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1、关于肠易激综合征的新概念关于肠易激综合征的新概念现在学习的是第1页，共52页旧概念旧概念：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 现在学习的是第2页，共52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.现在学
2、习的是第3页，共52页该病缺乏可解释症状的形态学改该病缺乏可解释症状的形态学改变和生化异常变和生化异常现在学习的是第4页，共52页Psychologic disturbance relates to patients who see physicians Psychosocial factors influence health care seekingIBS Non-patientsIBS Non-patientsl lnormalnormallIBS patientsPsychologicdisturbanceIBS-PsychosocialIBS-Psychosocial现在学习的是第5
3、页，共52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 现在学习的是第6页，共52页What causes IBS?现在学习的是第7页，共52页 Development of IBS pathophysiology Development of IBS pathophysiologyl l l l l inflammationinflammationl l 5
4、-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 1
5、990 2000Abnormal network regulationAbnormal network regulationOf nerve-immune-endocrineOf nerve-immune-endocrineIBS molecular biologyIBS molecular biology.现在学习的是第8页，共52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第一阶段第一阶段现在学习的是第9页，共52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
6、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 第二阶段第二阶段现在学习的是第10页，共52页 Visceral Hypersensitivity Visceral Hypersensitivity hyperalgesiahyperalgesia allodynia allodyniaEndogenousEndogenousModulationModulation.cortex.cortex
7、.Brainstem.BrainstemEnd End organ sensitivityorgan sensitivity.silent.silentnociceptorsnociceptorsSpinalSpinalHyperexcitabilityHyperexcitability.Nitric oxide.Nitric oxideActivationActivationLong-termLong-termHyperalgesiaHyperalgesia.tonic cortical regulationtonic cortical regulation.Neuroplasticity.
8、Neuroplasticity现在学习的是第11页，共52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 第二阶段第二阶段现在学习的是第12页，共52页Serotonin(5-HT)in the human gut 5-HT5-HT1 1 5-HT 5-HT3 3 5-HT 5-HT4 4 Gastric accommod
9、ation Gastric accommodation Transit Transit Colonic tone Colonic tone Sensation?Sensation?Secretion Secretion 现在学习的是第13页，共52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 第二阶段第二阶段现在学习的是
10、第14页，共52页Psychologic Psychologic distressdistressYounger Younger ageageDuration of Duration of abdominal painabdominal painDuration of Duration of diarrheadiarrheaFemalesFemalesFactors PredictingGI SymptomsIBS-Post Infectious现在学习的是第15页，共52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
11、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 第二阶段第二阶段现在学习的是第16页，共52页l lMechanosensitive Mechanosensitive afferentafferentSensitized spinal circuitsDorsal root ganglionRepeated Repeated stimulationstimulation现在学习的是第17页，共52页Descending Visceral Pa
12、in PathwayThalamusThalamusPAGLocus coeruleusAmygdalaColonSerotonergicNoradrenergicCaudal raphe nucleusOpioidergicRostral ventral medulla现在学习的是第18页，共52页现在学习的是第19页，共52页MotilityMotilitySecretionSecretionBlood FlowBlood FlowInflammationInflammationSightSoundSmellSomatosensoryCognitionAffectViscerosensor
13、yInputIntegrationEffect现在学习的是第20页，共52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
14、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 现在学习的是第21页，共52页Extracellular network regulation Nerve cellsNerve cellsImmune cellsImmune cellsEndocrine cellsEndocrine cellsCytokine,receptor,Cytokine,receptor,peptide,5-HTpeptide,5-HT现在学习的是第22页，共52页How to develop in a person?现在学习的是第23页，共52页Predisposing Predisposing
15、 factorsfactorsPsycho-Psycho-PhysiologicalPhysiologicaltriggerstriggersConcurrentConcurrentmodifiersmodifiersBrain-gutBrain-gutdysregulationdysregulationEarlyEarlylifelifeGenetic vulnerability,Genetic vulnerability,Enviromnent eg illnessEnviromnent eg illnessBehavior reinforcement,Behavior reinforce
16、ment,abuseabuse现在学习的是第24页，共52页Predisposing Predisposing factorsfactorsPsycho-Psycho-PhysiologicalPhysiologicaltriggerstriggersConcurrentConcurrentmodifiersmodifiersBrain-gutBrain-gutdysregulationdysregulationEarlyEarlylifelifeGenetic Genetic EnvironmentEnvironmentChronic Chronic threat&threat&prolon
17、ged prolonged effortful effortful copingcopingEntericEntericInfection/Infection/Inflammation/Inflammation/toxinstoxins现在学习的是第25页，共52页Predisposing Predisposing factorsfactorsPsycho-Psycho-PhysiologicalPhysiologicaltriggerstriggersConcurrentConcurrentmodifiersmodifiersBrain-gutBrain-gutdysregulationdy
18、sregulationEarlyEarlylifelifeGenetic Genetic EnvironmentEnvironmentChronic Chronic threat&threat&prolonged prolonged effortful effortful copingcopingEntericEntericInfection/Infection/Inflammation/Inflammation/toxinstoxinsStress-responseStress-responseneuromodulationneuromodulationPost-infectivePost-
19、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现在学习的是第26页，共52页Predisposing Predisposing fa
20、ctorsfactorsPsycho-Psycho-PhysiologicalPhysiologicaltriggerstriggersConcurrentConcurrentmodifiersmodifiersBrain-gutBrain-gutdysregulationdysregulationEarly lifeEarly lifeEnteric infectionEnteric infectionInflammation,Inflammation,traumatraumaStress-responseStress-responseneuromodulationneuromodulati
21、onPost-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 threatProlon
22、ged threat&effortful coping&effortful copingCNSENSENSCorticalCorticalArousalArousal(anxiety)(anxiety)VisceralVisceralhypersensitivityhypersensitivityGI symptomsGI symptomsEI symptomsEI symptomsIBSIBSDysmotilityDysmotilityAlteredAlteredEpithelialEpithelialpermeabilitypermeability现在学习的是第27页，共52页How to
23、 diagnose？现在学习的是第28页，共52页诊断诊断l l 以症状为基础以症状为基础现在学习的是第29页，共52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 诊断标准现在学习的是第30页，共52页Rome I Criteria Rome II Criteria at least 12 weeks,which need not at least 12 weeks,which need not be con
24、secutive,in the past 12 be consecutive,in the past 12 months,of abdominal discomfort months,of abdominal discomfort or pain that has two of three or pain that has two of three featuresfeatures -relieved by defecation;and/or -relieved by defecation;and/or -onset associated with a change in -onset ass
25、ociated 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 s
26、ymptoms 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-associated with a change in consistency of stool;and
27、of 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
28、feeling of abdominal bloating or feeling of abdominal distention distention 现在学习的是第31页，共52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 pain the past 12 months,of abdominal dis
29、comfort or pain that has two of three featuresthat 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)
30、And/or And/or And/or And/or现在学习的是第32页，共52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及每大便频率异常（异常定义为排便每天多于三次及每周少于三次）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解功能性肠病的诊断均假设症状没有结构性和生化性解释释现在学习的是第33页，共52页该诊断的体现的几个重要原则
31、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作为作为一个特定的症候群有别于其他肠道功能行疾病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）（如功能性腹泻、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，规定其间至个月，规定其间至少有少有1212周时间有症状，但可以不连续，反应了本病周时间有症状，但可以不连续，
32、反应了本病慢性、反复发作的特点，可使器质性疾病特别是慢性、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，提高粪便性状的改变，可使更多病例得到诊断，提高诊断诊断的敏感性的敏感性。现在学习的是第34页，共52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。现在学习的是第35页，共52页表现分
33、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 中之一项现在学习的是第36页，共52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，但无项现在学习的是第37页，共52页表现分型表现分型 分型依据的症状分型依据的症状：
34、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 现在学习的是第38页，共52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、腹部包块现在学习的是第39页，共52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、肿瘤家近期排便习惯改变、肿瘤家族史、族史、4040岁岁现在学习的是第40页，共52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
35、瘦、便血、腹部包块彻底检查彻底检查近期排便习惯改变、肿瘤家族近期排便习惯改变、肿瘤家族史、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 否否现在学习的是第41页，共52页What is the best management approach?现在学习的是第42页，共52页治疗治疗 个体化、综合治疗现在学习的是第43页，共52页治疗原则治疗原则A comprehensive multicomponent approachTreatment program is based on dominant symptom and their severity,and on p
36、sychosocial factors,and etiological factors 现在学习的是第44页，共52页Drugs for dominant in IBSAbdominal Abdominal painpainAntispasmodicsAntispasmodicsTricyclicTricyclicAntidepressantsAntidepressantsSSRISSRI DiarrheaDiarrhea Constipation Constipation FiberFiberOsmotic laxativesOsmotic laxativesTegaserodTegaser
37、odPEG solutionPEG solutionLoperamideLoperamideCholestyramineCholestyramineDiphenoxylateDiphenoxylate现在学习的是第45页，共52页治疗原则治疗原则A comprehensive multicomponent approachTreatment program is based on dominant symptom and their severity,and on psychosocial factors,and etiological factors 现在学习的是第46页，共52页 Mild
38、 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/sensa
39、tion)treatments (motility/sensation)treatmentsAll All Therapeutic relationship/continuity of care Therapeutic relationship/continuity of care education/reassuranceeducation/reassurance 现在学习的是第47页，共52页治疗原则治疗原则A comprehensive multicomponent approachTreatment program is based on dominant symptom and th
40、eir severity,and on psychosocial factors,and etiological factors 现在学习的是第48页，共52页心理治疗心理治疗 What can we do?How to do?现在学习的是第49页，共52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)现在学习的是第50页，共52页DefinitionPathogenesisDiagnosisTreatment现在学习的是第51页，共52页感感谢谢大大家家观观看看现在学习的是第52页，共52页