《内科学课件：功能性胃肠道疾病(英文版).ppt》由会员分享，可在线阅读，更多相关《内科学课件：功能性胃肠道疾病(英文版).ppt（68页珍藏版）》请在三一办公上搜索。
1、Functional Gastrointestinal Disorders (FGIDs),Functional Gastrointestinal Di,Functional Gastrointestinal Disorders,What are the FGIDs definitions?What is the clinical presentations?What is the differential diagnosis?What is the diagnostic strategy?What is a rational treatment strategy?,Functional Ga
2、strointestinal Di,Chronic and recurrent symptoms of the gastrointestinal (GI) tract: pain nausea vomiting bloating diarrhea constipation Without detectable structural or biochemical abnormalities,Definition of FGIDs,Chronic and recurrent symptoms,What is a FGIDs?,Many regard FGID as a psychological
3、disorderAbsence of organic diseaseFGID can be understood in context of integrated biopsychosocial model of illness and diseaseSymptoms are physiologically multidetermined and modifiable by social, cultural, psychological factorsDrossman DA. Gastroenterology 2006,What is a FGIDs?,Rome III functional
4、gastrointestinal disorders (FGIDs)A: Functional esophageal disordersB: Functional gastroduodenal disordersC: Functional bowel disordersD: Functional abdominal pain syndrome (FAPS)E: Functional gallbladder and sphincter of Oddi disordersF: Functional anorectal disordersG: Childhood functional GI diso
5、rders: neonate/toddlerH: Childhood functional GI disorders: child/adolescent,classified by anatomic region,Rome III functional gastroint,A: Functional esophageal disordersA1: Functional heartburnA2: Functional chest pain of presumed esophageal originA3: Functional dysphagiaA4: GlobusB: Functional ga
6、stroduodenal disordersB1: Functional dyspepsia (FD)B1a: Postprandial distress syndrome (PDS)B1b: Epigastric pain syndrome (EPS)B2: Belching disordersB2a: AerophagiaB2b: Unspecified excessive belchingB3: Nausea and vomiting disordersB3a: Chronic idiopathic nausea (CIN)B3b: Functional vomitingB3c: Cyc
7、lic vomiting syndrome (CVS)B4: Rumination syndrome in adults,内科学课件：功能性胃肠道疾病(英文版),C: Functional bowel disordersC1: Irritable bowel syndrome (IBS)C2: Functional bloatingC3: Functional constipationC4: Functional diarrheaC5: Unspecified functional bowel disorderD: Functional abdominal pain syndrome (FAP
8、S)E: Functional gallbladder and sphincter of Oddi disordersE1: Functional gallbladder disorderE2: Functional biliary SO disorderE3: Functional pancreatic SO disorderF: Functional anorectal disordersF1: Functional fecal incontinenceF2: Functional anorectal painF2a: Chronic proctalgiaF2a1: Levator ani
9、 syndromeF2a2: Unspecified functional anorectal painF2b: Proctalgia fugaxF3: Functional defecation disordersF3a: Dyssynergic defecationF3b: Inadequate defecatory propulsion,C: Functional bowel disorders,G: Childhood functional GI disorders: neonate/toddlerG1: Infant regurgitationG2: Infant ruminatio
10、n syndromeG3: Cyclic vomiting syndromeG4: Infant colicG5: Functional diarrheaG6: Infant dyscheziaG7: Functional constipationH. Childhood functional GI disorders: child/adolescentH1: Vomiting and aerophagiaH1a: Adolescent rumination syndromeH1b: Cyclic vomiting syndromeH1c: AerophagiaH2: Abdominal pa
11、in-related FGIDH2a: Functional dyspepsiaH2b: Irritable bowel syndromeH2c: Abdominal migraineH2d: Childhood functional abdominal painH2d1: Childhood functional abdominalpain syndromeH3: Constipation and incontinenceH3a: Functional constipationH3b: Non-retentive fecal incontinence,G: Childhood functio
12、nal GI dis,Functional Dyspepsia(FD),Functional Dyspepsia(FD),Definition,Persistent or recurrent pain or discomfort centered in the upper abdomen: including epigastric pain, early satiety, nausea, vomiting, bloating, and anorexia No structural or biochemical abnormalty.,DefinitionPersistent or recurr
13、,Etiology,H pylori infectionPsychological FeaturesPost-infectionGenetic factors,EtiologyH pylori infection,Helicobacter pylori infection?,ControversialRelationship between Helicobacter pylori infection and FD was failed to be identified H.pylori eradication therapy in FD results in a significant eff
14、ect in H.pylori positive FD Guidelines recommended H.pylori eradication therapy in H.pylori positive FD patients.,Fock KM. J Gastroenterol Hepatol 2011,Helicobacter pylori infection,Psychological features,Psychological stress exacerbates FD symptoms. Higher levels of anxiety and depression have been
15、 found. A link between childhood abuse and functional gastrointestinal disorders.,Psychological featuresPsycholo,Post-infectious dyspepsia has been described as a distinct clinical entity, based on a large retrospective study that showed a subset of dyspeptic patients who had a history suggestive of
16、 post-infectious dyspepsia.,Post-infection,Post-infectious dyspepsia has,Development of dyspepsia was increased fivefold at 1 year after acute Salmonella gastroenteritis early satiety, weight loss, nausea, and vomiting Infectious FD was associated with persisting focal T-cell aggregates, decreased C
17、D4+ cells and increased macrophage counts in the duodenum impaired ability of the immune system,Mearin F. Gastroenterology 2005 Kindt S. Neurogastroenterol Motil 2009,Development of dyspepsia was,G-protein beta3 (GNB3) subunit C825T was first reported as a candidate gene for FD susceptibility. Howev
18、er, the data are inconsistent in countries. Significant link between homozygous 825C allele of GNB3 protein and dyspepsia was reported from Germany and the USA. On the other hand, the association between T allele of GNB3 C825T polymorphism and dyspepsia was reported from Japan and Netherlands. Assoc
19、iation of serotonin transporter promoter (SERT-P) gene polymorphism and FD was reported negatively from a USA community and Netherlands. However SERT SL genotype was significantly associated with PDS. Involvement of IL-17F, migration inhibitory factor (MIF), catechol-o-methyltransferase (COMT) gene
20、val158met, 779 TC of CCK-1 intron 1, cyclooxygenase-1 (COX-1), transient receptor potential cation channel, subfamily V, member 1 (TRPV1) 315C and regulated upon activation normal T cell expressed and secreted (RANTES) polymorphisms was reported in Japanese studies.,Genetic factors,Oshima T. J Gastr
21、oenterol Hepatol 2011,G-protein beta3 (GNB3) subuni,Pathophysiology,Abnormal motilityVisceral hypersensitivityGastric acid,Pathophysiology,Delayed gastric emptyingLower gastric complianceAntral hypomotilityGastric dysrhythmiasImpaired duodenojejunal motility,Abnormal motility,Abnormal motility,Visce
22、ral hypersensitivity,Hypersensitivity to gastric balloon distention: suggesting abnormal afferent functionReflex hyporeactivity: suggesting either abnormal afferent or abnormal efferent function,Visceral hypersensitivityHyper,Gastric acid,Stress acid Acid hypersensitivity Acid-suppressive drugspain,
23、Gastric acid Stress acid ,Rome III Bothersome postprandial fullnessEarly satiationEpigastric painEpigastric burningNo evidence of structural diseases,Clinical presentations,The symptoms may be intermittent or continuous, and may or may not be related to meals.,Rome III Clinical presentation,Epigastr
24、ic pain Epigastric refers to the region between the umbilicus and lower end of the sternum, and marked by the midclavicular lines. Pain refers to a subjective, unpleasant sensation; some patients may feel that tissue damage is occurring. Other symptoms may be extremely bothersome without being inter
25、preted by the patient as pain.Epigastric burning Epigastric refers to the region between the umbilicus and lower end of the sternum, and marked by the midclavicular lines. Burning refers to an unpleasant subjective sensation of heat.,Epigastric pain,Postprandial fullness An unpleasant sensation like
26、 the prolonged persistence of food in the stomach. Early satiation A feeling that the stomach is overfilled soon after starting to eat, out of proportion to the size of the meal being eaten, so that the meal cannot be finished. Previously, the term “early satiety” was used, but satiation is the corr
27、ect term for the disappearance of the sensation of appetite during food ingestion.,Tack J, Talley NJ, Camilleri M, Holtmann G, Hu P, Malagelada JR, Stanghellini V. Functional gastroduodenal disorders. Gastroenterology. 2006 Apr;130(5):1466-79.,Postprandial fullness Tack J,内科学课件：功能性胃肠道疾病(英文版),Epigast
28、ric pain/discomfort 90% Post-prandial fullness 75% Bloating 75% Post-prandial nausea 50% Early satiation 50% Belching 45% Weight loss 30% Nausea and vomiting 20%,Epigastric pain/discomfort ,FD subclassification :,Rome III defined as two subgroupsPostprandial Distress Syndrome, PDSBothersome postpran
29、dial fullnessEarly satiationEpigastric pain syndrome, EPSEpigastric painEpigastric burning,FD subclassification :Rome III,FD remains a diagnosis of exclusion:Careful history and physical examinationUpper endoscopy is necessaryThe others: exclusion of chronic peptic ulcer disease, gastroesophageal re
30、flux disease, malignancy, pancreatico-biliary disease,Diagnosis,FD remains a diagnosis of excl,Alarm symptoms and signs,Unintentional weight loss 3 kgUnexplained iron deficiency anaemiaGastro-intestinal bleedingDysphagiaAbdominal mass,Endoscopy,Alarm symptoms and signsEndosc,B1. FUNCTIONAL DYSPEPSIA
31、Diagnostic criteria* Must include:. One or more of the following:a. Bothersome postprandial fullnessb. Early satiationc. Epigastric paind. Epigastric burningAND. No evidence of structural disease (including at upper endoscopy) that is likely to explain the symptoms* Criteria fulfilled for the last 6
32、 months with symptom onsetat least 3 months prior to diagnosis,Rome III criteria,B1. FUNCTIONAL DYSPEPSIARome I,B1a. Postprandial Distress SyndromeDiagnostic criteria* Must include one or both of the following:. Bothersome postprandial fullness, occurring after ordinary-sized meals, at least several
33、 times per week. Early satiation that prevents finishing a regular meal, at least several times per weekSupportive criteria. Upper abdominal bloating or postprandial nausea or excessive belching can be present. Epigastric pain syndrome may coexist,B1a. Postprandial Distress Syn,B1b. Epigastric Pain
34、SyndromeDiagnostic criteria* Must include all of the following:. Pain or burning localized to the epigastrium of at least moderate severity, at least once per week. The pain is intermittent. Not generalized or localized to other abdominal or chest regions. Not relieved by defecation or passage of fl
35、atus. Not fulfilling criteria for gallbladder and sphincter of Oddi disorders,B1b. Epigastric Pain Syndrome,B1b. Epigastric Pain SyndromeSupportive criteria. The pain may be of a burning quality, but without a retrosternal component. The pain is commonly induced or relieved by ingestion of a meal, b
36、ut may occur while fasting. Postprandial distress syndrome may coexist,B1b. Epigastric Pain Syndrome,内科学课件：功能性胃肠道疾病(英文版),内科学课件：功能性胃肠道疾病(英文版),内科学课件：功能性胃肠道疾病(英文版),Differential Diagnosis,GERD: Heartburn is the predominant symptom Upper endoscopy Esophageal pH monitoring,Differential DiagnosisGERD: He,D
37、ifferential Diagnosis,IBS: overlap symptom co-exist with FD PU,Differential DiagnosisIBS: ove,Treatment,The goal is to accept, diminish, and cope with symptoms rather than eliminate them. The most important aspects include explanation that the symptoms are not imaginary, evaluation of relevant psych
38、osocial factors, and dietary advice.,TreatmentThe goal is to accept,Pharmacological therapies,H. pylori therapy ? controversialAcid suppression and prokinetic agents (digestive agents) ? may helpGut analgesics ? Relaxants of the nervous system of the gut may be beneficialAntidepressant? May help,Pha
39、rmacological therapiesH. py,Summaries of treatment trialsProkinetic agents placebo (RRR 50%)H2 antagonists placebo (RRR 30%)PPI and bismuth salts placeboNo benefit from antacids or sucralfate,Summaries of treatment trials,Visceral analgesiaSerotonin receptor antagonistSomatostatin analogue - octreot
40、idePsychotherapyAlternative medicineHerbal and natural products (peppermint, caraway)acupuncture,Visceral analgesia,Irritable Bowel Syndrome (IBS),Irritable Bowel Syndrome (IBS,Definition,Irritable bowel syndrome (IBS) is a functional GI disorder characterized by abdominal pain or discomfort and alt
41、ered bowel habits.Without demonstrable organic disease,DefinitionIrritable bowel synd,Etiology and Pathophysiology,Psychological FeaturesAbnormal motilityVisceral hypersensitivityInflammation and bacteriaFood intolerance,Etiology and PathophysiologyPs,Psychological Features,1)Psychological stress ex
42、acerbates GI symptoms.2)Psychological disturbances modify the experience of illness and illness behaviors such as health care seeking.3) Psychosocial factors affect health status and clinical outcome.,Psychological Features1)Psycho,Psychological stress exacerbates GI symptoms in everyone- but to a g
43、reater degree in patients with IBS50% of patients with IBS seen at referral centers meet the criteria for a psychological disorderPatients with FGIDs who are non health care seeking do not show more psychological disorder than normalsChronic illness such as IBS has psychosocial consequencesDrossman
44、DA. Gastroenterology 2006,Psychological Features,Psychological stress exacerbat,Altered gut reactivity (motility, secretion) in response to luminal (e.g., meals, gut distention, inflammation, bacterial factors) or provocative environmental (psychosocial stress) stimuli, resulting in symptoms of diar
45、rhea and/or constipation,Abnormal motility,Abnormal motility,Pre-prandial colonic tone and motility is increased in IBS patientsFGIDs patients like IBS have greater motility response to stressors- both physiologic and psychologic when compared to normalVassallo MJ. Mayo Clinic Proc 1992Drossman DA.
46、Gastro 2002,Abnormal motility,Pre-prandial colonic tone and,A hypersensitive gut with enhanced visceral perception and pain,Visceral hypersensitivity,Repetitive rectal balloon inflations lead to a progressive increase in pain that occurs longer and with greater intensity than controlsMunakata K. Gas
47、troenterology 1997,Visceral hypersensitivity Re,Bacterial Flora,Eradication of small intestinal bacterial overgrowth reduces symptoms of IBSAnderson ML. Am J Gastroenterology 2000Normalization of lactulose breath testing correlates with symptomatic improvement in IBSPimentel M. Am J Gastroenterology
48、 2003,Bacterial FloraEradication of,Inflammation,50% IBS patients have increased activated mucosal inflammatory cellsChadwick VS. Gastroenterology 200233% patients with IBS can correlate symptoms to an enteric infection25% of patients with an acute enteric infection go on to develop IBS like or dysp
49、eptic symptomsGwee KA. Gut 1999,Inflammation50% IBS patients h,The main types of food sensitivity,http:/,The main types of food sensiti,Clinical presentations,Abdominal discomfort or pain Disordered defecation,Clinical presentationsAbdomina,IBS pain is associated with defecation or a change in bowel
50、 function and can occur throughout the abdomen:Upper abdomen pain is often associated with bloating and may worsen after meals. Cramping can occur around the belly button and through the lower abdomen. Lower abdomen pain is most likely to be eased by a bowel movement.,IBS pain is associated with de,
