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,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,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,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,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),消化不良,病理生理-Statement13,Pathogenesisoffunctionaldyspepsiaismultifactorial.FD的发病机理是多因素的,JNeurogastroenterolMotil2012;18:150-168,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,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,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,病理生理-Statement16,Psychosocialfactorsmayplayaroleinfunctionaldyspepsia.心理社会因素在FD中可能起作用。,HojoM,MiwaH,etal.JGastroenterHepatol2004,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,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,病理生理-Statement19,Post-infectiousfunctionaldyspepsiaoccursinasubsetofpatients.感染后FD可发生于某些患者。,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,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,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,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,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,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),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,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,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,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,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),7trialssymrelief2387PPIpts40.3%1338Placpts32.7%*不同于西方亚洲需要进一步证实,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,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,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),Result(s)thatcanexplainThesymptom(s),yes,no,亚洲共识,2011,FunctionalDyspepsia,功能性消化不良治疗流程,H.Pyloritestanderadication,Ifnotdonebefore,Dietarymodifications,Predominantsymptom(s),Postprandialfullness,earlysatiation,Upperabdominalbloating,nausea,vomitingorbelching,ProkineticagentWithorwithoutPPI,PPIwitho