜检查，目前在全国开展很普通，主要有小儿电子胃肠镜、小肠镜等，对克隆病、溃疡性结肠炎有诊断意义，并可用于其分泌物涂片检查及粘膜活检行病理检查或涂片找虫卵等。 Pediatric endoscopy, currently carried out in the country commonly, mainly including pediatric gastrointestinal endoscope and endoscopy,used in diagnosis of Crohns disease, ulcerative colitis, and can be used in the aspirate smears and mucosal biopsy.,十四、诊断,根据病因、发病季节、年龄、大便的性状、排便的次数可作出初步诊断，必要时应进行细菌、病毒及寄生虫等病原学检查、对于脱水程度及性质，有无酸中毒及钾、钙等电解质缺乏的判定，可根据临床表现作出症状诊断。 we can make an initial diagnosis according to the etiology, incidence, age, stool traits, the frequency of defecation, take examinations for bacteria, viruses and parasites , examination for the degree of dehydration, and nature,whether there is acidosis and potassium, calcium and other electrolyte deficiency, and can make symptoms diagnosis according to clinical manifestations.,（一）临床诊断,1)诊断依据 大便性状有改变，呈水样便、糊状便、粘液便或脓血便。大便次数增多。a watery, mushy stool, mucous or pus and blood seen in the stool.The defecate increased.2）病程分类1、急性腹泻病（acute diarrheal disease）： 病程在2周以内 (within 2 weeks) 2、迁延性腹泻病(persistent diarrheal disease)： 病程在2周-2个月 (2 weeks-2 months)3、慢性腹泻(chronic diarrheal disease)： 病程在2个月以上。 (over