医学肠易激综合征课件

肠易激综合征的新概念 Newest concepts in irritable bowel syndrome IBS 旧概念： 过敏性结肠炎 易激结肠 或黏液性结肠炎 新概念：一种以腹痛或腹部不适伴排便 习惯改变为特征的功能性肠病 a group of functional bowel disorders in which discomfort or pain is associated with defecation or a change in bowel habit , and with features of disordered defecation. 该病缺乏可解释症状的形态学 改变和生化异常 Psychologic disturbance relates to patients who see physicians Psychosocial factors influence health care seeking IBS Non-patients l l normalnormal lIBS patients Psycho logic disturb ance IBS - Psychosocial 流行病学研究 西方国家 患病率 5-24% 美国 人群 10-20% 就诊率 30 $80亿 国内 北京 潘国宗 7.26 广州 陈旻湖 5.6 就诊率 22.4 What causes IBS ? Development of IBS pathophysiology l l l inflammation l 5-HT mediated hypersensitivity l and gut motility l Brain-gut interaction l Visceral hypersensitivity lAbnormal motor function l1950 1960 1970 1980 1990 2000 Abnormal network regulationAbnormal network regulation Of nerve-immune-endocrineOf nerve-immune-endocrine IBS molecular biologyIBS molecular biology . IBS发病机制的认识 l临床症状 l l腹痛、不适 l大便异常， l流行病学等 l第一阶段 IBS发病机制的认识 l临床症状 运动异常 l 感觉异常 l 社会心理致病 l腹痛、不适 压力、电活动 l大便异常， 敏感性、 5-HT l流行病学等 炎症、脑肠交流 l第一阶段 第二阶段 Visceral Hypersensitivity hyperalgesia allodynia EndogenousEndogenous ModulationModulation .cortex.cortex .Brainstem.Brainstem End organ sensitivity .silent nociceptors SpinalSpinal HyperexcitabilityHyperexcitability .Nitric oxide.Nitric oxide ActivationActivation Long-termLong-term HyperalgesiaHyperalgesia . . tonic cortical regulationtonic cortical regulation . .NeuroplasticityNeuroplasticity IBS发病机制的认识 l临床症状 运动异常 l 感觉异常 l 社会心理致病 l腹痛、不适 压力、电活动 l大便异常， 敏感性、 5-HT l流行病学等 炎症、脑肠交流 l第一阶段 第二阶段 Serotonin(5-HT) in the human gut 5-HT1 5-HT3 5-HT4 Gastric accommodation Transit Colonic tone Sensation ? Secretion IBS发病机制的认识 l临床症状 运动异常 l 感觉异常 l 社会心理致病 l腹痛、不适 压力、电活动 l大便异常， 敏感性、 5-HT l流行病学等 炎症、脑肠交流 l第一阶段 第二阶段 PsychologicPsychologic distressdistress Younger Younger ageage Duration of Duration of abdominal abdominal painpain Duration of Duration of diarrheadiarrhea FemalesFemales Factors Predicting GI Symptoms IBS - Post Infectious IBS发病机制的认识 l临床症状 运动异常 l 感觉异常 l 社会心理致病 l腹痛、不适 压力、电活动 l大便异常， 敏感性、 5-HT l流行病学等 炎症、脑肠交流 l第一阶段 第二阶段 lMechanosensitive afferent Sensitized spinal circuits Dorsal root ganglion Repeated stimulation Descending Visceral Pain Pathway Thalamus PAG Locus coeruleus Amygdala Colon Serotonergic Noradrenergic Caudal raphe nucleus Opioidergic Rostral ventral medulla Motility Secretion Blood Flow Inflammation Sight Sound Smell Somatosensory Cognition Affect Viscerosensory InputIntegration Effect IBS发病机制的认识 l临床症状 运动异常 分子生物学阶段 l 感觉异常 网络调控 l 社会心理致病 l腹痛、不适 压力、电活动 l大便异常， 炎症、敏感性 l流行病学等 5-HT、脑肠交流 l第一阶段 第二阶段 第三阶段 一一氧化氮氧化氮 5 5HTHT及受体及受体 多巴胺及受体多巴胺及受体 胃肠道激素及受体胃肠道激素及受体 细胞因子及受体细胞因子及受体 细胞信号转导蛋白细胞信号转导蛋白 离子及离子通道离子及离子通道 Extracellular network regulation Nerve cellsNerve cells Immune cellsImmune cellsEndocrine cellsEndocrine cells Cytokine, receptor, Cytokine, receptor, peptide, 5-HTpeptide, 5-HT How to develop in a person? Predisposing Predisposing factorsfactors Psycho-Psycho- PhysiologicalPhysiological triggerstriggers ConcurrentConcurrent modifiersmodifiers Brain-gutBrain-gut dysregulationdysregulation EarlyEarly lifelife Genetic vulnerability,Genetic vulnerability, Enviromnent eg Enviromnent eg illnessillness Behavior reinforcement,Behavior reinforcement, abuseabuse Predisposing Predisposing factorsfactors Psycho-Psycho- PhysiologicalPhysiological triggerstriggers ConcurrentConcurrent modifiersmodifiers Brain-gutBrain-gut dysregulationdysregulation EarlyEarly lifelife Genetic Genetic EnvironmentEnvironment Chronic Chronic threat and/or -onset associated with a change in frequency of stool; and/or -onset associated with a change in form(appearance) of stool At least 3 months continuous / At least 3 months continuous / recurrent symptoms of the following recurrent symptoms of the following -Abdominal pain or discomfort that is -Abdominal pain or discomfort that is -associated with a change in frequency -associated with a change in frequency of stool and/or of stool and/or -associated with a change in -associated with a change in consistency of stool; and consistency of stool; and Two or more of the following at least Two or more of the following at least 25% of the time25% of the time altered stool frequency (3/day or altered stool frequency (3/day or 3次； 块状或硬便； 稀烂便或水样便； 排便费力； 排便急迫感。 表现分型 分型依据的症状： 每周排便3次； 块状或硬便； 稀烂便或水样便； 排便费力； 排便急迫感。 便秘为主型便秘为主型 或或 项中之一项或以上，而无项中之一项或以上，而无 项项 项中之二项或以上，可伴有项中之二项或以上，可伴有 中中 之一项之一项 表现分型 分型依据的症状： 每周排便3次； 块状或硬便； 稀烂便或水样便； 排便费力； 排便急迫感。 腹泻为主型腹泻为主型 项中之一项或以上，而无项中之一项或以上，而无 项项 或或 项中之二项或以上，可伴有项中之二项或以上，可伴有 中一中一 项，但无项，但无项项 表现分型 分型依据的症状： 每周排便3次； 块状或硬便； 稀烂便或水样便； 排便费力； 排便急迫感。 腹泻便秘交替型腹泻便秘交替型 诊断流程 问诊查体 发热、消瘦、便血、腹部包块发热、消瘦、便血、腹部包块 诊断流程 问诊查体 有有 无无 发热、消瘦、便血、腹部包块发热、消瘦、便血、腹部包块 彻底检查彻底检查 近期排便习惯改变、肿瘤近期排便习惯改变、肿瘤 家族史、家族史、4040岁岁 诊断流程 问诊查体 有有 无无 发热、消瘦、便血、腹部包块发热、消瘦、便血、腹部包块 彻底检查彻底检查 近期排便习惯改变、肿瘤近期排便习惯改变、肿瘤 家族史、家族史、4040岁岁 肠镜或钡灌肠肠镜或钡灌肠 大便常规大便常规OBOB 是是 否否 What is the best management approach? 治疗 个体化、综合治疗 治疗原则 A comprehensive multicomponent approach Treatment program is based on dominant symptom and their severity, and on psychosocial factors , and etiological factors Drugs for dominant in IBS Abdominal Abdominal painpain Antispasmodics Tricyclic Antidepressants SSRI DiarrheaDiarrhea Constipation Constipation FiberFiber Osmotic laxativesOsmotic laxatives TegaserodTegaserod PEG solutionPEG solution LoperamideLoperamide CholestyramineCholestyramine DiphenoxylateDiphenoxylate 治疗原则 A comprehensive multicomponent approach Treatment program is based on dominant symptom and their severity, and on psychosocial factors , and etiological factors Mild Mild Lifestyle and dietary modification Lifestyle and dietary modification Severe Severe Realistic Realistic goalsgoalsAntidepressants Antidepressants Referral for pain managementReferral for pain management Moderate Moder