小儿腹泻
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EKG：U wave, depressed ST segment, flat or inverted T wave
dehydration
vomiting, diarrhea poor intake
[K+]
＋
mild or no hypokalemia
acidosis ＋ K shift from intercellular to plasma + [K ]
Non-inflammatory diarrhea
feeding problems
milk allergy
malabsorption: disaccharidase deficiencies, CF…
climate factors
anatomic defects: malrotation, microvillous atropy… molitity disorders
dry
severe
very delayed
highly dry very sunken anuria, no tear
10% (100 ml/ kg) 15%
slightly dry
slightly dry
slightly depressed sunken
warm
still well
cool, pale
I. clinic aspects of hypokalemia
K+ < 3.5mmol/L
abdominal distension
muscle weakness, paralysis, tendon reflex (-)
bluntness of heart tone, arrhythmia, etc
immature intestinal flora (neonate)
Inflammatory diarrhea
Enteral infections:
bacteria: E. coli, Campylobacter jejuni, Salmonella, Yersinia, S. aureus, etc
abnormality of the glucose-sodium transport system toxigenic
bacteria
invasive
food induced
invade and toxin (LT, ST) epithelial cells proliferate in epithelia cells cAMP cGMP
absorption secretion electrolyte transport maldigestion, transport defects, ingestion of unabsorbable solute transit time
defect in neuromuscular unit(s) stasis (bacterial overgrowth)
--- The Johns Hopkins Hospital, The Harriet lane handbook, 6th edition
Diarrhea: imbalance in the intestine handling
of water and electrolytes
Adults:
small intestine: absorb 10 ~ 11 L / day a combination of ingested and secreted fluid
intestinal transit
Etiology
Infantile diarrhea
Pathogenic mechanism
Type of diarrhea
Clinical aspects Diagnosis
Treatment
III. Type of diarrhea
1. according to clinical course
cold, mottled
irritable/ lethargic very sick
Type of dehydration
isotonic incidence losses 70~80 % Na+ = water hypotonic 10~15 % hypertonic 10~20%
[Na+]mmol/L 130 ~ 150 disorder acute
Infantile Diarrhea
Usual stool output is 10 g/kg/d in children and 200 g/d
in adults.
Diarrhea is increased water in stool, resulting in increased stool frequency or loose consistency.
undigested and unabsorbed food, digested by resident microflora
intestinal secretion
mucosa erosions and ulceration
organic acid osmotic force
diarrhea disturbance of fluid， electrolytes
begin self-limited condition, subside within a few days < 2y, 50% < 1y clinical presentation and course of illness:
depending on the host depending on the infecting organisms
colon: 0.5 L / day
Importance of Diarrhea
In under five children
Diarrhea is a leading cause of:
Malnutrition
Morbidity
Mortality
Infantile diarrhea
Treatment
IV. Clinical aspects
mild
stool movements < 10 /d
severe diarrhea
> 10 /d
stool characteristics来自百度文库
systemic
loose
less mild
watery, mucousy
appetite , vomiting
laxative abuse
etc
Etiology
Infantile diarrhea
Pathogenic mechanism
Type of diarrhea
Clinical aspects Diagnosis
Treatment
virus
villi damage structural lesions, enzymatic deficiency
moderate dehydration
severe dehydration
dehydration
isotonic dehydration type of dehydration hypotonic dehydration hypertonic dehydration
Degree of dehydration
delivery to the tissues
lactic acidosis
kidney hypoperfusion
urine output
excretion acid
Metabolic acidosis
Clinical manifestation:
lethargic, pale, compensatory hyperventilation
rehydration
diuresis corrected acidosis
gluconeogenesis
blood dilution
K＋shift back to cell
Hypokalemia
II. Hypocalcemia and hypomagnesemia
Causes: poor intake, malabsorption, increased loss Clinical manifestations: asymptomatic, neuromuscular irritability, tetany
Etiology
Infantile diarrhea
Pathogenic mechanism
Type of diarrhea
Clinical aspects Diagnosis
Treatment
I. Etiology
Immature of digestive, neurologic system poor modulation of GI quick growth, burden of GI lower SIgA
Symptoms of tetany may be provoked when dehydration
and acidosis are corrected ( ionized Ca++)
III. Metabolic acidosis: causes
Loss of bicarbonate from the body Poor intake, malabsorption Dehydration hypoperfusion starvation ketoacidosis inadequate oxygen
diarrhea
<130
Na+ > water
>150
water > Na+
malnutrition
given glucose only
fever, given
free water
main symptom
circulation
CNS
Electrolytes and acid-base disturbance
Acute：< 2 w
Persistent：2 w～2 m
Chronic：> 2 m
2. according to disease intensity mild diarrhea
severe diarrhea
3. according to mechanisms
primary mechanism secretory diarrhea osmotic diarrhea motility diarrhea increased motility decreased motility invasive diarrhea defect
mild loss of fluid skin mucous membranes fontanel, eyeballs tears, uresis circulation general condition
5% (50 ml/ kg)
moderate
dry, delayed capillary refill
manifestations
disturbance of fluid
energy , fever, etc
moderate-severe dehydration
and electrolytes
hypokalemia, acidosis, etc
mild dehydration degree of dehydration
inflammation, mucosal surface area and / or colonic reabsorption motility
Etiology
Infantile diarrhea
Pathogenic mechanism
Type of diarrhea
Clinical aspects Diagnosis
virus: rotavirus, enteric adenovirus, astrovirus, Norwalk virus, etc Fungi: candida albicans
parasites: giardia lamblia, etc
Parenteral infections:
urinary tract infection, pneumonia, tympanitis, meningitis, etc
dehydration
vomiting, diarrhea poor intake
[K+]
＋
mild or no hypokalemia
acidosis ＋ K shift from intercellular to plasma + [K ]
Non-inflammatory diarrhea
feeding problems
milk allergy
malabsorption: disaccharidase deficiencies, CF…
climate factors
anatomic defects: malrotation, microvillous atropy… molitity disorders
dry
severe
very delayed
highly dry very sunken anuria, no tear
10% (100 ml/ kg) 15%
slightly dry
slightly dry
slightly depressed sunken
warm
still well
cool, pale
I. clinic aspects of hypokalemia
K+ < 3.5mmol/L
abdominal distension
muscle weakness, paralysis, tendon reflex (-)
bluntness of heart tone, arrhythmia, etc
immature intestinal flora (neonate)
Inflammatory diarrhea
Enteral infections:
bacteria: E. coli, Campylobacter jejuni, Salmonella, Yersinia, S. aureus, etc
abnormality of the glucose-sodium transport system toxigenic
bacteria
invasive
food induced
invade and toxin (LT, ST) epithelial cells proliferate in epithelia cells cAMP cGMP
absorption secretion electrolyte transport maldigestion, transport defects, ingestion of unabsorbable solute transit time
defect in neuromuscular unit(s) stasis (bacterial overgrowth)
--- The Johns Hopkins Hospital, The Harriet lane handbook, 6th edition
Diarrhea: imbalance in the intestine handling
of water and electrolytes
Adults:
small intestine: absorb 10 ~ 11 L / day a combination of ingested and secreted fluid
intestinal transit
Etiology
Infantile diarrhea
Pathogenic mechanism
Type of diarrhea
Clinical aspects Diagnosis
Treatment
III. Type of diarrhea
1. according to clinical course
cold, mottled
irritable/ lethargic very sick
Type of dehydration
isotonic incidence losses 70~80 % Na+ = water hypotonic 10~15 % hypertonic 10~20%
[Na+]mmol/L 130 ~ 150 disorder acute
Infantile Diarrhea
Usual stool output is 10 g/kg/d in children and 200 g/d
in adults.
Diarrhea is increased water in stool, resulting in increased stool frequency or loose consistency.
undigested and unabsorbed food, digested by resident microflora
intestinal secretion
mucosa erosions and ulceration
organic acid osmotic force
diarrhea disturbance of fluid， electrolytes
begin self-limited condition, subside within a few days < 2y, 50% < 1y clinical presentation and course of illness:
depending on the host depending on the infecting organisms
colon: 0.5 L / day
Importance of Diarrhea
In under five children
Diarrhea is a leading cause of:
Malnutrition
Morbidity
Mortality
Infantile diarrhea
Treatment
IV. Clinical aspects
mild
stool movements < 10 /d
severe diarrhea
> 10 /d
stool characteristics来自百度文库
systemic
loose
less mild
watery, mucousy
appetite , vomiting
laxative abuse
etc
Etiology
Infantile diarrhea
Pathogenic mechanism
Type of diarrhea
Clinical aspects Diagnosis
Treatment
virus
villi damage structural lesions, enzymatic deficiency
moderate dehydration
severe dehydration
dehydration
isotonic dehydration type of dehydration hypotonic dehydration hypertonic dehydration
Degree of dehydration
delivery to the tissues
lactic acidosis
kidney hypoperfusion
urine output
excretion acid
Metabolic acidosis
Clinical manifestation:
lethargic, pale, compensatory hyperventilation
rehydration
diuresis corrected acidosis
gluconeogenesis
blood dilution
K＋shift back to cell
Hypokalemia
II. Hypocalcemia and hypomagnesemia
Causes: poor intake, malabsorption, increased loss Clinical manifestations: asymptomatic, neuromuscular irritability, tetany
Etiology
Infantile diarrhea
Pathogenic mechanism
Type of diarrhea
Clinical aspects Diagnosis
Treatment
I. Etiology
Immature of digestive, neurologic system poor modulation of GI quick growth, burden of GI lower SIgA
Symptoms of tetany may be provoked when dehydration
and acidosis are corrected ( ionized Ca++)
III. Metabolic acidosis: causes
Loss of bicarbonate from the body Poor intake, malabsorption Dehydration hypoperfusion starvation ketoacidosis inadequate oxygen
diarrhea
<130
Na+ > water
>150
water > Na+
malnutrition
given glucose only
fever, given
free water
main symptom
circulation
CNS
Electrolytes and acid-base disturbance
Acute：< 2 w
Persistent：2 w～2 m
Chronic：> 2 m
2. according to disease intensity mild diarrhea
severe diarrhea
3. according to mechanisms
primary mechanism secretory diarrhea osmotic diarrhea motility diarrhea increased motility decreased motility invasive diarrhea defect
mild loss of fluid skin mucous membranes fontanel, eyeballs tears, uresis circulation general condition
5% (50 ml/ kg)
moderate
dry, delayed capillary refill
manifestations
disturbance of fluid
energy , fever, etc
moderate-severe dehydration
and electrolytes
hypokalemia, acidosis, etc
mild dehydration degree of dehydration
inflammation, mucosal surface area and / or colonic reabsorption motility
Etiology
Infantile diarrhea
Pathogenic mechanism
Type of diarrhea
Clinical aspects Diagnosis
virus: rotavirus, enteric adenovirus, astrovirus, Norwalk virus, etc Fungi: candida albicans
parasites: giardia lamblia, etc
Parenteral infections:
urinary tract infection, pneumonia, tympanitis, meningitis, etc