功能消化不良functionaldyspepsiaFD課件

1、功能性消化不良(functional dyspepsia FD )浙江大學(xué)醫(yī)學(xué)院附屬邵逸夫醫(yī)院消化科 戴寧 消化不良的定義指源于胃十二指腸區(qū)域的癥狀，有上腹痛，燒灼、餐后飽脹、早飽及其它，如上腹氣脹、惡心、嘔吐和噯氣上腹痛位于胸骨劍突下與臍水平以上、兩側(cè)鎖骨中線之間區(qū)域的疼痛Epigastric pain refers to a subjective, intense and unpleasant sensation in the epigastrium, which can lead patients to believe that some tissue damage is occurri

2、ng 消化不良的流行病學(xué)我國(guó)廣東：18.9%，女性多見(jiàn) 內(nèi)科門診約11.1%，消化內(nèi)科達(dá)52.9% 每年消化不良新發(fā)病例約占人群的1%-6%多數(shù)長(zhǎng)期慢性、反復(fù)發(fā)作約1/2的患者會(huì)就醫(yī) 促使就診的因素：癥狀和對(duì)疾病的擔(dān)憂Tack J, et al. In Rome III: FGID. 2006 Chen minhu, et al. Jour Chin Inter Med;1998消化不良 病理生理 - Statement 13Pathogenesis of functional dyspepsia is multifactorial.FD的發(fā)病機(jī)理是多因素的100 75 50 25 0a b

3、c d e f% 證據(jù)等級(jí) 高100J Neurogastroenterol Motil 2012;18:150-168病理生理胃十二指腸動(dòng)力紊亂、內(nèi)臟高敏是FD主要病理生理機(jī)制FD的胃十二指腸動(dòng)力障礙 胃排空延緩 胃容受功能受損 胃內(nèi)食物異常分布 胃竇動(dòng)力低弱 胃電節(jié)律紊亂 MMC頻率減少 餐后胃底收縮過(guò)度病理生理 - Statement 16Psychosocial factors may play a role in functional dyspepsia.心理社會(huì)因素在FD中可能起作用。100 75 50 25 0a b c d e f% 證據(jù)等級(jí) 中84.215.8Study We

4、ight relative risk(95% CI)Tanum et al6.50 0.81(0.61-1.09)Song et al3.00 0.43(0.23-0.81)Arieti et al4.78 0.64(0.41-0.98)McHardy et al2.13 0.24(0.10-0.60) 0.55(0.36-0.85)0.1 10In favor of true drugsIn favor of placeboHojo M,Miwa H, et al. J Gastroenter Hepatol 2004病理生理 - Statement 17Gastric acid may b

5、e responsible for the symptoms in a subset of patients with functional dyspepsia.胃酸可能對(duì)一部分FD患者的癥狀起作用。100 75 50 25 0a b c d e f% 證據(jù)等級(jí) 中89.510.5- 酸灌注誘發(fā)癥狀- PPI治療反應(yīng) 病理生理 - Statement 18H. pylori may play a role in pathogenesis of functional dyspepsia.Hp在FD的發(fā)病機(jī)制中可能起作用。100 75 50 25 0a b c d e f% 證據(jù)等級(jí) 中52.63

6、1.65.310.5FD的Hp陽(yáng)性率：39-87%根除Hp對(duì)FD的影響？ - FD相對(duì)危險(xiǎn)度下降10% - 薈萃分析：改善FD癥狀 OR=3.61 - 對(duì)動(dòng)力和感知影響？Jin X, Li YM. Systematic review and meta-analysis from Chinese literature: the association between Helicobacter pylori eradication and improvement of functional dyspepsia. Helicobacter 2007;12:541-546.Jin X, et al:

7、Helicobacter 2007病理生理 - Statement 19Post-infectious functional dyspepsia occurs in a subset of patients.感染后FD可發(fā)生于某些患者。100 75 50 25 0a b c d e f% 證據(jù)等級(jí) 中73.726.3Candidate Genotypes: FDGNB3 (825 CC 基因型)GNB3 (TT 純和基因型)GNB3 (825T 等位基因)SNPs (單核苷酸多態(tài)性 )HTR2AMAGI2IL -9IL4R病理生理 - Statement 21Dietary factors a

8、nd lifestyle may be involved in the pathogenesis of functional dyspepsia.食物因素和生活方式可能涉及FD的發(fā)病機(jī)制。100 75 50 25 0a b c d e f% 證據(jù)等級(jí) 低94.7 5.3某些食物引起癥狀可能因內(nèi)臟高敏 胃腸激素出現(xiàn)以下一種或多種癥狀 餐后飽脹感 早飽上腹痛上腹燒灼感無(wú)能解釋引起上述癥狀的器質(zhì)、系統(tǒng)和代謝性疾病證據(jù)癥狀出現(xiàn)在診斷前6個(gè)月，且近3個(gè)月有癥狀功能性消化不良 (Functional Dyspepsia)Tack et al., Gastroenterology 2006; 130(5):

9、1466-79.Rome III警報(bào)征象表現(xiàn)無(wú)有意減輕體重進(jìn)行性吞咽困難反復(fù)或持續(xù)嘔吐消化道出血證據(jù)貧血發(fā)熱家族胃癌病史新近出現(xiàn)的消化不良癥狀 40 y (UGI惡性腫瘤高發(fā)區(qū)) 4. 治療 8條 - Statement 第22-29治療總原則藥物治療 - Hp根除 - 抑酸治療 - 促動(dòng)力劑 - 草藥治療 - 抗抑郁焦慮藥特殊食物J Neurogastroenterol Motil 2012;18:150-168治療 - Statement 22An integrated approach addressing physiological, biological, psychological

10、 and social factors is recommended for all FD patients.對(duì)所有的FD患者應(yīng)采取針對(duì)生理、生物、精神和社會(huì)因素的整體方法。100 75 50 25 0a b c d e f% 證據(jù)等級(jí) 低84.210.5 5.3J Neurogastroenterol Motil 2012;18:150-168FD 與飲食十二指腸內(nèi)灌注脂肪會(huì)導(dǎo)致FD病人出現(xiàn)癥狀，而健康志愿者沒(méi)有少量油膩會(huì)引起胃脹氣、飽脹和惡心癥狀；相比碳水化合物，等熱量的高脂肪食物會(huì)引起更多的FD癥狀上腹飽脹和胃脹氣與攝入的脂肪量直接相關(guān)治療 - Statement 23Where soc

11、io-economic conditions allow, H. pylori testing and eradication should be part of the management strategy for all patients in Asia who present with dyspepsia.如果社會(huì)經(jīng)濟(jì)情況許可，Hp試驗(yàn)和根除應(yīng)是亞洲有消化不良患者的治療方案的一部分。100 75 50 25 0a b c d e f% 證據(jù)等級(jí) 高58.042.0- 有利于預(yù)防胃癌、降低潰瘍病復(fù)發(fā)薈萃顯示對(duì)Hp陽(yáng)性的FD有益建議進(jìn)一步證實(shí) 治療 - Statement 26Prokin

12、etics may provide symptom relief in some functional dyspepsia patients. 促動(dòng)力劑有可能減輕有些FD患者癥狀。100 75 50 25 0a b c d e f% 證據(jù)等級(jí) 中90.010.0兩項(xiàng) 薈萃分析證明有利：24RCT n=3178 比plac高10%27RCT n=3435 比plac高30%需在亞洲進(jìn)一步證實(shí)治療 - statement 28Anti-depressant and anxiolytic agents have a role in the management of functional dyspe

13、psia, despite the limited evidence.盡管證據(jù)有限，抗抑郁焦慮藥物對(duì)治療FD有一定的作用。 100 75 50 25 0a b c d e f% 證據(jù)等級(jí) 低80.020.0- 非藥物心理治療- 抗抑郁藥治療研究有限- 可能要驗(yàn)證 Functional Dyspepsia 功能性消化不良治療流程H.Pylori test and eradication,If not done before Dietary modificationsPredominant symptom (s)Postprandial fullness, early satiation,Upper abdominal bloating, nausea, vomiting or belchingProkinetic agentWith or without PPIPPI with or without prokinetic agentEpi