小 儿 腹 泻 Infantile Diarrhea 目的要求 Objective 临床表现 Clinical menifestations 概述 Summary 诊断、鉴别诊断 Diagnosis & Differential Diagnosis 病因 Etiology 治疗原则 Principle of Treatment 发病机制 Pathogenesis

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

病因 Etiology 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

Pathogeny of infection inside intestinal tract 病因 Etiology 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

发病机制 细菌性肠炎 肠毒素 细菌侵袭肠粘膜 不耐热肠毒素 耐热肠毒素 充血、水肿、溃疡 腺苷酸环化酶 鸟苷酸环化酶 血或粘冻状便 CAMP↑ CGMP↑ 痢疾样改变 Na+ Cl- H2O↑ 小肠液分泌↑ 腹泻

Pathogenesis Bacterial enteritis Enterotoxin Heat-labile enterotoxin Heat-stable enterotoxin Bacteria invasive oral mucosa Adenyl cyclase Guanylic cyclase Congest, dropsy, ulcer cAMP↑ cGMP↑ Na+ Cl- H2O↑ Small intestine juice secrete↑ Stool (blood, mucus shreds, pus) Diarrhea

病毒性肠炎发病机制 病毒颗粒 小肠粘膜带有微绒毛的上皮细胞 肠粘膜上皮细胞脱落，绒毛变短 双糖酶活性↓ 钠葡萄糖载体的偶联转运障碍 糖类分解吸收障碍 钠、葡萄糖吸收障碍 肠道内乳酸↑ 肠道内钠、葡萄糖↑ 肠渗透压↑ 回吸收水电解质能力↓ 水样泻

Pathogenesis of Viral Enteritis Virus particles Microvillares epithelial cells on Small intestine mucous membrane Shedding of epithelial cells on intestine mucous membrane, intestinal villus shortening Disaccharidase activity↓ Na +, glucose coupling transporter disorder Carbohydrate decomposition & absorption disorder Na +, glucose absorption disorder Intestinal Na + & glucose↑ Intestinal lactic acid↑ Intestines osmotic pressure↑ Reabsorbed water-electrolyte↓ Watery diarrhea

胃内食物积滞，胃酸少，肠道下段细菌上移繁殖 非感染性腹泻发病机制 饮食不当 胃内食物积滞，胃酸少，肠道下段细菌上移繁殖 分解产生短链有机酸 胺类↑ 细菌、毒性产物 肠内渗透压↑ 肠蠕动↑ 门脉系统进入血循环 渗透性腹泻 中毒症状(内源性感染)

Pathogenesis of Noninfectious Diarrhea Improper diet Gastric stanated food，less gastric acid, lower intestinal bacteria up-moving & propagation Decomposition producing shout chain organic acid Amines↑ Bacteria & toxicity products Portal vein system entering blood circulation Intestinal osmotic pressure↑ Enterokinesia↑ Toxicosis symptom (endogenous infection) Osmotic diarrhea

临床表现 Clinical Menifestations 一 根据病程分类Classified by course 急性腹泻（<2周） Acute diarrhea（<2 weeks） 迁延性腹泻（ 2周~2月）Persisting diarrhea （2 weeks~2 months） 慢性腹泻（ >2月） Chronic diarrhea（ >2 months ） 二 根据病情分类Classified by patient’s 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

临床表现 Clinical Menifestations 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

Diagnosis & Differential Diagnosis 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 Fluid therapy 口服补液 Oral rehydration salts, 静脉补液 Iintravenous rehydration 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 Fluid 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 Fluid Therapy 小儿腹泻液体疗法 Infantile Diarrhea Fluid Therapy

目的要求 Objective 了解小儿体液平衡的特点 熟悉小儿水、电解质和酸碱失衡的病理生理 掌握小儿电解质和酸碱平衡紊乱的临床表现 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 不同年龄的体液分布（占体重的％） 一 体液的总量和分布 年龄 总量 细胞外液 细胞内液 血浆 间质液 足月新生儿 78 一 体液的总量和分布 不同年龄的体液分布（占体重的％） 年龄 总量 细胞外液 细胞内液 血浆 间质液 足月新生儿 78 6 37 35 1岁 70 5 25 40 2～14岁 66 20 成人 55～66 10～15 40～45  

Body water compartments related to age (total body mass%) Characteristic of Infantile Body Fluid Balance A. Total body water & its distribution Body water compartments related to age (total body mass%) Age TBW ECF ICF Plasma ISF Newborn infant 78 6 37 35 1 year 70 5 25 40 2～14 years 66 20 Adult 55～66 10～15 40～45 TBW: total body water ECF: extracellular fluid ICF: intracellular fluid ISF: interestitial fluid

Characteristic of Infantile Body Fluid Balance 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

Characteristic of Infantile Body Fluid Balance 小儿体液平衡的特点 Characteristic of Infantile Body Fluid Balance 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（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 adult’s amount ). Infant’s water exchange amount is 1 / 2 of ECF , the adult’s 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.

水电解质酸碱平衡紊乱 一 脱水程度 表现程度 失水量 神 态 眼眶、 前囟 皮肤弹性 口唇粘膜 眼泪 尿量 休克 轻度脱水 5％ 一 脱水程度 表现程度 失水量 神 态 眼眶、 前囟 皮肤弹性 口唇粘膜 眼泪 尿量 休克 轻度脱水 5％ （50ml / kg） 精神稍差，略有烦躁不安 稍凹陷 稍差 略干燥 有 稍少 无 中度脱水 5～10％ （50～100ml / kg） 精神萎靡，烦躁不安 明显凹陷 差 干燥 少 明显减少 重度脱水 >10％ （100～120ml / kg） 昏睡，昏迷 深陷 极差 极干燥 极少或无

Depressed, hyperirritable Disturbances of Water, Electrolyte & Acid-base Balance A. Degree of dehydration Dehydration Mild Moderate Severe Decrease in body weight 5％ (50ml / kg) 5～10％ (50～100ml / kg) >10％ (100～120ml / kg) Psyche Depressed, hyperirritable Depressed, hyperirritable Lethargic, coma Orbit, Fontanel Sunken ± Sunken Severely sunken Skin turgor Normal ± Decrease Markedly decrease Mucous membranes Dry ± Dry Severely dry Tears Decrease ± Absent Urine Mild oliguria oliguria Anuria Blood pressure Normal Low

水电解质酸碱平衡紊乱 二 脱水性质 临床表现 脱水性质 病因 血清纳 病理生理及临床特点 等渗脱水 低渗脱水 高渗脱水 130～150 二 脱水性质 临床表现 脱水性质 病因 血清纳 病理生理及临床特点 等渗脱水 多见急性胃肠液丢失 130～150 mmol / L 细胞外液量减少，细胞内外渗 透压相等脱水量与脱水体征平衡 低渗脱水 多见慢性胃肠液丢失 <130 细胞外液明显减少，易发生休 克，脱水征比其他两种脱水严重 高渗脱水 高热、感染多见 >150 细胞内液减少明显，脱水征 比其他两种为轻

Disturbances of Water, Electrolyte & Acid-base Balance B. Type of dehydration Type of dehydration Pathogeny Serum sodium Pathophysiology & clinical characteristic Isosmotic Acute gastrointestinal fluid lose 130～150 mmol / L ECF: decrease, Osmotic pressure (intracellular = extracellular) Dehydrant volume accord with dehydrant physical sign Hypotonic Chronic gastrointestinal fluid lose <130 ECF: severely decrease, Easily shock ， Severer dehydrant sign than the other two kinds Hyperosmotic High grade fever, Infection >150 ICF: severely decrease, Milder dehydrant sign than the other two kinds

Disturbances of Water, Electrolyte & Acid-base Balance 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、氯化氨、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.）

Disturbances of Water, Electrolyte & Acid-base Balance 水电解质酸碱平衡紊乱 Disturbances of Water, Electrolyte & Acid-base Balance （二） 分度 Degree 轻度 Mild HCO3- 18~13 mmol / L 中度 Moderate HCO3- 13~9 mmol / L 重度 Severe HCO3- <9 mmol / L

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）

Disturbances of Water, Electrolyte & Acid-base Balance 水电解质酸碱平衡紊乱 Disturbances of Water, Electrolyte & Acid-base Balance （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 Muscle——inertia of limbs，muscular tension down，severely retardant paralysis，respiratory muscle paralysis

Disturbances of Water, Electrolyte & Acid-base Balance 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－期综合症心律↓，房室传导阻滞， 心肌纤维变性，局限性坏死，心肌收缩乏力，心音低炖 心电图，出现U波，U≥T，T波增宽、低平、倒置 Heart—— heart rate increasing, arrhythmia, Adams－Stokes syndrome, heart rate decreasing，atrioventricular block, heart sound lowering, cardiogram: U wave appearing，U≥T，flattened T wave

Disturbances of Water, Electrolyte & Acid-base Balance 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

Common Solution of Fluid Therapy 液体疗法时常用的溶液 Common Solution of Fluid 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

常用混合液Common mixed solution 液体疗法时常用的溶液 Common Solution of Fluid Therapy 常用混合液Common mixed solution 0.9%NaCl 1.4%NaHCO3 5~10%G.S 2:1(等张含钠液) 2份 1份 3:2:1(1/2张含钠液) 3份 4:3:2(2/3张含钠液) 4份 1/3张含钠液 6份

Infantile Diarrhea Liquid Therapy 小儿腹泻液体疗法 Infantile Diarrhea Liquid Therapy 一 定量 Volume 总 量 Total volume 累积损失量 Cumulated losing volume 维持输入阶段（生理需要，继续损失）Keep transfusing period（physiological need, losing continuing） 轻 90～120ml/kg 50ml/kg 40-70ml/kg 中 120～150ml/kg 50-100/kg 重 150～180ml/kg 100-120ml/kg

Infantile Diarrhea Liquid Therapy 小儿腹泻液体疗法 Infantile Diarrhea Liquid Therapy 二 定性 Quality 脱水种类 Dehydrant category 累积损失量Cumulated losing volume 维持输入阶段（生理需要，继续损失）Keep transfusing period（physiological need, losing continuing） 低渗性脱水 Hypotonic dehydration 4:3:2 1/3～1/4张含钠液 Sodic solution 等渗性脱水 Isosmotic dehydration 2:3:1 高渗性脱水 Hyperosmotic Dehydration 1/3张含钠液Sodic solution

Infantile Diarrhea Liquid Therapy 小儿腹泻液体疗法 Infantile Diarrhea Liquid Therapy 三 定速 Speed 总 量 Total volume 累积损失量Cumulated losing volume 维持输入阶段（生理需要，继续损失）Keep transfusing period（physiological need, losing continuing） 24h 8～12h 12～16h 8～10ml / kg /h 5ml / kg /h

Infantile Diarrhea Liquid Therapy 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 扩 容 量 Volume 溶 液 名 称 Solution 速 度 Speed 20ml/kg 2:1或1.4％NaHCO3 30～60min 注：总量不超过300ml Total volume ≤ 300ml

Infantile Diarrhea Liquid Therapy 小儿腹泻液体疗法 Infantile Diarrhea Liquid Therapy 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.

Infantile Diarrhea Liquid Therapy 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 0.2～0.3％（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 6 hours of preadmission, bladder percussing－dull note) Kalium supplement concentration: 0.2～0.3％(≯0.3％) Venoclysis period of total Kalium supplement per day ≮8 hours

小儿腹泻液体疗法 病案分析 患儿，男，9个月，因腹泻2天于98年8月10日入院。 2天前因吃未煮豆腐花后出现排黄色蛋花汤样大便，量多，无红白冻子，无里急后重，每日排便10～15次，入院前6小时排便一次，量少，尿黄。体查：T38ºC，R32次/分，P120次/分，烦躁不安，体查不合作，前稳囟1.5×1.5cm2，凹陷，眼眶凹陷，皮肤弹性差，唇干燥，舌粘膜干燥，咽（－），心率120次/分，率齐，心音稍钝，双肺（－），腹稍隆起，腹软，肝肋下1.5cm未扪及，肠鸣音10～12次/分，未闻及高调音，双下肢膝腱反射阴性。

Infantile Diarrhea Liquid Therapy Case analysis Infant, male, 9 months, diarrhea 2 days, admission date 1998-08-10. After eating un-boiled bean curd 2 days ago, yellow waterish stools, bulky, no blood, no tenesmus, defecation 10～15/day; one stool 6 hours of preadmission, a little, yellow urine. Physical examination：T38ºC, R32/min, P120/min, dyspyoria, Fontanel 1.5×1.5cm2, sunken, orbit sunken, decreased Skin turgor, dry lip, dry periglottis, pharynx (－), heart rate 120/min, no arrhythmia, mild dull heart sounds, lungs(－), mild abdomen swelling, soft abdomen, not palpated liver 1.5cm below ribs, bowel sounds 10～12/min, no high notes，two lower limbs patellar reflex (negative)