Download - BOALA DIAREICA ACUTA
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Boala diareica acutaBoala diareica acuta
Sef lucrari Dr. Letiția DuceacSef lucrari Dr. Letiția Duceac
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DefinitieDefinitie
Malabsorbtie temporara a apei, Malabsorbtie temporara a apei, electrolitilor si a unor principii alimentare electrolitilor si a unor principii alimentare → evacuare accelerata a continutului → evacuare accelerata a continutului intestinalintestinalCresterea brusca a numarului de scaune Cresterea brusca a numarului de scaune si reducerea consistentei acestorasi reducerea consistentei acestoraAcuta = limitata la 7-10 zileAcuta = limitata la 7-10 zile
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Etiologie - infectioasaEtiologie - infectioasa
BacteriiBacterii – – Shighela, Salmonela, E.coli, Shighela, Salmonela, E.coli, Campilobacter jejuni, Stafilococul auriu, Yersinia Campilobacter jejuni, Stafilococul auriu, Yersinia enterocolitica, vibrionul holeric.(sezon cald)enterocolitica, vibrionul holeric.(sezon cald)
VirusuriVirusuri – – Rotavirus, Adenovirus, Astrovirus, Rotavirus, Adenovirus, Astrovirus, Coronavirus, Cytomegalovirus. (sezon rece)Coronavirus, Cytomegalovirus. (sezon rece)
ParazitiParaziti – – Criptosporide, Giardia lamblia, Criptosporide, Giardia lamblia, E.histolitica, Isospora beli, MicrosporideE.histolitica, Isospora beli, Microsporide
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EtiologieEtiologie
Dismicrobism intestinal secundar antibioticelorDismicrobism intestinal secundar antibioticelor
Erori alimentareErori alimentare
Diareea parenterala (asociata altor afectiuni)Diareea parenterala (asociata altor afectiuni)
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Mecanisme patogeniceMecanisme patogenice
Producere toxine (vibrio cholerae)Producere toxine (vibrio cholerae)
Aderenta la mucoasa intestinala cu efect citolitic Aderenta la mucoasa intestinala cu efect citolitic local (E. coli)local (E. coli)
Invazie epiteliu (Shigella) – diaree sangvinolenta, Invazie epiteliu (Shigella) – diaree sangvinolenta, bacteriemiebacteriemie
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ConsecinteConsecinteModificarea florei intestinaleModificarea florei intestinale
Scade activitatea enzimatica locala Scade activitatea enzimatica locala → ajung in → ajung in colon nutrienti nedigeraticolon nutrienti nedigerati
Scade suprafata de absorbtie activa a nutrientilorScade suprafata de absorbtie activa a nutrientilor
Scade absorbtia apei si electrolitilor + creste Scade absorbtia apei si electrolitilor + creste secretia activasecretia activa
Accelerarea motilitatii intestinaleAccelerarea motilitatii intestinale
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PERICOL MAJORPERICOL MAJOR
DESHITRATAREADESHITRATAREAMALNUTRITIAMALNUTRITIA
BacteriemieBacteriemieConvulsiiConvulsii
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Manifestari cliniceManifestari clinice
Scaune diareice, 4-10/ziScaune diareice, 4-10/zi
VarsaturiVarsaturi
Colici abdominale, tenesmeColici abdominale, tenesme
Meteorism abdominal (fermentatie; pareza intest.)Meteorism abdominal (fermentatie; pareza intest.)
Alterarea starii generaleAlterarea starii generale
Febra (deshidratare/ infectie)Febra (deshidratare/ infectie)
Scaderea in greutate (deshidratare, malnutritie)Scaderea in greutate (deshidratare, malnutritie)
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Estimarea deshidratariiEstimarea deshidratariiDeshidratare usoara = pierdere ponderala < 5%Deshidratare usoara = pierdere ponderala < 5%
Mucoase normaleMucoase normaleSete – usoaraSete – usoaraLacrimi – prezenteLacrimi – prezenteTurgor – normalTurgor – normalFontanela anterioara – normalaFontanela anterioara – normalaPliu cutanat – elasticPliu cutanat – elasticVolum urinar – normalVolum urinar – normalColaps – absentColaps – absentComportament neurologic - normalComportament neurologic - normal
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Estimarea deshidratariiEstimarea deshidratariiDeshidratare moderata = pierdere ponderala 5-10%Deshidratare moderata = pierdere ponderala 5-10%
Mucoase - uscateMucoase - uscateSete – intensaSete – intensaLacrimi – +/-Lacrimi – +/-Turgor – diminuatTurgor – diminuatFontanela anterioara – deprimataFontanela anterioara – deprimataPliu cutanat – revine lentPliu cutanat – revine lentVolum urinar – redusVolum urinar – redusColaps – timp recolorare capilar usor alungitColaps – timp recolorare capilar usor alungitComportament neurologic - iritabilComportament neurologic - iritabil
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Estimarea deshidratariiEstimarea deshidratariiDeshidratare severa = pierdere ponderala > 10%Deshidratare severa = pierdere ponderala > 10%
Mucoase – “prajite”Mucoase – “prajite”Sete – intensaSete – intensaLacrimi – absenteLacrimi – absenteTurgor – flascTurgor – flascFontanela anterioara – deprimataFontanela anterioara – deprimataPliu cutanat – persistentPliu cutanat – persistentVolum urinar – mult redusVolum urinar – mult redusColaps – marmorare, cianoza, extremitati reci, hipovolemie, Colaps – marmorare, cianoza, extremitati reci, hipovolemie, tahicardietahicardieTulburari acidobaziceTulburari acidobaziceComportament neurologic – iritabil – convulsiiComportament neurologic – iritabil – convulsii
- letargic - coma- letargic - coma
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Evaluare paraclinicaEvaluare paraclinica
CoprocitogramaCoprocitogramaExamen direct CampylobacterExamen direct CampylobacterAg fecal rotavirus, adenovirusAg fecal rotavirus, adenovirusCoproculturaCoproculturaCoproparazitologic (eventual)Coproparazitologic (eventual)
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Evaluare paraclinicaEvaluare paraclinica
HLGHLGSdr. InflamatorSdr. InflamatorParametrii ASTRUP – evaluare echilibru acido-Parametrii ASTRUP – evaluare echilibru acido-bazic (pH sangv., bazic (pH sangv., PCO2, bicarbonatul, bazele tampon, excesul de baze)Electroliti Examen urinaFunctie hepaticaFunctie renalaGlicemie
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Atitudine terapeuticaAtitudine terapeuticaTratament etiologic (unde e posibil)Tratament etiologic (unde e posibil)HidratareaHidratareaDieta Dieta Simptomatic:Simptomatic:
- Antitermice – paracetamol, ibuprofen- Antitermice – paracetamol, ibuprofen - Smecta- Smecta - Hidrasec- Hidrasec - Antiemetice – metoclopramid (0,5mg/kg/zi)- Antiemetice – metoclopramid (0,5mg/kg/zi)Refacerea florei intestinale - probioticeRefacerea florei intestinale - probiotice
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Hidratarea Hidratarea Obiectivul principal in tratamentObiectivul principal in tratament
Repaus digestiv complet pentru 4 ore (in functie de Repaus digestiv complet pentru 4 ore (in functie de gravitate)gravitate)
Pierderi sub 5% - hidratare orala – SROPierderi sub 5% - hidratare orala – SROPierderi 5-10% + varsaturi – PEV la inceput apoi Pierderi 5-10% + varsaturi – PEV la inceput apoi p.o.p.o.Pierderi > 10% (de obicei asociaza si dezechilibre Pierderi > 10% (de obicei asociaza si dezechilibre acidobazice) acidobazice) → spitalizare→ spitalizare
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Hidratarea cu SRO la domiciliuHidratarea cu SRO la domiciliuDeshidratare moderata (5-10%) calea orala este practic, Deshidratare moderata (5-10%) calea orala este practic, singura cale recomandabilasingura cale recomandabila
GESOL (20g glucoza; 3,5 g Na Cl; 2,5 g Na HCO3; 1,5 g GESOL (20g glucoza; 3,5 g Na Cl; 2,5 g Na HCO3; 1,5 g KCl), care se dizolva intr-un litru de apa fiarta si racita. KCl), care se dizolva intr-un litru de apa fiarta si racita.
Alternative Humanna electrolyt, Toppfer BessauAlternative Humanna electrolyt, Toppfer Bessau
Varsaturile pot fi o problema redutabila Varsaturile pot fi o problema redutabila
Administrarea SRO cu lingurita sau cu pipeta in cantitati Administrarea SRO cu lingurita sau cu pipeta in cantitati mici (1-5 ml) la 2-3 minute, 150-200 ml/kg/zi, ½ se mici (1-5 ml) la 2-3 minute, 150-200 ml/kg/zi, ½ se administreaza in primele 4-6 oreadministreaza in primele 4-6 ore
5% - 50ml/kg in primele 4 ore5% - 50ml/kg in primele 4 ore10% - 100ml/kg in 4-6 ore10% - 100ml/kg in 4-6 ore
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Dieta - clasicDieta - clasicRepaus digestiv – hidratare 12-24 hRepaus digestiv – hidratare 12-24 h
Dieta de tranzitie (morcov, orez, roscove, mar, Dieta de tranzitie (morcov, orez, roscove, mar, bananebanane
Realimentarea cu produse dietetice (delactozat, fara Realimentarea cu produse dietetice (delactozat, fara zaharuri complexe si grasimi)zaharuri complexe si grasimi)
Revenirea la alimentatia completaRevenirea la alimentatia completa DEPASIT, FAVORIZEAZA MALNUTRITIADEPASIT, FAVORIZEAZA MALNUTRITIA
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Atitudinea actuala in BDAAtitudinea actuala in BDA
Oprirea alimentatiei (4-6 ore)Oprirea alimentatiei (4-6 ore)
Rehidratarea – primele 4 oreRehidratarea – primele 4 ore
Realimentarea – trecerea la alimentatia Realimentarea – trecerea la alimentatia anterioaraanterioara
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Atitudinea actuala in BDAAtitudinea actuala in BDA Ghidurile recente de practica ale ESPGHAN (European Society for Paediatric Gastroenterology , Hepatology and Nutrition) si ESPID (European Society for Paediatric Infectious Disease) recomanda realimentarea precoce a copiilor cu boala diareica acuta, nefiind necesara dieta de tranzitie sau diete restrictive, nici formulele de lapte delactozate, in majoritatea cazurilor de boala diareica acuta simpla dupa etapa de rehidratare orala fiind indicate continuarea alaptarii sau reluarea regimului alimentar complet,incluzand formula de lapte cu continut normal de lactoza
Nu se infometeaza copilulNu se infometeaza copilul
Aceasta abordare reduce durata diareei, imbunatateste curba ponderala, fara a creste rata de esec a tratamentului sau durata spitalizarii.
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Spitalizarea se impune dacaSpitalizarea se impune daca
Deshidratarea > 10%Deshidratarea > 10%Varsaturi incoercibileVarsaturi incoercibileStare de nutritia anterioara – precaraStare de nutritia anterioara – precaraComplianta familiei = deficitaraComplianta familiei = deficitara
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ObservatiiObservatii
Exista diaree parenteralaExista diaree parenteralaColici + diaree cu sange sugestiva pentru Colici + diaree cu sange sugestiva pentru dizenterie – poate ascunde o invaginatie dizenterie – poate ascunde o invaginatie intestinalaintestinala