Diarrhea  Disease <ul><li>mbbs.weebly.com </li></ul>
Major cause of children’s(﹤5y) death in developing countries in 2002 ARI diarrhea Malaria measles AIDS Disease in perinata...
 
<ul><li>General introduction </li></ul><ul><li>Classification  </li></ul><ul><li>Predisposing factor </li></ul><ul><li>Eti...
  General introduction <ul><li>Concept  common disease in childhood </li></ul><ul><li>frequency and characters of stool </...
<ul><li>General introduction </li></ul><ul><li>Classification </li></ul><ul><li>Predisposing factor </li></ul><ul><li>Etio...
Causes Course Degree Infectious diarrhea: virus,  bacterium, fungi, parasites Noninfectious diarrhea: diet,  weather, othe...
<ul><li>General introduction </li></ul><ul><li>Classification </li></ul><ul><li>Predisposing factor </li></ul><ul><li>Etio...
<ul><li>Gastric acid secretion  , secretion and activity of enzyme  , quality and quantity of diet change quickly. </li></...
Predisposing factor-2 Defense system: not mature Three defense system (  ): microflora, epithelium, immunity
<ul><li>Grow and develop  , demand for nutrients  , burden of the stomach and intestines  , easy to indigestion.  </li></u...
Relation between feeding and infection in infants(﹤3m) ( Howie et al 1990 ) Artificial feeding: easy to intestinal infecti...
Breast feeding Days % of total faecal micro-organisms Artificial feeding Days % of total faecal micro-organisms Bacillus b...
<ul><li>General introduction </li></ul><ul><li>Classification </li></ul><ul><li>Predisposing factor </li></ul><ul><li>Etio...
Infectious animal Infectious human water Susceptible  population food fecal   -  oral   way Etiology-1: intraenteric infec...
From Kapikian AZ, Chanock RM. Rotaviruses. In: Fields Virology 3rd ed. Philadelphia, PA: Lippincott-Raven; 1996:1659. Deve...
<ul><li>Rotavirus </li></ul><ul><li>Astrovirus </li></ul><ul><li>Calicivirus: Norwalk virus,  sapovirus </li></ul><ul><li>...
Death for rotavirus infection in children  ﹤ 5y (‰) Intraenteric infection---rotavirus  0.0-0.1 0.6-0.9 1.0-1.9 2.0-3.4 0....
Intraenteric infection---rotavirus  20-side body(65-75nm) Nucleus: 45-50nm Shape: wheel Life: 7m Bear acid -20℃: keep long
Photo Credit : F.P. Williams, U.S. Environmental Protection Agency;  Adapted from Parashar et al, Emerg  Inft Dis 199814(4...
<ul><li>Bacillus coli    enteropathogenic E. coli ………………………EPEC   enterotoxigenic E. coli …………………………ETEC   enteroinvasive ...
<ul><li>Disorder intestinal function </li></ul><ul><li>Infect intestinal tract directly </li></ul><ul><li>Irritation of re...
<ul><li>Dietary factors </li></ul><ul><ul><li>quality and quantity of food (feeding starch and fat too early)  </li></ul><...
<ul><li>General introduction </li></ul><ul><li>Classification </li></ul><ul><li>Predisposing factor </li></ul><ul><li>Etio...
<ul><li>Osmotic diarrhea : much poorly absorbed and hyperosmotic solute </li></ul><ul><li>Secretory diarrhea : electrolyte...
Pathogenesis-1: enterotoxin  Adenylate cyclase Intestinal juice secretion   Labile toxin ( LT ) CAMP  H 2 O, Na + , Cl -...
产毒性大肠杆菌  附着到小肠粘膜上进行繁殖  在小肠上部,通过 菌毛上的粘附因子  肠毒素  不耐热肠毒素   Labile toxin, LT   耐热肠毒素   stable toxin, ST   腺苷酸环化酶  鸟苷酸环化酶  细胞内 ...
Pathogenesis-2: bacterium invades enteron invade Small intestine colon Enteron wall mucosa: congestion,  edema, effusion, ...
侵袭性细菌    在肠粘膜侵袭和繁殖   炎症改变   (充血、肿胀、炎性细胞浸润、渗出和溃疡)     水和电解质不能完全吸收    腹泻   便中 WBC, RBC 大量增加  严重中毒症状   侵袭性肠炎发病机制
Virus  invasion Pathogenesis-3: virus infection recrement  Disacchride  Poorly  decomposed lactose  Osmotic diarrhea Na ...
病毒性肠炎发病机理  病毒侵入小肠粘膜绒毛上皮细胞并复制 粘膜受累,绒毛被破坏   绒毛缩短  微绒毛肿胀,紊乱并脱落  线粒体、内质网膨胀  双糖酶活性下降 载体减少 消化吸收面积减少 双糖(乳糖)吸收减少   葡萄糖钠与载体结合 偶联转运吸...
Pathogenesis-4:  noninfectious diarrhea Food fermn  mydesis Enteric osmotic pressure  Digestive function disorder Osmotic...
饮食不当引起腹泻发生机理  食物质、量不当  食物消化吸收障碍而积滞在上消化道  胃酸度下降  肠道下部细菌上移并繁殖  内源性感染  发酵、腐败  有机酸(乳酸、乙酸) 胺类   肠腔内渗透压增高  肠蠕动增强   腹泻、脱水、电解质紊乱、酸...
<ul><li>The RV is composed by 11 geme segments  , NSP4( 非结构蛋白 4 )  is the  closeness of Pathogenesis </li></ul>The study p...
A 组 RV 病毒基因组功能 <ul><li>基因片段 :  1  2  3  4  6  9 </li></ul><ul><li>编码 </li></ul><ul><li>结构蛋白 :  VP1  VP2  VP3  VP4  VP6  VP...
<ul><li>General introduction </li></ul><ul><li>classification </li></ul><ul><li>Predisposing factor </li></ul><ul><li>Etio...
<ul><li>Dehydration </li></ul><ul><li>Metabolic acidosis </li></ul><ul><li>Electrolytes disorder </li></ul>Digestive tract...
Mild and severe  diarrhea  <ul><li>Mild: the times of stool and character change </li></ul><ul><li>——  stool : frequency ,...
<ul><li>Severe: accompany dehydration, electrolytes  </li></ul><ul><li>abnormality and  general toxicity symptoms </li></u...
Degree   Quality   mild moderate Hypotonic  dehydration.Na + ﹤ 130mmol/L Hypertonic dehydration.Na + ﹥150mmol/L Clinical m...
Severity clinical signs of dehydration Dehydration  mild moderate severe Water loss By weight Spirit  Skin Mucous  Anterio...
Anuria tachypnea Anterior fontanel and eye ball Depressed No Tear Cool, weak pulse, shock Dry, pale, Gray mottled apathy ,...
Eye socket depressed, rima oculi not closed
Xerocheilia, chap
Dehydration  Same proportion  loss P IF C P IF C Electrolyte loss more P  hypotonic, IF+C  hypertonic Cell expansion Sever...
<ul><li>Vomiting and diarrhea : Alkalinity intestinal juice lost </li></ul><ul><li>Eat   :calorie  , malabsorption  lipoc...
<ul><li>Dispirited, dysphoria, drowsiness, coma </li></ul><ul><li>Hypernea  (Kussmauls  breathing) , exhalation cool </li>...
<ul><li>K +  (potassium)<3.5mmol/L (normal: 3.5 ~ 5.5 mmol/L) </li></ul><ul><li>causes :   </li></ul><ul><li>Excessive los...
<ul><li>depressed </li></ul><ul><li>Tension of skeletal muscle  , tendon reflex , </li></ul><ul><li>even respiratory muscl...
<ul><li>Ca 2+ ﹤1.75mmol/L (7mg/dl) ;  </li></ul><ul><li>Mg 2+ ﹤0.6mmol/L (1.5mg/dl). </li></ul><ul><li>Symptoms usually oc...
<ul><li>General introduction </li></ul><ul><li>Classification </li></ul><ul><li>Predisposing factor </li></ul><ul><li>Etio...
<ul><li>Season : cool months (autumn and winter)  </li></ul><ul><li>Age : 6m~2y </li></ul><ul><li>Symptom : fever, vomit, ...
<ul><li>Season : summer  </li></ul><ul><li>Symptom : vomit and diarrhea, no obvious general toxicity symptoms. </li></ul><...
<ul><li>Similar with bacillary dysentery. </li></ul><ul><li>Symptom : diarrhea with fever, nausea, vomit, abdominal pain, ...
<ul><li>Pathogen : usually Blastomyces albicans. </li></ul><ul><li>Age : ﹤2y. </li></ul><ul><li>Complication  by other inf...
<ul><li>General introduction </li></ul><ul><li>Classification </li></ul><ul><li>Predisposing factor </li></ul><ul><li>Etio...
<ul><li>Gastric mucosa analosis    bacterium and yeast fungus </li></ul><ul><li>Intestinal mucosa thinner  indigestion a...
<ul><li>vicious cycle </li></ul>malnutrition diarrhea Diarrhea + malnutrition: mortality  4 times higher than normal child...
<ul><li>General introduction </li></ul><ul><li>Classification </li></ul><ul><li>Predisposing factor </li></ul><ul><li>Etio...
<ul><li>Not difficult </li></ul><ul><li>According to clinical manifestation, laboratory tests and character of stool.  </l...
<ul><li>General introduction </li></ul><ul><li>Classification </li></ul><ul><li>Predisposing factor </li></ul><ul><li>Etio...
<ul><li>Usually ﹤6m, bloating, breast-feeding. </li></ul><ul><li>Usually with eczema. </li></ul><ul><li>Normal appetite, g...
<ul><li>Epidemiology character </li></ul><ul><li>Stool culture: a dysentery bacillus discovered </li></ul>Differential dia...
<ul><li>Symptom : ardent fever, severe toxicity symptoms, abdominal pain and distension, vomit frequently. </li></ul><ul><...
<ul><li>General introduction </li></ul><ul><li>Classification </li></ul><ul><li>Predisposing factor </li></ul><ul><li>Etio...
<ul><li>Adjust and continue feeding,  not abrosia or  </li></ul><ul><li>restricting water, prevent malnutrition.  </li></u...
 
Emphasis  Etiology (in/ex/no)   Pathogenesis (4+ex/b/v/no)  Clinical  manifestation Diagnosis   Differential Diagnosis (p/...
Case example  An 8 – month boy had diarrhea and vomited for 3 days, urine stream reduced, irritability. PE: Pulse rate 150...
Answer  diagnosis <ul><li>Acute diarrhea  </li></ul><ul><li>severe dehydration </li></ul><ul><li>hypokalemia </li></ul>
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Infantile Diarrhea

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Infantile Diarrhea

  1. 1. Diarrhea Disease <ul><li>mbbs.weebly.com </li></ul>
  2. 2. Major cause of children’s(﹤5y) death in developing countries in 2002 ARI diarrhea Malaria measles AIDS Disease in perinatal stage others 18% 25% 23% 4% 5% 10% 15% WHO/UNICEF. Clinical management of acute diarrhea Sources: The world health report 2003, WHO,Geneva.
  3. 4. <ul><li>General introduction </li></ul><ul><li>Classification </li></ul><ul><li>Predisposing factor </li></ul><ul><li>Etiology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Clinical features of several common enteritis </li></ul><ul><li>Persistent diarrhea </li></ul><ul><li>Diagnosis </li></ul><ul><li>Differential Diagnosis </li></ul><ul><li>Treatment </li></ul>Content
  4. 5.   General introduction <ul><li>Concept common disease in childhood </li></ul><ul><li>frequency and characters of stool </li></ul><ul><li>Ages 6m~2y 50% < 1y </li></ul><ul><li>Seasons viral origins—late autumn and spring beginning bacterial origins—summer </li></ul><ul><li>noninfectious diarrhea— every season </li></ul>Multiple sources and factors
  5. 6. <ul><li>General introduction </li></ul><ul><li>Classification </li></ul><ul><li>Predisposing factor </li></ul><ul><li>Etiology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Clinical features of several common enteritis </li></ul><ul><li>Persistent diarrhea </li></ul><ul><li>Diagnosis </li></ul><ul><li>Differential Diagnosis </li></ul><ul><li>Treatment </li></ul>Content
  6. 7. Causes Course Degree Infectious diarrhea: virus, bacterium, fungi, parasites Noninfectious diarrhea: diet, weather, others Acute : <2w persistent : 2w  2m chronic : >2m Mild: the times of stool and character change Severe: accompany dehydration, electrolytes abnormality and general toxicity symptoms Classification
  7. 8. <ul><li>General introduction </li></ul><ul><li>Classification </li></ul><ul><li>Predisposing factor </li></ul><ul><li>Etiology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Clinical features of several common enteritis </li></ul><ul><li>Persistent diarrhea </li></ul><ul><li>Diagnosis </li></ul><ul><li>Differential Diagnosis </li></ul><ul><li>Treatment </li></ul>Content
  8. 9. <ul><li>Gastric acid secretion , secretion and activity of enzyme , quality and quantity of diet change quickly. </li></ul><ul><li>Water metabolism , tolerance of hydropenia , easy to body fluid disorder. </li></ul><ul><li>Nerves, endocrine, circulation, liver and renal function: not mature, easy to digestive tract function disorder. </li></ul>Predisposing factor-1 Development of infancy digestive system : not mature
  9. 10. Predisposing factor-2 Defense system: not mature Three defense system ( ): microflora, epithelium, immunity
  10. 11. <ul><li>Grow and develop , demand for nutrients , burden of the stomach and intestines , easy to indigestion. </li></ul><ul><li>Artifical feeding: enteritis morbility 10 times higher </li></ul><ul><li>than breast feeding. </li></ul><ul><li>milk: nutritional ingredient destroyed </li></ul><ul><li>milk tool: disinfection. </li></ul>Predisposing factor-3&4 3 4 <ul><li>The lower level of serum immunoglobulin, especially serum IgA located in gastrointestinal tract is smaller than others. Disorder microbial population of digestive tract resulting from using antibacterial drugs for a long time or normal microbial population have not been established in neonates. </li></ul>
  11. 12. Relation between feeding and infection in infants(﹤3m) ( Howie et al 1990 ) Artificial feeding: easy to intestinal infection Pure breast milk n=95 Partial breast milk n=126 Laboratory milk n=257 p Gastrointestinal infection 2.9 % 5.1 % 15.7 % <0.001 Respiratory infection 25.6 % 24.2 % 37.0 % <0.05
  12. 13. Breast feeding Days % of total faecal micro-organisms Artificial feeding Days % of total faecal micro-organisms Bacillus bifidus Bacillus coli Bacillus faecalis 5 10 15 20 0 10 15 20 25 5 0 10 15 20 25 According to Harmsen et al., 2000 Artificial feeding: easy to disorder microbial population 0 10 20 30 40 50 60 70 80 90 100 0 10 20 30 40 50 60 70 80 90 100
  13. 14. <ul><li>General introduction </li></ul><ul><li>Classification </li></ul><ul><li>Predisposing factor </li></ul><ul><li>Etiology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Clinical features of several common enteritis </li></ul><ul><li>Persistent diarrhea </li></ul><ul><li>Diagnosis </li></ul><ul><li>Differential Diagnosis </li></ul><ul><li>Treatment </li></ul>Content
  14. 15. Infectious animal Infectious human water Susceptible population food fecal - oral way Etiology-1: intraenteric infection
  15. 16. From Kapikian AZ, Chanock RM. Rotaviruses. In: Fields Virology 3rd ed. Philadelphia, PA: Lippincott-Raven; 1996:1659. Developed country Bacterium Uncertain reason Rotavirus Calicivirus Rotavirus Bacillus coli Parasite Other bacterium Adenovirus Calicivirus Astrovirus Adenovirus Astrovirus Uncertain reason Developing country Distribution of etiological agent Intraenteric infection
  16. 17. <ul><li>Rotavirus </li></ul><ul><li>Astrovirus </li></ul><ul><li>Calicivirus: Norwalk virus, sapovirus </li></ul><ul><li>Enterovirus: Coxsackie virus, echovirus, enteric adenovirus </li></ul><ul><li>Coronavirus: torovirus </li></ul>Intraenteric infection---virus Virus 80% infantile diarrhea in cold months.
  17. 18. Death for rotavirus infection in children ﹤ 5y (‰) Intraenteric infection---rotavirus 0.0-0.1 0.6-0.9 1.0-1.9 2.0-3.4 0.2-0.5
  18. 19. Intraenteric infection---rotavirus 20-side body(65-75nm) Nucleus: 45-50nm Shape: wheel Life: 7m Bear acid -20℃: keep long
  19. 20. Photo Credit : F.P. Williams, U.S. Environmental Protection Agency; Adapted from Parashar et al, Emerg Inft Dis 199814(4) 561–570 Rotavirus in stool by electronmicroscop Intraenteric infection---rotavirus
  20. 21. <ul><li>Bacillus coli enteropathogenic E. coli ………………………EPEC enterotoxigenic E. coli …………………………ETEC enteroinvasive E. coli …………………………..EIEC enterhemorrhagic E. coli ………………………EHEC enteroadherent aggregative E. coli ……………EAEC </li></ul><ul><li>Campylobacter jejuni, Yersinia enterocolitica, others </li></ul><ul><li>Fungi : blastomyces albicans </li></ul><ul><li>Protozoa (parasite) : giardia lamblia, amebic protozoa </li></ul>Intraenteric infection---bacterium etc.
  21. 22. <ul><li>Disorder intestinal function </li></ul><ul><li>Infect intestinal tract directly </li></ul><ul><li>Irritation of rectum (eg. bladder infection) </li></ul><ul><li>alteration of intestinal flora </li></ul><ul><li>Much antibiotics used transport of carbohydrate </li></ul><ul><li>lactase </li></ul>Etiology-2: extraenteric infection Pneumonia, URI, USI, otitis media, skin infection, etc.
  22. 23. <ul><li>Dietary factors </li></ul><ul><ul><li>quality and quantity of food (feeding starch and fat too early) </li></ul></ul><ul><ul><li>Allergic diarrhea: milk or bean </li></ul></ul><ul><ul><li>Primary and secondary disaccharidase deficiency </li></ul></ul>Etiology-3: noninfectious causes <ul><li>Weather factors </li></ul><ul><ul><li>Cool enterokinesia </li></ul></ul><ul><ul><li>Hot secretion of digestive juice and gastric </li></ul></ul><ul><ul><li>take milk because of thirsty </li></ul></ul>
  23. 24. <ul><li>General introduction </li></ul><ul><li>Classification </li></ul><ul><li>Predisposing factor </li></ul><ul><li>Etiology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Clinical features of several common enteritis </li></ul><ul><li>Persistent diarrhea </li></ul><ul><li>Diagnosis </li></ul><ul><li>Differential Diagnosis </li></ul><ul><li>Treatment </li></ul>Content
  24. 25. <ul><li>Osmotic diarrhea : much poorly absorbed and hyperosmotic solute </li></ul><ul><li>Secretory diarrhea : electrolytes hypersecretion </li></ul><ul><li>Exudative diarrhea : inflammatory states causing liquor exudation </li></ul><ul><li>Motility disturbance : dynamic abnormality of intestine </li></ul><ul><li>Noninfectious diarrhea : feeding factors </li></ul>Pathogenesis Usually combination of several mechanisms
  25. 26. Pathogenesis-1: enterotoxin Adenylate cyclase Intestinal juice secretion  Labile toxin ( LT ) CAMP  H 2 O, Na + , Cl - transfer into enteric cavity Stable toxin ( ST ) Guanylate cyclase GTP CGMP  ATP activate activate Volume of intestinal juice diarrhea
  26. 27. 产毒性大肠杆菌 附着到小肠粘膜上进行繁殖 在小肠上部,通过 菌毛上的粘附因子 肠毒素 不耐热肠毒素 Labile toxin, LT 耐热肠毒素 stable toxin, ST 腺苷酸环化酶 鸟苷酸环化酶 细胞内 ATP cAMP  GTP cGMP  抑制小肠绒毛上皮细胞吸收 Na + 、 Cl - 和水,并促进 Cl - 分泌 肠液中 Na + 、 Cl - 和水总量增多,超过结肠吸收限度 大量水样腹泻 激活 激活 肠毒素引起的肠炎发病机理 —— 以产毒性大肠杆菌为例
  27. 28. Pathogenesis-2: bacterium invades enteron invade Small intestine colon Enteron wall mucosa: congestion, edema, effusion, ulser and hemorrhage Poorly absorption of H 2 O and electrolyte diarrhea
  28. 29. 侵袭性细菌   在肠粘膜侵袭和繁殖   炎症改变 (充血、肿胀、炎性细胞浸润、渗出和溃疡)   水和电解质不能完全吸收   腹泻   便中 WBC, RBC 大量增加 严重中毒症状   侵袭性肠炎发病机制
  29. 30. Virus invasion Pathogenesis-3: virus infection recrement  Disacchride Poorly decomposed lactose  Osmotic diarrhea Na + transport block H 2 O  electrolyte  disaccharidase
  30. 31. 病毒性肠炎发病机理 病毒侵入小肠粘膜绒毛上皮细胞并复制 粘膜受累,绒毛被破坏 绒毛缩短 微绒毛肿胀,紊乱并脱落 线粒体、内质网膨胀 双糖酶活性下降 载体减少 消化吸收面积减少 双糖(乳糖)吸收减少 葡萄糖钠与载体结合 偶联转运吸收障碍 营养物质吸收减少 部分乳糖分解为小分子的乳酸 渗透压增加 水样腹泻
  31. 32. Pathogenesis-4: noninfectious diarrhea Food fermn mydesis Enteric osmotic pressure  Digestive function disorder Osmotic diarrhea Over-feeding, No proper dietary
  32. 33. 饮食不当引起腹泻发生机理 食物质、量不当 食物消化吸收障碍而积滞在上消化道 胃酸度下降 肠道下部细菌上移并繁殖 内源性感染 发酵、腐败 有机酸(乳酸、乙酸) 胺类 肠腔内渗透压增高 肠蠕动增强 腹泻、脱水、电解质紊乱、酸中毒 分解食物 中毒症状 肝解毒功能不全 毒素进入血循环
  33. 34. <ul><li>The RV is composed by 11 geme segments , NSP4( 非结构蛋白 4 ) is the closeness of Pathogenesis </li></ul>The study progression by RV cause diarrhea
  34. 35. A 组 RV 病毒基因组功能 <ul><li>基因片段 : 1 2 3 4 6 9 </li></ul><ul><li>编码 </li></ul><ul><li>结构蛋白 : VP1 VP2 VP3 VP4 VP6 VP7 </li></ul><ul><li>( 核心 ) ( 核心 ) ( 核心 ) ( 外壳 ) ( 内壳 ) ( 外壳 区分 G 血清型 1-14) </li></ul><ul><li>裂解 抗原区分 (A-G 组 ) </li></ul><ul><li>VP5 VP8 A 组为Ⅰ ,Ⅱ 亚群 </li></ul><ul><li>( P 血清型 1-44 ) </li></ul><ul><li>基因片段 : 5 7 8 10 11 </li></ul><ul><li>编码 </li></ul><ul><li>非结构蛋白 : NS53 NS34 NS35 NS28 NS26 </li></ul><ul><li>(NSP1 NSP2 NSP3 NSP4 NSP5) </li></ul>
  35. 36. <ul><li>General introduction </li></ul><ul><li>classification </li></ul><ul><li>Predisposing factor </li></ul><ul><li>Etiology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Clinical features of several common enteritis </li></ul><ul><li>Persistent diarrhea </li></ul><ul><li>Diagnosis </li></ul><ul><li>Differential Diagnosis </li></ul><ul><li>Treatment </li></ul>Content
  36. 37. <ul><li>Dehydration </li></ul><ul><li>Metabolic acidosis </li></ul><ul><li>Electrolytes disorder </li></ul>Digestive tract symptom Water, electrolytes and acid-base disorder <ul><li>Diarrhea </li></ul><ul><li>vomit </li></ul><ul><li>Abdominal pain </li></ul>Clinical manifestation
  37. 38. Mild and severe diarrhea <ul><li>Mild: the times of stool and character change </li></ul><ul><li>—— stool : frequency ,loose, liquid, </li></ul><ul><li>color: yellow or greenyellow, </li></ul><ul><li>smell: sour flavor, shape: egg soup </li></ul><ul><li>—— vomiting: seldom </li></ul><ul><li>—— general poisoning symptom: without </li></ul><ul><li>—— dehydration, electrolytes abnormality </li></ul><ul><li>and general toxicity symptoms': none </li></ul>
  38. 39. <ul><li>Severe: accompany dehydration, electrolytes </li></ul><ul><li>abnormality and general toxicity symptoms </li></ul><ul><li>— digestive tract symptom : diarrhea serious ,mucus blood sample stool, anorexia, nausea, abdominal </li></ul><ul><li>pain and abdominal distention </li></ul><ul><li>— general poisoning symptom : lethargy, dysphoria, </li></ul><ul><li>unconsciousness and coma </li></ul><ul><li>— dehydration, electrolytes abnormality , </li></ul><ul><li>acid base imbalance </li></ul>Mild and severe diarrhea
  39. 40. Degree Quality mild moderate Hypotonic dehydration.Na + ﹤ 130mmol/L Hypertonic dehydration.Na + ﹥150mmol/L Clinical manifestation-1: dehydration severe Isotonic dehydration.Na + :130~150mmol/L
  40. 41. Severity clinical signs of dehydration Dehydration mild moderate severe Water loss By weight Spirit Skin Mucous Anterior fontanel and eye ball Tear thirst Urine output Peripheral circulation < 50ml/kg < 5% Slightly dispirited slightly agitated Slightly dry Slightly dry Slightly depressed Normal slightly decreased normal 50 ~ 100ml/kg 5% ~ 10% Dispirited Agitated Dry, pale Very dry depressed Reduced increased Little or no Little cool 100 ~ 120ml/kg > 10% Extremely dispirited apathy, hypnody, coma Gray mottled Parched depressed greatly No Greatly increased No urine output Cool, weak pulse, shock
  41. 42. Anuria tachypnea Anterior fontanel and eye ball Depressed No Tear Cool, weak pulse, shock Dry, pale, Gray mottled apathy ,dispirited Skin and Mocous dry Weight decrease
  42. 43. Eye socket depressed, rima oculi not closed
  43. 44. Xerocheilia, chap
  44. 45. Dehydration Same proportion loss P IF C P IF C Electrolyte loss more P hypotonic, IF+C hypertonic Cell expansion Severe Easy to shock P: plasma, IF: interstitial fluid, C: cell Isotonic P IF C Water loss more P hypertonic IF+C hypotonic Cell hydration Mild Thirsty Acute diarrhea after vomiting greatly Hypotonic Hypertonic
  45. 46. <ul><li>Vomiting and diarrhea : Alkalinity intestinal juice lost </li></ul><ul><li>Eat :calorie , malabsorption  lipoclasis  keto-bodies </li></ul><ul><li>Hypovolemia  pachemia  blood flow slowly  </li></ul><ul><li>hypoxia  anaerobic glycolysis  lactic acid </li></ul><ul><li>dehydration  blood flow  excluding acid  </li></ul><ul><li>acid metabolic product </li></ul>Clinical manifestation-2: metabolic acidosis Causes:
  46. 47. <ul><li>Dispirited, dysphoria, drowsiness, coma </li></ul><ul><li>Hypernea (Kussmauls breathing) , exhalation cool </li></ul><ul><li>Expiratory gas smells ketone </li></ul><ul><li>Cherry lips </li></ul><ul><li>Nausea, vomit </li></ul>Metabolic acidosis--clinical manifestation Mild: breath frequency slightly Severe: occur:
  47. 48. <ul><li>K + (potassium)<3.5mmol/L (normal: 3.5 ~ 5.5 mmol/L) </li></ul><ul><li>causes : </li></ul><ul><li>Excessive losses: vomit, diarrhea. </li></ul><ul><li>Inadequate intake. </li></ul><ul><li>Renal function of keeping kalium ,it continues excluding kalium when with hypokalemia. </li></ul>Clinical manifestation-3: electrolyte disorder Hypokalemia
  48. 49. <ul><li>depressed </li></ul><ul><li>Tension of skeletal muscle , tendon reflex , </li></ul><ul><li>even respiratory muscle weakness </li></ul><ul><li>Tension of smooth muscle , abdominal distention </li></ul><ul><li>intestinal sound or disappear </li></ul><ul><li>Myocardium excitability , arrhythmia, ECG: T-wave </li></ul><ul><li>is low or inversion, U-wave occurs, prolonged P-R </li></ul><ul><li>interval and Q-T interval, ST section descending. </li></ul><ul><li>Baseosis </li></ul>hypokalemia Clinical manifestation: nerve and muscular excitability
  49. 50. <ul><li>Ca 2+ ﹤1.75mmol/L (7mg/dl) ; </li></ul><ul><li>Mg 2+ ﹤0.6mmol/L (1.5mg/dl). </li></ul><ul><li>Symptoms usually occur after dehydration and </li></ul><ul><li>acidosis resolved, or fluid replacement. </li></ul><ul><li>Clinical manifestation: thrill, tetany, convulsion. </li></ul><ul><li>If convulsion hasn’t relieved after supplement </li></ul><ul><li>calcium, pay attention to hypomagnesemia. </li></ul>hypocalcemia & hypomagnesemia
  50. 51. <ul><li>General introduction </li></ul><ul><li>Classification </li></ul><ul><li>Predisposing factor </li></ul><ul><li>Etiology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Clinical features of several common enteritis </li></ul><ul><li>Persistent diarrhea </li></ul><ul><li>Diagnosis </li></ul><ul><li>Differential Diagnosis </li></ul><ul><li>Treatment </li></ul>Content
  51. 52. <ul><li>Season : cool months (autumn and winter) </li></ul><ul><li>Age : 6m~2y </li></ul><ul><li>Symptom : fever, vomit, mild general toxicity symptoms. </li></ul><ul><li>Stool : frequency, amount, water; yellow-water or egg soup-like; a small amount of mucus. </li></ul><ul><li>Dehydration : mild/moderate , isotonic/hypertonic </li></ul><ul><li>Complication: convulsion, myocardium damaged. </li></ul><ul><li>Prognosis : self-limited, course: 3~8d. </li></ul><ul><li>Viral antigen detection : from stool. </li></ul>Several common enteritis-1: Rotavirus enteritis ->human rotavirus (HRV)
  52. 53. <ul><li>Season : summer </li></ul><ul><li>Symptom : vomit and diarrhea, no obvious general toxicity symptoms. </li></ul><ul><li>Stool : water-like or egg soup-like, without mucus, blood or pus, no WBC (test under microscope). </li></ul><ul><li>Dehydration : dehydration, electrolyte and acid-base disorder usually occur. </li></ul><ul><li>Prognosis : self-limited, course: 3~7d. </li></ul>Several common enteritis-2: ETEC enteritis 产毒性细菌 ETEC enteritis
  53. 54. <ul><li>Similar with bacillary dysentery. </li></ul><ul><li>Symptom : diarrhea with fever, nausea, vomit, abdominal pain, tenesmus. Severe general toxicity symptoms, e.g. ardent fever, consciousness change, even septic shock. </li></ul><ul><li>Stool : with mucus, blood and pus, smell of fish, with WBC (test under microscope). </li></ul><ul><li>Stool culture : pathogenic bacterium. </li></ul>Several common enteritis-3: EIEC enteritis 侵袭性细菌 EIEC enteritis
  54. 55. <ul><li>Pathogen : usually Blastomyces albicans. </li></ul><ul><li>Age : ﹤2y. </li></ul><ul><li>Complication by other infection, or after using antibiotics for long time. </li></ul><ul><li>Persistent course , usually thrush companion. </li></ul><ul><li>Stool : yellow thin stool, more foam with mucus, sometimes tofukasu-like. </li></ul><ul><li>test under microscope: fungal spore and hypha. </li></ul>Several common enteritis-4: fungal enteritis fungal enteritis
  55. 56. <ul><li>General introduction </li></ul><ul><li>Classification </li></ul><ul><li>Predisposing factor </li></ul><ul><li>Etiology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Clinical features of several common enteritis </li></ul><ul><li>Persistent diarrhea </li></ul><ul><li>Diagnosis </li></ul><ul><li>Differential Diagnosis </li></ul><ul><li>Treatment </li></ul>Content
  56. 57. <ul><li>Gastric mucosa analosis  bacterium and yeast fungus </li></ul><ul><li>Intestinal mucosa thinner  indigestion and malabsorption </li></ul><ul><li>Bacterium in upper small intestine  enterocyte damaged </li></ul><ul><li>Dynamic abnormality of intestine. </li></ul><ul><li>Using antibiotics for long time. </li></ul><ul><li>Immune function defect  liability to agents </li></ul>Persistent diarrhea acute diarrhea without proper or thorough treatment. Causes:
  57. 58. <ul><li>vicious cycle </li></ul>malnutrition diarrhea Diarrhea + malnutrition: mortality 4 times higher than normal children
  58. 59. <ul><li>General introduction </li></ul><ul><li>Classification </li></ul><ul><li>Predisposing factor </li></ul><ul><li>Etiology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Clinical features of several common enteritis </li></ul><ul><li>Persistent diarrhea </li></ul><ul><li>Diagnosis </li></ul><ul><li>Differential Diagnosis </li></ul><ul><li>Treatment </li></ul>Content
  59. 60. <ul><li>Not difficult </li></ul><ul><li>According to clinical manifestation, laboratory tests and character of stool. </li></ul>Diagnosis + + Infectious Or Noninfectious Dehydration Degree and quality Electrolyte disturbances And Disturbance of acid-base balance
  60. 61. <ul><li>General introduction </li></ul><ul><li>Classification </li></ul><ul><li>Predisposing factor </li></ul><ul><li>Etiology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Clinical features of several common enteritis </li></ul><ul><li>Persistent diarrhea </li></ul><ul><li>Diagnosis </li></ul><ul><li>Differential Diagnosis </li></ul><ul><li>Treatment </li></ul>Content
  61. 62. <ul><li>Usually ﹤6m, bloating, breast-feeding. </li></ul><ul><li>Usually with eczema. </li></ul><ul><li>Normal appetite, growth and developed. </li></ul><ul><li>After cofood addition, stool turns to normal. </li></ul><ul><li>A special type of lactose intolerance </li></ul>Differential diagnosis-1: physiological diarrhea
  62. 63. <ul><li>Epidemiology character </li></ul><ul><li>Stool culture: a dysentery bacillus discovered </li></ul>Differential diagnosis-2: dysentery Bacillary dysentery Amebic dysentery <ul><li>Madder red jam-like stool </li></ul><ul><li>Stool : ameba trophozoite discovered </li></ul>
  63. 64. <ul><li>Symptom : ardent fever, severe toxicity symptoms, abdominal pain and distension, vomit frequently. </li></ul><ul><li>Stool : first, yellow thin or egg soup-like; </li></ul><ul><li>then, red pasty or adsuki bean soup-like. </li></ul><ul><li>X-ray of abdomen : local aerate and expansion in </li></ul><ul><li>small intestine, intestinal wall pneumatosis. </li></ul>Differential diagnosis-3: necrotic enteritis
  64. 65. <ul><li>General introduction </li></ul><ul><li>Classification </li></ul><ul><li>Predisposing factor </li></ul><ul><li>Etiology </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Clinical features of several common enteritis </li></ul><ul><li>Persistent diarrhea </li></ul><ul><li>Diagnosis </li></ul><ul><li>Differential Diagnosis </li></ul><ul><li>Treatment </li></ul>Content
  65. 66. <ul><li>Adjust and continue feeding, not abrosia or </li></ul><ul><li>restricting water, prevent malnutrition. </li></ul><ul><li>Prevent and cure dehydration. </li></ul><ul><li>Rational administration: proper antibiotics, microecosystem preparation, assist-digestive drugs, mucosa protectant, antivomit drugs. Usually disusing antidiarrheal. </li></ul><ul><li>Strengthen nursing, symptomatic treatment, prevent </li></ul><ul><li>complications. </li></ul><ul><li>Fluid therapy (next week lesson) </li></ul>Treatment
  66. 68. Emphasis Etiology (in/ex/no) Pathogenesis (4+ex/b/v/no) Clinical manifestation Diagnosis Differential Diagnosis (p/d/n) Treatment Predisposing (4)
  67. 69. Case example An 8 – month boy had diarrhea and vomited for 3 days, urine stream reduced, irritability. PE: Pulse rate 150/min, weight loss was 10%, blood pressure 65/40mmHg, skin color showed grey and skin turgor looked like tents. Mucous membranes were very dry; eye ball was sunken greatly, anterior fontanel depressed greatly. Abdomen distended, bowel sound diminished. Questions: 1.What is the diagnosis? 2.How to administer the fluid therapy?
  68. 70. Answer diagnosis <ul><li>Acute diarrhea </li></ul><ul><li>severe dehydration </li></ul><ul><li>hypokalemia </li></ul>
  69. 71. thank you!

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