肠易激综合征的新概念.ppt

肠易激综合征的新概念肠易激综合征的新概念(ginin)(ginin)Newest concepts in irritable bowel syndromeIBS张虎华西(Hux)(Hux)医院消化科第一页，共五十三页。旧概念旧概念(ginin)(ginin)：过敏性结肠炎 易激结肠易激结肠 或黏液性结肠炎或黏液性结肠炎 第二页，共五十三页。新概念新概念：一种(y zh(y zh n n)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.第三页，共五十三页。该病缺乏可解释该病缺乏可解释(jish)(jish)症状的形态症状的形态学改变和生化异常学改变和生化异常第四页，共五十三页。Psychologic disturbance relates to patients who see physicians Psychosocial factors influence health care seekingIBS Non-patientsIBS Non-patientsl lnormalnormallIBS patientsPsychologicdisturbanceIBS-PsychosocialIBS-Psychosocial第五页，共五十三页。流行病学流行病学(li xn(li xn bn bn xu)xu)研究研究西方国家西方国家 患病率患病率 5-24%5-24%美国美国 人群人群 10-20%10-20%就诊就诊(ji zhn)(ji zhn)率率 30 30$80$80亿亿 国内国内 北京北京 潘国宗潘国宗 7.26 7.26 广州广州 陈旻湖陈旻湖 5.6 5.6 就诊率 22.4 第六页，共五十三页。What causes IBS?第七页，共五十三页。Development of IBS pathophysiologyl ll l l inflammation inflammationl l 5-HT mediated hypersensitivity 5-HT mediated hypersensitivityl l and gut motility and gut motilityl l Brain-gut interactionBrain-gut interactionl l Visceral hypersensitivity Visceral hypersensitivityl lAbnormal motor functionAbnormal motor functionl l1950 1960 1970 1980 1990 20001950 1960 1970 1980 1990 2000Abnormal network regulationAbnormal network regulationOf nerve-immune-endocrineOf nerve-immune-endocrineIBS molecular biologyIBS molecular biology.第八页，共五十三页。IBS发病发病(f bng)(f bng)机制的认识机制的认识l l临床症状临床症状l l l l腹痛腹痛(f tn(f tn)、不适、不适l l大便异常，大便异常，l l流行病学等流行病学等l l第一阶段第一阶段第九页，共五十三页。IBS发病发病(f bng)(f bng)机制的认识机制的认识l l临床症状临床症状 运动异常运动异常l l 感觉异常感觉异常l l 社会心理致病社会心理致病l l腹痛、不适腹痛、不适(bsh)(bsh)压力、电活动压力、电活动 l l大便异常，大便异常，敏感性敏感性、5-HT5-HTl l流行病学等流行病学等 炎症炎症、脑肠交流脑肠交流l l第一阶段第一阶段 第二阶段第二阶段第十页，共五十三页。Visceral Hypersensitivity Visceral Hypersensitivity hyperalgesiahyperalgesia allodynia allodyniaEndogenousEndogenousModulationModulation.cortex.cortex.Brainstem.BrainstemEnd End organ organ sensitivitysensitivity.silent.silentnociceptorsnociceptorsSpinalSpinalHyperexcitabilityHyperexcitability.Nitric oxide.Nitric oxideActivationActivationLong-termLong-termHyperalgesiaHyperalgesia.tonic cortical regulationtonic cortical regulation.Neuroplasticity.Neuroplasticity第十一页，共五十三页。IBS发病机制发病机制(jzh)(jzh)的认识的认识l l临床症状临床症状 运动运动(yndng)(yndng)异常异常l l 感觉异常感觉异常l l 社会心理致病社会心理致病l l腹痛、不适腹痛、不适 压力、电活动压力、电活动 l l大便异常，大便异常，敏感性敏感性、5-HT5-HTl l流行病学等流行病学等 炎症炎症、脑肠交流脑肠交流l l第一阶段第一阶段 第二阶段第二阶段第十二页，共五十三页。Serotonin(5-HT)in the human gut 5-HT5-HT1 1 5-HT 5-HT3 3 5-HT 5-HT4 4 Gastric accommodation Gastric accommodation Transit Transit Colonic tone Colonic tone Sensation?Sensation?Secretion Secretion 第十三页，共五十三页。IBS发病发病(f bng)(f bng)机制的认识机制的认识l l临床症状临床症状 运动异常运动异常l l 感觉感觉(g(g nju)nju)异常异常l l 社会心理致病社会心理致病l l腹痛、不适腹痛、不适 压力、电活动压力、电活动 l l大便异常，大便异常，敏感性敏感性、5-HT5-HTl l流行病学等流行病学等 炎症炎症、脑肠交流脑肠交流l l第一阶段第一阶段 第二阶段第二阶段第十四页，共五十三页。Psychologic Psychologic distressdistressYounger Younger ageageDuration of abdominal painDuration of Duration of diarrheadiarrheaFemalesFemalesFactors PredictingGI SymptomsIBS-Post Infectious第十五页，共五十三页。IBS发病发病(f bng)(f bng)机制的认识机制的认识l l临床症状临床症状 运动异常运动异常l l 感觉异常感觉异常l l 社会心理致病社会心理致病l l腹痛腹痛(f tn(f tn)、不适、不适 压力、电活动压力、电活动 l l大便异常，大便异常，敏感性敏感性、5-HT5-HTl l流行病学等流行病学等 炎症炎症、脑肠交流脑肠交流l l第一阶段第一阶段 第二阶段第二阶段第十六页，共五十三页。l lMechanosensitive Mechanosensitive afferentafferentSensitized spinal circuitsDorsal root ganglionRepeated Repeated stimulationstimulation第十七页，共五十三页。Descending Visceral Pain PathwayThalamusThalamusPAGLocus coeruleusAmygdalaColonSerotonergicNoradrenergicCaudal raphe nucleusOpioidergicRostral ventral medulla第十八页，共五十三页。第十九页，共五十三页。MotilityMotilitySecretionSecretionBlood FlowBlood FlowInflammationInflammationSightSoundSmellSomatosensoryCognitionAffectViscerosensoryInputIntegrationEffect第二十页，共五十三页。IBS发病机制发病机制(jzh)(jzh)的认识的认识l l临床症状临床症状 运动异常运动异常 分子生物学阶段分子生物学阶段l l 感觉异常感觉异常 网络网络(w(w nglu)nglu)调控调控 l l 社会心理致病社会心理致病l l腹痛、不适腹痛、不适 压力、电活动压力、电活动 l l大便异常，大便异常，炎症、炎症、敏感性敏感性l l流行病学等流行病学等 5-HT5-HT、脑肠交流脑肠交流l l第一阶段第一阶段 第二阶段第二阶段 第三阶段第三阶段一氧化氮一氧化氮5 5HTHT及受体及受体多巴胺及受体多巴胺及受体胃肠道激素胃肠道激素(j s)(j s)及受体及受体细胞因子及受体细胞因子及受体细胞信号转导蛋白细胞信号转导蛋白离子及离子通道离子及离子通道 第二十一页，共五十三页。Extracellular network regulation Nerve cellsNerve cellsImmune cellsImmune cellsEndocrine cellsEndocrine cellsCytokine,receptor,Cytokine,receptor,peptide,5-HTpeptide,5-HT第二十二页，共五十三页。How to develop in a person?第二十三页，共五十三页。Predisposing Predisposing factorsfactorsPsycho-Psycho-PhysiologicalPhysiologicaltriggerstriggersConcurrentConcurrentmodifiersmodifiersBrain-gutBrain-gutdysregulationdysregulationEarlyEarlylifelifeGenetic vulnerability,Genetic vulnerability,Enviromnent eg illnessEnviromnent eg illnessBehavior reinforcement,Behavior reinforcement,abuseabuse第二十四页，共五十三页。Predisposing Predisposing factorsfactorsPsycho-Psycho-PhysiologicalPhysiologicaltriggerstriggersConcurrentConcurrentmodifiersmodifiersBrain-gutBrain-gutdysregulationdysregulationEarlyEarlylifelifeGenetic Genetic EnvironmentEnvironmentChronic Chronic threat&threat&prolonged prolonged effortful effortful copingcopingEntericEntericInfection/Infection/Inflammation/Inflammation/toxinstoxins第二十五页，共五十三页。Predisposing Predisposing factorsfactorsPsycho-Psycho-PhysiologicalPhysiologicaltriggerstriggersConcurrentConcurrentmodifiersmodifiersBrain-gutBrain-gutdysregulationdysregulationEarlyEarlylifelifeGenetic Genetic EnvironmentEnvironmentChronic Chronic threat&threat&prolonged prolonged effortful effortful copingcopingEntericEntericInfection/Infection/Inflammation/Inflammation/toxinstoxinsStress-responseStress-responseneuromodulationneuromodulationPost-infectivePost-infectiveneuromodulationneuromodulationPersonality,emotionalPersonality,emotionalSupport,age,gender,Support,age,gender,Sleep dysfunctionSleep dysfunctionLife event stress,Life event stress,Food allergens,Food allergens,Altered bowel floraAltered bowel flora第二十六页，共五十三页。Predisposing Predisposing factorsfactorsPsycho-Psycho-PhysiologicalPhysiologicaltriggerstriggersConcurrentConcurrentmodifiersmodifiersBrain-gutBrain-gutdysregulationdysregulationEarly lifeEarly lifeEnteric infectionEnteric infectionInflammation,Inflammation,traumatraumaStress-responseStress-responseneuromodulationneuromodulationPost-infectivePost-infectiveneuromodulationneuromodulationPersonality,emotionalPersonality,emotionalSupport,age,gender,Support,age,gender,Sleep dysfunctionSleep dysfunctionLife event stress,Life event stress,Food allergens,Food allergens,Altered bowel floraAltered bowel floraProlonged threatProlonged threat&effortful coping&effortful copingCNSENSENSCorticalCorticalArousalArousal(anxiety)(anxiety)VisceralVisceralhypersensitivityhypersensitivityGI symptomsGI symptomsEI symptomsEI symptomsIBSIBSDysmotilityDysmotilityAlteredAlteredEpithelialEpithelialpermeabilitypermeability第二十七页，共五十三页。How to diagnose？第二十八页，共五十三页。诊断诊断(zhndun)(zhndun)l l 以症状以症状(zhngzhung)(zhngzhung)为基础为基础第二十九页，共五十三页。诊断诊断(zhndun)(zhndun)标准标准l lManning标准 1978年l lRome I 1992年 l lRome II 1999年l lRome III 2006年?l l2003年三月 广州首届全国IBS会议 决定采用国际(guj)(guj)认同的Rome II 诊断标准第三十页，共五十三页。Rome I Criteria Rome II Criteria at least 12 weeks,which need not be at least 12 weeks,which need not be consecutive,in the past 12 months,of consecutive,in the past 12 months,of abdominal discomfort or pain that has abdominal discomfort or pain that has two of three featurestwo of three features -relieved by defecation;and/or -relieved by defecation;and/or -onset associated with a change in -onset associated with a change in frequency of stool;and/orfrequency of stool;and/or -onset associated with a change in -onset associated with a change in form(appearance)of stoolform(appearance)of stool At least 3 months continuous/At least 3 months continuous/recurrent symptoms of the following recurrent symptoms of the following-Abdominal pain or discomfort that is-Abdominal pain or discomfort that is-associated with a change in frequency of stool-associated with a change in frequency of stool and/or and/or-associated with a change in consistency of-associated with a change in consistency of stool;and stool;and Two or more of the following at least Two or more of the following at least 25%of the time25%of the time altered stool frequency(3/day or 3/day or 3/week)3/week)altered stool passage(straining,urgency)altered stool passage(straining,urgency)passage of mucus passage of mucus bloating or feeling of abdominal distention bloating or feeling of abdominal distention 第三十一页，共五十三页。The Rome II criteria at least 12 weeks,which need not be consecutive,in at least 12 weeks,which need not be consecutive,in the past 12 months,of abdominal discomfort or the past 12 months,of abdominal discomfort or pain that has two of three featurespain that has two of three featuresRelievedRelieved by by defecation defecationonsetonset associated with associated with change in change in frequency frequency onset onset associated with associated with change in form change in form(appearance)(appearance)And/or And/or And/or And/or第三十二页，共五十三页。支持支持IBS诊断的症状诊断的症状(zhngzhung)(zhngzhung)累积累积l l大便频率异常大便频率异常(ychng)(ychng)（异常（异常(ychng)(ychng)定义为排便每天多于定义为排便每天多于三次及每周少于三次）三次及每周少于三次）l l大便性状异常（粗、硬便或稀、水便）大便性状异常（粗、硬便或稀、水便）l l排便过程异常（摒力、便急或排便不急感）排便过程异常（摒力、便急或排便不急感）l l粘液便粘液便l l气胀或腹胀感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功能性肠病的诊断均假设症状没有结构性和生化性解释解释第三十三页，共五十三页。该诊断的体现该诊断的体现(t(t xin)xin)的几个重要原的几个重要原则则l l诊断应建立在诊断应建立在排除器质性疾病排除器质性疾病(jbng)(jbng)的基础上l lIBSIBS属于肠道属于肠道功能性功能性疾病疾病l l强调腹痛或腹部不适与排便的关系强调腹痛或腹部不适与排便的关系，体现，体现IBSIBS作为一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）性腹泻、功能性便秘、功能性腹痛等）l l该诊断标准将判断的时间延长至该诊断标准将判断的时间延长至1212个月，规定其个月，规定其间至少有间至少有1212周时间有症状，但可以不连续，反应周时间有症状，但可以不连续，反应了本病慢性、反复发作的特点，可使器质性疾病了本病慢性、反复发作的特点，可使器质性疾病特别是特别是肠道肿瘤的漏诊几率降低肠道肿瘤的漏诊几率降低l l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，提高诊断的敏感性诊断的敏感性。第三十四页，共五十三页。表现表现(bi(bi oxin)oxin)分型分型分型依据的症状：每周排便3次；块状或硬便；稀烂(xln)(xln)便或水样便；排便费力；排便急迫感。第三十五页，共五十三页。表现表现(bi(bi oxin)oxin)分型分型分型依据的症状：每周排便每周排便333次；次；块状或硬便；块状或硬便；稀烂便或水样便；稀烂便或水样便；排便费力排便费力(fi l)(fi l)；排便急迫感。排便急迫感。便秘(bin m)(bin m)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 中之一项第三十六页，共五十三页。表现表现(bi(bi oxin)oxin)分型分型 分型依据的症状分型依据的症状：每周排便每周排便333次；次；块状或硬便；块状或硬便；稀烂稀烂(xln)(xln)便或水样便；便或水样便；排便费力；排便费力；排便急迫感。排便急迫感。腹泻(fxi)(fxi)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，但无项第三十七页，共五十三页。表现表现(bi(bi oxin)oxin)分型分型 分型依据的症状分型依据的症状：每周排便3次；块状或硬便；块状或硬便；稀烂稀烂(xln)(xln)便或水样便；便或水样便；排便费力；排便急迫感。腹泻便秘(bin m)(bin m)交替型 第三十八页，共五十三页。诊断诊断(zhndun)(zhndun)流程流程 问诊查体 发热、消瘦发热、消瘦(xioshu)(xioshu)、便血、腹部包块、便血、腹部包块第三十九页，共五十三页。诊断诊断(zhndun)(zhndun)流程流程 问诊查体 有有有有 无无无无 发热、消瘦发热、消瘦(xioshu)(xioshu)、便血、腹部包块、便血、腹部包块彻底彻底(chd(chd)检检查查近期排便习惯改变、肿瘤家近期排便习惯改变、肿瘤家族史、族史、4040岁岁第四十页，共五十三页。诊断诊断(zhndun)(zhndun)流程流程 问诊查体 有有有有 无无无无 发热发热(f r)(f r)、消瘦、便血、腹部包块、消瘦、便血、腹部包块彻底(chd(chd)检查近期排便习惯改变、肿瘤家族史、近期排便习惯改变、肿瘤家族史、4040岁岁 肠镜或钡灌肠肠镜或钡灌肠 大便常规大便常规OBOB是是 否否第四十一页，共五十三页。What is the best management approach?第四十二页，共五十三页。治疗治疗(zhlio)(zhlio)个体化、综合(zngh)(zngh)治疗第四十三页，共五十三页。治疗治疗(zhlio)(zhlio)原则原则A comprehensive multicomponent approachTreatment program is based on dominant symptom and their severity,and on psychosocial factors,and etiological factors 第四十四页，共五十三页。Drugs for dominant in IBSAbdominal Abdominal painpainAntispasmodicsAntispasmodicsTricyclicTricyclicAntidepressantsAntidepressantsSSRISSRI DiarrheaDiarrhea Constipation Constipation FiberFiberOsmotic laxativesOsmotic laxativesTegaserodTegaserodPEG solutionPEG solutionLoperamideLoperamideCholestyramineCholestyramineDiphenoxylateDiphenoxylate第四十五页，共五十三页。治疗治疗(zhlio)(zhlio)原则原则A comprehensive multicomponent approachTreatment program is based on dominant symptom and their severity,and on psychosocial factors,and etiological factors 第四十六页，共五十三页。Mild Lifestyle and dietary modification Mild Lifestyle and dietary modificationSevere Realistic goalsSevere Realistic goalsAntidepressants Antidepressants Referral for pain management Referral for pain managementModerate Gut acting agents PsychologicModerate Gut acting agents Psychologic (motility/sensation)treatments (motility/sensation)treatmentsAll All Therapeutic relationship/continuity of care Therapeutic relationship/continuity of care education/reassuranceeducation/reassurance 第四十七页，共五十三页。治疗治疗(zhlio)(zhlio)原则原则A comprehensive multicomponent approachTreatment program is based on dominant symptom and their severity,and on psychosocial factors,and etiological factors 第四十八页，共五十三页。心理治疗心理治疗(xn l(xn l zh lio)zh lio)What can we do?How to do?第四十九页，共五十三页。心理治疗心理治疗(xn l(xn l zh lio)zh lio)第一层次(cngc)(cngc)：一般性心理治疗或支持性心理治疗（supportive psychotherapy）第二层次(cngc)(cngc)：心理治疗干预(psychotherapeutic intervention)第五十页，共五十三页。DefinitionPathogenesisDiagnosisTreatment第五十一页，共五十三页。第五十二页，共五十三页。内容(nirng)总结肠易激综合征的新概念Newest concepts in irritable bowel syndromeIBS。(anxiety)。大便频率异常（异常定义为排便每天多于(du y)三次及每周少于三次）。大便性状异常（粗、硬便或稀、水便）。近期排便习惯改变、肿瘤家族史、40岁。第一层次：一般性心理治疗或支持性心理治疗（supportive psychotherapy）。谢谢第五十三页，共五十三页。