Diarrhea

Introduction to diarrhea Normal people usually have bowel movements once a day. Individuals have 2 or 3 bowel movements per day or once every 2 to 3 days. The characteristics of feces are normal. The average weight of feces per day is 150-200g, and the water content is 60%-75%. . Diarrhea is a common symptom. It means that the frequency of bowel movements is significantly higher than the frequency of usual habits. The faeces are thin, the water is increased, the daily defecation is more than 200g, or the undigested food or pus and mucus, diarrhea is often accompanied. Defecation urgency, anal discomfort, incontinence and other symptoms, diarrhea is divided into acute and chronic. Acute diarrhea is acute, and the course of disease is within 2 to 3 weeks. Chronic diarrhea refers to recurrent diarrhea with a course of disease of more than two months or intermittent within 2 to 4 weeks. basic knowledge The proportion of illness: 0.12% Susceptible people: no special people Mode of infection: non-infectious Complications: syncope malnutrition

Cause of diarrhea

Bacterial infection (20%):

1 Bacterial dysentery: more acute onset, often chills, fever, abdominal pain, diarrhea and sensation after urgency, may be associated with nausea and vomiting, diarrhea characterized by mucus pus and blood, varying times per day, microscopically found a large amount of red blood cells in the stool , white blood cells, stool culture can be found in Shigella.

2 Salmonella infection: more than a history of unclean diet, often abdominal distension, abdominal pain and diarrhea symptoms, stools are mainly loose or watery stools, less pus and blood, stool 3 to 5 times a day, stool culture can be Pathogenic bacteria (Salmonella or Salmonella typhimurium, etc.) were found.

3 Escherichia coli enteritis: often have a history of unclean diet, acute onset, may have chills, fever and abdominal pain, diarrhea and other symptoms, may be accompanied by vomiting, diarrhea is mostly water-like stools, there may be Mucus and pus and blood can be found in stool culture.

4 Campylobacter intestinal infection: the symptoms are generally mild, manifested as pain in the upper abdomen accompanied by diarrhea, with loose stools or watery stools as the main performance, antibiotic treatment.

5 small intestine, Yersinia colonic infection: clinical manifestations are similar to Campylobacter infection, diarrhea and other symptoms are often mild.

6 intestinal Staphylococcus aureus infection: more acute onset, may have chills, fever, abdominal pain and diarrhea and other symptoms, diarrhea is mainly thin stools, may be accompanied by a small amount of mucus pus and blood, stool culture can establish a diagnosis, the disease It is often found after the use of broad-spectrum antibiotics, hormones or major surgery, and Staphylococcus aureus can be found in stool culture.

7 acute hemorrhagic necrotizing enterocolitis: now more thought to be associated with Clostridium perfringens or Clostridium perfringens infection, acute onset, abdominal pain, diarrhea and other symptoms are generally heavier, abdominal pain is more severe and can be spread throughout the abdomen May be persistent pain or paroxysmal aggravation, early diarrhea can be loose stools or watery stools, more than 10 times a day, and then can bring blood, heavy can be bloody, often accompanied by chills, Fever, nausea and vomiting, etc., this disease is more common in adolescents.

8 pseudomembranous colitis: occurs after long-term use of antibiotics, can also occur in patients with low immune function, mostly due to intestinal infection caused by Clostridium difficile infection, the toxin of the bacteria damage the intestinal mucosa Function, the clinical features are more frequent stools, the weight can reach more than 20 times a day, the feces can have mucus pus and blood, and even bloody water samples, sometimes can discharge the pseudomembrane of egg pattern, often accompanied by fever, palpitations, dehydration, Electrolyte disorder, hypotension and other symptoms of systemic poisoning, when the stool is used for anaerobic culture, pathogenic bacteria can be found, and metronidazole and vancomycin are effective.

9 cholera: caused by Vibrio cholerae infection, clinical manifestations vary in severity, mild symptoms are mild, often watery diarrhea, several times a day, may be accompanied by nausea, vomiting, abdominal pain and other symptoms; severe stools More, large can be rice soup, patients often have fever, dehydration, hypotension and other systemic poisoning performance, stool culture can find pathogenic bacteria.

Protozoal and parasitic infections (20%):

1 amoebic dysentery: onset is generally more urgent, often have fever, abdominal pain and diarrhea and other symptoms, diarrhea several times a day to more than 10 times, stool with mucus pus and blood, sometimes stool is dark red or jam-like, the amount is more, Stinking, fresh stool examination can be confirmed if amebic trophozoites are found, and metronidazole or tinidazole is effective.

2 acute schistosomiasis: generally occurs in the first time infected with a large number of cercariae cercariae, often chills, fever, bloating, cough, abdominal pain and diarrhea and other symptoms, diarrhea is not serious, ranging from 3 to 5 times a day, can be loose or With mucus, the eosinophils in the peripheral blood are increased. If the patient is repeatedly infected, it is often accompanied by hepatosplenomegaly.

3 Piriformis infection: 3 to 5 times a day, mostly for watery stools or loose stools, less mucus, can be diagnosed by finding flagellates in the feces, and metronidazole is effective.

4 trichomoniasis infection: Intestinal trichomoniasis infection can also cause diarrhea, stools vary from several times a day, mainly to loose stools, with mucus.

Viral infection (10%):

More common in intestinal rotavirus infection, intestinal adenovirus infection, clinical symptoms are generally mild, may have abdominal pain, diarrhea, etc., diarrhea varies from several times a day, mainly to loose stools or watery stools.

Fungal infections (15%):

Long-term application of antibiotics, hormones or chronically consuming diseases in the middle and late stages, the patient's intestines may develop fungal infections, causing intestinal mucosal congestion, edema, erosion and ulceration leading to diarrhea, manifested as increased stool frequency, light is soft It can be accompanied by mucus, several times a day, sometimes the stool is egg-like; in severe cases, it can be mucus pus and blood samples, and the stool can be diagnosed by routine examination to find or culture the fungus.

Food poisoning (10%):

1 After eating food contaminated with Staphylococcus aureus, Salmonella, Halophilic bacillus or Botox, there may be symptoms of fever, abdominal pain, vomiting, diarrhea and dehydration, which is called food poisoning. Lean or watery stools, often accompanied by mucus, a few may have pus and blood.

2 taking poisonous cockroaches, puffer fish, larger fish gallbladder and other toxic chemical poisons, such as poisonous rat drugs, pesticides, etc. can occur diarrhea, diarrhea is mainly loose or watery stools, less pus, may be accompanied There are symptoms such as vomiting and abdominal pain. In addition to diarrhea, the above various toxicants have their own special symptoms.

Allergic reaction (5%):

Such as food allergies (milk, fish, shrimp, seafood products, etc.) can cause abdominal pain, diarrhea; allergic purpura and other diseases can be accompanied by increased intestinal peristalsis and diarrhea, diarrhea is often characterized by thin watery stools, often accompanied by stomach ache.

Drugs: a variety of drugs can cause diarrhea, such as erythromycin, magnesium hydroxide, neomycin, lincomycin, magnesium sulfate, sorbitol, mannitol, 5-fluoroureaidine, reserpine (reserpine) ), propranolol (propranolol), etc., these drugs cause different mechanisms of diarrhea; some chemicals such as phosphorus, arsenic, mercury and alcoholism can cause acute diarrhea, diarrhea often with loose stools and watery samples Mainly, often no mucus pus and blood.

Causes of Chronic Diarrhea There are many causes of chronic diarrhea. In general, it can be divided into the following seven aspects. Clinically, chronic diarrhea is more common, so the characteristics of the disease are briefly explained for identification.

(1) Intestinal infection: It is the most common cause of chronic diarrhea.

1 bacterial infection:

A. Chronic bacillary dysentery: Acute bacillary dysentery can not be completely cured and can be evolved into chronic, and it can also be acute on a chronic basis. It can be manifested as 3 to 5 times a day in stool, which may be accompanied by mucus, pus and blood. A small number of patients have pain in the left lower abdomen. The positive rate of stool culture in chronic bacillary dysentery is low, generally only 15% to 30%. Therefore, pathogens should be found after repeated cultures.

B. Intestinal tuberculosis: more common in adolescents and young adults, more women than men, the most common site of this disease is the end of the ileum or the right colon. Diarrhea is the main symptom of ulcerative intestinal tuberculosis, often alternating with constipation, characterized by diarrhea Feces are mushy or watery, ranging from 3 to 5 times a day, and severe cases up to 10 times, often accompanied by fever, night sweats and other symptoms of tuberculosis, X-ray barium enema or colonoscopy can confirm the diagnosis.

2 protozoal and parasitic infections:

A. Chronic amoebic dysentery (also known as slow-lived amoebic enteritis): 3 to 5 times a day, the stool is mushy and sparse, may be accompanied by mucus or blood, and typical jam-like stools are rare in chronic cases. The course of the disease can be prolonged for several months. For several years, the course of the disease can be repeated and acute, and the amoebic trophozoites can often be found in fresh feces.

B. Chronic schistosomiasis: Chronic schistosomiasis can occur diarrhea, 3 to 5 times a day, mostly loose stools, may be accompanied by mucus or pus and blood, patients often have schistosomiasis liver fibrosis, the diagnosis depends on serum Antibody assays and fecal or rectal mucosal biopsy found eggs.

C. Piriformis or Trichomonas infection: Chronic people can have stools several times a day, often for loose stools or watery stools, sometimes with mucus, and can be diagnosed when Piriformis or Trichomonas is found in the feces.

3 chronic fungal enteritis: often occurs in the long-term use of antibiotics, hormones, but also prone to the late stage of chronic wasting disease, manifested as diarrhea, severe with mucus or pus and blood, and can be repeated, fungus can be found in the stool Confirmed diagnosis.

(2) Intestinal non-specific inflammation or non-infectious inflammation:

1 Chronic non-specific ulcerative colitis: It is considered to be an autoimmune disease. In recent years, there has been an increasing trend in China. It occurs in young and middle-aged people. The lesion mainly invades the rectum, sigmoid colon and descending colon, and can also invade the right colon. For light, heavy and outbreak type 3, the lightest type is the most common, the lighter is 3 to 4 times a day, and the heavy one can reach more than 10 times. The stool is mushy or loose, often mixed with mucus pus and blood, and the heavy one is only discharged. Mucus pus and no faecal, often accompanied by abdominal pain, urgency and other symptoms, a small number of cases may have joint pain and other extraintestinal symptoms, X-ray barium enema and colonoscopy is very helpful in the diagnosis, the disease in the onset of symptoms, After treatment, it can generally be controlled to make the disease in a remission period, and if it is not maintained, it can relapse.

2Crohn disease (Crohn's disease): It is also an autoimmune disease. It is far less common in Europe than in Europe and America. It occurs in young adults. The lesion can invade the whole digestive tract, but it is more common in the ileum and its adjacent cecum. The characteristics of diarrhea are 3 to 6 times of stool every day, mostly mushy or loose stools, and there are few mucus pus and blood; there is often tenderness in the right lower abdomen, sometimes the lower right abdomen can be paralyzed and mass, and a few patients may have arthritis, etc. Extraintestinal manifestations, X-ray barium enema and colonoscopy are helpful for diagnosis. The disease also has the characteristics of symptom onset and relief, and the disease can be prolonged for many years.

3 chronic radiation enteritis: patients with cervical cancer or pelvic malignant tumors, if diarrhea occurs within weeks or months after receiving radiation therapy, the possibility of radiation enteritis should be considered, mainly manifested as mucus and bloody stools, often accompanied by urgency and heavy, and there is pain in the rectum. Colonoscopy may show that the mucosa of the lesion (the mucosa damaged after radiotherapy) is hyperemia, erosion or oozing, and the disease may last for many years without healing.

(3) Absorptive syndrome: The classification of malabsorption syndrome is very complicated. Malabsorption can be caused by stomach and small bowel diseases, and can also be caused by liver and gallbladder and pancreatic diseases.

1 primary malabsorption:

A. Tropical steatorrhea: also known as tropical inflammatory diarrhea, occurs in the tropics, the cause is still unknown, generally considered to be related to protein, folic acid and B vitamin deficiency, diarrhea is characterized by a large amount of feces, with Stench, about one-third of patients present with steatorrhea.

B. Nontropic steatorrhea: also known as glial intestinal disease, primary steatorrhea or celiac disease, the patient's intestinal mucosa lacks a peptide-degrading enzyme, so it can not be decomposed and toxic. Alpha-glycoprotein, alpha-glycoprotein has a detrimental effect on intestinal villi and intestinal epithelial cells, eventually leading to malabsorption (barley, wheat and oats contain alpha-glycoprotein), diarrhea is characterized by steatorrhea, and the amount of feces is It is oily and smelly, and stools vary from several times a day.

2 secondary malabsorption:

A. After gastrectomy: more common after total gastrectomy and Biro II surgery, because the food quickly enters the small intestine, causing insufficient secretion of enterokinase, pancreatic digestive enzymes and bile, or insufficient pancreatic bile mixed with food. Can cause malabsorption and cause diarrhea. In addition, if gastrointestinal surgery causes bacterial overgrowth (blindness syndrome), the formation of micelles due to bacterial decomposition and bile salts can cause steatorrhea.

B. Chronic hepatobiliary diseases: such as chronic hepatitis, cirrhosis and intrahepatic bile duct obstruction, etc., due to the lack of bile salts, fat can not be emulsified and transported, it can lead to steatorrhea.

C. Intestinal disease: excessive small bowel resection (such as short bowel syndrome when the small intestine is removed more than 75% of the total length or only 120cm remaining), stomach, colon fistula or stomach, ileal fistula can be due to the absorption area of the small intestine Decrease, or food that passes through the small intestine or jejunum and through the fistula to the colon, can eventually lead to diarrhea.

D. Chronic pancreatic diseases: such as chronic pancreatitis, pancreatic cancer, etc., due to insufficient pancreatic secretion, pancreatic enzyme deficiency caused by fat and protein digestion and absorption disorders and cause diarrhea.

E. Small intestinal mucosal diffuse lesions: such as small intestine malignant lymphoma, Whipple disease, etc., due to intestinal mucosal damage and lymphatic vessel dilatation or obstruction and other factors leading to steatorrhea; scleroderma, due to gastrointestinal mucosa and submucosa Atrophy can eventually cause digestive dysfunction and lead to diarrhea.

(4) Endocrine diseases: Many endocrine diseases are associated with symptoms of diarrhea. Patients may sometimes be diagnosed in the Department of Gastroenterology due to diarrhea, so they must be identified.

1 hyperthyroidism: 10% to 15% of patients with hyperthyroidism have diarrhea, but diarrhea is generally not serious, several times a day, mostly soft stool or watery stool, no mucus pus and blood, less abdominal pain, patients often have more Sweat, heart palpitations, weight loss, goiter and exophthalmos.

2 Diabetes: The cause of diarrhea is related to pancreatic exocrine dysfunction and intestinal motility dysfunction. Diarrhea can be soft stool or watery stool, or it can be steatorrhea, often no mucus pus and blood, several times a day, a few patients can It is characterized by intractable diarrhea.

3 hypoparathyroidism and medullary thyroid tumor: the former may cause neuro-muscle stress-induced diarrhea due to hypocalcemia, but diarrhea is generally not serious, ranging from 2 to 3 times a day, the latter is due to The tumor releases calcitonin and causes diarrhea.

4 adrenal insufficiency: when the adrenal cortical function is low, it can cause the secretion of gastric acid and pepsin, and often accompanied by intestinal absorption dysfunction, it can occur diarrhea, often mushy, not many times.

5 pancreatic cholera syndrome (also known as Verner-Morrison syndrome, WDHA syndrome, watery diarrhea - hypokalemia - no gastric acid syndrome or vasoactive intestinal peptide tumor, namely Vipoma): this disease is rare, there are scattered cases reported in the country, This disease is caused by abnormal secretion of vasoactive intestinal peptide (VIP) in tumor cells. It is believed that the VIP of adult patients is mostly from islet cell tumor, while the VIP of children is mostly from ganglioneuroma or ganglion neuroblastoma. The clinical features are watery diarrhea, low potassium and true no gastric acid (reported cases have normal gastric acid secretion), the diagnosis depends on VIP measurement, B-ultrasound, CT or MRI examination found tumor.

6 gastrinoma (Zollinger-Ellison syndrome, Zhuo-Ehrlich syndrome): due to the secretion of a large number of gastrin from pancreatic islet non--cell tumor, a large number of gastrin stimulated parietal cells to secrete a large amount of gastric acid, diarrhea and a large number Gastric acid and gastric juice secretion, the disease is often accompanied by stomach, duodenal multiple ulcer formation, diagnosis depends on gastric juice analysis, gastrin level determination and B-ultrasound, CT or MRI examination of the tumor (the tumor is mostly located in the pancreatic tissue A few are located in other parts of the abdominal cavity).

(5) Neoplastic diseases: There are the following benign or malignant tumors.

1 Gastrointestinal malignant lymphoma: The most invasive part of gastrointestinal lymphoma is the ileum, which is less affected by the colon. In addition to diarrhea, it is often accompanied by abdominal pain or abdominal mass. A few patients can have bloody stools as the main performance.

2 type of cancer syndrome: diarrhea and serotonin secreted by carcinoid cells, bradykinin and serotonin and other vascular active substances, carcinogenesis is most common in the appendix, other parts of the intestine can also occur, except diarrhea Patients often have paroxysmal redness in the face or neck or upper body (also known as "redness"), and a few are accompanied by bronchial asthma symptoms.

3 colon cancer: middle and late rectal or sigmoid colon cancer may have mucus pus and bloody stool, and with pain in the left lower abdomen and urgency, diarrhea is an important symptom of right colon cancer, often manifested as loose stool or mushy stool, no obvious mucus pus (But there are often red blood cells and pus cells under the microscope). Patients are usually accompanied by abdominal pain, weight loss and anemia. The left colon cancer is mainly caused by secret or chronic intestinal obstruction, but if there is infection or cancer rupture, It is characterized by pus and blood.

4 intestinal adenomatous polyps or polyposis: may be due to surface bleeding, erosion or ulceration of polyps leading to secretory diarrhea, in addition to diarrhea, blood is also one of the important symptoms of intestinal polyps.

(6) gastrointestinal dysfunction disease: irritable bowel syndrome (IBS), IBS is a group of intestinal dysfunction syndrome consisting of abdominal discomfort or abdominal pain accompanied by abnormal bowel movements, the patient's intestine There are no organic lesions or abnormal biochemical indicators. The formerly referred to as mucinous colitis, irritating colon or allergic colitis are now collectively referred to as IBS. The occurrence of this disease is often associated with mental stress and emotional excitement. Relationship, that is, mental and psychological factors have an important impact on the onset of disease. In addition, stress and/or intestinal infections (such as dysentery, enteritis, etc.) are often an important cause of IBS, and in recent years, the incidence of IBS has been studied intensively. IBS is considered to have visceral paresthesia, and the sensitivity of the colon to stimulation is increased to cause abnormal bowel movements (diarrhea or constipation or diarrhea constipation alternately). In 2000, the latest diagnostic standard for IBS, the Rome II standard, was issued internationally. :

1 diagnosis: This disease first needs to rule out the explanation of the symptoms of tissue structure or biochemical abnormalities.

At least 3 months in 21 years, there are repeated abdominal pain or abdominal discomfort accompanied by 2 of the following 3 bowel movement abnormalities.

A. The abdominal pain is relieved or relieved after the operation.

B. The frequency of defecation is abnormal (ie >3 times/d or <3 times/week).

C. Abnormal bowel shape (lean or dry hard), the Rome II standard is gradually accepted by multinational gastroenterologists, diarrhea-type IBS patients often have diarrhea after abdominal pain or discomfort, and then abdominal pain or Discomfort relieved or relieved, the stool is characterized by loose stools, soft stools, a few watery stools, the number of times per day, often more than 3 times, feces without pus, a few may be accompanied by mucus, Chinese medicine diagnosis is "five Diarrhea, can be considered as a manifestation of IBS, patients often have abdominal pain or abdominal discomfort before dawn, most have bowel sounds hyperthyroidism, pain relief or relief after abdominal pain, generally diarrhea 2 to 3 times before breakfast After breakfast, diarrhea can often stop, and a few patients are prone to abdominal pain and diarrhea after each meal. This is because the stomach-colon reflex is caused by eating, that is, after the stomach contains food, it causes colonic hyperactivity and the patient has abdomen. Hidden pain or discomfort, followed by a sense of convenience, this performance should also be considered to be caused by colonic dysfunction.

(7) Other factors:

1 intestinal flora imbalance: diarrhea due to long-term application of broad-spectrum antibiotics, resulting in a disorder of the normal flora of the intestine, severe cases can induce pseudomembranous colitis.

2 uremia: diarrhea caused by uremic enteritis, stool 3 to 5 times a day, mostly paste or watery stool.

Pathogenesis

The mechanism of causing diarrhea is very complicated. A diarrheal disease often involves multiple factors. Generally, the pathogenesis of diarrhea is classified into the following four categories according to pathophysiology.

1. Abnormal secretion function

Diarrhea caused by abnormal secretion function is also called secretory diarrhea or exudative diarrhea. The normal intestinal mucosa has the function of secretion and absorption, and regulates the absorption of water, nutrients and electrolytes, and the water lost from the feces. Basically stable, when the intestinal secretion function exceeds its absorption function, it will inevitably lead to diarrhea, Escherichia coli endotoxin, Vibrio cholerae or Clostridium difficile endotoxin caused by a large amount of watery diarrhea is intestinal secretion Or a typical representative of exudative diarrhea, the mechanism is that endotoxin binds to receptors on the brush border of epithelial cells, which in turn activates adenylyl cyclase in intestinal mucosal cells, allowing intracellular second messenger cAMP (loop) Adenosine phosphate), cGMP (cyclic guanosine monophosphate) and calcium ions increase, which in turn increases the intracellular water and chlorine secretion into the intestinal lumen, up to 1 ~ 2L per hour, after Clostridium difficile infection through Ca Increased secretion of diarrhea, a large amount of liquid can not be absorbed by the small intestine and large intestine mucosa, it will inevitably lead to diarrhea, other diseases such as gastrinoma (Zollinger-Ellison syndrome), vasoactive intestinal peptide tumor (Vipoma), diarrhea caused by pancreatic cholera syndrome, etc. is also secretory diarrhea, in addition, intestinal infectious and non-infectious inflammation (such as dysentery bacillus, Salmonella, Mycobacterium tuberculosis, amoeba, Yell Sennis and viruses, fungal infections, non-specific ulcerative colitis and Crohn's disease, radiation intestinal damage, etc.) are diarrhea caused by increased intestinal secretion.

2. Increased osmotic pressure

Diarrhea caused by elevated osmotic pressure in the intestinal lumen is also called osmotic diarrhea or hypertonic diarrhea. In normal people, food decomposition products such as sugars, fats, proteins and electrolytes are in chylomicrons, intestinal kinase and Under the action of various pancreatic enzymes, it has been absorbed or diluted. Therefore, the contents of the ileum are isotonic. If it is empty, the contents of the ileum are hypertonic, that is, when the osmotic pressure in the intestinal lumen is increased, The osmotic pressure between plasma and intestinal contents is different. When the osmotic pressure difference between the two increases, in order to maintain the osmotic pressure gradient, the water in the plasma will quickly pass through the intestinal mucosa and enter the intestinal lumen. Until the contents of the intestine are diluted to isotonic, a large amount of fluid in the intestine can cause diarrhea.

When pancreatic lesions (such as chronic pancreatitis, pancreatic cancer, pancreatic cystic fibrosis, etc.) or hepatobiliary lesions (chronic hepatitis, cirrhosis, liver cancer, biliary calculi, biliary tract inflammation and biliary tract tumors, etc.), due to lack of various digestion Enzyme or fat emulsification disorders can cause sugar, fat and protein in the empty, ileal digestion, absorption disorders, so that the contents of the intestinal cavity are in a hypertonic state, it will inevitably lead to diarrhea, in a few cases, severe Atrophic gastritis or invasive gastric cancer due to decreased gastric juice and gastric acid secretion, food digestion in the stomach is weakened, food will directly enter the small intestine and lead to increased intestinal osmotic pressure, can also cause diarrhea, lactose caused by congenital lactase deficiency Absorptive malabsorption is not uncommon in China. Among them, about 60% of the enzyme-deficient patients may develop symptoms such as diarrhea and abdominal pain after eating milk or dairy products. These patients are intolerant to lactose, and the undigested lactose in the intestine passes through the intestines. Bacterial glycolysis produces a large amount of gas such as carbon dioxide, and the decomposed lactic acid and other short-chain organic acids cause an increase in intestinal osmotic pressure, thus causing The diarrhea is also hyperosmotic diarrhea. In addition, diarrhea caused by certain drugs such as magnesium sulfate, magnesium oxide, mannitol, sorbitol and lactulose is also hyperosmotic diarrhea.

3. Absorption dysfunction

Diarrhea caused by malabsorption of nutrients is also called malabsorption diarrhea, and various diseases that cause intestinal mucosal damage or reduced absorption area can cause diarrhea; intestinal infectious and non-infectious diseases can cause damage to intestinal mucosa. That is, the microvilli on the surface of the small intestine mucosa may be destroyed, resulting in a decrease in the absorption area and diarrhea; a significant reduction in the absorption area after most of the intestines may cause diarrhea; pediatric celiac disease, tropical and non-tropical steatorrhea (wheat gum) Intestinal disease), etc. due to the reduction of microvilli in the small intestine, atrophy, resulting in decreased absorption area and diarrhea; in addition, mesenteric vascular or lymphatic lesions (such as obstruction, reflux obstruction, etc.) can also cause malabsorption diarrhea; High pressure (causal hypertensive gastric mucosal lesions), right heart dysfunction or constrictive pericarditis, if not treated promptly, can cause gastrointestinal mucosal congestion, resulting in intestinal mucosal absorption disorders leading to diarrhea In addition, under normal circumstances, the combined bile salt reabsorbs at the end of the ileum and reaches the liver (intestinal hepatic circulation), such as severe lesions at the end of the ileum, such as the intestine After the extensive resection of the nucleus, Crohn's disease, tumor or ileum end, the combined absorption of bile salts is reduced, and the bound bile salt entering the colon is significantly increased, which can be decomposed into bischolic acid by colonic bacteria, which stimulates the increase of colonic mucosal secretion. And water, salt absorption decreases and causes diarrhea.

4. Gastrointestinal dysfunction

Diarrhea caused by dysfunction of the gastrointestinal tract is also called dysfunctional diarrhea, functional diarrhea or hyperkinetic diarrhea. When the gastrointestinal tract increases, the chyme and water stay in the gastrointestinal tract. Shortening of time, resulting in incomplete absorption and diarrhea; intestinal inflammation, infectious lesions can stimulate the intestinal wall, increase intestinal motility and increase diarrhea, some patients with anxiety, emotional stress accompanied by abdominal pain and diarrhea, usually Known as irritable bowel syndrome (IBS), the main cause of diarrhea is intestinal dysfunction or hypertrophy of the stomach-colon. In addition, some endocrine diseases such as hyperthyroidism and diabetes can also cause diarrhea. The reason is also related to intestinal hyperfunction; when the peristalsis is too slow, the chyme stays in the intestine for too long, such as causing excessive bacterial growth can also lead to diarrhea, in addition, propranolol, mosapride, etc. Some drugs can cause diarrhea when they cause increased intestinal peristalsis.

Diarrhea prevention

(1) Develop good hygiene habits. Caregivers and children should wash their hands thoroughly with soap before and after meals.

(2) Guarantee the consumption of clean water.

(3) Do not eat spoiled food, the raw fruits should be washed.

(4) Avoid contact and infection between children.

Diarrhea complications Complications, syncope, malnutrition

Acute viral myocarditis: medically known as viral myocarditis, is one of the most dangerous complications of diarrhea. Some diarrhea can be caused by viruses. The virus that causes myocarditis most often is an enteric virus called Coxsackie virus. It can directly enter the cardiomyocytes to cause damage, and can also cause some harmful substances in the body to damage the cardiomyocytes, leading to myocardial degeneration, and also involving the pericardium, endocardium, if the heart pacing system is invaded, it will be life-threatening.

Cardiovascular and cerebrovascular accidents: This is a complication that can cause death in acute diarrhea in the elderly. During diarrhea, a lot of water and sodium in the body, potassium, calcium, magnesium and other cations are discharged from the stool. The loss of water makes the body dehydrated, and the blood volume Reduced, increased blood viscosity, slow blood flow, easy to form thrombosis and block blood vessels, coronary artery obstruction causes angina and myocardial infarction, cerebrovascular obstruction causes ischemic stroke, sodium, potassium, calcium, magnesium is an important cation in the body In addition to maintaining blood acid-base balance, it plays an important role in maintaining nerve conduction function and heartbeat rhythm. When it is lacking, it can cause severe heart rhythm disorder and sudden death.

Hypoglycemia: When appetite is usually reduced during diarrhea, the food intake is insufficient. At this time, hepatic glycogen stored in the body needs to be decomposed to maintain blood sugar stability, while the elderly do not have enough hepatic glycogen storage to convert into blood sugar. When blood sugar is lowered, The elderly are prone to fatigue, sweating, palpitations, pale and fainting, and a series of hypoglycemia symptoms. The normal blood glucose concentration is 3.9-6.2 mmol/L. When the blood glucose concentration is lower than 3.0 mmol/L, the spirit will appear. Symptoms are even coma, often causing sudden death.

Dehydration and acidosis: It is the main fatal cause of acute diarrhea. The carbon dioxide produced by metabolism in the body is usually discharged through the respiratory. The rest of the waste needs to be transported through the kidneys and excreted by the urine. The amount of urine is reduced due to water loss during the dehydration. In severe cases, even without urine, this will reduce the discharge of waste generated by metabolism in the body and accumulate in the body, causing symptoms of poisoning in the body. In addition to respiratory changes, clinical manifestations may also be fatigue and weakness and neurological symptoms.

Recurrence of stomach disease: After diarrhea, the digestive function of the human body gradually declines, and the intestinal disease resistance is also weakened, which makes the burden of gastrointestinal function worse, often leading to the recurrence of stomach diseases.

Symptoms of diarrhea Common symptoms Habitual diarrhea Intestinal absorption of water increased in the feces to see the eggs... Bacterial infection in the watery stools in the aftermath of heavy food refers to unexplained pain ileocecal dysfunction insufficiency

Gastrointestinal symptoms

Frequently, each time the amount of feces is not much and there is a sensation in the urgency, the lesions are mostly in the rectum or sigmoid colon; small bowel lesions are not irritated after severe urgency, abdominal pain in the lower abdomen or left lower abdomen, abdominal pain can be relieved after defecation, often sigmoid or rectal lesions, Small bowel lesions diarrhea, pain in the umbilical cord, pain after bowel movements are not relieved, secretory diarrhea often without abdominal pain symptoms.

2. Number of diarrhea and fecal traits

Acute diarrhea can be more than 10 times a day, the stool is thin, such as bacterial infection (bacterial dysentery) often with blood and pus, such as sugar or jam-like feces, suggesting that it may be amoebic dysentery, thin watery stool Commonly seen in food poisoning, hemorrhagic necrotic enteritis discharges bloody bloody stools with a foul smell.

3. Accompanying symptoms

(1) people with fever can be seen in acute bacterial dysentery, typhoid or paratyphoid fever, intestinal tuberculosis, colon cancer, small intestine malignant lymphoma, Crohn's disease, acute exacerbation of non-specific ulcerative colitis, sepsis, viral enteritis, Thyroid crisis and so on.

(2) with obvious wasting can be seen in gastrointestinal malignant tumors and malabsorption syndrome.

(3) with rash or subcutaneous hemorrhage seen in sepsis, typhoid or paratyphoid, measles, allergic purpura, pellagra and so on.

(4) with arthralgia or swelling found in Crohn's disease, chronic non-specific ulcerative colitis, lupus erythematosus, intestinal tuberculosis, Whipple's disease.

(5) with abdominal mass in the gastrointestinal malignant tumor, intestinal tuberculosis, Crohn's disease and schistosomiasis granuloma.

(6) Commonly associated with severe dehydration, secretory diarrhea such as cholera and bacterial food poisoning, also seen in uremia.

Diarrhea check

Laboratory inspection

Fecal examination

Fecal traits are mushy, loose or watery, with a large amount or stench, no mucus in the stool, pus or only fat, often suggesting small bowel diarrhea or liver, gallbladder, pancreatic hypofunction diarrhea; Fecal volume is small, including mucus, pus and blood is more suggestive of colonic diarrhea; protozoa, parasites or eggs are found in the feces, and other causes can be excluded, which can be prompted for protozoa, parasitic diarrhea; fecal culture can be separated A variety of pathogenic bacteria have important value for diagnosis, but it should be emphasized that the manure should be fresh, and the inspection should be timely, otherwise it will affect the diagnosis. In addition, if the culture is negative, the infectious diarrhea cannot be easily denied. Send stool culture and sometimes get positive results.

2. Pancreatic exocrine function test

If diarrhea is suspected to be caused by pancreatic disease, pancreatic exocrine function tests such as a test (Lundh test), benzoyl-tyrosine-p-aminobenzoic acid test (PABA test), and secretin test should be performed. .

3. Intestinal absorption function test

(1) Determination of fat globules, nitrogen content, muscle fiber and chymotrypsin content in feces: When the fat globule is more than 100 in the microscope under high power field (Sultan III staining method), fat malabsorption may be considered; when the nitrogen content in the feces increases Considering the absorption of carbohydrates; the increase of muscle fibers in feces and the decrease of chymotrypsin content suggest that the small intestine is malabsorbed.

(2) D-xylose test: D-xylose excretion in urine is often reduced in patients with poor intestinal absorption.

(3) Radionuclide labeled vitamin B12 absorption test (Schilling test): In the small intestine absorption dysfunction, the urinary radionuclide content is significantly lower than normal.

4. Breath test

Most of them are 14C-triacylglycerol breath test. After oral administration of 14C-labeled triacylglycerol, the 14C-labeled CO2 exhaled from the lungs is reduced, and the 14C-labeled CO2 excretion in the feces is increased. More 13C breath test can observe the absorption of sugar, and also has important diagnostic value for lactose malabsorption. In addition, there are 14C glycine breath test.

Film degree exam

1. X-ray examination: barium meal or barium enema examination can understand the functional status of the gastrointestinal tract, peristalsis, etc., for small intestinal malabsorption, intestinal tuberculosis, Crohn's disease, ulcerative colitis, lymphoma, colon cancer, etc. Important diagnostic value.

2. B-ultrasound, CT or MRI examination: can observe the liver, biliary tract and pancreas and other organs with diarrhea-related lesions, can also provide a basis for intestinal tumor lesions, therefore, B-ultrasound, CT and MRI examination for digestion Absorptive diarrhea and neoplastic diarrhea have diagnostic value.

3. Colonoscopy: colonoscopy on the end of the ileum, such as intestinal tuberculosis, Crohn's disease, other ulcerative lesions and large intestinal lesions, such as ulcerative colitis, colon, rectal polyps and cancer, chronic schistosomiasis, etc. Both have important diagnostic value.

4. Retrograde cholangiopancreatography: has important diagnostic value for biliary and pancreatic lesions.

5. Small colonoscopy: Although colonoscopy is not universally developed (new enteroscopy is about to come out), it has important diagnostic significance for small intestinal malabsorption and Whipple disease. Small intestinal mucosa can be observed under direct colonoscopy. Histopathological examination can determine changes in microvilli and glands.

Diagnostic diagnosis of diarrhea

diagnosis

Most patients with acute or chronic diarrhea need only be diagnosed according to their medical history, physical signs and necessary laboratory tests, such as stool routine and culture. When the diagnosis cannot be made after routine routine examination, further examination should be considered, but due to There are many items for examination, so it is necessary to make a choice in combination with the characteristics of each patient's diarrhea. For example, when it is judged that the patient's diarrhea is likely to be caused by small bowel disease, the examination for the diagnosis of small bowel disease should be selected; Diarrhea is caused by large bowel disease, and should be checked for the diagnosis of colorectal diseases.

1. History and clinical manifestations: A detailed understanding of medical history and clinical manifestations is important for the diagnosis of acute or chronic diarrhea. It is possible to initially estimate the cause of diarrhea or the location of the lesion, and the site of abdominal pain or sputum and mass is often indicated. The site of the lesion, such as pain in the right lower quadrant, tenderness or sputum and mass should be considered for intestinal tuberculosis, Crohn's disease, amoebic granulomatosis or right colon cancer.

2. Rectal examination: rectal examination for rectal lesions, such as rectal cancer, ulcerative proctitis, rectal polyps and other pathological diagnosis is extremely valuable, for stool with mucus, pus and blood, rectal examination should be listed as the first choice Regular inspection.

Differential diagnosis

Acute diarrhea

(1) acute bacterial dysentery: acute bacterial dysentery (acute dysentery) is the most common cause of infectious diarrhea, mainly in the summer and autumn, it is feasible to become a large, small epidemic, the incubation period is mostly 1 to 2 days, long up to 7 days, patients often chills, fever and discomfort sudden onset, abdominal pain, diarrhea, defecation more than 10 times a dozen times a day, often accompanied by urgency, nausea, vomiting and dehydration, feces can be watery at the beginning of the disease After the discharge of pus and blood or mucus and blood, a large amount of red, white blood cells can be seen by microscopic examination, and dysentery can be cultured by fecal culture.

Poisonous bacillary dysentery is more common in children or older, debilitating, malnourished, poisonous sputum sputum sometimes with hyperthermia, convulsions and other symptoms of toxemia as the main performance, need to take cotton swabs from the anus to take the stool for microscopic examination Or bacterial culture can often be diagnosed.

Acute bacillary dysentery should be differentiated from amebic dysentery. The main points of identification are:

1 amebic dysentery is mostly distributed, often without fever, generally no urgency and heavy.

2 defecation situation, less than the number of acute diarrhea, the amount is more, often jam-like.

3 Abdominal tenderness is lighter, mostly in the lower right abdomen.

The lysate amoeba trophozoites and their cysts can be found in the feces.

(2) Salmonella properties Food poisoning: Salmonella properties Food poisoning is the main form of bacterial food poisoning.

1 often outbreaks due to contamination of food (meat, eggs, fish).

2 often more than one person or a group of people in the collective canteen, the pathogenic bacteria to enteritis, typhoid fever and Salmonella choleraesuis is more common, the incubation period is generally 8 ~ 24h.

3 manifested as acute gastroenteritis, often accompanied by chills, fever and other symptoms of systemic infection, early bacteremia, may be associated with abdominal cramps, flatulence, nausea, vomiting and other symptoms, occasionally urgency and heavy.

4 diarrhea watery stool, dark yellow or green, stench, several times a day to dozens of times, the stool mixed with undigested food and a small amount of mucus, occasionally pus.

Cholera-like fulminant acute gastroenteritis-type Salmonella infection, patients with severe vomiting and diarrhea, early rise in body temperature, then decreased, often severe dehydration, electrolyte imbalance, muscle spasm, oliguria or no urine, such as rescue If it is not timely, it can die in a short period of time due to peripheral circulatory failure or acute renal failure. The identification of other bacterial infectious gastroenteritis is mainly the cultivation of Salmonella in the patient's vomit or feces.

(3) Viral gastroenteritis: The main manifestation of viral gastroenteritis is summer epidemics in children or adults, aseptic diarrhea, clinically characterized by highly contagious and extremely low mortality, with mild fever. Discomfort, nausea, vomiting and loose stools.

The main diagnostic basis is:

1 Summer is popular and highly contagious.

2 The clinical symptoms and signs are mild, and the course of the disease is self-limiting.

3 Excluding diarrhea caused by other cells.

4 Rotavirus can be isolated from feces.

(4) Cholera and para-cholera: The paracholera is caused by Vibrio Eltor. The epidemic characteristics are different from those of cholera. Most of them are endemic, and can also be sporadic or jumping. The culture characteristics, clinical manifestations and pathological changes of this strain are both The same is true for Vibrio cholera.

1 clinical features of cholera:

A. The incubation period is generally 2 to 3 days, and can be as short as several hours or as long as 6 days.

B. Rapid onset, vomiting and diarrhea are severe, vomiting is jetting, repeated, feces and vomit are rice bran water samples, and the amount of defecation is large without fecal matter.

C. Severe dehydration can cause peripheral circulatory failure, blood pressure drops and shock, severe cases can have high fever, oliguria, no urine, kidney failure and death.

D. Often accompanied by muscle spasm, especially the gastrocnemius and abdominal muscles are obvious.

2 diagnosis basis:

A. Epidemiological characteristics.

B. Typical clinical manifestations.

C. Special bacteriological examination and serological examination.

(5) pseudomembranous colitis: pseudomembranous colitis is caused by the abnormal proliferation of refractory Clostridium in the intestine, which produces a large amount of toxins. The pseudomembrane can be detected from the stool of the patient, and the appearance of the pseudomembrane is mostly Translucent substance, egg white sample, difficult to identify with the naked eye, put it into 10% formaldehyde solution, the appearance is clearer.

1 clinical features: ascites-like stool, severe cases mixed with pseudomembrane, diarrhea several times a day to dozens of times, rarely pus and blood, there are many incentives, such as large surgery, large area burns, serious infection, the application of broad-spectrum antibiotics Wait.

2 diagnosis basis:

A. There are predisposing factors.

B. There is a pseudomembrane in the stool.

C. Enterobacterial biopsy or fecal culture can detect refractory Clostridium or detect the toxin of this bacterium.

(6) Schistosomiasis: 84.6% of early schistosomiasis have diarrhea, which may be simple diarrhea, loose stools or watery samples, and some are diarrhea-like diarrhea. Most of the diarrhea is persistent, and a few are intermittent, and the length of the disease is not One.

Diagnostic points:

1 History of contact with infected water.

2 fecal hair follicle hatching method is positive.

3 colonoscopy mucosal biopsy, found that schistosomiasis eggs can be diagnosed.

2. Chronic diarrhea

(1) Chronic bacterial dysentery: Chronic bacterial dysentery (chronic bacillary dysentery) is often caused by the improper treatment of acute bacillary dysentery. Bacteriological analysis has gradually reduced the Shiga type bacterium in the past 10 years, while the Freund's type and The Song type is relatively increased, and the Freund's type is prone to become chronic.

The clinical features of chronic bacillary dysentery can be classified into the following three types according to clinical manifestations:

1 Chronic occultation type: The patient has a history of acute bacillary dysentery, which has been asymptomatic for more than two months, but there is pathological change in colonoscopy or faecal culture of dysentery bacilli.

2 Chronic prolonged type: patients may have different degrees of abdominal symptoms, such as abdominal pain, abdominal distension, long-term diarrhea or diarrhea constipation alternately, feces intermittently or often with mucus or pus and blood, left lower quadrant tenderness, sigmoid colon thickening thick and easy to reach Patients often have malnutrition, weight loss and fatigue.

3 Chronic acute attack: patients in the chronic process, for some reason, such as cold, eating disorders, acute attack, abdominal pain and diarrhea, pus, urgency and weight, may be associated with fever, clinical and acute bacillary similar .

The main diagnosis basis of chronic bacillary dysentery:

1 past history of acute dysentery

2 The appearance of feces is mucinous, mucus bloody stool or pus and blood, and red blood cells and white blood cells can be seen by microscopy.

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