家庭醫業 1 2 前言 (diarrhea) 250 14 30 14 30 (1) (osmotic diarrhea) (2) (secretory diarrhea) (3) (inflammatory diarrhea) Herbert L. DuPont.MD 2014 4 1 馬偕紀念醫院家庭醫學科住院醫師 2 馬偕紀念醫院家庭醫學科主治醫師 infectious diarrhea, immunocompetent adult The New England Journal of Medicine [1] 流行病學 (Centers for Disease Control and Prevention, CDC) 1 7 9 0.6 3-7% 83% 65 (1) (Clostridium difficile) (2) (Norovirus) [2] 致病機轉 (Salmonella) (Campylobacter) 228 家庭醫學與基層醫療 第八期
(Shiga toxin-production Escherichia coli) (Vibrio) (Yersinia) 50% ( ) [3] 18 4 8 36% [4] 危險因子 (1) (2) (3) (4) (proton pump inhibitors, PPIs) 臨床處理評估流程 ( 1) (tenesmus) (Shigella) (Shiga toxin-production Escherichia coli) 38.5 (vital signs) ( )48 (1) (2) <15,000/mm 3 家庭醫學與基層醫療 第八期 229
圖 1 成人急性腹瀉的思考診斷流程, 資料來源 : 參考資料 1 ( ) (1) 6 ( ) (2) ( )72 (3) ( )15,000/mm 3 (4) (5) (6) 2.5g/dL (7) (fulminant course) (megacolon) 230 家庭醫學與基層醫療 第八期
(colectomy) 14 診斷檢查 (PCR) (dehydration) (electrolyte) (creatinine) (Complete blood count) (leukocytosis) (shift to left) (1) ( )38.5 (2) (3) ( ( )14 ) (4) (cholera-like) (dehydration) (dysentery) (PCR) (sensitivity) (transient colonization) DNA PCR (colitis) (Clostridium difficile stool toxin) (flexible sigmoidoscopy) (unprotected anal intercourse) (proctoscopy) (proctitis) (Giardia infection) 家庭醫學與基層醫療 第八期 231
(Celiac disease) (esophagogastroduodenoscopy) (Abdominal computed tomography) (mucosal thickening) 治療 (anti-motility) Loperamide 4mg 2mg 8mg (dysentery) (1) (febrile dysentery) (2) (travelers dirrhea) (3) (Hospital-associated diarrhea) (4) (Antibiotic-associated diarrhea) 1. Fluoroquinolone cephalosporin 7 14 ( ) 2. metronidazole 500mg 3 10 vancomycin 125mg 4 10 (anti-secretory) Crofelemer (Fulzaq) [5] (probiotics) (antibiotic-associated diarrhea) 結語 Herbert L. DuPont.MD (1) (2) ( )38.5 (3) 232 家庭醫學與基層醫療 第八期
(4) 14 參考資料 1. DuPont, HL: Acute infectious diarrhea in immunocompetent adults. NEJM 2014; 370: 1532-9. 2. Hall AJ, Curns AT, McDonald LC, Parashar UD, Lopman BA: The roles of Clostridium difficile and norovirus among gastroenteritis-associated deaths in the United States, 1999-2007. Clin Infect Dis 2012;55:216-23. 3. Anderson EJ, Shippee DB, Weinrobe MH et al: Indirect protection of adults from rotavirus by pediatric rotavirus vaccination. Clin Infect Dis 2013;56:755-60. 4. Painter JA, Hoekstra RM, Ayers T, et al: Attribution of foodborne illnesses, hospitalizations, and deaths to food commodities by using outbreak data, United States, 1998-2008. Emerg Infect Dis 2013; 19:407-15. 5. DiCesare D, DuPont HL, Mathewson JJ et al:a double blind, randomized, placeboocontrolled study of SP-303 (Provir) in the symptomatic treatment of acute diarrhea among travelers to Jamaica and Mexico. Am J Gastroenterol 2002;97:2585-8. 家庭醫學與基層醫療 第八期 233