肠易激综合征的新概念.ppt

1、肠易激综合征的新概念 Newest concepts in irritable bowel syndrome IBS,张虎华西医院消化科,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

2、的形态学改变和生化异常,Psychologic disturbance relatesto patients who see physiciansPsychosocial factors influencehealth care seeking,IBS Non-patients,normal,IBS patients,Psychologic disturbance,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 ?,

3、Development of IBS pathophysiologyinflammation5-HT mediated hypersensitivityand gut motilityBrain-gut interactionVisceral hypersensitivity Abnormal motor function 1950 1960 1970 1980 1990 2000,Abnormal network regulation Of nerve-immune-endocrine,IBS molecular biology,.,IBS发病机制的认识,临床症状腹痛、不适大便异常，流行病学

4、等第一阶段,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,Visceral Hypersensitivityhyperalgesiaallodynia,Endogenous Modulation .cortex .Brainstem,End organ sensitivity .silent nociceptors,Spinal Hyperexcitability .Nitric oxide Activation,Long-term Hyperalgesia .tonic cor

5、tical regulation .Neuroplasticity,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,Serotonin(5-HT) in the human gut,5-HT1 5-HT3 5-HT4Gastric accommodation Transit Colonic tone Sensation ?Secretion ,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

6、流第一阶段 第二阶段,Psychologic distress,Younger age,Duration of abdominal pain,Duration of diarrhea,Females,Factors Predicting GI Symptoms,IBS - Post Infectious,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,Mechanosensitive afferent,Sensitized spinal circuits,Dorsal root g

7、anglion,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,Inp

8、ut,Integration,Effect,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, ,Extracellular network regulation,Nerve cells,Immune cells,Endocrine cells,Cytokine, receptor, peptide, 5-HT,How to develop i

9、n a person?,Predisposing factors,Psycho- Physiological triggers,Concurrent modifiers,Brain-gut dysregulation,Early life,Genetic vulnerability, Enviromnent eg illness Behavior reinforcement, abuse,Predisposing factors,Psycho- Physiological triggers,Concurrent modifiers,Brain-gut dysregulation,Early l

10、ife,Genetic Environment,Chronic threat & prolonged effortful coping,Enteric Infection/ Inflammation/ toxins,Predisposing factors,Psycho- Physiological triggers,Concurrent modifiers,Brain-gut dysregulation,Early life,Genetic Environment,Chronic threat & prolonged effortful coping,Enteric Infection/ I

11、nflammation/ toxins,Stress-response neuromodulation,Post-infective neuromodulation,Personality, emotional Support, age, gender, Sleep dysfunction,Life event stress, Food allergens, Altered bowel flora,Predisposing factors,Psycho- Physiological triggers,Concurrent modifiers,Brain-gut dysregulation,Ea

12、rly life,Enteric infection Inflammation, trauma,Stress-response neuromodulation,Post-infective neuromodulation,Personality, emotional Support, age, gender, Sleep dysfunction,Life event stress, Food allergens, Altered bowel flora,Prolonged threat &effortful coping,CNS,ENS,Cortical Arousal (anxiety),V

13、isceral hypersensitivity,GI symptoms,EI symptoms,IBS,Dysmotility,Altered Epithelial permeability,How to diagnose ？,诊断,以症状为基础,诊断标准,Manning标准 1978年 Rome I 1992年 Rome II 1999年 Rome III 2006年 ?2003年三月 广州首届全国IBS会议 决定采用国际认同的Rome II 诊断标准,Rome I Criteria Rome II Criteria, at least 12 weeks, which need not b

14、e consecutive, in the past 12 months, of abdominal discomfort or pain that has two of three features-relieved by defecation; 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 / recurrent sympt

15、oms of the following -Abdominal pain or discomfort that is -associated with a change in frequency of stool and/or -associated with a change in consistency of stool; and Two or more of the following at least 25% of the timealtered stool frequency (3/day or 3/week)altered stool passage (straining, urg

16、ency)passage of mucusbloating or feeling of abdominal distention,The Rome II criteria,at least 12 weeks, which need not be consecutive, in the past 12 months, of abdominal discomfort or pain that has two of three features,Relievedbydefecation,onsetassociated withchange in frequency,onset associated

17、with change in form (appearance),And/or,And/or,支持IBS诊断的症状累积,大便频率异常（异常定义为排便每天多于三次及每周少于三次） 大便性状异常（粗、硬便或稀、水便） 排便过程异常（摒力、便急或排便不急感） 粘液便 气胀或腹胀感 功能性肠病的诊断均假设症状没有结构性和生化性解释,该诊断的体现的几个重要原则,诊断应建立在排除器质性疾病的基础上 IBS属于肠道功能性疾病 强调腹痛或腹部不适与排便的关系，体现IBS作为一个特定的症候群有别于其他肠道功能行疾病（如功能性腹泻、功能性便秘、功能性腹痛等） 该诊断标准将判断的时间延长至12个月，规定其间至少有1

18、2周时间有症状，但可以不连续，反应了本病慢性、反复发作的特点，可使器质性疾病特别是肠道肿瘤的漏诊几率降低 该诊断标准在必备条件中没有对排便次数和粪便性状作硬性规定，只强调腹痛或腹部不适伴有排便次数和粪便性状的改变，可使更多病例得到诊断，提高诊断的敏感性。,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。,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,或, 项中之一项或以上，而无 项, 项中之二项或以上，可伴有 中之一项,表现分型,分型依据的症状： 每周排便3次； 块状或硬便；

19、 稀烂便或水样便； 排便费力； 排便急迫感。,腹泻为主型, 项中之一项或以上，而无 项,或, 项中之二项或以上，可伴有 中一项，但无项,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, ,诊断流程,问诊查体,发热、消瘦、便血、腹部包块,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,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,What is the best manageme

20、nt 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 pain,Antispasmodics Tricyclic Antidepressants SSRI,Diarrhea,Constipation,

21、Fiber Osmotic laxatives Tegaserod PEG solution,Loperamide Cholestyramine Diphenoxylate,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 Lifestyle and dietary modification,Severe

22、Realistic goalsAntidepressants Referral for pain management,Moderate Gut acting agents Psychologic(motility/sensation) treatments,All Therapeutic relationship/continuity of care education/reassurance,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,心理治疗,What can we do?How to do?,心理治疗,第一层次：一般性心理治疗或支持性心理治疗（supportive psychotherapy）,第二层次：心理治疗干预(psychotherapeutic intervention),Definition Pathogenesis Diagnosis Treatment,谢谢,