肠易激综合征的新概念PPT参考幻灯片.ppt

肠易激综合征的新概念NewestconceptsinirritablebowelsyndromeIBS,张虎华西医院消化科,1,旧概念：过敏性结肠炎易激结肠或黏液性结肠炎,2,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agroupoffunctionalboweldisordersinwhichdiscomfortorpainisassociatedwithdefecationorachangeinbowelhabit,andwithfeaturesofdisordereddefecation.,3,该病缺乏可解释症状的形态学改变和生化异常,4,PsychologicdisturbancerelatestopatientswhoseephysiciansPsychosocialfactorsinfluencehealthcareseeking,IBSNon-patients,normal,IBSpatients,Psychologicdisturbance,IBS-Psychosocial,5,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22.4,6,WhatcausesIBS?,7,DevelopmentofIBSpathophysiologyinflammation5-HTmediatedhypersensitivityandgutmotilityBrain-gutinteractionVisceralhypersensitivityAbnormalmotorfunction195019601970198019902000,AbnormalnetworkregulationOfnerve-immune-endocrine,IBSmolecularbiology,.,8,IBS发病机制的认识,临床症状腹痛、不适大便异常，流行病学等第一阶段,9,IBS发病机制的认识,临床症状运动异常感觉异常社会心理致病腹痛、不适压力、电活动大便异常，敏感性、5-HT流行病学等炎症、脑肠交流第一阶段第二阶段,10,VisceralHypersensitivityhyperalgesiaallodynia,EndogenousModulation.cortex.Brainstem,Endorgansensitivity.silentnociceptors,SpinalHyperexcitability.NitricoxideActivation,Long-termHyperalgesia.toniccorticalregulation.Neuroplasticity,11,IBS发病机制的认识,临床症状运动异常感觉异常社会心理致病腹痛、不适压力、电活动大便异常，敏感性、5-HT流行病学等炎症、脑肠交流第一阶段第二阶段,12,Serotonin(5-HT)inthehumangut,5-HT15-HT35-HT4GastricaccommodationTransitColonictoneSensation?Secretion,13,IBS发病机制的认识,临床症状运动异常感觉异常社会心理致病腹痛、不适压力、电活动大便异常，敏感性、5-HT流行病学等炎症、脑肠交流第一阶段第二阶段,14,Psychologicdistress,Youngerage,Durationofabdominalpain,Durationofdiarrhea,Females,FactorsPredictingGISymptoms,IBS-PostInfectious,15,IBS发病机制的认识,临床症状运动异常感觉异常社会心理致病腹痛、不适压力、电活动大便异常，敏感性、5-HT流行病学等炎症、脑肠交流第一阶段第二阶段,16,Mechanosensitiveafferent,Sensitizedspinalcircuits,Dorsalrootganglion,Repeatedstimulation,17,DescendingVisceralPainPathway,Thalamus,PAG,Locuscoeruleus,Amygdala,Colon,Serotonergic,Noradrenergic,Caudalraphenucleus,Opioidergic,Rostralventralmedulla,18,19,MotilitySecretionBloodFlowInflammation,SightSoundSmellSomatosensory,CognitionAffect,Viscerosensory,Input,Integration,Effect,20,IBS发病机制的认识,临床症状运动异常分子生物学阶段感觉异常网络调控社会心理致病腹痛、不适压力、电活动大便异常，炎症、敏感性流行病学等5-HT、脑肠交流第一阶段第二阶段第三阶段,一氧化氮5HT及受体多巴胺及受体胃肠道激素及受体细胞因子及受体细胞信号转导蛋白离子及离子通道,21,Extracellularnetworkregulation,Nervecells,Immunecells,Endocrinecells,Cytokine,receptor,peptide,5-HT,22,Howtodevelopinaperson?,23,Predisposingfactors,Psycho-Physiologicaltriggers,Concurrentmodifiers,Brain-gutdysregulation,Earlylife,Geneticvulnerability,EnviromnentegillnessBehaviorreinforcement,abuse,24,Predisposingfactors,Psycho-Physiologicaltriggers,Concurrentmodifiers,Brain-gutdysregulation,Earlylife,GeneticEnvironment,Chronicthreatand/or-onsetassociatedwithachangeinfrequencyofstool;and/or-onsetassociatedwithachangeinform(appearance)ofstool,Atleast3monthscontinuous/recurrentsymptomsofthefollowing-Abdominalpainordiscomfortthatis-associatedwithachangeinfrequencyofstooland/or-associatedwithachangeinconsistencyofstool;andTwoormoreofthefollowingatleast25%ofthetimealteredstoolfrequency(3/dayor40岁,40,诊断流程,问诊查体,有无,发热、消瘦、便血、腹部包块,彻底检查,近期排便习惯改变、肿瘤家族史、40岁,肠镜或钡灌肠,大便常规OB,是,否,41,Whatisthebestmanagementapproach?,42,治疗,个体化、综合治疗,43,治疗原则,AcomprehensivemulticomponentapproachTreatmentprogramisbasedondominantsymptomandtheirseverity,andonpsychosocialfactors,andetiologicalfactors,44,DrugsfordominantinIBS,Abdominalpain,AntispasmodicsTricyclicAntidepressantsSSRI,Diarrhea,Constipation,FiberOsmoticlaxativesTegaserodPEGsolution,LoperamideCholestyramineDiphenoxylate,45,治疗原则,AcomprehensivemulticomponentapproachTreatmentprogramisbasedondominantsymptomandtheirseverity,andonpsychosocialfactors,andetiologicalfactors,46,MildLifestyleanddietarymodification,SevereRealisticgoalsAntidepressantsReferralforpainmanagement,ModerateGutactingagentsPsychologic(motility/sensation)treatments,AllTherapeuticrelationship/continuityofcareeducation/reassurance,47,治疗原则,AcomprehensivemulticomponentapproachTreatmentprogramisbasedondominantsymptomandtheirseverity,andonpsychosocialfacto