湘雅兒科精品-Infantile-Diarrhea課件

小兒腹瀉

中南大學(xué)兒科學(xué)教研室郭青第十一章第八節(jié)Vocabulary

hypochlorhydria－胃酸過少

normalflora－正常菌叢colibacillus－大腸桿菌

campylobacter－彎曲菌Yersinia－耶爾松菌adenylcyclase－腺苷酸環(huán)化酶guanyliccyclase－鳥苷酸環(huán)化酶microvillares－微絨毛Staphylocaccusaureus－金黃色葡萄球菌pseudomembranousenterocolitis－偽膜性小腸結(jié)腸炎

小兒腹瀉InfantileDiarrhea目的要求

Objective概述

Summary病因

Etiology發(fā)病機(jī)制

Pathogenesis臨床表現(xiàn)

Clinicalmenifestations診斷、鑒別診斷

Diagnosis&DifferentialDiagnosis

治療原則

PrincipleofTreatment概述

Summary

小兒腹瀉(腹瀉病)，是由多病原、多因素引起以腹瀉為主的一組疾病，容易并發(fā)水、電解質(zhì)、酸堿平衡紊亂。根據(jù)病因可分為感染性（較多見）和非感染性兩類，發(fā)病年齡多在2歲以下，1歲以內(nèi)者約占半數(shù)。近30年來本病發(fā)病率和病死率已明顯降低，但仍是小兒的常見病和死亡原因。

Infantilediarrheaiscausedbymulti-pathogeny&multifactor.Themainsymptomisdiarrhea.Itiseasilycomplicatedbydisturbancesofwater,electrolyteandacid-basebalance.Accordingaspathogeny,itcanbeclassifiedbytheinfected(most)andthenon-infected.Itoccursusuallylessthan2yearsold,about50%lessthan1year.Althoughtheincidenceandthemortalityofthediseasehaveevidentlydecreasedbylate30years,itoftenoccursininfantsandresultsininfants’death.病因

Etiology一、易感因素Predisposingfactors

1.

消化系統(tǒng)特點(diǎn)(胃酸↓,消化酶↓,酶活性↓,生長發(fā)育快)

Characteristicofdigestivesystem(hypochlorhydria,digestenzyme↓,enzymaticactivity↓,fastdevelopingandgrowth)

2.機(jī)體防御功能較差(胃酸↓,免疫球蛋白↓,SIgA↓,正常菌叢)

Organismdefensehypofunction(hypochlorhydria,immuneglobulin↓,SIgA↓,normalflora)

3.

人工喂養(yǎng)Non-human-milkfeed病因

Etiology二感染因素Infectedfactors

1.腸道內(nèi)感染(細(xì)菌、真菌、病毒、寄生蟲)

Intestinaltractinfection(bacteria,fungus,virus,parasite)2.腸道外感染(中耳炎、上感、肺炎、皮膚感染等)

Extraintestinaltractinfection(tympanitis,upperrespiratorytractinfection,pneumonia,skininfectionetc)三非感染因素Noninfectiousfactors

1.飲食因素Food2.氣候因素Climate病因

Etiology腸內(nèi)感染常見病原Pathogenyofinfectioninsideintestinaltract

1.

大腸桿菌

Colibacillus(EPECETECEIECEHECEAEC）

2.彎曲菌Campylobacter1972Belgium

－1981Shanghai3.

耶爾松菌Yersinia1973USA

－1980Fujian4.

抗生素誘發(fā)的腸炎Enteritisresultedfromantibiotics

5.輪狀病毒Rotavirus1973Australia

－1978BeijingEnterotoxinHeat-intolerantenterotoxinHeat-resistantenterotoxinAdenylcyclase

Guanyliccyclase

cGMP↑c(diǎn)AMP↑Na+

Cl-

H2O↑Smallintestinejuicesecrete↑Diarrhea

BacteriainvasiveoralmucosaCongest,dropsy,ulcerStool(blood,mucusshreds,pus)PathogenesisBacterialenteritisCarbohydratedecomposition&absorptiondisorderSheddingofepithelialcellsonintestinemucousmembrane,intestinalvillusshorteningIntestinal

lacticacid↑IntestinalNa+&glucose↑Disaccharidaseactivity↓WaterydiarrheaNa+,glucosecouplingtransporterdisorderNa+,glucoseabsorptiondisorderReabsorbedwater-electrolyte↓PathogenesisofViralEnteritisIntestinesosmoticpressure↑VirusparticlesMicrovillaresepithelialcellsonSmallintestinemucousmembrane

胃內(nèi)食物積滯，胃酸少，腸道下段細(xì)菌上移繁殖腸內(nèi)滲透壓↑腸蠕動↑細(xì)菌、毒性產(chǎn)物滲透性腹瀉分解產(chǎn)生短鏈有機(jī)酸胺類↑門脈系統(tǒng)進(jìn)入血循環(huán)非感染性腹瀉發(fā)病機(jī)制中毒癥狀(內(nèi)源性感染)飲食不當(dāng)Gastric

stanatedfood，lessgastricacid,lowerintestinalbacteriaup-moving&propagationIntestinalosmoticpressure↑Enterokinesia↑Bacteria&toxicityproductsOsmoticdiarrheaDecompositionproducingshoutchainorganicacidAmines↑PortalveinsystementeringbloodcirculationPathogenesisofNoninfectiousDiarrheaToxicosissymptom(endogenousinfection)Improperdiet臨床表現(xiàn)

ClinicalMenifestations一根據(jù)病程分類Classifiedbycourse

急性小兒腹瀉（<2周）Acuteinfantilediarrhea（<2weeks） 遷延性小兒腹瀉（2周~2月）Persisting

infantilediarrhea

（2weeks~2months）慢性小兒腹瀉（>2月）Chronicinfantilediarrhea（

>2months）二根據(jù)病情分類Classifiedbypatient’scondition

輕型腹瀉

無明顯脫水及全身中毒癥狀MilddiarrheaDehydration&toxicosissymptomarelessevidently

重型腹瀉有較明顯的脫水,電解質(zhì)紊亂,全身中毒癥狀SeverediarrheaDehydration,disturbancesofelectrolyteandacid-basebalanceandtoxicosissymptomareevidently三

根據(jù)病因分類

Classifiedbypathogeny

輪狀病毒腸炎Rotavirusenteritis，大腸桿菌腸炎

Escherichiacolienteritis

空腸彎曲菌腸炎Campylobacterjejunienteritis,耶爾森菌小腸結(jié)炎Yersiniaenterocolitis四

抗生素誘發(fā)的腸炎

Antibioticprovocativeenteritis

金黃色葡萄球菌腸炎Staphylocaccusaureusenterocolitis,偽膜性小腸結(jié)腸炎 pseudomembranousenterocolitis,真菌性結(jié)腸炎fungalcolonitis臨床表現(xiàn)

ClinicalMenifestations診斷和鑒別診斷Diagnosis&DifferentialDiagnosis

非侵襲性腸炎：生理性腹瀉、小腸吸收功能障礙Non-invasiveenteritis

Physiologicdiarrhea，Intestinalmalabsorption侵襲性腸炎：菌痢、壞死性腸炎Invasiveenteritis

Bacillarydysentery，Enteritisnecroticcans小兒液體療法

InfantileLiquidTherapy

目的要求Objective概述

Summary小兒體液平衡的特點(diǎn)

CharacteristicofInfantileBodyFluidBalance水電解質(zhì)和酸堿平衡紊亂DisturbancesofWater,Electrolyte,&Acid-basebalance液體療法時常用的溶液CommonSolutionofLiquidTherapy小兒腹瀉液體療法InfantileDiarrheaLiquidTherapy目的要求Objective了解小兒體液平衡的特點(diǎn)

Realized:CharacteristicofInfantileBodyFluidBalance熟悉小兒水、電解質(zhì)和酸堿失衡的病理生理

Befamiliarwith:

PathophysiologyofInfantileFluid,Electrolyte&Acid-baseImbalance掌握小兒電解質(zhì)和酸堿平衡紊亂的臨床表現(xiàn)

Mastered:

ClinicalmenifestationsofInfantileDisturbancesofWater,Electrolyte&Acid-baseBalance熟悉液體療法常用溶液的組成及臨床應(yīng)用

Befamiliarwith:CommonSolutionComponentofLiquidTherapy掌握小兒腹瀉的液體療法

Mastered:

LiquidTherapyofInfantileDiarrhea小兒體液平衡的特點(diǎn)一體液的總量和分布不同年齡的體液分布（占體重的％）

年齡

總量

細(xì)胞外液

細(xì)胞內(nèi)液血漿間質(zhì)液足月新生兒78637351歲70525402～14歲6652040成人55～66510～1540～45Characteristic

ofInfantileBodyFluidBalanceA.

Totalbodywater&itsdistributionBodywatercompartmentsrelatedtoage(totalbodymass%)

Age

TBWECF

ICFPlasmaISFNewborninfant78637351year70525402～14years6652040Adult55～66510～1540～45TBW:

totalbodywaterECF:extracellularfluidICF:intracellularfluidISF:interestitialfluid三水代謝的特點(diǎn)Watermetabolism

1.水的需要量大，交換率快，不顯性失水多（為成人2倍）。嬰兒每日水交換量為細(xì)胞外液量的1/2，成人僅為1/7。

Largewaterrequirements,swiftwaterexchange,unobvious

waterloss(doubleadult’samount).Infant’swaterexchangeamountis1/2ofECF,theadult’sisjust1/7.體液調(diào)節(jié)功能不成熟，小兒腎臟的濃縮和稀釋功能不成熟。

Immaturebodyliquidregulatingfunction,immatureconcentrationanddilutionfunctionofinfantile.小兒體液平衡的特點(diǎn)Characteristic

of

Infantile

Body

Fluid

Balance水電解質(zhì)酸堿平衡紊亂一脫水程度表現(xiàn)程度失水量神態(tài)眼眶、前囟皮膚彈性口唇粘膜眼淚尿量休克輕度脫水5％（50ml/kg）精神稍差，略有煩躁不安稍凹陷稍差略干燥有稍少無中度脫水5～10％（50～100ml/kg）精神萎靡，煩躁不安明顯凹陷差干燥少明顯減少無重度脫水>10％（100～120ml/kg）昏睡，昏迷深陷極差極干燥無極少或無有DisturbancesofWater,Electrolyte&Acid-baseBalanceA.DegreeofdehydrationDehydrationMildModerateSevereDecreaseinbodyweight5％(50ml/kg)5～10％(50～100ml/kg)>10％(100～120ml/kg)PsycheDepressed,hyperirritableDepressed,hyperirritableLethargic,comaOrbit,FontanelSunken±SunkenSeverelysunkenSkinturgorNormal±DecreaseMarkedlydecreaseMucousmembranesDry±DrySeverelydryTearsDecrease±DecreaseAbsentUrineMildoliguriaoliguriaAnuriaBloodpressureNormalNormalLowTypeofdehydrationPathogenySerumsodiumPathophysiology&clinicalcharacteristicIsosmoticAcutegastrointestinalfluidlose130～150mmol/LECF:decrease,Osmoticpressure(intracellular=extracellular)DehydrantvolumeaccordwithdehydrantphysicalsignHypotonicChronicgastrointestinalfluidlose<130mmol/LECF:severelydecrease,Easilyshock，SevererdehydrantsignthantheothertwokindsHyperosmoticHighgradefever,Infection>150mmol/LICF:severelydecrease,MilderdehydrantsignthantheothertwokindsDisturbancesofWater,Electrolyte&Acid-baseBalanceB.Propertyofdehydration水電解質(zhì)酸堿平衡紊亂DisturbancesofWater,Electrolyte&Acid-baseBalance三代謝性酸中毒Metabolicacidosis（一）發(fā)生原因Pathogeny1.體內(nèi)堿性物質(zhì)丟失過多（消化道、腎臟丟失）Theloseoflargeamountofbasicsubstances（gastrointestinaltract,kidneys）2.酸性代謝產(chǎn)物產(chǎn)生過多（饑餓、糖尿病、腎衰、缺氧）ToomuchAcidmetabolite（hungriness,diabetes,renalfailure,hypoxia）3.攝入酸性物質(zhì)過多（長期服氯化鈣、氯化鎂、靜滴鹽酸精氨酸或鹽酸賴氨酸、復(fù)合氨基酸、水楊酸等）Toomuchacidsubstanceintake（longtimetotakecalciumchloride,ammoniumchloride,aminoacidetc.）（二）分度Degree輕度Mild HCO3-

18~13mmol/

L中度ModerateHCO3-

13~9mmol/

L重度Severe HCO3-

<9mmol/

L

水電解質(zhì)酸堿平衡紊亂DisturbancesofWater,Electrolyte&Acid-baseBalance水電解質(zhì)酸堿平衡紊亂DisturbancesofWater,Electrolyte&Acid-baseBalance四低鉀血癥Hypokalemia（一）病因Pathogeny1.攝入不足Lackofintake2.丟失過多（消化液丟失、利尿從腎臟丟失）

Lossofkaliumfromkidneysorgastrointestinaltract3.其他途徑（燒傷、透析治療不當(dāng)）Burn,dialysisetc.4.鉀在細(xì)胞內(nèi)外分布異常（堿中毒、胰島素治療、周期性麻痹）

Abnormalkaliumdistributioninsideoroutsidecells

（alkalosis,insulintherapy、periodicanesthesia）（二）臨床表現(xiàn)Clinicalmenifetation1.神經(jīng)——精神萎靡

Nervoussystem——depressed2.肌肉骨骼肌——四肢肌乏力，肌張力↓，嚴(yán)重遲緩性癱瘓，呼吸肌麻痹

Muscle——inertiaoflimbs，musculartensiondown，severelyretardantparalysis，respiratorymuscleparalysis水電解質(zhì)酸堿平衡紊亂DisturbancesofWater,Electrolyte&Acid-baseBalance3.心臟心率↑，心律失常，阿－期綜合癥，房室傳導(dǎo)阻滯，

心肌纖維變性，局限性壞死，心肌收縮乏力，心音低鈍

心電圖，出現(xiàn)U波，U≥T，T波增寬、低平、倒置

Heart——heartrateincreasing,arrhythmia,Adams－Stokessyndrome,heartratedecreasing，atrioventricularblock,heartsoundlowering,cardiogram:Uwaveappearing，U≥T，flattenedTwave水電解質(zhì)酸堿平衡紊亂DisturbancesofWater,Electrolyte&Acid-baseBalance4.腎臟腎小管上皮細(xì)胞空泡變性，對ADH的反應(yīng)低下，濃縮功能減低，尿量增多，腎小管泌H–

增加，回吸收HCO3-

增加，氯的回吸收減少，可發(fā)生低鉀、低氯堿中毒，伴反常性酸性尿。

Kidney——concentratingfunctionlowering,urinevolumeincreasing水電解質(zhì)酸堿平衡紊亂DisturbancesofWater,Electrolyte&Acid-baseBalance液體療法時常用的溶液CommonSolutionofLiquidTherapy一非電解質(zhì)溶液Nonelectrolyte

solution

5％、10％

glucose二電解質(zhì)溶液Electrolytesolution

0.9％

NaCl、1.4％、5％

NaHCO3、10％

KCl三混合溶液Mixedsolutions

見下表refertothefollowingtable液體療法時常用的溶液CommonSolutionofLiquidTherapy常用混合液Commonmixedsolution0.9%NaCl1.4%NaHCO35~10%G.S2:1(等張含鈉液)2份1份3:2:1(1/2張含鈉液)2份1份3份4:3:2(2/3張含鈉液)4份2份3份1/3張含鈉液2份1份6份小兒腹瀉液體療法InfantileDiarrheaLiquidTherapy一定量Volume總量Totalvolume累積損失量Cumulatedlosingvolume維持輸入階段（生理需要，繼續(xù)損失）Keeptransfusingperiod（physiologicalneed,losingcontinuing）輕90～120ml/kg45～60ml/kg45～60ml/kg中120～150ml/kg60～75ml/kg60～75ml/kg重150～180ml/kg75～90ml/kg75～90ml/kg二定性

Quality脫水種類Dehydrantcategory累積損失量Cumulatedlosingvolume維持輸入階段（生理需要，繼續(xù)損失）Keeptransfusingperiod（physiologicalneed,losingcontinuing）低滲性脫水Hypotonicdehydration4:3:21/3～1/4張含鈉液Sodicsolution等滲性脫水Isosmoticdehydration3:2:11/3～1/4張含鈉液Sodicsolution高滲性脫水HyperosmoticDehydration1/3張含鈉液Sodicsolution1/3～1/4張含鈉液Sodicsolution小兒腹瀉液體療法InfantileDiarrheaLiquidTherapy三定速Speed總量Totalvolume累積損失量Cumulatedlosingvolume維持輸入階段（生理需要，繼續(xù)損失）Keeptransfusingperiod（physiologicalneed,losingcontinuing）24h8～12h12～16h8～10ml/kg/h5ml/kg/h小兒腹瀉液體療法InfantileDiarrheaLiquidTherapy四休克擴(kuò)容Shockvolumeexpansion，定量、定性、定速擴(kuò)容量Volume溶液名稱Solution速度Speed20ml/kg2:1或1.4％NaHCO330～60min小兒腹瀉液體療法InfantileDiarrheaLiquidTherapy注：總量不超過300mlTotalvolume

≤

300ml五代謝性酸中毒的治療Treatmentofmetabolicacidosis

輕、中度代謝性酸中毒不須另行處理。

Mildormoderatemetabolicacidosismetabolicacidosis:Nospecialtreatment

重度代謝性酸中毒Severemetabolicacidosis：

1.4%NaHCO33ml/kg，[HCO3-]levelcanincreaseabout1mmol.小兒腹瀉液體療法InfantileDiarrheaLiquidTherapy六低鉀血癥的治療Treatmentofhypokalemia

見尿補(bǔ)鉀（入院前6小時排尿，膀胱叩診濁音），補(bǔ)鉀濃度

0.2～0.3％（不能超過0.3％），每日補(bǔ)鉀總量靜滴時