醫(yī)學(xué)教程 腸易激綜合征的新概念

腸易激綜合征的新概念

Newestconceptsinirritablebowelsyndrome

IBS張虎華西醫(yī)院消化科整理ppt舊概念：

過敏性結(jié)腸炎易激結(jié)腸或黏液性結(jié)腸炎

整理ppt

新概念：一種以腹痛或腹部不適伴排便習(xí)慣改變?yōu)樘卣鞯墓δ苄阅c病…agroupoffunctionalboweldisordersinwhichdiscomfortorpainisassociatedwithdefecationorachangeinbowelhabit,andwithfeaturesofdisordereddefecation.整理ppt該病缺乏可解釋癥狀的形態(tài)學(xué)改變和生化異常

整理pptPsychologicdisturbancerelatestopatientswhoseephysiciansPsychosocialfactorsinfluencehealthcareseekingIBSNon-patientsnormalIBSpatientsPsychologicdisturbanceIBS-Psychosocial整理ppt流行病學(xué)研究西方國家患病率5---24%

美國人群10-20%就診率30％$80億

國內(nèi)北京潘國宗7.26％廣州陳旻湖5.6％就診率22.4％

整理pptWhatcausesIBS?整理pptDevelopmentofIBSpathophysiology｛

inflammation5-HTmediatedhypersensitivityandgutmotility

Brain-gutinteractionVisceralhypersensitivityAbnormalmotorfunction195019601970198019902000AbnormalnetworkregulationOfnerve-immune-endocrineIBSmolecularbiology…….整理pptIBS發(fā)病機(jī)制的認(rèn)識臨床癥狀

腹痛、不適大便異常，流行病學(xué)等第一階段整理pptIBS發(fā)病機(jī)制的認(rèn)識臨床癥狀運動異常感覺異常社會心理致病腹痛、不適壓力、電活動大便異常，敏感性、5-HT流行病學(xué)等炎癥、腦腸交流第一階段第二階段整理pptVisceralHypersensitivity

hyperalgesiaallodyniaEndogenousModulation.cortex.BrainstemEndorgansensitivity

.silent

nociceptorsSpinalHyperexcitability.NitricoxideActivationLong-termHyperalgesia.toniccorticalregulation.Neuroplasticity整理pptIBS發(fā)病機(jī)制的認(rèn)識臨床癥狀運動異常感覺異常社會心理致病腹痛、不適壓力、電活動大便異常，敏感性、5-HT流行病學(xué)等炎癥、腦腸交流第一階段第二階段整理pptSerotonin(5-HT)inthehumangut

5-HT15-HT35-HT4Gastricaccommodation↑↑Transit↓↑↑

Colonictone↓↑Sensation↑?Secretion↑

整理pptIBS發(fā)病機(jī)制的認(rèn)識臨床癥狀運動異常感覺異常社會心理致病腹痛、不適壓力、電活動大便異常，敏感性、5-HT流行病學(xué)等炎癥、腦腸交流第一階段第二階段整理pptPsychologicdistressYoungerageDurationofabdominalpainDurationofdiarrheaFemalesFactorsPredictingGISymptomsIBS-PostInfectious整理pptIBS發(fā)病機(jī)制的認(rèn)識臨床癥狀運動異常感覺異常社會心理致病腹痛、不適壓力、電活動大便異常，敏感性、5-HT流行病學(xué)等炎癥、腦腸交流第一階段第二階段整理pptMechanosensitive

afferentSensitizedspinalcircuitsDorsalrootganglionRepeatedstimulation整理pptDescendingVisceralPainPathwayThalamusPAGLocuscoeruleusAmygdalaColonSerotonergicNoradrenergicCaudalraphenucleusOpioidergicRostralventralmedulla整理ppt整理pptMotilitySecretionBloodFlowInflammationSightSoundSmellSomatosensoryCognitionAffectViscerosensoryInputIntegrationEffect整理pptIBS發(fā)病機(jī)制的認(rèn)識臨床癥狀運動異常分子生物學(xué)階段感覺異常網(wǎng)絡(luò)調(diào)控社會心理致病腹痛、不適壓力、電活動大便異常，炎癥、敏感性流行病學(xué)等5-HT、腦腸交流第一階段第二階段第三階段一氧化氮5－HT及受體多巴胺及受體胃腸道激素及受體細(xì)胞因子及受體細(xì)胞信號轉(zhuǎn)導(dǎo)蛋白離子及離子通道

●●●整理pptExtracellularnetworkregulationNervecellsImmunecellsEndocrinecellsCytokine,receptor,peptide,5-HT整理pptHowtodevelopinaperson?整理pptPredisposingfactorsPsycho-PhysiologicaltriggersConcurrentmodifiersBrain-gutdysregulationEarlylifeGeneticvulnerability,EnviromnentegillnessBehaviorreinforcement,abuse整理pptPredisposingfactorsPsycho-PhysiologicaltriggersConcurrentmodifiersBrain-gutdysregulationEarlylifeGeneticEnvironmentChronicthreat&prolongedeffortfulcopingEntericInfection/Inflammation/toxins↑↓整理pptPredisposingfactorsPsycho-PhysiologicaltriggersConcurrentmodifiersBrain-gutdysregulationEarlylifeGeneticEnvironmentChronicthreat&prolongedeffortfulcopingEntericInfection/Inflammation/toxins↓Stress-responseneuromodulationPost-infectiveneuromodulationPersonality,emotionalSupport,age,gender,SleepdysfunctionLifeeventstress,Foodallergens,Alteredbowelflora↑整理pptPredisposingfactorsPsycho-PhysiologicaltriggersConcurrentmodifiersBrain-gutdysregulationEarlylifeEntericinfectionInflammation,trauma↓Stress-responseneuromodulationPost-infectiveneuromodulationPersonality,emotionalSupport,age,gender,SleepdysfunctionLifeeventstress,Foodallergens,Alteredbowelflora↑Prolongedthreat&effortfulcopingCNSENSCorticalArousal(anxiety))VisceralhypersensitivityGIsymptomsEIsymptomsIBSDysmotilityAlteredEpithelialpermeability整理pptHowtodiagnose？整理ppt診斷

以癥狀為基礎(chǔ)整理ppt診斷標(biāo)準(zhǔn)Manning標(biāo)準(zhǔn)1978年RomeI1992年RomeII1999年RomeIII2006年?2003年三月廣州首屆全國IBS會議決定采用國際認(rèn)同的RomeII診斷標(biāo)準(zhǔn)整理pptRomeICriteriaRomeIICriteria●atleast12weeks,whichneednotbeconsecutive,inthepast12months,ofabdominaldiscomfortorpainthathastwoofthreefeatures-relievedbydefecation;and/or-onsetassociatedwithachangeinfrequencyofstool;and/or-onsetassociatedwithachangeinform(appearance)ofstool●Atleast3monthscontinuous/recurrentsymptomsofthefollowing-Abdominalpainordiscomfortthatis-associatedwithachangeinfrequencyofstooland/or-associatedwithachangeinconsistencyofstool;and●Twoormoreofthefollowingatleast25%ofthetimealteredstoolfrequency(>3/dayor<3/week)alteredstoolpassage(straining,urgency)passageofmucusbloatingorfeelingofabdominaldistention整理pptTheRomeIIcriteriaatleast12weeks,whichneednotbeconsecutive,inthepast12months,ofabdominaldiscomfortorpainthathastwoofthreefeaturesRelievedbydefecationonsetassociatedwithchangeinfrequencyonsetassociatedwithchangeinform(appearance)And/orAnd/or整理ppt支持IBS診斷的癥狀累積大便頻率異常（異常定義為排便每天多于三次及每周少于三次）大便性狀異常（粗、硬便或稀、水便）排便過程異常（摒力、便急或排便不急感）粘液便氣脹或腹脹感功能性腸病的診斷均假設(shè)癥狀沒有結(jié)構(gòu)性和生化性解釋整理ppt該診斷的體現(xiàn)的幾個重要原則診斷應(yīng)建立在排除器質(zhì)性疾病的基礎(chǔ)上IBS屬于腸道功能性疾病強(qiáng)調(diào)腹痛或腹部不適與排便的關(guān)系，體現(xiàn)IBS作為一個特定的癥候群有別于其他腸道功能行疾?。ㄈ绻δ苄愿篂a、功能性便秘、功能性腹痛等）該診斷標(biāo)準(zhǔn)將判斷的時間延長至12個月，規(guī)定其間至少有12周時間有癥狀，但可以不連續(xù)，反應(yīng)了本病慢性、反復(fù)發(fā)作的特點，可使器質(zhì)性疾病特別是腸道腫瘤的漏診幾率降低該診斷標(biāo)準(zhǔn)在必備條件中沒有對排便次數(shù)和糞便性狀作硬性規(guī)定，只強(qiáng)調(diào)腹痛或腹部不適伴有排便次數(shù)和糞便性狀的改變，可使更多病例得到診斷，提高診斷的敏感性。整理ppt表現(xiàn)分型分型依據(jù)的癥狀：①每周排便<3次；②每天排便>3次；③塊狀或硬便；④稀爛便或水樣便；⑤排便費力；⑥排便急迫感。整理ppt表現(xiàn)分型●分型依據(jù)的癥狀：

①每周排便<3次；②每天排便>3次；③塊狀或硬便；④稀爛便或水樣便；⑤排便費力；⑥排便急迫感?！癖忝貫橹餍突颌佗邰蓓椫兄豁椈蛞陨?，而無②④⑥項①③⑤項中之二項或以上，可伴有②④⑥中之一項整理ppt表現(xiàn)分型●分型依據(jù)的癥狀：①每周排便<3次；②每天排便>3次；③塊狀或硬便；④稀爛便或水樣便；⑤排便費力；⑥排便急迫感?！窀篂a為主型②④⑥項中之一項或以上，而無①③⑤項或②④⑥項中之二項或以上，可伴有①⑤中一項，但無③項整理ppt表現(xiàn)分型●分型依據(jù)的癥狀：①每周排便<3次；②每天排便>3次；③塊狀或硬便；④稀爛便或水樣便；⑤排便費力；⑥排便急迫感?！窀篂a便秘交替型①②③④⑤⑥整理ppt診斷流程問診＋查體

發(fā)熱、消瘦、便血、腹部包塊整理ppt診斷流程問診＋查體

有無發(fā)熱、消瘦、便血、腹部包塊徹底檢查近期排便習(xí)慣改變、腫瘤家族史、>40歲整理ppt診斷流程問診＋查體

有無發(fā)熱、消瘦、便血、腹部包塊徹底檢查近期排便習(xí)慣改變、腫瘤家族史、>40歲腸鏡或鋇灌腸大便常規(guī)＋OB是否整理pptWhatisthebestmanagementapproach?整理ppt治療個體化、綜合治療整理ppt治療原則AcomprehensivemulticomponentapproachTreatmentprogramisbasedondominantsymptomandtheirseverity,andonpsychosocialfactors,andetiologicalfactors整理pptDrugsfordominantinIBSAbdominalpainAntispasmodicsTricyclicAntidepressantsSSRI

Diarrhea

ConstipationFiberOsmoticlaxativesTegaserodPEGsolutio