09级大5上课件-内科学8rome

1、Functional Gastrointestinal Disorders (FGIDs)Han XinjingDepartment of GastroenterologyThe Second Affiliated Hospital of CQMURefers to Rome III Disorders and CriteriaFunctional Gastrointestinal Disorders What are the FGIDs definitions?What is the clinical presentations?What is the differential diagno

2、sis?What is the diagnostic strategy?What is a rational treatment strategy?Chronic and recurrent symptoms of the gastrointestinal (GI) tract: pain nausea vomiting bloating diarrhea constipation Without detectable structural or biochemical abnormalitiesDefinition of FGIDsWhat is a FGIDs?Many regard FG

3、ID as a psychological disorderAbsence of organic diseaseFGID can be understood in context of integrated biopsychosocial model of illness and diseaseSymptoms are physiologically multidetermined and modifiable by social, cultural, psychological factorsDrossman DA. Gastroenterology 2006 Rome III functi

4、onal gastrointestinal disorders (FGIDs)A: Functional esophageal disordersB: Functional gastroduodenal disordersC: Functional bowel disordersD: Functional abdominal pain syndrome (FAPS)E: Functional gallbladder and sphincter of Oddi disordersF: Functional anorectal disordersG: Childhood functional GI

5、 disorders: neonate/toddlerH: Childhood functional GI disorders: child/adolescentclassified by anatomic regionA: Functional esophageal disordersA1: Functional heartburnA2: Functional chest pain of presumed esophageal originA3: Functional dysphagiaA4: GlobusB: Functional gastroduodenal disordersB1: F

6、unctional dyspepsia (FD)B1a: Postprandial distress syndrome (PDS)B1b: Epigastric pain syndrome (EPS)B2: Belching disordersB2a: AerophagiaB2b: Unspecified excessive belchingB3: Nausea and vomiting disordersB3a: Chronic idiopathic nausea (CIN)B3b: Functional vomitingB3c: Cyclic vomiting syndrome (CVS)

7、B4: Rumination syndrome in adultsC: Functional bowel disordersC1: Irritable bowel syndrome (IBS)C2: Functional bloatingC3: Functional constipationC4: Functional diarrheaC5: Unspecified functional bowel disorderD: Functional abdominal pain syndrome (FAPS)E: Functional gallbladder and sphincter of Odd

8、i disordersE1: Functional gallbladder disorderE2: Functional biliary SO disorderE3: Functional pancreatic SO disorderF: Functional anorectal disordersF1: Functional fecal incontinenceF2: Functional anorectal painF2a: Chronic proctalgiaF2a1: Levator ani syndromeF2a2: Unspecified functional anorectal

9、painF2b: Proctalgia fugaxF3: Functional defecation disordersF3a: Dyssynergic defecationF3b: Inadequate defecatory propulsionG: Childhood functional GI disorders: neonate/toddlerG1: Infant regurgitationG2: Infant rumination syndromeG3: Cyclic vomiting syndromeG4: Infant colicG5: Functional diarrheaG6

10、: Infant dyscheziaG7: Functional constipationH. Childhood functional GI disorders: child/adolescentH1: Vomiting and aerophagiaH1a: Adolescent rumination syndromeH1b: Cyclic vomiting syndromeH1c: AerophagiaH2: Abdominal pain-related FGIDH2a: Functional dyspepsiaH2b: Irritable bowel syndromeH2c: Abdom

11、inal migraineH2d: Childhood functional abdominal painH2d1: Childhood functional abdominalpain syndromeH3: Constipation and incontinenceH3a: Functional constipationH3b: Non-retentive fecal incontinenceFunctional Dyspepsia(FD)DefinitionPersistent or recurrent pain or fort centered in the upper abdomen

12、: including epigastric pain, early satiety, nausea, vomiting, bloating, and anorexia No structural or biochemical abnormalty.EtiologyH pylori infectionPsychological FeaturesPost-infectionGenetic factors Helicobacter pylori infection?ControversialRelationship between Helicobacter pylori infection and

13、 FD was failed to be identified H.pylori eradication therapy in FD results in a significant effect in H.pylori positive FD Guidelines mended H.pylori eradication therapy in H.pylori positive FD patients. Fock KM. J Gastroenterol Hepatol 2011Psychological featuresPsychological stress exacerbates FD s

14、ymptoms. Higher levels of anxiety and depression have been found. A link between childhood abuse and functional gastrointestinal disorders.Post-infectious dyspepsia has been described as a distinct clinical entity, based on a large retrospective study that showed a subset of dyspeptic patients who h

15、ad a history suggestive of post-infectious dyspepsia. Post-infection Development of dyspepsia was increased fivefold at 1 year after acute Salmonella gastroenteritis early satiety, weight loss, nausea, and vomiting Infectious FD was associated with persisting focal T-cell aggregates, decreased CD4+

16、cells and increased macrophage counts in the duodenum impaired ability of the immune systemMearin F. Gastroenterology 2005 Kindt S. Neurogastroenterol Motil 2009 G-protein beta3 (GNB3) subunit C825T was first reported as a candidate gene for FD susceptibility. However, the data are inconsistent in c

17、ountries. Significant link between homozygous 825C allele of GNB3 protein and dyspepsia was reported from Germany and the USA. On the other hand, the association between T allele of GNB3 C825T polymorphism and dyspepsia was reported from Japan and Netherlands. Association of serotonin transporter pr

18、omoter (SERT-P) gene polymorphism and FD was reported negatively from a USA community and Netherlands. However SERT SL genotype was significantly associated with PDS. Involvement of IL-17F, migration inhibitory factor (MIF), catechol-o-methyltransferase (COMT) gene val158met, 779 TC of CCK-1 intron

19、1, cyclooxygenase-1 (COX-1), transient receptor potential cation channel, subfamily V, member 1 (TRPV1) 315C and regulated upon activation normal T cell expressed and secreted (RANTES) polymorphisms was reported in Japanese studies.Genetic factors Oshima T. J Gastroenterol Hepatol 2011Pathophysiolog

20、yAbnormal motilityVisceral hypersensitivityGastric acidDelayed gastric emptyingLower gastric complianceAntral hypomotilityGastric dysrhythmiasImpaired duodenojejunal motilityAbnormal motilityVisceral hypersensitivityHypersensitivity to gastric balloon distention: suggesting abnormal afferent functio

21、nReflex hyporeactivity: suggesting either abnormal afferent or abnormal efferent functionGastric acid Stress acid Acid hypersensitivity Acid-suppressive drugspainRome III Bothersome postprandial fullnessEarly satiationEpigastric painEpigastric burningNo evidence of structural diseasesClinical presen

22、tations The symptoms may be intermittent or continuous, and may or may not be related to meals.Epigastric pain Epigastric refers to the region between the umbilicus and lower end of the sternum, and marked by the midclavicular lines. Pain refers to a subjective, unpleasant sensation; some patients m

23、ay feel that tissue damage is occurring. Other symptoms may be extremely bothersome without being interpreted by the patient as pain.Epigastric burning Epigastric refers to the region between the umbilicus and lower end of the sternum, and marked by the midclavicular lines. Burning refers to an unpl

24、easant subjective sensation of heat.Postprandial fullness An unpleasant sensation like the prolonged persistence of food in the stomach. Early satiation A feeling that the stomach is overfilled soon after starting to eat, out of proportion to the size of the meal being eaten, so that the meal cannot

25、 be finished. Previously, the term “early satiety” was used, but satiation is the correct term for the disappearance of the sensation of appetite during food ingestion.Tack J, Talley NJ, Camilleri M, Holtmann G, Hu P, Malagelada JR, Stanghellini V. Functional gastroduodenal disorders. Gastroenterolo

26、gy. 2006 Apr;130(5):1466-79. Epigastric fort 90% Post-prandial fullness 75% Bloating 75% Post-prandial nausea 50% Early satiation 50% Belching 45% Weight loss 30% Nausea and vomiting 20%FD subclassification :Rome III defined as two subgroupsPostprandial Distress Syndrome, PDSBothersome postprandial

27、fullnessEarly satiationEpigastric pain syndrome, EPSEpigastric painEpigastric burningFD remains a diagnosis of exclusion:Careful history and physical examinationUpper endoscopy is necessaryThe others: exclusion of chronic peptic ulcer disease, gastroesophageal reflux disease, malignancy, pancreatico

28、-biliary diseaseDiagnosisAlarm symptoms and signsUnintentional weight loss 3 kgUnexplained iron deficiency anaemiaGastro-intestinal bleedingDysphagiaAbdominal massEndoscopyB1. FUNCTIONAL DYSPEPSIADiagnostic criteria* Must include:. One or more of the following:a. Bothersome postprandial fullnessb. E

29、arly satiationc. Epigastric paind. Epigastric burningAND. No evidence of structural disease (including at upper endoscopy) that is likely to explain the symptoms* Criteria fulfilled for the last 6 months with symptom onsetat least 3 months prior to diagnosisRome III criteriaB1a. Postprandial Distres

30、s SyndromeDiagnostic criteria* Must include one or both of the following:. Bothersome postprandial fullness, occurring after ordinary-sized meals, at least several times per week. Early satiation that prevents finishing a regular meal, at least several times per weekSupportive criteria. Upper abdomi

31、nal bloating or postprandial nausea or excessive belching can be present. Epigastric pain syndrome may coexistB1b. Epigastric Pain SyndromeDiagnostic criteria* Must include all of the following:. Pain or burning localized to the epigastrium of at least moderate severity, at least once per week. The

32、pain is intermittent. Not generalized or localized to other abdominal or chest regions. Not relieved by defecation or passage of flatus. Not fulfilling criteria for gallbladder and sphincter of Oddi disordersB1b. Epigastric Pain SyndromeSupportive criteria. The pain may be of a burning quality, but

33、without a retrosternal component. The pain is commonly induced or relieved by ingestion of a meal, but may occur while fasting. Postprandial distress syndrome may coexistDifferential DiagnosisGERD: Heartburn is the predominant symptom Upper endoscopy Esophageal pH monitoring Differential DiagnosisIB

34、S: overlap symptom co-exist with FD PUTreatmentThe goal is to accept, diminish, and cope with symptoms rather than eliminate them. The most important aspects include explanation that the symptoms are not imaginary, evaluation of relevant psychosocial factors, and dietary advice.Pharmacological thera

35、piesH. pylori therapy ? controversialAcid suppression and prokinetic agents (digestive agents) ? may helpGut analgesics ? Relaxants of the nervous system of the gut may be beneficialAntidepressant? May helpSummaries of treatment trialsProkinetic agents placebo (RRR 50%)H2 antagonists placebo (RRR 30

36、%)PPI and bismuth salts placeboNo benefit from antacids or sucralfateVisceral analgesiaSerotonin receptor antagonistSomatostatin analogue - octreotidePsychotherapyAlternative medicineHerbal and natural products (peppermint, caraway)acupunctureIrritable Bowel Syndrome (IBS)DefinitionIrritable bowel s

37、yndrome (IBS) is a functional GI disorder characterized by abdominal pain or fort and altered bowel habits.Without demonstrable organic diseaseEtiology and PathophysiologyPsychological FeaturesAbnormal motilityVisceral hypersensitivityInflammation and bacteriaFood intolerancePsychological Features1)

38、Psychological stress exacerbates GI symptoms.2)Psychological disturbances modify the experience of illness and illness behaviors such as health care seeking.3) Psychosocial factors affect health status and clinical e. Psychological stress exacerbates GI symptoms in everyone- but to a greater degree

39、in patients with IBS50% of patients with IBS seen at referral centers meet the criteria for a psychological disorderPatients with FGIDs who are non health care seeking do not show more psychological disorder than normalsChronic illness such as IBS has psychosocial consequencesDrossman DA. Gastroente

40、rology 2006Psychological Features Altered gut reactivity (motility, secretion) in response to luminal (e.g., meals, gut distention, inflammation, bacterial factors) or provocative environmental (psychosocial stress) stimuli, resulting in symptoms of diarrhea and/or constipation Abnormal motilityPre-

41、prandial colonic tone and motility is increased in IBS patientsFGIDs patients like IBS have greater motility response to stressors- both physiologic and psychologic when compared to normalVassallo MJ. Mayo Clinic Proc 1992Drossman DA. Gastro 2002 Abnormal motility A hypersensitive gut with enhanced

42、visceral perception and painVisceral hypersensitivity Repetitive rectal balloon inflations lead to a progressive increase in pain that occurs longer and with greater intensity than controlsMunakata K. Gastroenterology 1997Bacterial FloraEradication of small intestinal bacterial overgrowth reduces sy

43、mptoms of IBSAnderson ML. Am J Gastroenterology 2000Normalization of lactulose breath testing correlates with symptomatic improvement in IBSPimentel M. Am J Gastroenterology 2003Inflammation50% IBS patients have increased activated mucosal inflammatory cellsChadwick VS. Gastroenterology 200233% pati

44、ents with IBS can correlate symptoms to an enteric infection25% of patients with an acute enteric infection go on to develop IBS like or dyspeptic symptomsGwee KA. Gut 1999The main types of food sensitivityFood IntolerancePrevalenceDairy Intolerance(includes Lactose intolerance)75%3 in 4 peopleYeast

45、 sensitivity(eg. Candida infections)33%1 in 3 peopleGluten sensitivity(Wheat intolerance)15%1 in 7 peopleFructose or Sugar sensitivity35%1 in 3 peopleFood allergy1%1 in 100 people Clinical presentationsAbdominal fort or pain Disordered defecationIBS pain is associated with defecation or a change in

46、bowel function and can occur throughout the abdomen:Upper abdomen pain is often associated with bloating and may worsen after meals. Cramping can occur around the belly button and through the lower abdomen. Lower abdomen pain is most likely to be eased by a bowel movement.Common descriptions of IBS

47、pain are: Twingy, crampy Stitch-like Sharp and stabbing Constant abdominal aching Tenderness when abdomen is touched Bloating fort The severity of IBS pain can also be very changeable. Pain can range from mild to unbearable and be constant. Hard stoolsLoose stoolsROME III subclassificationIBS-CONSTI

48、PATION25% of stools are hard and lumpy25% of stools are loose and watery25% of stools are loose and watery25% of stools are hard and lumpyIBS-Untyped Insufficient abnormality of stool consistency to meet criteria for IBS-C, D, or MAlarm symptoms and signsAge 40Unintentional weight lossFamily history of GI malignancySevere unrelenting large volume diarrheaHematocheziaEndoscopyDiagnosisC1. Irritable Bowel SyndromeDiagnostic criterion*Recurrent abdominal pain or fort* at least 3 days/month in the last 3 months associated with two or m