医学教程 肠易激综合征的新概念

肠易激综合征的新概念

Newestconceptsinirritablebowelsyndrome

IBS张虎华西医院消化科整理ppt旧概念：

过敏性结肠炎易激结肠或黏液性结肠炎

整理ppt

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…agroupoffunctionalboweldisordersinwhichdiscomfortorpainisassociatedwithdefecationorachangeinbowelhabit,andwithfeaturesofdisordereddefecation.整理ppt该病缺乏可解释症状的形态学改变和生化异常

整理pptPsychologicdisturbancerelatestopatientswhoseephysiciansPsychosocialfactorsinfluencehealthcareseekingIBSNon-patientsnormalIBSpatientsPsychologicdisturbanceIBS-Psychosocial整理ppt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％

整理pptWhatcausesIBS?整理pptDevelopmentofIBSpathophysiology｛

inflammation5-HTmediatedhypersensitivityandgutmotility

Brain-gutinteractionVisceralhypersensitivityAbnormalmotorfunction195019601970198019902000AbnormalnetworkregulationOfnerve-immune-endocrineIBSmolecularbiology…….整理pptIBS发病机制的认识临床症状

腹痛、不适大便异常，流行病学等第一阶段整理pptIBS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整理pptVisceralHypersensitivity

hyperalgesiaallodyniaEndogenousModulation.cortex.BrainstemEndorgansensitivity

.silent

nociceptorsSpinalHyperexcitability.NitricoxideActivationLong-termHyperalgesia.toniccorticalregulation.Neuroplasticity整理pptIBS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整理pptSerotonin(5-HT)inthehumangut

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

Colonictone↓↑Sensation↑?Secretion↑

整理pptIBS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整理pptPsychologicdistressYoungerageDurationofabdominalpainDurationofdiarrheaFemalesFactorsPredictingGISymptomsIBS-PostInfectious整理pptIBS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整理pptMechanosensitive

afferentSensitizedspinalcircuitsDorsalrootganglionRepeatedstimulation整理pptDescendingVisceralPainPathwayThalamusPAGLocuscoeruleusAmygdalaColonSerotonergicNoradrenergicCaudalraphenucleusOpioidergicRostralventralmedulla整理ppt整理pptMotilitySecretionBloodFlowInflammationSightSoundSmellSomatosensoryCognitionAffectViscerosensoryInputIntegrationEffect整理pptIBS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5－HT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

●●●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诊断

以症状为基础整理ppt诊断标准Manning标准1978年RomeI1992年RomeII1999年RomeIII2006年?2003年三月广州首届全国IBS会议决定采用国际认同的RomeII诊断标准整理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整理ppt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12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。整理ppt表现分型分型依据的症状：①每周排便<3次；②每天排便>3次；③块状或硬便；④稀烂便或水样便；⑤排便费力；⑥排便急迫感。整理ppt表现分型●分型依据的症状：

①每周排便<3次；②每天排便>3次；③块状或硬便；④稀烂便或水样便；⑤排便费力；⑥排便急迫感。●便秘为主型或①③⑤项中之一项或以上，而无②④⑥项①③⑤项中之二项或以上，可伴有②④⑥中之一项整理ppt表现分型●分型依据的症状：①每周排便<3次；②每天排便>3次；③块状或硬便；④稀烂便或水样便；⑤排便费力；⑥排便急迫感。●腹泻为主型②④⑥项中之一项或以上，而无①③⑤项或②④⑥项中之二项或以上，可伴有①⑤中一项，但无③项整理ppt表现分型●分型依据的症状：①每周排便<3次；②每天排便>3次；③块状或硬便；④稀烂便或水样便；⑤排便费力；⑥排便急迫感。●腹泻便秘交替型①②③④⑤⑥整理ppt诊断流程问诊＋查体

发热、消瘦、便血、腹部包块整理ppt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岁整理ppt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是否整理pptWhatisthebestmanagementapproach?整理ppt治疗个体化、综合治疗整理ppt治疗原则AcomprehensivemulticomponentapproachTreatmentprogramisbasedondominantsymptomandtheirseverity,andonpsychosocialfactors,andetiologicalfactors整理pptDrugsfordominantinIBSAbdominalpainAntispasmodicsTricyclicAntidepressantsSSRI

Diarrhea

ConstipationFiberOsmoticlaxativesTegaserodPEGsolutio