Persistence and chronic diarrhea in children
Introduction
Introduction to pediatric prolongation and chronic diarrhea Prolonged diarrhea refers to the course of disease from 2 weeks to 2 months. Chronic diarrhea refers to the course of disease > 2 months. The combination of the two is called persistent diarrhea (persistentdiarrhea). Diagnosis of refractory diarrhea: 1 The age of onset is small, more common in small infants under 3 months; 2 course > 2 weeks; 3 combined with malnutrition and growth and development disorders; 4 ineffective by general treatment; 5 serious prognosis, high mortality . basic knowledge The proportion of illness: 0.04% Susceptible people: children Mode of infection: non-infectious Complications: abdominal pain, vomiting in children, dehydration, shock
Cause
Pediatric prolongation and the cause of chronic diarrhea
First, the cause of the disease
1. Host factors:
It is closely related to age, nutritional status, immunity and so on.
2. The role of intestinal microbes:
Vibrio and viruses (including rotavirus) do not cause prolonged diarrhea. In addition, a variety of pathogens causing acute diarrhea have been reported in foreign countries for prolonged diarrhea. They can be divided into 2 groups:
(1) Pathogens with equal separation rates of acute and persistent diarrhea:
Such as dysentery bacillus, Salmonella, toxin-producing Escherichia coli, Campylobacter jejuni, Yarrowia, Clostridium difficile and the like.
(2) Pathogens with high separation rate of persistent diarrhea:
They have adsorbent Escherichia coli (EAEC), pathogenic Escherichia coli (EPEC) and Cryptosporidium.
3. Intestinal mucosa continues to be damaged and repaired slowly:
Animal experiments have confirmed that protein-energy malnutrition delays intestinal mucosal repair, and trace elements such as zinc, iron, vitamin A, B12 and folic acid deficiency also affect intestinal mucosal repair.
Second, the pathogenesis
1. Pathogenesis of infectious diarrhea:
(1) The pathogen is adsorbed on the surface of the intestinal mucosa:
However, it does not invade and damage the mucosa, mainly relying on enterotoxin or cytotoxin to cause secretory diarrhea in the host. Intestinal mucosal epithelial cells are not damaged, the intestinal mucosa is intact, the stool is spawned, and no white blood cells are detected by microscopy.
(2) Pathogens directly invade epithelial cells:
And in the epithelial cells to multiply, destroy, and then enter the lamina propria to continue to multiply, and cause intestinal inflammation, resulting in diffuse edema of the intestinal mucosa, congestion, mucus bloody exudate in the intestinal lumen, mucosal necrosis, the formation of superficial ulcers. Clinical manifestations of abdominal pain, diarrhea, urgency and weight, mucus pus and blood is characteristic.
(3) destruction of intestinal mucosal villus epithelial cells:
These pathogens mainly invade the intestinal epithelial cells of the small intestine, deform the intestinal epithelial cells, irregularize, form villus vacuoles, epithelial cells fall off, the function of the newborn intestinal epithelial cells is not perfect, digestion and absorption dysfunction, and malabsorption occurs.
2, the pathogenesis of non-infectious diarrhea:
(1) osmotic diarrhea (osmotic diarrhea):
It refers to the absorption barrier of an absorbable solute, the osmotic pressure of the distal small intestine and the colon is increased, resulting in an increase in fluid reflux from the plasma to the intestinal lumen, an increase in the intestinal contents, an expansion of the intestine, and an increase in intestinal peristalsis. diarrhea. This condition is common in carbohydrate malabsorption.
Osmotic diarrhea is mostly caused by incomplete digestion and decomposition of food.
(2) secretory diarrhea (secretory diarrhea):
The absorption of water and electrolytes by the intestine is the net difference in intestinal absorption and secretion.
(3) Abdominal diarrhea:
Under normal conditions, 98% of the liquid in the digestive tract is reabsorbed, which requires sufficient area and sound absorption function of the digestive tract. Any disease that can damage the absorption area in the digestive tract and affect the absorption function of the digestive tract can affect the reabsorption of fluid in the intestine and cause diarrhea.
Abdominal diarrhea is roughly divided into the following cases, abnormal mucosal permeability, reduced absorption area, intestinal mucosal congestion, excessive bacterial growth, absorption inhibition, lymphatic obstruction, diarrhea caused by intestinal motility disorder.
Prevention
Child protracted and chronic diarrhea prevention
1. Promote breastfeeding, reasonable feeding, prevent malnutrition, and promote the growth and development of children.
2, pay attention to food hygiene, prevent digestive tract infectious diseases, for the treatment of (acute) diarrhea patients with the principle of treatment, rational use of drugs, to prevent prolonged disease.
3, enhance physical fitness, improve their own immunity: fully rest, more physical exercise, eat more fresh fruits and vegetables rich in vitamins.
Complication
Pediatric prolongation and complications of chronic diarrhea Complications, abdominal pain, vomiting, dehydration shock
First, abdominal pain:
It refers to the lesions of the internal and external organs caused by various reasons, and it is manifested as pain in the abdomen. Abdominal pain can be divided into acute and chronic.
Second, vomiting:
Vomiting is a kind of reflex action that the contents of the stomach are reversed into the esophagus and spit out through the mouth. It can be divided into three stages, nausea, retching and vomiting, but some vomiting can be a precursor to nausea or retching.
Third, dehydration:
Dehydration refers to the fact that the human body consumes a large amount of water due to lesions, but cannot be immediately replenished, causing a symptom of metabolic disorder. In severe cases, it may cause collapse and even life-threatening. It is necessary to rely on infusion to replenish body fluids.
Fourth, acidosis:
Under pathological conditions, when the body [BHCO3] decreases or [H2CO3] increases, the [BHCO3]/[H2CO3] ratio can be reduced, causing the blood pH to decrease, which is called acidosis. The accumulation of acidic substances in the blood and tissues of the body is characterized by an increase in the concentration of hydrogen ions in the blood and a decrease in the pH.
V. Shock:
The word shock is translated from the English Shock. It is a systemic pathological process in which all kinds of strong pathogenic factors act on the body, causing rapid decline of circulatory function, severe microcirculation perfusion of tissues and organs, and vital vital functions and metabolic disorders. Shock is an acute syndrome.
Symptom
Pediatric prolongation and symptoms of chronic diarrhea Common symptoms Slow diarrhea
1. Prolonged diarrhea:
The frequency of bowel movements increased 4 times a day, and the stool characteristics changed. It was watery stool, mucus or pus and bloody stool. The course of diarrhea was 2 weeks.
2, refractory diarrhea:
The age of onset is small, more common in less than 3 months, the course of diarrhea is more than 2 weeks, combined with malnutrition and growth and development disorders, the general treatment is ineffective, the prognosis is more serious.
3. Performance directly due to malabsorption:
Weight loss, delayed growth and development, pale, can have glossitis, abdominal distension and increased gas production caused by discomfort.
Most diarrhea, such as fat indigestion, stool color, soft stool, oily foam-like, a large amount, there is stench, this feces often tend to stain on the toilet, not easy to wash away.
4, secondary to the manifestations of various deficiencies of malabsorption:
The extent and extent of nutritional deficiencies are related to the severity of the primary disease and the size and size of the affected gastrointestinal tract.
There may be vitamin D and calcium deficiency, convulsions, hand, foot and ankle and bone and tooth development retardation.
Absorption of fat-soluble vitamin K can cause a decrease in prothrombin and a tendency to cause purpura and bleeding, and riboflavin deficiency can cause glossitis and angular cheilitis.
Abnormal protein absorption can lead to hypoproteinemia edema, usually seen in the lower extremities.
5. Relationship between prolonged diarrhea and nutrition:
Growth during diarrhea may slow down or stop, especially when diet is restricted.
Examine
Pediatric prolongation and examination of chronic diarrhea
The following checks are possible to confirm the diagnosis:
First, stool inspection:
High power microscope (400 times) white blood cells>15, a small amount of red blood cells can be clinically diagnosed bacillary dysentery; white blood cells 15 to diagnose enteritis. Microscopic examination can also detect the eggs, smear can be found in the amoeba trophozoites, Vibrio cholerae.
Second, serum immunological examination:
Various antigen-antibody immunological tests are helpful for the pathogenic diagnosis of various infectious diarrhea, such as the fattening reaction to the diagnosis of typhoid fever and paratyphoid fever.
Third, X-ray inspection:
X-ray under fluoroscopy, dynamic observation of esophagus, stomach, duodenum, small intestine, large intestine to the anus, the entire digestive tract movement function, morphology, with or without ulcers, with or without space-occupying lesions have important diagnostic value.
Fourth, ultrasonic inspection:
Abdominal B-ultrasound provides a basis for morphological diagnosis of gastrointestinal, hepatobiliary morphology, and space-occupying lesions.
5. Magnetic resonance imaging (MRI):
MRI is of great significance for the differential diagnosis of liver tumors, especially liver malignant tumors and cystic lesions. It can also be used for the diagnosis of inflammatory bowel disease and necrotizing enterocolitis, lymphoma and intestinal wall hematoma after trauma.
Sixth, CT examination:
It plays an important role in the differential diagnosis of abdominal diseases in children. It is mainly used for the diagnosis and differential diagnosis of abdominal mass, abdominal abscess, trauma, liver and pancreas.
Seven, fiber endoscopy, fiber colonoscopy and laparoscopy:
Upper gastrointestinal endoscopy includes three types: fiber endoscopy, electron endoscopy and passive enteroscopy. These endoscopes have clear images, can be photographed, videotaped, biopsy, and easy to treat, and have been widely used in pediatric clinics. Laparoscopy can be performed under direct vision or by taking a living tissue for pathological examination to confirm the diagnosis.
Eight, pathological examination:
The pathological examination of living tissue is decisive for the diagnosis of diarrhea. A histopathological diagnosis provides a pathological diagnosis for the diagnosis of the disease.
Nine, breathing test:
Because the method is simple, non-invasive, and suitable for children of all age groups, it can be widely used in the clinical of gastrointestinal diseases and become one of the effective means for diagnosing gastrointestinal diseases.
1. Hydrogen breath test:
(1) lactose hydrogen breath test:
For the diagnosis of lactose malabsorption.
(2) Sucrose hydrogen breath test:
For the diagnosis of primary sucrose-isomalt deficiency.
(3) Hydrogen breath test for diagnosing excessive growth of intestinal bacteria:
It can be used to diagnose bacterial overgrowth in the small intestine.
2, carbon dioxide breath test:
(1) Detection of fat absorption:
The 14C-labeled triolein breath test is a simple and reliable method for detecting fat malabsorption.
(2) Detection of carbohydrate absorption:
Lactose malabsorption can be diagnosed using a natural 13C-lactose breath test.
(3) Diagnosis of intestinal bacterial overgrowth:
The 14C-glycocholic acid test can be used to diagnose bacterial overgrowth in the small intestine.
(4) Urea breath test:
For the detection of Helicobacter pylori. In addition to being used for diagnosis, it can also be used for follow-up examination after antibacterial treatment. This test can accurately reflect the seroconversion, recurrence and reinfection of Helicobacter pylori, so it can be used as an important means to judge and screen effective drugs.
Diagnosis
Diagnosis and differentiation of children with chronic diarrhea
diagnosis
Diagnosis can be made based on medical history, clinical manifestations, and related examination results.
Differential diagnosis
First, the infection:
1, viral:
Such as rotavirus enteritis, enteric adenovirus diarrhea, norwalk virus diarrhea, calicivirus diarrhea, astrovirus diarrhea, enterovirus diarrhea .
2, bacterial:
Such as cholera, bacterial dysentery, diarrhea-causing Escherichia coli enteritis, Campylobacter jejuni enteritis, Salmonella enteritis, Yersinia enterocolitis, Clostridium perfringens enteritis, Clostridium difficile Enteritis (also known as pseudomembranous enterocolitis, PMC).
3. Fungi:
Such as Candida albicans enteritis
4. Protozoa:
Such as amoebic dysentery, giardiasis, cryptosporidis enteritis.
5. Parasites:
Such as schistosomiasis, clonorchiasis, trichuriasis (trichuriasis), trichiniasis (trichiniasis), ginger schizophrenia (fasicolopsiasis), hookworm disease.
Second, poisoning:
1. Bacterial food poisoning:
Such as Salmonella food poisoning, Staphylococcus aureus food poisoning, Proteus food poisoning, Vibrio parahaemolyticus food poisoning, botulism poisoning.
2, fungal food poisoning:
The main symptoms are gastrointestinal symptoms: vomiting, nausea, abdominal pain, bloating, diarrhea (prosthetic diarrhea is more prominent); followed by central nervous system symptoms: dizziness, headache, irritability, convulsions, coma, etc.; can also cause liver, Systemic diseases such as kidney and blood, severe cases may die due to peripheral circulatory failure or respiratory paralysis.
3. Toxic plant poisoning:
Such as poisonous mushroom poisoning, castor bean poisoning, ginkgo poisoning, tung oil poisoning, sprouting potato poisoning, rotten sweet potato poisoning, poisonous poisoning of pods.
4. Toxic animal poisoning:
Such as puffer fish poisoning, animal liver poisoning and so on.
Third, indigestion and malabsorption:
Such as glucan enteropathy, tropical inflammatory diarrhea (tropica1 sprue), lactose intolerance, congenital sucrose intolerance, congenital chloride diarrhea, trehalose Tolerance, glucose-galactose malabsorption, Hartnup disease (tryptophan metabolism), abetalipoproteinemia (ABL), Anderson disease (chylomicron retention), cystic fibrosis (cystic) Fibrosis of pancreas), Whippie's disease, intestinal lymphangiectasia, short bowel syndrome, etc.
Fourth, chronic non-specific enteritis:
Such as Crohn's disease, ulcerative colitis (ulcerative colitis, etc.).
5. Allergic gastroenteopathy:
Also known as food allergy, refers to the body's intolerance to certain foods, or abnormal reactions caused by eating, and immune response.
Sixth, radiation enteritis:
Direct or indirect exposure to radioactive materials can cause human damage. Radiation enteritis refers to small bowel, colon and rectal injury caused by radiation treatment of pelvic, abdominal or retroperitoneal tumors, also known as intestinal radiation damage, the most common is radiation colitis.
Seven, intestinal Behcet's disease:
For multi-site mucosal ulcers, oral ulcers, iridocyclitis, membranous inflammation, genital ulcers as the main lesions, intestinal lesions are part of the systemic lesions, ulcers can diffuse from the oral cavity to the anus of all digestive tract mucosa The right colon and the terminal ileum are the most common sites.
Eight, drug-induced diarrhea:
Certain drugs can cause diarrhea, causing malabsorption syndrome and the like.
Nine, refractory diarrhea:
More common in infants, generally refers to within 3 months after birth, diarrhea lasts for more than 2 weeks, clinical exclusion of specific intestinal infections, often accompanied by digestive malabsorption, malnutrition, growth and development and other systemic symptoms, diarrhea prolonged, It is called refractory diarrhea.
