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1、旧概念旧概念：过敏性结肠炎过敏性结肠炎 易激结肠易激结肠 或黏液性结肠炎或黏液性结肠炎 l l第第1 1页页/共共5252页页 新概念新概念：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 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.l l第第2 2页页/共共5252页页该病缺乏可解释症状的形态学该病缺乏
2、可解释症状的形态学改变和生化异常改变和生化异常l l第第3 3页页/共共5252页页Psychologic disturbance relates to patients who see physicians Psychosocial factors influence health care seekingIBS Non-patientsl lnormalnormallIBS patientsPsychologicdisturbanceIBS-Psychosociall l第第4 4页页/共共5252页页流行病学研究流行病学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
3、群人群 10-20%10-20%就诊率就诊率 3030$80$80亿亿 国内国内 北京北京 潘国宗潘国宗 7.267.26 广州广州 陈旻湖陈旻湖 5.65.6 就诊率就诊率 22.422.4 l l第第5 5页页/共共5252页页What causes IBS?l l第第6 6页页/共共5252页页 Development of IBS pathophysiology Development of IBS pathophysiologyl ll l l inflammationinflammationl l 5-HT mediated hypersensitivity 5-HT mediat
4、ed 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 regulationAbnorm
5、al network regulationOf nerve-immune-endocrineOf nerve-immune-endocrineIBS molecular biologyIBS molecular biology.l l第第7 7页页/共共5252页页IBS发病机制的认识发病机制的认识l l临床症状临床症状l l l l腹痛、不适腹痛、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l l第第8 8页页/共共5252页页IBS发病机制的认识发病机制的认识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
6、 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l l第第9 9页页/共共5252页页 Visceral Hypersensitivity Visceral Hypersensitivity hyperalgesiahyperalgesia allodynia allodyniaEndogenousEndogenousModulationModulation.cortex.cortex.Brainstem.BrainstemEnd End o
7、rgan organ sensitivitysensitivity.silent.silentnociceptorsnociceptorsSpinalSpinalHyperexcitabilityHyperexcitability.Nitric oxide.Nitric oxideActivationActivationLong-termLong-termHyperalgesiaHyperalgesia.tonic cortical regulationtonic cortical regulation.Neuroplasticity.Neuroplasticityl l第第1010页页/共共
8、5252页页IBS发病机制的认识发病机制的认识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 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l l第第1111页页/共共5252页页Serotonin(5-HT)in the human gut 5-HT5-HT1 1 5-HT 5-HT3 3 5-HT 5-HT4 4 Gastric accommodation Gastric accommo
9、dation Transit Transit Colonic tone Colonic tone Sensation?Sensation?Secretion Secretion l l第第1212页页/共共5252页页IBS发病机制的认识发病机制的认识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 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l l第第1313页页/共共5252页页Psyc
10、hologic Psychologic distressdistressYounger Younger ageageDuration of Duration of abdominal abdominal painpainDuration of Duration of diarrheadiarrheaFemalesFemalesFactors PredictingGI SymptomsIBS-Post Infectiousl l第第1414页页/共共5252页页IBS发病机制的认识发病机制的认识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
11、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l l第第1515页页/共共5252页页lMechanosensitive afferentSensitized spinal circuitsDorsal root ganglionRepeated stimulationl l第第1616页页/共共5252页页Descending Visceral Pain PathwayThalamusPAGLocus coeruleusAmygdalaCol
12、onSerotonergicNoradrenergicCaudal raphe nucleusOpioidergicRostral ventral medullal l第第1717页页/共共5252页页l l第第1818页页/共共5252页页MotilitySecretionBlood FlowInflammationSightSoundSmellSomatosensoryCognitionAffectViscerosensoryInputIntegrationEffectl l第第1919页页/共共5252页页IBS发病机制的认识发病机制的认识l l临床症状临床症状 运动异常运动异常 分子生
13、物学阶段分子生物学阶段l l 感觉异常感觉异常 网络调控网络调控 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及受体胃肠道激素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 l l第第2020页页/共共5252页页Extracellular network reg
14、ulation Nerve cellsNerve cellsImmune cellsImmune cellsEndocrine cellsEndocrine cellsCytokine,receptor,Cytokine,receptor,peptide,5-HTpeptide,5-HTl l第第2121页页/共共5252页页How to develop in a person?l l第第2222页页/共共5252页页Predisposing Predisposing factorsfactorsPsycho-Psycho-PhysiologicalPhysiologicaltriggerst
15、riggersConcurrentConcurrentmodifiersmodifiersBrain-gutBrain-gutdysregulationdysregulationEarlyEarlylifelifeGenetic vulnerability,Genetic vulnerability,Enviromnent eg illnessEnviromnent eg illnessBehavior reinforcement,Behavior reinforcement,abuseabusel l第第2323页页/共共5252页页Predisposing Predisposing fac
16、torsfactorsPsycho-Psycho-PhysiologicalPhysiologicaltriggerstriggersConcurrentConcurrentmodifiersmodifiersBrain-gutBrain-gutdysregulationdysregulationEarlyEarlylifelifeGenetic Genetic EnvironmentEnvironmentChronic Chronic threat&threat&prolonged prolonged effortful effortful copingcopingEntericEnteri
17、cInfection/Infection/Inflammation/Inflammation/toxinstoxinsl l第第2424页页/共共5252页页Predisposing Predisposing factorsfactorsPsycho-Psycho-PhysiologicalPhysiologicaltriggerstriggersConcurrentConcurrentmodifiersmodifiersBrain-gutBrain-gutdysregulationdysregulationEarlyEarlylifelifeGenetic Genetic Environme
18、ntEnvironmentChronic Chronic threat&threat&prolonged prolonged effortful effortful copingcopingEntericEntericInfection/Infection/Inflammation/Inflammation/toxinstoxinsStress-responseStress-responseneuromodulationneuromodulationPost-infectivePost-infectiveneuromodulationneuromodulationPersonality,emo
19、tionalPersonality,emotionalSupport,age,gender,Support,age,gender,Sleep dysfunctionSleep dysfunctionLife event stress,Life event stress,Food allergens,Food allergens,Altered bowel floraAltered bowel floral l第第2525页页/共共5252页页Predisposing Predisposing factorsfactorsPsycho-Psycho-PhysiologicalPhysiologi
20、caltriggerstriggersConcurrentConcurrentmodifiersmodifiersBrain-gutBrain-gutdysregulationdysregulationEarly lifeEarly lifeEnteric infectionEnteric infectionInflammation,Inflammation,traumatraumaStress-responseStress-responseneuromodulationneuromodulationPost-infectivePost-infectiveneuromodulationneur
21、omodulationPersonality,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 copingCNSEN
22、SENSCorticalCorticalArousalArousal(anxiety)(anxiety)VisceralVisceralhypersensitivityhypersensitivityGI symptomsGI symptomsEI symptomsEI symptomsIBSIBSDysmotilityDysmotilityAlteredAlteredEpithelialEpithelialpermeabilitypermeabilityl l第第2626页页/共共5252页页How to diagnose？l l第第2727页页/共共5252页页诊断诊断l l 以症状为基础
23、以症状为基础l l第第2828页页/共共5252页页诊断标准诊断标准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 决定采用国际认同的Rome II 诊断标准l l第第2929页页/共共5252页页Rome I Criteria Rome II Criteria at least 12 weeks,which need not at least 12 weeks,which need not be consecutive,in the past 12 be co
24、nsecutive,in the past 12 months,of abdominal months,of abdominal discomfort or pain that has two discomfort or pain that has two of three featuresof three features -relieved by defecation;and/or -relieved by defecation;and/or -onset associated with a change -onset associated with a change in frequen
25、cy of stool;and/orin frequency of stool;and/or -onset associated with a change -onset associated with a change in form(appearance)of stoolin form(appearance)of stool At least 3 months continuous/At least 3 months continuous/recurrent symptoms of the following recurrent symptoms of the following-Abdo
26、minal pain or discomfort that is-Abdominal pain or discomfort that is-associated with a change in frequency-associated with a change in frequency of stool and/or of stool and/or-associated with a change in-associated with a change in consistency of stool;and consistency of stool;and Two or more of t
27、he following at least Two or more of the following at least 25%of the time25%of the time altered stool frequency(3/day or altered stool frequency(3/day or 3/week)3/week)altered stool passage(straining,altered stool passage(straining,urgency)urgency)passage of mucus passage of mucus bloating or feeli
28、ng of abdominal bloating or feeling of abdominal distention distention l l第第3030页页/共共5252页页The 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 two
29、of abdominal discomfort or pain that has two of three featuresthree 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)
30、And/or And/or And/or And/orl l第第3131页页/共共5252页页支持支持IBS诊断的症状累积诊断的症状累积l l大便频率异常（异常定义为排便每天多于三次大便频率异常（异常定义为排便每天多于三次及每周少于三次）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功能性肠病的诊断均假设症状没有结构性和生化性解释性解释l l第第3232页页/共共5252页页该诊断
31、的体现的几个重要原则该诊断的体现的几个重要原则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的基础上的基础上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作为一个特定的症候群有别于其他肠道功能行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、功能性腹疾病（如功能性腹泻、功能性便秘、功能性腹痛等）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，规定个月，规定其间至少有其间至少有1212周时间有症状，但可以不连续，周时间有症状，但可
32、以不连续，反应了本病慢性、反复发作的特点，可使器质反应了本病慢性、反复发作的特点，可使器质性疾病特别是性疾病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，提高得到诊断，提高诊断的敏感性诊断的敏感性。l l第第3333页页/共共5252页页表现分型表现分型分型依据的症状：每周排便3次；块状或硬便；稀烂便或水样便；排便费力；排便急迫感。l l
33、第第3434页页/共共5252页页表现分型表现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；排便急迫感。排便急迫感。便秘为主型或 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l l第第3535页页/共共5252页页表现分型表现分型 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；稀烂便或水样便；稀烂便或水样便；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l l第第3636页页/共共
34、5252页页表现分型表现分型 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；稀烂便或水样便；稀烂便或水样便；排便费力；排便费力；排便急迫感。排便急迫感。腹泻便秘交替型腹泻便秘交替型 l l第第3737页页/共共5252页页诊断流程诊断流程 问诊查体 发热、消瘦、便血、腹部包块发热、消瘦、便血、腹部包块l l第第3838页页/共共5252页页诊断流程诊断流程 问诊查体 有有有有 无无无无 发热、消瘦、便血、腹部包块发热、消瘦、便血、腹部包块彻底检查彻底检查近期排便习惯改变、肿瘤近期排便习惯改变、肿瘤家族史、家族史、4040岁岁l l第第3939页页/共共52
35、52页页诊断流程诊断流程 问诊查体 有有有有 无无无无 发热、消瘦、便血、腹部包块发热、消瘦、便血、腹部包块彻底检查彻底检查近期排便习惯改变、肿瘤近期排便习惯改变、肿瘤家族史、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l l第第4040页页/共共5252页页What is the best management approach?l l第第4141页页/共共5252页页治疗治疗 个体化、综合治疗l l第第4242页页/共共5252页页治疗原则治疗原则A comprehensive multicomponent approachTreatment prog
36、ram is based on dominant symptom and their severity,and on psychosocial factors,and etiological factors l l第第4343页页/共共5252页页Drugs for dominant in IBSAbdominal Abdominal painpainAntispasmodicsAntispasmodicsTricyclicTricyclicAntidepressantsAntidepressantsSSRISSRI DiarrheaDiarrhea Constipation Constipa
37、tion FiberFiberOsmotic laxativesOsmotic laxativesTegaserodTegaserodPEG solutionPEG solutionLoperamideLoperamideCholestyramineCholestyramineDiphenoxylateDiphenoxylatel l第第4444页页/共共5252页页治疗原则治疗原则A comprehensive multicomponent approachTreatment program is based on dominant symptom and their severity,an
38、d on psychosocial factors,and etiological factors l l第第4545页页/共共5252页页 Mild Lifestyle and dietary modification Mild Lifestyle and dietary modificationSevere Realistic goalsSevere Realistic goalsAntidepressants Antidepressants Referral for pain management Referral for pain managementModerate Gut acti
39、ng 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 l l第第4646页页/共共5252页页治疗原则治疗原则A comprehens
40、ive multicomponent approachTreatment program is based on dominant symptom and their severity,and on psychosocial factors,and etiological factors l l第第4747页页/共共5252页页心理治疗心理治疗 What can we do?How to do?l l第第4848页页/共共5252页页心理治疗心理治疗 第一层次：一般性心理治疗或支持性心理治疗（supportive psychotherapy）第二层次：心理治疗干预(psychotherapeutic intervention)l l第第4949页页/共共5252页页DefinitionPathogenesisDiagnosisTreatmentl l第第5050页页/共共5252页页l l第第5151页页/共共5252页页l感谢您的观看。感谢您的观看。l l第第5252页页/共共5252页页