腸易激綜合征的新概念

1、腸易激綜合征的新概念Newest concepts in irritable bowel syndromeIBS,張虎華西醫(yī)院消化科,舊概念： 過敏性結(jié)腸炎 易激結(jié)腸 或黏液性結(jié)腸炎,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 …a group of functional bowel di

2、sorders in which discomfort or pain is associated with defecation or a change in bowel habit , and with features of disordered defecation.,該病缺乏可解釋癥狀的形態(tài)學(xué)改變和生化異常,Psychologic disturbance relates to patients who see physi

3、cians Psychosocial factors influence health care seeking,IBS Non-patients,normal,IBS patients,Psychologicdisturbance,IBS - Psychosocial,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

4、 國內(nèi) 北京 潘國宗 7.26％ 廣州 陳旻湖 5.6％ 就診率 22.4％,What causes IBS ?,Development of IBS pathophysiology ｛

5、 inflammation 5-HT mediated hypersensitivity

6、 and gut motility Brain-gut interaction Visceral hypersensitivityAbnormal motor function1950 1960 1970

7、 1980 1990 2000,,Abnormal network regulationOf nerve-immune-endocrine,,IBS molecular biology,,,,,…….,,IBS發(fā)病機制的認(rèn)識,臨床癥狀 腹痛、不適大便異常，流行病學(xué)等第一階段,,,,IBS發(fā)病機制的認(rèn)識,臨床癥狀

8、 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

9、行病學(xué)等 炎癥、腦腸交流第一階段 第二階段,,,,,Visceral Hypersensitivity hyperalgesia allodynia,,,,,EndogenousModulation.cortex.Brainstem,,End organ sensitivi

10、ty.silentnociceptors,SpinalHyperexcitability.Nitric oxideActivation,Long-termHyperalgesia.tonic cortical regulation.Neuroplasticity,IBS發(fā)病機制的認(rèn)識,臨床癥狀 運動異常

11、 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,,,,,Sero

12、tonin(5-HT) in the human gut,5-HT1 5-HT3 5-HT4 Gastric accommodation ↑ ↑ Transit ↓ ↑

13、 ↑ Colonic tone ↓ ↑ Sensation ↑ ? Secretion

14、 ↑,IBS發(fā)病機制的認(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

15、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,,,,,,,,,,,,,,Psychologic distress,Younger age,Duration of abdominal pain,Duration of diarrhea,Females,Factors PredictingG

16、I Symptoms,,,IBS - Post Infectious,IBS發(fā)病機制的認(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

17、 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,,,,,,Mechanosensitive afferent,Sensitized spinal circuits,Dorsal root ganglion,Repeated stimulation,,Descending

18、Visceral Pain Pathway,Thalamus,PAG,Locus coeruleus,Amygdala,Colon,Serotonergic,Noradrenergic,Caudal raphe nucleus,Opioidergic,Rostral ventral medulla,,,MotilitySecretionBlood FlowInflammation,,,SightSoundSmellSoma

19、tosensory,CognitionAffect,Viscerosensory,,,,Input,Integration,Effect,,,,,IBS發(fā)病機制的認(rèn)識,臨床癥狀 運動異常 分子生物學(xué)階段 感覺異常

20、 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

21、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,,,,,,● ● ●,Extracellular network regulation,,,,,,Nerve cells,Immune cells,Endocrine cells,Cytokine, receptor, peptide, 5-HT,,,,,How to develop in a person?,,Pre

22、disposing factors,Psycho-Physiologicaltriggers,Concurrentmodifiers,Brain-gutdysregulation,Earlylife,,,Genetic vulnerability,Enviromnent eg illnessBehavior reinforcement,abuse,Predisposing factors,Psycho-Physio

23、logicaltriggers,Concurrentmodifiers,Brain-gutdysregulation,Earlylife,,,Genetic Environment,Chronic threat & prolonged effortful coping,EntericInfection/Inflammation/toxins,,,↑↓,Predisposing factors,Psych

24、o-Physiologicaltriggers,Concurrentmodifiers,Brain-gutdysregulation,Earlylife,,,Genetic Environment,Chronic threat & prolonged effortful coping,EntericInfection/Inflammation/toxins,,,↓,Stress-responseneu

25、romodulation,Post-infectiveneuromodulation,Personality, emotionalSupport, age, gender,Sleep dysfunction,Life event stress,Food allergens,Altered bowel flora,,,↑,,,Predisposing factors,Psycho-Physiologicaltriggers

26、,Concurrentmodifiers,Brain-gutdysregulation,Early life,,,Enteric infectionInflammation,trauma,,,↓,Stress-responseneuromodulation,Post-infectiveneuromodulation,Personality, emotionalSupport, age, gender,Sleep dysf

27、unction,Life event stress,Food allergens,Altered bowel flora,,,↑,,,Prolonged threat&effortful coping,CNS,ENS,CorticalArousal(anxiety)),Visceralhypersensitivity,GI symptoms,EI symptoms,IBS,Dysmotility,AlteredEp

28、ithelialpermeability,,,,,,,,,,,,,How to diagnose ？,診斷,以癥狀為基礎(chǔ),診斷標(biāo)準(zhǔn),Manning標(biāo)準(zhǔn) 1978年Rome I 1992年 Rome II 1999年Rome III 2006年

29、 ?2003年三月 廣州首屆全國IBS會議 決定采用國際認(rèn)同的Rome II 診斷標(biāo)準(zhǔn),Rome I Criteria 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 fea

30、tures -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 / recurre

31、nt symptoms 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

32、25% of the time altered stool frequency (>3/day or < 3/week) altered stool passage (straining, urgency) passage of mucus bloating or feeling of abdominal distention,,The Rome II criteria,at

33、least 12 weeks, which need not be consecutive, in the past 12 months, of abdominal discomfort or pain that has two of three features,Relieved by defecation,onset associated with change in frequency,onset associate

34、d with change in form(appearance),And/or,And/or,,,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,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調(diào)腹痛或腹

35、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。,表現(xiàn)分型,分

36、型依據(jù)的癥狀： ①每周排便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。,表現(xiàn)分型,●分型依據(jù)的癥狀： ①每周排便3次； ③塊狀或硬便； ④

37、稀爛便或水樣便； ⑤排便費力； ⑥排便急迫感。,●便秘為主型,或,① ③ ⑤ 項中之一項或以上，而無 ② ④ ⑥項,① ③ ⑤ 項中之二項或以上，可伴有② ④ ⑥ 中之一項,表現(xiàn)分型,●分型依據(jù)的癥狀： ①每周排便3次； ③塊狀或硬便；

38、 ④稀爛便或水樣便； ⑤排便費力； ⑥排便急迫感。,●腹瀉為主型,② ④ ⑥項中之一項或以上，而無 ① ③ ⑤ 項,或,② ④ ⑥項中之二項或以上，可伴有① ⑤中一項，但無③項,表現(xiàn)分型,●分型依據(jù)的癥狀： ①每周排便3次； ③塊狀或硬便； ④稀爛便或水樣便； ⑤排

39、便費力； ⑥排便急迫感。,●腹瀉便秘交替型,① ② ③ ④ ⑤ ⑥,診斷流程,問診＋查體,,發(fā)熱、消瘦、便血、腹部包塊,,,,,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,,,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,

40、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,,What is the best management approach?,治療,個體化、綜合治療,治療原則,A comprehensive multicomponent approachTreatment program is based on dominant symptom and their severity, and on psy

41、chosocial factors , and etiological factors,Drugs for dominant in IBS,Abdominal pain,AntispasmodicsTricyclicAntidepressantsSSRI,Diarrhea,Constipation,FiberOsmotic laxativesTegaserodPEG solution,LoperamideCholesty

42、ramineDiphenoxylate,治療原則,A comprehensive multicomponent approachTreatment program is based on dominant symptom and their severity, and on psychosocial factors , and etiological factors,,,,,,,Mild

43、 Lifestyle and dietary modification,Severe Realistic goalsAntidepressants Referral for pain management,Moderate Gut acting agents Psychologic

44、 (motility/sensation) treatments,All Therapeutic relationship/continuity of care education/reassurance,治療原則,A comprehensive multicomponent approachTreatment program is based on d

45、ominant symptom and their severity, and on psychosocial factors , and etiological factors,心理治療,What can we do?How to do?,心理治療,第一層次：一般性心理治療或支持性心理治療（supportive psychotherapy）,第二層次：心理治療干預(yù)(psychotherapeutic intervention),D