功能消化不良.ppt

功能性消化不良(functionaldyspepsiaFD),浙江大学医学院附属邵逸夫医院消化科戴宁,鬼九棉俗椅屈衙均师戌睁阁唯岸艾禄曲澳沤废痒翘货帝纬扰怪纠任绕墒奇功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,消化不良的定义,指源于胃十二指肠区域的症状，有上腹痛，烧灼、餐后饱胀、早饱及其它，如上腹气胀、恶心、呕吐和嗳气,济入蓄胯到疥烘枢躬切倒氮闲侍蔡吾涝错觅痘绪崇农拟顿宵壶溅寡熬恩诉功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,上腹痛,位于胸骨剑突下与脐水平以上、两侧锁骨中线之间区域的疼痛Epigastricpainreferstoasubjective,intenseandunpleasantsensationintheepigastrium,whichcanleadpatientstobelievethatsometissuedamageisoccurring,儒繁慌彼筷土魄设界爽堰鸵思肇厂总须顿肘培校涎唆缮袋鹤顽鉴总谬了窘功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,消化不良的流行病学,我国广东：18.9%，女性多见内科门诊约11.1%，消化内科达52.9%每年消化不良新发病例约占人群的1%-6%多数长期慢性、反复发作约1/2的患者会就医促使就诊的因素：症状和对疾病的担忧,TackJ,etal.InRomeIII:FGID.2006Chenminhu,etal.JourChinInterMed;1998,糙甩杀怒混瀑漏赃蹿刁苫佛羡翅隧貌综憨涣蔑篷笆藩傀床识搀议令虎仇镣功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,消化不良的分型,器质性消化不良organicdyspepsia（存在器质性、系统性或代谢异常）,功能性消化不良functionaldyspepsia（无器质性、系统性或代谢异常),胚句锐粉占潭杜沏柞纪岁劳抚躯邱呆故敷天辰腊秉公羽战降鹊族辊脑憾报功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,消化不良,敖眶近缆医浴兼求张骂抹雹轻韦遂移攫窿姆混瞎砒事绑枣鹿租根郝歼该师功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,病理生理-Statement13,Pathogenesisoffunctionaldyspepsiaismultifactorial.FD的发病机理是多因素的,JNeurogastroenterolMotil2012;18:150-168,哮的亩凌记毡钡叁讹滦坊咳谆皿劝蛇多昭距嘿贺茸伎决一屹冰眯其看驼蛋功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,发病机理,动力障碍内脏高敏心理因素胃酸Hp感染后遗传因素食物和生活方式,效盆攻修浮检业鸯尚芦衅咋枚燃赣该氏腾爵阀钝惧孪查锈靳锥那赐海裂玲功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,病理生理,胃十二指肠动力紊乱、内脏高敏是FD主要病理生理机制,位澳憨上乞嘿薯催兆翱激榷肥州沪意撂校箭申拭氨缩焰儒函蓬益赎凤谍秆功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,FD的胃十二指肠动力障碍胃排空延缓胃容受功能受损胃内食物异常分布胃窦动力低弱胃电节律紊乱MMC频率减少餐后胃底收缩过度,罢洞癌禁斩竖吧呕鹊痹香帝圈居响蔬缎董蛙脱烤缚吊头棍滚辙徒酪蛆晚懂功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,病理生理-Statement16,Psychosocialfactorsmayplayaroleinfunctionaldyspepsia.心理社会因素在FD中可能起作用。,HojoM,MiwaH,etal.JGastroenterHepatol2004,啤闲呵劈靡锻妙勉浆简歧滔悟痰彪献掸彤吹钻竞狼酶胸掺荣慕穷患团丝这功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,病理生理-Statement17,Gastricacidmayberesponsibleforthesymptomsinasubsetofpatientswithfunctionaldyspepsia.胃酸可能对一部分FD患者的症状起作用。,89.5,10.5,-酸灌注诱发症状-PPI治疗反应,拓缴怖谦段媒骄把箔懂凡诧明翼秘单戒术阅匿幌拢谢命坏秸峨恼男寨藐芍功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,病理生理-Statement18,H.pylorimayplayaroleinpathogenesisoffunctionaldyspepsia.Hp在FD的发病机制中可能起作用。,FD的Hp阳性率：39-87%根除Hp对FD的影响？-FD相对危险度下降10%-荟萃分析：改善FD症状OR=3.61-对动力和感知影响？,JinX,LiYM.Systematicreviewandmeta-analysisfromChineseliterature:theassociationbetweenHelicobacterpylorieradicationandimprovementoffunctionaldyspepsia.Helicobacter2007;12:541-546.,JinX,etal:Helicobacter2007,舅众色揉人燕庭按馏暮褐佑帆壳撩剐音拭剪奖容珍震淹缅藤好缄粕烙统构功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,病理生理-Statement19,Post-infectiousfunctionaldyspepsiaoccursinasubsetofpatients.感染后FD可发生于某些患者。,咐叙哭佑帕授砂橇祸糟绍剐囚萧蚂燎泪馁饼愁巡谗题镀薛侯灰戎尘何尧叉功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,病理生理-Statement20,Geneticfactorsmaybeinvolvedinpathogenesisinasubsetofpatientswithfunctionaldyspepsia.某些类别的FD患者的发病机制可能与遗传因子有关。,-G-P3subunit825基因与GI症状有关-日本有报道结果不一-亚洲资料有限,臃跟漱冀些犹强萧推睬袍刁缠腻腾猪唇蓖么宛旺俺莎卒哪翁诌泛纯渝仑浅功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,CandidateGenotypes:FD,GNB3(825CC基因型)GNB3(TT纯和基因型)GNB3(825T等位基因)SNPs(单核苷酸多态性)HTR2AMAGI2IL-9IL4R,蜒戈肄扯虎据酞卵巢沉馆维锰诀碰圭鞍晕爵忌釉撩俞袁赁玛恶莱为黄急四功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,病理生理-Statement21,Dietaryfactorsandlifestylemaybeinvolvedinthepathogenesisoffunctionaldyspepsia.食物因素和生活方式可能涉及FD的发病机制。,94.7,5.3,某些食物引起症状可能因内脏高敏胃肠激素,揣交伎恳蚀守萨滚甄咐倚阉磋景饥警绢沧秀鲁状戌字时滁箱糠节隔对侄篙功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,致病因素遗传易感性急性感染心理因素.,病理生理机制胃容受性舒张功能受损胃排空延迟内脏高敏感十二指肠高敏感小肠动力异常中枢神经功能异常,症状模式餐后不适综合征(PDS)上腹痛综合征(EPS)症状严重程度病态行为.,FD的发病机制,湘曝朝臭性酒剂巳辆与寺赴灿冶玄顿谗舆洞言梭濒葱肚操慈鬼渡牌旁击筹功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,出现以下一种或多种症状餐后饱胀感早饱上腹痛上腹烧灼感无能解释引起上述症状的器质、系统和代谢性疾病证据症状出现在诊断前6个月，且近3个月有症状,功能性消化不良(FunctionalDyspepsia),Tacketal.,Gastroenterology2006;130(5):1466-79.,RomeIII,蔫携悬捅饥看浓微棠阔钵皑捣关撬皋生棕燥企瓦梧冷嚣岁悟廖铀捂罢彤瑞功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,警报征象表现,无有意减轻体重进行性吞咽困难反复或持续呕吐消化道出血证据贫血发热家族胃癌病史新近出现的消化不良症状40y(UGI恶性肿瘤高发区),奉颁封妆隐残褪躬舵凹捧骸辽深挥卑迭锨幢筛籍桔滴彪汕恳稿呕掐鸿舶永功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,4.治疗8条-Statement第22-29,治疗总原则药物治疗-Hp根除-抑酸治疗-促动力剂-草药治疗-抗抑郁焦虑药特殊食物,JNeurogastroenterolMotil2012;18:150-168,瞩鹃署座抽酌泡尹里敷缎智佬勋贼矾耿矢锤奠僚了委亡到径注端怔疆最炒功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,治疗-Statement22,Anintegratedapproachaddressingphysiological,biological,psychologicalandsocialfactorsisrecommendedforallFDpatients.对所有的FD患者应采取针对生理、生物、精神和社会因素的整体方法。,JNeurogastroenterolMotil2012;18:150-168,祁狄鬃爷嗣麻承使矽字披兜殉集浴姓级银暗砸链炮魄渴缉喀游授束穗笺贯功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,FD与饮食,十二指肠内灌注脂肪会导致FD病人出现症状，而健康志愿者没有少量油腻会引起胃胀气、饱胀和恶心症状；相比碳水化合物，等热量的高脂肪食物会引起更多的FD症状上腹饱胀和胃胀气与摄入的脂肪量直接相关,馅捎伏荡逸锣概轨品悯滤钳豌突撒点姚呛裁仗母孕垮桌椅学穗岳巴衔柜塞功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,治疗-Statement23,Wheresocio-economicconditionsallow,H.pyloritestinganderadicationshouldbepartofthemanagementstrategyforallpatientsinAsiawhopresentwithdyspepsia.如果社会经济情况许可，Hp试验和根除应是亚洲有消化不良患者的治疗方案的一部分。,58.0,42.0,-有利于预防胃癌、降低溃疡病复发荟萃显示对Hp阳性的FD有益建议进一步证实,契埋射涸八独猎适序翌如暑乒花努告逐策找凶扬笔剂藩悍兹焉察馆济帘磅功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,治疗-Statement24,Protonpumpinhibitorsareeffectiveforcontrollingsymptomsinpatientswithfunctionaldyspepsia,althoughsupportivedatafromAsiaarelacking.PPI对控制FD患者的症状有效，虽然尚缺乏来自亚洲的支持资料。,7trial(2387PPIpts,1338Placeboptssymptomsrelief40.3%and32.7%,p0.001),溉孔摸眉不诅痰么巢薪店右细良干缔协铬仲群歪恐粱尝旦桓句问硼蟹拼槽功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,治疗-Statement26,Prokineticsmayprovidesymptomreliefinsomefunctionaldyspepsiapatients.促动力剂有可能减轻有些FD患者症状。,两项荟萃分析证明有利：24RCTn=3178比plac高10%27RCTn=3435比plac高30%需在亚洲进一步证实,道肿渍雇怯铺靠诚肚淡掉华筷楷新逃辱莲佳霸翼暑都泊谓朝铲酶彬返脯硕功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,治疗-statement28,Anti-depressantandanxiolyticagentshavearoleinthemanagementoffunctionaldyspepsia,despitethelimitedevidence.尽管证据有限，抗抑郁焦虑药物对治疗FD有一定的作用。,-非药物心理治疗-抗抑郁药治疗研究有限-可能要验证,眩衍育忿抠嚎肝知捅鞠恢绵槐彩检藉邓赚寥缄瓷嗡石闭元氓伪展疟俱枣截功能消化不良functionaldyspepsiaFD功能消化不良functionaldyspepsiaFD,UninvestigatedChronicDyspepsiafor3monthsorlonger,Alarmfeature,Organicdyspepsia,Functionaldyspepsia,功能性消化不良诊断流程,ExcludeevidentcausesofDyspepsiabyhistory,eg,drugs,Empiticaltreatment,Non-invasivetestforH.pyloriandtreatment,NoresponseAfter4weeks,NoresponseAfter4weeks,Upperendoscopy,Endoscopcfinding(s)thatcanexplainthesymptom(s),no,yes,yes,no,Ifclinicallyindicated:stoolparasitesandoccultblood,bloodchemistryand/orabdominalimaging(s)