幽门螺杆菌感染

幽门螺杆菌感染 儿童幽门螺杆菌感染的治疗 首都医科大学附属北京儿童医院 沈惠青 一、Hp感染的临床诊断及根除 (一)Hp感染的临床诊断 2003年中华医学会全国Hp共识会议规定，判断Hp的现症感染主要通过细菌培养、组织学检查，尿素呼气试验、快速尿素酶试验以及粪便抗原检查，而血清Hp抗体检测只能作为曾经感染的一个证据。对于临床诊断，只要任意一项现症感染实验方法阳性，就可以判断存在Hp感染。而科研诊断要求更为严格，需要细菌培养阳性或其它的任意两项现症感染实验阳性，才能判断存在Hp感染。血清学检查阳性只能用于流行病学调查。Hp现症感染条带检查是近两年新出现的检测方法，其应用还有待于今后进一步的实验及大宗的临床研究报道来证实。 (二)Hp感染根除的判断 判断Hp感染的治疗是否成功，一般是在治疗结束4周后选用一些非侵入性的检测方法，如尿素酶试验、呼气试验、或粪便抗原等来进行检查。 1.儿童Hp感染的诊断标准: position for future reference. Installation using special lifting pole rotor 6.4.4.6 rotor lift, box spirit level to check the rotor axis neck of Yang, on both sides of the rotor should be lateral raises and numerical deviation of ? 0.10MM, qualified before the official lifting. Hoisting of the rotor dynamic and static clearance should be measured, rotors check clearance to prevent rotor colliding. 6.4.4.7 stationary blade carrier, diaphragm and sealing upper cylinder on the inside and install the mounting bolts, bolts and bolt holes in the surface should be coated with molybdenum disulfide. Follow the manufacturers stamp marked to install good sealing ring and spring. Check the sealing ring and spring plate, shall conform to the technical requirements manufacturers drawings. Bolt: ... Measurement with measurement tools, special tools, temporary connection bolts and connection tool equipped and in good condition. The rotor shaft to have fixed, such as thrust, bearing plates fixed installation, in case of wear of the rotor is too large. The coupling gasket check measurements: measured data processing according to gasket, clean the coupling gasket surface clean and Burr-free, check the coupling gasket thickness data, shim thickness deviation of ? 0.02mm, parallel degree deviation of ? 0.02mm. Coupling temporary bolts ready: preparing 4-8 bolt diameter coupling bolt hole diameter 0.5-1.0mm. 6.4.5.2 shaft coupling 6.4.5.2.1 General requirements in both the relative position of the flange according to the manufacturer's mark, if there is no mark, two flange scoop bias complement each other and take care of the bolt hole alignment, hit the mark as basis for alignment and coupling is finally being joined. Each measurement in the two couplings along (1)细菌培养阳性。 (2)组织学见到大量典型细菌。 13(3)快速尿素酶试验、C呼气试验证实存在Hp感染。 2.儿童Hp根治标准: 2000年，中华儿科杂志发表的小儿幽门螺杆菌感染诊断治疗中规定，儿童Hp根治标准为:停药1月以上进行复查，上述检查转为阴性。 二、Hp治疗适应症 目前，Hp的感染率比较高，尤其在儿童可以高达50%，甚至80,90%。那么，是不是所有的患者发现有Hp感染就需要治疗呢,这是一直以来争论比较多的问题。现在越来越多的学者开始认识到并不是说所有的患者都需要治疗。在2000年欧洲Maastricht ?共识中提到:对于Hp感染的治疗分为三类:推荐治疗、建议治疗和不能够确定是否需要治疗。推荐治疗的疾病包括消化性溃疡、早期胃癌切除术后、胃MALT淋巴瘤，萎缩性胃炎，胃癌家族史以及依据患者意愿。建议治疗包括正使用或准备使用NSAID的患者和部分FD患者。不能够确定是否需要治疗的包括没有高危因素为预防胃癌进行Hp根治和没有症状的Hp相关性的胃炎。 2005年，Maastricht Ш又出现了一些新的变化。在2000年的基础上增加了一些内容。Maastricht Ш指出不明原因的缺铁性贫血和血小板减少性紫癜推荐进行Hp的根治治疗。同时，强调儿童慢性再发性腹痛不是Hp检测根治的指征，但是在排除其它病因后应该予以检查和治疗。在治疗上，目前认为14天疗程的治疗效果要优于7天。 2003年中华医学会全国Hp共识会议提出的Hp治疗适应症和欧洲的共识意见基本上接近，也分为3大类，包括必须治疗，支持治疗和不明确。必须治疗的疾病包括消化性溃疡(无论活动或非活动，有无并发症)、早期胃癌术后、胃MALT淋巴瘤和有明显异常的慢性胃炎(糜烂、中重肠化生、萎缩、非典型性增生)。支持治疗的情况包括长期使position for future reference. Installation using special lifting pole rotor 6.4.4.6 rotor lift, box spirit level to check the rotor axis neck of Yang, on both sides of the rotor should be lateral raises and numerical deviation of ? 0.10MM, qualified before the official lifting. Hoisting of the rotor dynamic and static clearance should be measured, rotors check clearance to prevent rotor colliding. 6.4.4.7 stationary blade carrier, diaphragm and sealing upper cylinder on the inside and install the mounting bolts, bolts and bolt holes in the surface should be coated with molybdenum disulfide. Follow the manufacturers stamp marked to install good sealing ring and spring. Check the sealing ring and spring plate, shall conform to the technical requirements manufacturers drawings. Bolt: ... Measurement with measurement tools, special tools, temporary connection bolts and connection tool equipped and in good condition. The rotor shaft to have fixed, such as thrust, bearing plates fixed installation, in case of wear of the rotor is too large. The coupling gasket check measurements: measured data processing according to gasket, clean the coupling gasket surface clean and Burr-free, check the coupling gasket thickness data, shim thickness deviation of ? 0.02mm, parallel degree deviation of ? 0.02mm. Coupling temporary bolts ready: preparing 4-8 bolt diameter coupling bolt hole diameter 0.5-1.0mm. 6.4.5.2 shaft coupling 6.4.5.2.1 General requirements in both the relative position of the flange according to the manufacturer's mark, if there is no mark, two flange scoop bias complement each other and take care of the bolt hole alignment, hit the mark as basis for alignment and coupling is finally being joined. Each measurement in the two couplings along 用NSAID、胃癌家族史、部分功能性消化不良和胃食管返流病。不明确的有两种情况，胃肠道外疾病和个人强烈要求。 三、Hp治疗方案 (一)Hp治疗药物 1.抗生素:包括阿莫西林(A)、甲硝唑(M)、克拉霉素(C)、呋喃唑酮(F)、四环素(T)等。 2.质子泵抑制剂(PPI):包括奥美拉唑、兰索拉唑、潘托拉唑等。 3.铋制剂:枸橼酸铋雷尼替丁(RBC)和铋剂(枸橼酸铋钾、果胶铋)(B)。 (二)治疗方案 Hp的治疗方案分为一线方案和二线方案。 一线方案是质子泵抑制剂或枸橼酸铋雷尼替丁剂两类中的一种，加上两种抗生素，可选用的抗生素有阿莫西林和克拉霉素、甲硝唑和克拉霉素、呋喃唑酮和阿莫西林，呋喃唑酮和克拉霉素等。 二线方案也称四联疗法，即PPI加铋制剂加两种抗生素，疗程7,14天。二线方案主要用于一线方案无效或出现反复感染时。 儿童抗Hp药物剂量: 克拉霉素15mg/kg?d，BID;阿莫西林50mg/kg?d，BID;奥美拉唑0.4,0.8mg/kg?d， QD(或BID);甲硝唑15,20mg/kg?d，BID;胶体次枸橼酸铋5,8mg/kg?d，TID。其中铋制剂的使用药较为慎重，因为铋制剂可以通过血脑屏障，造成中枢神经系统不可逆的损害。 四、Hp耐药问题 position for future reference. Installation using special lifting pole rotor 6.4.4.6 rotor lift, box spirit level to check the rotor axis neck of Yang, on both sides of the rotor should be lateral raises and numerical deviation of ? 0.10MM, qualified before the official lifting. Hoisting of the rotor dynamic and static clearance should be measured, rotors check clearance to prevent rotor colliding. 6.4.4.7 stationary blade carrier, diaphragm and sealing upper cylinder on the inside and install the mounting bolts, bolts and bolt holes in the surface should be coated with molybdenum disulfide. Follow the manufacturers stamp marked to install good sealing ring and spring. Check the sealing ring and spring plate, shall conform to the technical requirements manufacturers drawings. Bolt: ... Measurement with measurement tools, special tools, temporary connection bolts and connection tool equipped and in good condition. The rotor shaft to have fixed, such as thrust, bearing plates fixed installation, in case of wear of the rotor is too large. The coupling gasket check measurements: measured data processing according to gasket, clean the coupling gasket surface clean and Burr-free, check the coupling gasket thickness data, shim thickness deviation of ? 0.02mm, parallel degree deviation of ? 0.02mm. Coupling temporary bolts ready: preparing 4-8 bolt diameter coupling bolt hole diameter 0.5-1.0mm. 6.4.5.2 shaft coupling 6.4.5.2.1 General requirements in both the relative position of the flange according to the manufacturer's mark, if there is no mark, two flange scoop bias complement each other and take care of the bolt hole alignment, hit the mark as basis for alignment and coupling is finally being joined. Each measurement in the two couplings along 目前，Hp耐药问题比较严重。其耐药率，在不同国家、地区和人群也不尽相同。 甲硝唑已出现全球性耐药，韩国90%，芬兰30%，中国30%,50%，其中女性多见;儿童耐药率为8%,31.8%。克拉霉素的耐药率较甲硝唑稍低，发展中国家5,10%，发达国家可达42.9%，我国上海、北京为5.1%,10%，有报道儿童耐药为18.2%。阿莫西林比较低，成人为9.1%;儿童少见耐药报道。 (一)避免耐药菌株产生 避免耐药菌株的产生，是治疗Hp感染的关键。 1.严格掌握Hp根除的适应症，选用正规有效的治疗药物。 2.治疗，足疗程。 3.避免治疗扩大化以及滥用抗生素。 4.对于根治失败的患者，建议先做药敏再用药。 5.提高病人的依从性 6.出现反复耐药的患者，使用PPI三联疗法疗程延长至2周。 (二)常用抗Hp药物治疗方案的根除率 position for future reference. Installation using special lifting pole rotor 6.4.4.6 rotor lift, box spirit level to check the rotor axis neck of Yang, on both sides of the rotor should be lateral raises and numerical deviation of ? 0.10MM, qualified before the official lifting. Hoisting of the rotor dynamic and static clearance should be measured, rotors check clearance to prevent rotor colliding. 6.4.4.7 stationary blade carrier, diaphragm and sealing upper cylinder on the inside and install the mounting bolts, bolts and bolt holes in the surface should be coated with molybdenum disulfide. Follow the manufacturers stamp marked to install good sealing ring and spring. Check the sealing ring and spring plate, shall conform to the technical requirements manufacturers drawings. Bolt: ... Measurement with measurement tools, special tools, temporary connection bolts and connection tool equipped and in good condition. The rotor shaft to have fixed, such as thrust, bearing plates fixed installation, in case of wear of the rotor is too large. The coupling gasket check measurements: measured data processing according to gasket, clean the coupling gasket surface clean and Burr-free, check the coupling gasket thickness data, shim thickness deviation of ? 0.02mm, parallel degree deviation of ? 0.02mm. Coupling temporary bolts ready: preparing 4-8 bolt diameter coupling bolt hole diameter 0.5-1.0mm. 6.4.5.2 shaft coupling 6.4.5.2.1 General requirements in both the relative position of the flange according to the manufacturer's mark, if there is no mark, two flange scoop bias complement each other and take care of the bolt hole alignment, hit the mark as basis for alignment and coupling is finally being joined. Each measurement in the two couplings along PPI+Amo+Cla 1w 83.3 PPI+Amo+Cla 2w 100.0 PPI+Amo+Met 2w 97.0 CBS+Amo+Cla 2w 54.0 CBS+Amo+Met 2w 83.0 CBS+Met+Cla 2w 93.0 CBS+Fur+Cla 2w 91.0 从上表数据可以看出，PPI加阿莫西林加克拉霉素治疗组的根除率比较高，儿科通常选择这组方案对儿童进行治疗。 (三)Hp治疗失败的原因及处理 1.Hp治疗失败的原因: 主要包括三个方面:患者的依从性差、疗程或剂量不足和细菌耐药性。通常治疗失败与临床医师对Hp感染的认识、向患者所做的解释以及用药的方法有一定的关系。 2.Hp治疗失败的处理: 如果出现了治疗失败，可采取的处理措施有选用二线药物、延长疗程、以及根据药敏选择抗生素，或结合当地耐药谱选择抗生素。利福布汀、呋喃唑酮、左氧氟沙星等耐药 较少，可以选用，但儿科应用经验较少。 五、有关概念 position for future reference. Installation using special lifting pole rotor 6.4.4.6 rotor lift, box spirit level to check the rotor axis neck of Yang, on both sides of the rotor should be lateral raises and numerical deviation of ? 0.10MM, qualified before the official lifting. Hoisting of the rotor dynamic and static clearance should be measured, rotors check clearance to prevent rotor colliding. 6.4.4.7 stationary blade carrier, diaphragm and sealing upper cylinder on the inside and install the mounting bolts, bolts and bolt holes in the surface should be coated with molybdenum disulfide. Follow the manufacturers stamp marked to install good sealing ring and spring. Check the sealing ring and spring plate, shall conform to the technical requirements manufacturers drawings. Bolt: ... Measurement with measurement tools, special tools, temporary connection bolts and connection tool equipped and in good condition. The rotor shaft to have fixed, such as thrust, bearing plates fixed installation, in case of wear of the rotor is too large. The coupling gasket check measurements: measured data processing according to gasket, clean the coupling gasket surface clean and Burr-free, check the coupling gasket thickness data, shim thickness deviation of ? 0.02mm, parallel degree deviation of ? 0.02mm. Coupling temporary bolts ready: preparing 4-8 bolt diameter coupling bolt hole diameter 0.5-1.0mm. 6.4.5.2 shaft coupling 6.4.5.2.1 General requirements in both the relative position of the flange according to the manufacturer's mark, if there is no mark, two flange scoop bias complement each other and take care of the bolt hole alignment, hit the mark as basis for alignment and coupling is finally being joined. Each measurement in the two couplings along 1.根除(eradication):停止抗Hp治疗4周后，复查Hp阴性。 2.复发(recrudescence):Hp只是暂时被抑制，停药后Hp会立即再出现。 3.再感染(re-infection):经过抗Hp治疗后Hp已经被确定根除，以后又出现的新的感染。 六、儿童Hp诊断和治疗应注意的问题 131.C呼气试验在儿童非常可靠，但在,2岁幼儿的价值需要评估。 2.儿童Hp感染的治疗适应症应强调要依据内镜及组织病理学结果。 3.需要监测儿童Hp根除治疗效果，一般选择可靠的非侵入检查方法。 4.建议家长同时进行Hp检查，避免反复感染的发生。 5.Hp感染对发展中国家儿童危害较大，成人的Hp感染大多在儿童期获得。 6.Hp感染是儿童慢性胃炎和消化性溃疡的主要病因，慢性胃炎、消化性溃疡患儿要常规检测Hp。 7.对于儿童Hp的治疗根治要慎重，避免扩大化，强调正规治疗。 您的位置:首页 > 我的继续教育 > 全文 position for future reference. Installation using special lifting pole rotor 6.4.4.6 rotor lift, box spirit level to check the rotor axis neck of Yang, on both sides of the rotor should be lateral raises and numerical deviation of ? 0.10MM, qualified before the official lifting. Hoisting of the rotor dynamic and static clearance should be measured, rotors check clearance to prevent rotor colliding. 6.4.4.7 stationary blade carrier, diaphragm and sealing upper cylinder on the inside and install the mounting bolts, bolts and bolt holes in the surface should be coated with molybdenum disulfide. Follow the manufacturers stamp marked to install good sealing ring and spring. Check the sealing ring and spring plate, shall conform to the technical requirements manufacturers drawings. Bolt: ... Measurement with measurement tools, special tools, temporary connection bolts and connection tool equipped and in good condition. The rotor shaft to have fixed, such as thrust, bearing plates fixed installation, in case of wear of the rotor is too large. The coupling gasket check measurements: measured data processing according to gasket, clean the coupling gasket surface clean and Burr-free, check the coupling gasket thickness data, shim thickness deviation of ? 0.02mm, parallel degree deviation of ? 0.02mm. Coupling temporary bolts ready: preparing 4-8 bolt diameter coupling bolt hole diameter 0.5-1.0mm. 6.4.5.2 shaft coupling 6.4.5.2.1 General requirements in both the relative position of the flange according to the manufacturer's mark, if there is no mark, two flange scoop bias complement each other and take care of the bolt hole alignment, hit the mark as basis for alignment and coupling is finally being joined. Each measurement in the two couplings along 小儿消化道传染病的变迁与合理用药 幽门螺杆菌感染与儿童胃肠疾病研究进展 重庆儿童医院感染消化科 朱朝敏 HP与儿童哪些胃肠道疾病有关? HP的临床表现有哪些? 一、流行病学 近年来幽门螺杆菌(HP)在儿童中的高感染引起广泛的关注，大量人群血清流行病学调查资料显示，人类幽门螺杆菌感染可能 在儿童期已经获得。目前已经公认HP与儿童胃炎、胃溃疡关系十分密切，甚至与胃癌和胃淋巴瘤也有一定的关系。因此，研究儿童 HP感染对控制和消除人群HP感染有十分重要的意义。 据相关资料报道，中国儿童HP感染 率为48.98%-77.78%，并随年龄递增。 position for future reference. Installation using special lifting pole rotor 6.4.4.6 rotor lift, box spirit level to check the rotor axis neck of Yang, on both sides of the rotor should be lateral raises and numerical deviation of ? 0.10MM, qualified before the official lifting. Hoisting of the rotor dynamic and static clearance should be measured, rotors check clearance to prevent rotor colliding. 6.4.4.7 stationary blade carrier, diaphragm and sealing upper cylinder on the inside and install the mounting bolts, bolts and bolt holes in the surface should be coated with molybdenum disulfide. Follow the manufacturers stamp marked to install good sealing ring and spring. Check the sealing ring and spring plate, shall conform to the technical requirements manufacturers drawings. Bolt: ... Measurement with measurement tools, special tools, temporary connection bolts and connection tool equipped and in good condition. The rotor shaft to have fixed, such as thrust, bearing plates fixed installation, in case of wear of the rotor is too large. The coupling gasket check measurements: measured data processing according to gasket, clean the coupling gasket surface clean and Burr-free, check the coupling gasket thickness data, shim thickness deviation of ? 0.02mm, parallel degree deviation of ? 0.02mm. Coupling temporary bolts ready: preparing 4-8 bolt diameter coupling bolt hole diameter 0.5-1.0mm. 6.4.5.2 shaft coupling 6.4.5.2.1 General requirements in both the relative position of the flange according to the manufacturer's mark, if there is no mark, two flange scoop bias complement each other and take care of the bolt hole alignment, hit the mark as basis for alignment and coupling is finally being joined. Each measurement in the two couplings along HP感染呈全球分布，感染率从1%到79%不等，多数地区50%左右。西方发达国家儿童HP感染较少，5岁以下则 更少见，发达国家10岁以下HP感染率，如美国0.1%-1%、法国3.5%、澳大利亚14.3%。而在发展中国家儿童HP感染率明显高于发达国家，如阿尔及利亚、冈比亚等国10岁以内的HP感染率已达到45%,90%。 HP感染增长曲线可分为二个时期: 第一期为“剧增期”，见于5岁以下儿童，感染率以每年4%的速度增长，8岁时已达23.6%;第二期为“缓增期”，见于5,40岁人群，感染率每年增长 1%; 第二期为“平坦期”见于40岁以上的人群，感染率基本不再上升。儿童HP感染除与年龄有很大关系外，与社会经济状况、地理环境、种族等也有密切关系。 HP的传染源及传播途径目前尚不完全清楚。但多数学者认为人是主要传染源，其次为动物。传播途径主要通过口-口，或通过粪-口途径。Gibert用N—PCR方法检测HP感染其阳性率为60%，说明口腔唾液的确存在HP，为口-口传播提供了依据。另外，用筷子共餐和母亲习惯将食物咀嚼后再喂孩子的国家和地区，HP感染率比分餐者要高得多，也证实了-口是重要的传播途径。Satoh等研究了10例“胃镜后”急性胃炎患者，这l0例病人在做胃镜前，血清抗HP抗体阴性，但在做胃镜3,4天后出现了急性胃炎的症状，8周内有8例血清抗HP抗体刚性，9例病人再次胃镜检查，所取胃粘膜发现有HP存在，说明胃镜之间的交叉感染也是不可忽视的。密切接触可增加感染的机会，使得HP感染呈明显的家庭聚集现象。 Balli等评估了普通人群HP感染在家庭内传播的比率，结果提示双亲感染家庭儿童HP感染的患病率为44%，显著高于双亲阴性家庭的21%，多因素分析发现，其感染危险性前者是后者的两倍以上。 二、HP与儿童胃肠疾病关系 position for future reference. Installation using special lifting pole rotor 6.4.4.6 rotor lift, box spirit level to check the rotor axis neck of Yang, on both sides of the rotor should be lateral raises and numerical deviation of ? 0.10MM, qualified before the official lifting. Hoisting of the rotor dynamic and static clearance should be measured, rotors check clearance to prevent rotor colliding. 6.4.4.7 stationary blade carrier, diaphragm and sealing upper cylinder on the inside and install the mounting bolts, bolts and bolt holes in the surface should be coated with molybdenum disulfide. Follow the manufacturers stamp marked to install good sealing ring and spring. Check the sealing ring and spring plate, shall conform to the technical requirements manufacturers drawings. Bolt: ... Measurement with measurement tools, special tools, temporary connection bolts and connection tool equipped and in good condition. The rotor shaft to have fixed, such as thrust, bearing plates fixed installation, in case of wear of the rotor is too large. The coupling gasket check measurements: measured data processing according to gasket, clean the coupling gasket surface clean and Burr-free, check the coupling gasket thickness data, shim thickness deviation of ? 0.02mm, parallel degree deviation of ? 0.02mm. Coupling temporary bolts ready: preparing 4-8 bolt diameter coupling bolt hole diameter 0.5-1.0mm. 6.4.5.2 shaft coupling 6.4.5.2.1 General requirements in both the relative position of the flange according to the manufacturer's mark, if there is no mark, two flange scoop bias complement each other and take care of the bolt hole alignment, hit the mark as basis for alignment and coupling is finally being joined. Each measurement in the two couplings along 1、HP与儿童胃炎 近年来，随着儿童胃镜的开展及普及 1986年，Hill等报道了四名胃炎的儿科病人感染了HP。相继Drumm等观察到在67名患慢性活动性胃炎的病人和对HP感染的深入研究，越来越多事实 表明HP感染与病变程度相关。 中，70%感染了HP。对志愿者进行试验，令其吞饮含HP菌落形成单位的碱性胨水，结果在8天后出现无酸性胃炎症 状，10天时复胃镜显示急性胃炎，粘膜有大量的HP。其他大量研究已证实，儿童胃炎总是伴随HP感染。 许春娣等报道了245例儿童非溃疡性消化不良，其中慢性浅表性胃炎224例，慢性萎缩性胃炎11例，非活动性胃炎88例，活动性胃炎32例，HP感染率分别为49.11%、90.01%、43.56%、96.97%; 徐晓华等对1442例儿童进行了血清抗HP抗体检测，并对其中有消化道症状的916例行胃镜检查，结果慢性浅表性胃炎HP感染率为51.54%，慢性萎缩性胃炎为75%。 我院对58例胃镜检查结果与HP尿素酶试验结果进行分析，发现结节性胃炎、非结节性胃炎、十二指肠炎的HP刚性检测率为62%。上述资料强烈提示HP与儿童慢性胃炎有密切关系，尤其与慢性萎缩性胃炎和活动性胃炎。 另外，从胃组织的病变程度来看，轻度慢性浅表性胃炎的HP感染率为32.7%-33.20%，中度则为83.78%,83.97%，而胃粘膜正 常者无1例发病。 2、HP与儿童消化性溃疡 HP是消化性溃疡的主要病因，该观点已被世界各国专家所接受。HP致溃疡的机制是通过致溃疡因素增强与抗溃疡因素减弱而形 成的。前者与HP使胃窦部G细胞分泌胃泌素升高、D细胞分泌生长抑素减少;后者与细胞毒素、尿素酶、蛋白酶、脂多糖、脂酶等 position for future reference. Installation using special lifting pole rotor 6.4.4.6 rotor lift, box spirit level to check the rotor axis neck of Yang, on both sides of the rotor should be lateral raises and numerical deviation of ? 0.10MM, qualified before the official lifting. Hoisting of the rotor dynamic and static clearance should be measured, rotors check clearance to prevent rotor colliding. 6.4.4.7 stationary blade carrier, diaphragm and sealing upper cylinder on the inside and install the mounting bolts, bolts and bolt holes in the surface should be coated with molybdenum disulfide. Follow the manufacturers stamp marked to install good sealing ring and spring. Check the sealing ring and spring plate, shall conform to the technical requirements manufacturers drawings. Bolt: ... Measurement with measurement tools, special tools, temporary connection bolts and connection tool equipped and in good condition. The rotor shaft to have fixed, such as thrust, bearing plates fixed installation, in case of wear of the rotor is too large. The coupling gasket check measurements: measured data processing according to gasket, clean the coupling gasket surface clean and Burr-free, check the coupling gasket thickness data, shim thickness deviation of ? 0.02mm, parallel degree deviation of ? 0.02mm. Coupling temporary bolts ready: preparing 4-8 bolt diameter coupling bolt hole diameter 0.5-1.0mm. 6.4.5.2 shaft coupling 6.4.5.2.1 General requirements in both the relative position of the flange according to the manufacturer's mark, if there is no mark, two flange scoop bias complement each other and take care of the bolt hole alignment, hit the mark as basis for alignment and coupling is finally being joined. Each measurement in the two couplings along 破坏胃粘膜。最新研究提出，HP对胃粘膜屏障损害，造成胃腔内的H+反弥散的“屋漏学说”及HP感染使血清胃泌素水平升高，促使胃酸分泌过多导致溃疡形成的“胃泌素关联”学说等。 据报道HP与成人十二指肠溃疡有强烈的相关性(人约95%)，与成人胃溃疡具有较强的相关性(大约70%)。在HP感染的成人胃炎患者中进行10年随访，发现溃疡的发生率高达90%以上，而HP阴性的胃炎患者中溃疡病的发生率仅1%:此外在消化性溃疡患者若不进行HP根除治疗，一年的复发率高达50-80%，而进行根治患者一年的复发率小于5%。儿童中原发性十二指肠溃疡及胃溃疡在10岁以内极少见到，一旦发生，从本质上看都可能是继发性的(如药源性、囊性纤维化、应激状态等)。儿童的消化性溃疡以十二指肠溃疡为主，是胃溃疡发生率的20,30倍。HP感染与儿童十二指肠溃疡关系，上海报道HP感染率为83.93%;天津报道为90.76%:重庆报道为75%与成人报道相似。HP感染与儿童胃溃疡关系没有成人密切，上海、天津、分别报道为28.57%、29.16%。 3、HP与胃癌 WHO下属国际癌症研究机构从流行病学资料认定HP是胃癌的第1类致癌原，1998年Watanabe的单独用HP感染蒙古沙土鼠诱发胃癌成功，证实了HP是胃癌的病因。同年Honda等也证明HP感染的动物经历了萎缩、肠化等病变于18可月约有40%诱发胃癌。儿童胃癌发病率很低，据统计从1960-1993年全世界报道了317例，其中小于10岁的仅1例，平均年龄15岁。有资料显示，在胃癌高发区，HP感染率相对较高。在中国许多地区已经观察到HP感染率与胃癌死亡率之间显著相关。 潘凯枫等对胃癌高发区儿童HP和cagA+1亚刑抗体进行调查，结果HP感染率为69.4%，其中3,4岁感染率为52.6%、9~10岁上升到85%、1l,12岁下降到66.7%，接近成人水平。儿童cagA+1亚型感染率71.4%，表明胃癌高发区儿童在儿童阶段即可感染HP，特别是cagA+1亚型感染率很高，与当地胃癌高发有明显关系。根除HP是否可以预防胃癌各国正在进行大规模介入试验，目前尚无结论，但多数认为术后根除HP治疗可以预防复发。 4、胃MALT淋巴瘤 position for future reference. Installation using special lifting pole rotor 6.4.4.6 rotor lift, box spirit level to check the rotor axis neck of Yang, on both sides of the rotor should be lateral raises and numerical deviation of ? 0.10MM, qualified before the official lifting. Hoisting of the rotor dynamic and static clearance should be measured, rotors check clearance to prevent rotor colliding. 6.4.4.7 stationary blade carrier, diaphragm and sealing upper cylinder on the inside and install the mounting bolts, bolts and bolt holes in the surface should be coated with molybdenum disulfide. Follow the manufacturers stamp marked to install good sealing ring and spring. Check the sealing ring and spring plate, shall conform to the technical requirements manufacturers drawings. Bolt: ... Measurement with measurement tools, special tools, temporary connection bolts and connection tool equipped and in good condition. The rotor shaft to have fixed, such as thrust, bearing plates fixed installation, in case of wear of the rotor is too large. The coupling gasket check measurements: measured data processing according to gasket, clean the coupling gasket surface clean and Burr-free, check the coupling gasket thickness data, shim thickness deviation of ? 0.02mm, parallel degree deviation of ? 0.02mm. Coupling temporary bolts ready: preparing 4-8 bolt diameter coupling bolt hole diameter 0.5-1.0mm. 6.4.5.2 shaft coupling 6.4.5.2.1 General requirements in both the relative position of the flange according to the manufacturer's mark, if there is no mark, two flange scoop bias complement each other and take care of the bolt hole alignment, hit the mark as basis for alignment and coupling is finally being joined. Each measurement in the two couplings along MALT是指粘膜相关淋巴组织(Mucosa associated lymphoid tissue)。胃MALT淋巴瘤是胃粘膜淋巴滤泡边缘带B淋巴细胞发生肿瘤，常发生于HP持续感染，是一种低度恶性肿瘤。胃原发性低度恶性淋巴瘤几乎都是MALT淋巴瘤。1991年Waterspout等首次指出HP和胃MALT淋巴瘤有关。1993年有学者报道根除HP后胃MALT淋巴瘤肉眼和组织学表现消除，完全消除率为77%,83%，最长1例随访7年无复发。关于HP在胃MALT淋巴瘤的形成机制尚不完全清楚，儿童HP感染与胃MALT淋巴瘤相关研究极少，迄今全世界报道了5例。由于HP感染往往发生在儿童期，而胃MALT淋巴瘤常发生在HP持续感染，故推测两者间存在明显关系。 三、儿童HP感染临床表现 HP感染儿童后大多为“无症状携带者”，部分则表现为慢性、反复性腹痛(82%)、呕吐(34.4%)、呕血、便 咖(15%)、嗳气、腹胀、消瘦、头痛、烦躁及口臭与我院观察资料基本一致。 慢性腹痛是儿童HP感染后最常见和 最突出表现。 韩红芬等报道289例以腹痛为主要表现的儿童，对其进行电子胃镜和HP检查，结果组织病变检出率100%，HP 感染率38.8%。 刘凤霖等报道123例再发性腹痛患儿HP检出率为57.7%。 Bansal等报道31例反复腹痛患儿中的浅表性胃炎和十二指肠球炎的HP感染率明显高于对照组(P<0.02)。 Oderda等曾对反复腹痛证实为HP性胃炎的儿童进行HP根除治疗，大多数儿童根除治疗后症状得以缓解，有13%的儿童症状复发。既往认为儿童的慢性腹痛与肠蛔虫、肠痉挛有关。 同时，临床也发现HP被清除后胃炎得以明显改善，而HP感染复发时炎症也随之加重情况，更一步证实了儿童胃炎与HP关系。从病理改变来看儿科的HP position for future reference. Installation using special lifting pole rotor 6.4.4.6 rotor lift, box spirit level to check the rotor axis neck of Yang, on both sides of the rotor should be lateral raises and numerical deviation of ? 0.10MM, qualified before the official lifting. Hoisting of the rotor dynamic and static clearance should be measured, rotors check clearance to prevent rotor colliding. 6.4.4.7 stationary blade carrier, diaphragm and sealing upper cylinder on the inside and install the mounting bolts, bolts and bolt holes in the surface should be coated with molybdenum disulfide. Follow the manufacturers stamp marked to install good sealing ring and spring. Check the sealing ring and spring plate, shall conform to the technical requirements manufacturers drawings. Bolt: ... Measurement with measurement tools, special tools, temporary connection bolts and connection tool equipped and in good condition. The rotor shaft to have fixed, such as thrust, bearing plates fixed installation, in case of wear of the rotor is too large. The coupling gasket check measurements: measured data processing according to gasket, clean the coupling gasket surface clean and Burr-free, check the coupling gasket thickness data, shim thickness deviation of ? 0.02mm, parallel degree deviation of ? 0.02mm. Coupling temporary bolts ready: preparing 4-8 bolt diameter coupling bolt hole diameter 0.5-1.0mm. 6.4.5.2 shaft coupling 6.4.5.2.1 General requirements in both the relative position of the flange according to the manufacturer's mark, if there is no mark, two flange scoop bias complement each other and take care of the bolt hole alignment, hit the mark as basis for alignment and coupling is finally being joined. Each measurement in the two couplings along 所致慢性胃炎中以浅表性胃炎为主，萎缩性胃炎较少见。除上述表现，有几项国内外研究表明感染了HP的儿童比未感染者身材要矮小，据统计，平均男性要矮1.9cm，女性要矮1.1cm，但最近国内一项调查表明无症状HP感染儿童的身高、体重与对照组无区别。另外，一些难治性贫血、寻麻疹、蛋白丢失性肠病等都和HP有一定关系 四、儿童HP感染诊断 HP感染诊断方法分为侵入性和非侵入性二大类。侵入性诊断方法包括快速尿素酶、组织切片染色、粘膜涂片革兰氏染色、细菌培养，多聚酶链反应(PCR);非侵入性诊断方法包括13C、14C尿素呼气试验、血清HP抗体检测。儿童HP感染诊断标准: 1、细菌培养刚阳性; 2、组织切片染色见到大量典型细菌; 3、组织切片染色见到大量细菌、尿素酶试验、13C-14C尿素呼气试验、血清HP-IgG、HP核酸任意二项刚阳性 4、两周内服用抗生素，上述试验可以出现假阴性。 日前国外有学者检测儿童大便中的HP抗原和小便中的HP抗体辅助诊断HP感染，并认为有很高的敏感性和特异性，尤其适合在儿童中开展。 五、儿童HP感染的治疗 1、 HP根除对象 1997年以来美国、欧洲、亚太地区胃肠病学和微生物学专家先后召开HP的共识会议提出治疗对象: position for future reference. Installation using special lifting pole rotor 6.4.4.6 rotor lift, box spirit level to check the rotor axis neck of Yang, on both sides of the rotor should be lateral raises and numerical deviation of ? 0.10MM, qualified before the official lifting. Hoisting of the rotor dynamic and static clearance should be measured, rotors check clearance to prevent rotor colliding. 6.4.4.7 stationary blade carrier, diaphragm and sealing upper cylinder on the inside and install the mounting bolts, bolts and bolt holes in the surface should be coated with molybdenum disulfide. Follow the manufacturers stamp marked to install good sealing ring and spring. Check the sealing ring and spring plate, shall conform to the technical requirements manufacturers drawings. Bolt: ... Measurement with measurement tools, special tools, temporary connection bolts and connection tool equipped and in good condition. The rotor shaft to have fixed, such as thrust, bearing plates fixed installation, in case of wear of the rotor is too large. The coupling gasket check measurements: measured data processing according to gasket, clean the coupling gasket surface clean and Burr-free, check the coupling gasket thickness data, shim thickness deviation of ? 0.02mm, parallel degree deviation of ? 0.02mm. Coupling temporary bolts ready: preparing 4-8 bolt diameter coupling bolt hole diameter 0.5-1.0mm. 6.4.5.2 shaft coupling 6.4.5.2.1 General requirements in both the relative position of the flange according to the manufacturer's mark, if there is no mark, two flange scoop bias complement each other and take care of the bolt hole alignment, hit the mark as basis for alignment and coupling is finally being joined. Each measurement in the two couplings along (1)HP感染的消化性溃疡，不论溃疡是初发或是复发，不论是活动或是静止，不论有无并发症(出血、穿孔)者; (2)HP感染的MALT淋巴瘤; (3)有明显的胃粘膜病变如糜烂、萎缩、肠化生等慢性胃炎; (4)早期胃癌根除后须长期服用非甾体类抗炎药者。 2、HP根除治疗方案 因为大多数抗生素在胃低PH值环境中活性降低和不能穿透粘液层到达细菌，因此HP根除是比较困难的，所以在选用抗生素时必须采用联合用药的方案。理想的方案应该是根除率高、无副作用、经济、方便、无耐药发生。中华医学会儿科分会感染消化组推荐治疗方案: (1)铋剂(4-6周)+H2RA(4-8周)+一种抗生素(羟氨苄青霉素4周、甲硝唑2周、替硝唑2周、呋喃唑酮2周、克拉霉素2周); (2)铋剂(4-6周)+二种抗生素; (3)质子泵抑制剂(PPl)+二种抗生素2周; (4)H2RA+二种抗生素2周。 目前最新推出的根治方案分为二大类，以PPI为基础的方案和以铋剂为基础的方案。在PPI和铋剂的基础上加二种抗生素组成三联疗法。常用的方案有: (1)PPI+羟氨苄青霉素+甲硝唑(或替硝唑)l周; (2)PPI+羟氨苄青霉素+克拉霉素l周; (3)PPI+克拉霉素，甲硝唑1周; position for future reference. Installation using special lifting pole rotor 6.4.4.6 rotor lift, box spirit level to check the rotor axis neck of Yang, on both sides of the rotor should be lateral raises and numerical deviation of ? 0.10MM, qualified before the official lifting. Hoisting of the rotor dynamic and static clearance should be measured, rotors check clearance to prevent rotor colliding. 6.4.4.7 stationary blade carrier, diaphragm and sealing upper cylinder on the inside and install the mounting bolts, bolts and bolt holes in the surface should be coated with molybdenum disulfide. Follow the manufacturers stamp marked to install good sealing ring and spring. Check the sealing ring and spring plate, shall conform to the technical requirements manufacturers drawings. Bolt: ... Measurement with measurement tools, special tools, temporary connection bolts and connection tool equipped and in good condition. The rotor shaft to have fixed, such as thrust, bearing plates fixed installation, in case of wear of the rotor is too large. The coupling gasket check measurements: measured data processing according to gasket, clean the coupling gasket surface clean and Burr-free, check the coupling gasket thickness data, shim thickness deviation of ? 0.02mm, parallel degree deviation of ? 0.02mm. Coupling temporary bolts ready: preparing 4-8 bolt diameter coupling bolt hole diameter 0.5-1.0mm. 6.4.5.2 shaft coupling 6.4.5.2.1 General requirements in both the relative position of the flange according to the manufacturer's mark, if there is no mark, two flange scoop bias complement each other and take care of the bolt hole alignment, hit the mark as basis for alignment and coupling is finally being joined. Each measurement in the two couplings along (4)铋剂+克拉霉素+甲硝唑2周; (5)铋剂+克拉霉索+呋喃唑酮2周; (6)铋剂+羟氨苄青霉素+甲硝唑2周。 儿童用药剂量如下: (1)奥美拉唑(PPI)0.8mg,1mg,(km.d)，每日1次; (2)羟氨苄青霉素5 0mg,(kg.d)，分2次一3次; (3)甲硝唑l 5mg一20mg,(kg.d)，替硝唑1 5mg,20mg,(km.d)分2次,3次; (4)克拉霉素l5mg,20mg,(kg.d)，分2次; (5)呋喃唑酮4mg,(km.d)，分2次,3次; (6)胶体次枸橼酸铋8mg,9mg,(kg.d)，分2次,3次。 3、根治标准 停药一个月以上进行复查，除血清指标外，其他指标转为阴性，即可认为治愈。 4、治疗失败原因及对策 治疗失败因素分病人相关因素和治疗相关因素二个方面。病人相关因素包括病人依从性差，细菌发生耐药尤其是克拉霉素、甲硝唑可以发生原发性耐药; 治疗相关因素包括制定方案不合理，疗程过短或药物组成不恰当及其他因素。对于治疗失败，首先应重复原治疗方案，同时应该调整治疗剂量和疗程，必要时 根据药敏修改治疗方案。 position for future reference. Installation using special lifting pole rotor 6.4.4.6 rotor lift, box spirit level to check the rotor axis neck of Yang, on both sides of the rotor should be lateral raises and numerical deviation of ? 0.10MM, qualified before the official lifting. Hoisting of the rotor dynamic and static clearance should be measured, rotors check clearance to prevent rotor colliding. 6.4.4.7 stationary blade carrier, diaphragm and sealing upper cylinder on the inside and install the mounting bolts, bolts and bolt holes in the surface should be coated with molybdenum disulfide. Follow the manufacturers stamp marked to install good sealing ring and spring. Check the sealing ring and spring plate, shall conform to the technical requirements manufacturers drawings. Bolt: ... Measurement with measurement tools, special tools, temporary connection bolts and connection tool equipped and in good condition. The rotor shaft to have fixed, such as thrust, bearing plates fixed installation, in case of wear of the rotor is too large. The coupling gasket check measurements: measured data processing according to gasket, clean the coupling gasket surface clean and Burr-free, check the coupling gasket thickness data, shim thickness deviation of ? 0.02mm, parallel degree deviation of ? 0.02mm. Coupling temporary bolts ready: preparing 4-8 bolt diameter coupling bolt hole diameter 0.5-1.0mm. 6.4.5.2 shaft coupling 6.4.5.2.1 General requirements in both the relative position of the flange according to the manufacturer's mark, if there is no mark, two flange scoop bias complement each other and take care of the bolt hole alignment, hit the mark as basis for alignment and coupling is finally being joined. Each measurement in the two couplings along 儿童HP是否根治尚无统一意见，因为有人认为儿童HP感染为自限性，且大部分儿童感染HP后临床并无症状。另外，小婴儿尽管给予根除 治疗其复发率仍然很高，如果不合并溃疡，根除HP后症状改善不明显。所以儿科界多数学者主张对于常规治疗有效和无症状的儿童HP感染，不需要抗HP治 疗。 责任编辑:秦颖然 position for future reference. Installation using special lifting pole rotor 6.4.4.6 rotor lift, box spirit level to check the rotor axis neck of Yang, on both sides of the rotor should be lateral raises and numerical deviation of ? 0.10MM, qualified before the official lifting. Hoisting of the rotor dynamic and static clearance should be measured, rotors check clearance to prevent rotor colliding. 6.4.4.7 stationary blade carrier, diaphragm and sealing upper cylinder on the inside and install the mounting bolts, bolts and bolt holes in the surface should be coated with molybdenum disulfide. Follow the manufacturers stamp marked to install good sealing ring and spring. Check the sealing ring and spring plate, shall conform to the technical requirements manufacturers drawings. Bolt: ... Measurement with measurement tools, special tools, temporary connection bolts and connection tool equipped and in good condition. The rotor shaft to have fixed, such as thrust, bearing plates fixed installation, in case of wear of the rotor is too large. The coupling gasket check measurements: measured data processing according to gasket, clean the coupling gasket surface clean and Burr-free, check the coupling gasket thickness data, shim thickness deviation of ? 0.02mm, parallel degree deviation of ? 0.02mm. Coupling temporary bolts ready: preparing 4-8 bolt diameter coupling bolt hole diameter 0.5-1.0mm. 6.4.5.2 shaft coupling 6.4.5.2.1 General requirements in both the relative position of the flange according to the manufacturer's mark, if there is no mark, two flange scoop bias complement each other and take care of the bolt hole alignment, hit the mark as basis for alignment and coupling is finally being joined. Each measurement in the two couplings along