内科学课件：功能性胃肠道疾病(英文版).ppt

1、Functional Gastrointestinal Disorders(FGIDs)nChronic and recurrent symptoms of the gastrointestinal(GI)tract:pain nausea vomiting bloating diarrhea constipation nWithout detectable structural or biochemical abnormalitiesDefinition of FGIDsWhat is a FGIDs?nMany regard FGID as a psychological disorder

2、nAbsence of organic diseasenFGID can be understood in context of integrated biopsychosocial model of illness and diseasenSymptoms are physiologically multidetermined and modifiable by social,cultural,psychological factorsDrossman DA.Gastroenterology 2006 Rome III functional gastrointestinal disorder

3、s(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 disorders:neonate/toddlerH:Childhood f

4、unctional GI disorders:child/adolescentclassified by anatomic regionA:Functional esophageal disordersA1:Functional heartburnA2:Functional chest pain of presumed esophageal originA3:Functional dysphagiaA4:GlobusB:Functional gastroduodenal disordersB1:Functional dyspepsia(FD)B1a:Postprandial distress

5、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:Cyclic vomiting syndrome(CVS)B4:Rumination syndrome in adultsC:Functional bowel disordersC1:

6、Irritable bowel syndrome(IBS)C2:Functional bloatingC3:Functional constipationC4:Functional diarrheaC5:Unspecified functional bowel disorderD:Functional abdominal pain syndrome(FAPS)E:Functional gallbladder and sphincter of Oddi disordersE1:Functional gallbladder disorderE2:Functional biliary SO diso

7、rderE3:Functional pancreatic SO disorderF:Functional anorectal disordersF1:Functional fecal incontinenceF2:Functional anorectal painF2a:Chronic proctalgiaF2a1:Levator ani syndromeF2a2:Unspecified functional anorectal painF2b:Proctalgia fugaxF3:Functional defecation disordersF3a:Dyssynergic defecatio

8、nF3b:Inadequate defecatory propulsionG:Childhood functional GI disorders:neonate/toddlerG1:Infant regurgitationG2:Infant rumination syndromeG3:Cyclic vomiting syndromeG4:Infant colicG5:Functional diarrheaG6:Infant dyscheziaG7:Functional constipationH.Childhood functional GI disorders:child/adolescen

9、tH1:Vomiting and aerophagiaH1a:Adolescent rumination syndromeH1b:Cyclic vomiting syndromeH1c:AerophagiaH2:Abdominal pain-related FGIDH2a:Functional dyspepsiaH2b:Irritable bowel syndromeH2c:Abdominal migraineH2d:Childhood functional abdominal painH2d1:Childhood functional abdominalpain syndromeH3:Con

10、stipation and incontinenceH3a:Functional constipationH3b:Non-retentive fecal incontinenceFunctional Dyspepsia(FD)DefinitionnPersistent or recurrent pain or discomfort centered in the upper abdomen:including epigastric pain,early satiety,nausea,vomiting,bloating,and anorexia nNo structural or biochem

11、ical abnormalty.EtiologynH pylori infectionnPsychological FeaturesnPost-infectionnGenetic factors Helicobacter pylori infection?lControversiallRelationship between Helicobacter pylori infection and FD was failed to be identified lH.pylori eradication therapy in FD results in a significant effect in

12、H.pylori positive FD l Guidelines recommended H.pylori eradication therapy in H.pylori positive FD patients.Fock KM.J Gastroenterol Hepatol 2011Psychological featureslPsychological stress exacerbates FD symptoms.lHigher levels of anxiety and depression have been found.lA link between childhood abuse

13、 and functional gastrointestinal disorders.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 post-infectious dyspepsia.Post-infectionl Development of dyspepsia was

14、 increased fivefold at 1 year after acute Salmonella gastroenteritis early satiety,weight loss,nausea,and vomiting l Infectious FD was associated with persisting focal T-cell aggregates,decreased CD4+cells and increased macrophage counts in the duodenum impaired ability of the immune systemMearin F.

15、Gastroenterology 2005 Kindt S.Neurogastroenterol Motil 2009l G-protein beta3(GNB3)subunit C825T was first reported as a candidate gene for FD susceptibility.However,the data are inconsistent in countries.Significant link between homozygous 825C allele of GNB3 protein and dyspepsia was reported from

16、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.l Association of serotonin transporter promoter(SERT-P)gene polymorphism and FD was reported negatively from a USA community and Netherlands.However

17、 SERT SL genotype was significantly associated with PDS.l Involvement of IL-17F,migration inhibitory factor(MIF),catechol-o-methyltransferase(COMT)gene 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

18、 upon activation normal T cell expressed and secreted(RANTES)polymorphisms was reported in Japanese studies.Genetic factors Oshima T.J Gastroenterol Hepatol 2011PathophysiologynAbnormal motilitynVisceral hypersensitivitynGastric acidlDelayed gastric emptyinglLower gastric compliancelAntral hypomotil

19、itylGastric dysrhythmiaslImpaired duodenojejunal motilityAbnormal motilityVisceral hypersensitivitynHypersensitivity to gastric balloon distention:suggesting abnormal afferent functionnReflex hyporeactivity:suggesting either abnormal afferent or abnormal efferent functionGastric acidn Stress acid n

20、Acid hypersensitivityn Acid-suppressive drugspainnRome III Bothersome postprandial fullnessEarly satiationEpigastric painEpigastric burningNo evidence of structural diseasesClinical presentations The symptoms may be intermittent or continuous,and may or may not be related to meals.nEpigastric pain E

21、pigastric 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 interpreted by the

22、patient as pain.nEpigastric 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.nPostprandial fullness An unpleasant sensation like the prolonged persistence of f

23、ood in the stomach.nEarly 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 correct term for the disappearance of the

24、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.l Epigastric pain/discomfort 90%l Post-prandial fullness 75%l Bloating 75%l Post-prandial nausea 50%l Ear

25、ly satiation 50%l Belching 45%l Weight loss 30%l Nausea and vomiting 20%FD subclassification:nRome III defined as two subgroupslPostprandial Distress Syndrome,PDSuBothersome postprandial fullnessuEarly satiationlEpigastric pain syndrome,EPSuEpigastric painuEpigastric burningFD remains a diagnosis of

26、 exclusion:nCareful history and physical examinationnUpper endoscopy is necessarynThe others:exclusion of chronic peptic ulcer disease,gastroesophageal reflux disease,malignancy,pancreatico-biliary diseaseDiagnosisAlarm symptoms and signsnUnintentional weight loss 3 kgnUnexplained iron deficiency an

27、aemianGastro-intestinal bleedingnDysphagianAbdominal massEndoscopyB1.FUNCTIONAL DYSPEPSIADiagnostic 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 end

28、oscopy)that is likely to explain the symptoms*Criteria fulfilled for the last 6 months with symptom onsetat least 3 months prior to diagnosisnRome III criteriaB1a.Postprandial Distress SyndromeDiagnostic criteria*Must include one or both of the following:.Bothersome postprandial fullness,occurring a

29、fter ordinary-sized meals,at least several 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 coexistB1b.Epigastric

30、Pain 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 fla

31、tus.Not fulfilling criteria for gallbladder and sphincter of Oddi disordersB1b.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,but may occur while fasting.Postprandia

32、l distress syndrome may coexistDifferential DiagnosisnGERD:Heartburn is the predominant symptom Upper endoscopy Esophageal pH monitoring Differential DiagnosisnIBS:overlap symptom co-exist with FDn PUTreatmentnThe goal is to accept,diminish,and cope with symptoms rather than eliminate them.nThe most

33、 important aspects include explanation that the symptoms are not imaginary,evaluation of relevant psychosocial factors,and dietary advice.Pharmacological therapiesnH.pylori therapy?controversialnAcid suppression and prokinetic agents(digestive agents)?may helpnGut analgesics?Relaxants of the nervous

34、 system of the gut may be beneficialnAntidepressant?May helpnSummaries of treatment trialslProkinetic agents placebo(RRR 50%)lH2 antagonists placebo(RRR 30%)lPPI and bismuth salts placebolNo benefit from antacids or sucralfatenVisceral analgesiaSerotonin receptor antagonistSomatostatin analogue-octr

35、eotidenPsychotherapynAlternative medicinelHerbal and natural products(peppermint,caraway)lacupunctureIrritable Bowel Syndrome(IBS)DefinitionnIrritable bowel syndrome(IBS)is a functional GI disorder characterized by abdominal pain or discomfort and altered bowel habits.nWithout demonstrable organic d

36、iseaseEtiology and PathophysiologynPsychological FeaturesnAbnormal motilitynVisceral hypersensitivitynInflammation and bacterianFood intolerancePsychological Features1)Psychological stress exacerbates GI symptoms.2)Psychological disturbances modify the experience of illness and illness behaviors suc

37、h as health care seeking.3)Psychosocial factors affect health status and clinical outcome.nPsychological stress exacerbates GI symptoms in everyone-but to a greater degree in patients with IBSn50%of patients with IBS seen at referral centers meet the criteria for a psychological disordernPatients wi

38、th FGIDs who are non health care seeking do not show more psychological disorder than normalsnChronic illness such as IBS has psychosocial consequencesDrossman DA.Gastroenterology 2006Psychological Features Altered gut reactivity(motility,secretion)in response to luminal(e.g.,meals,gut distention,in

39、flammation,bacterial factors)or provocative environmental(psychosocial stress)stimuli,resulting in symptoms of diarrhea and/or constipation Abnormal motilitynPre-prandial colonic tone and motility is increased in IBS patientsnFGIDs patients like IBS have greater motility response to stressors-both p

40、hysiologic and psychologic when compared to normalVassallo MJ.Mayo Clinic Proc 1992Drossman DA.Gastro 2002 Abnormal motility A hypersensitive gut with enhanced visceral perception and painVisceral hypersensitivity Repetitive rectal balloon inflations lead to a progressive increase in pain that occur

41、s longer and with greater intensity than controlsMunakata K.Gastroenterology 1997Bacterial FloranEradication of small intestinal bacterial overgrowth reduces symptoms of IBSAnderson ML.Am J Gastroenterology 2000nNormalization of lactulose breath testing correlates with symptomatic improvement in IBS

42、Pimentel M.Am J Gastroenterology 2003Inflammationn50%IBS patients have increased activated mucosal inflammatory cellsChadwick VS.Gastroenterology 2002n33%patients with IBS can correlate symptoms to an enteric infectionn25%of patients with an acute enteric infection go on to develop IBS like or dyspe

43、ptic symptomsGwee KA.Gut 1999The main types of food sensitivityFood IntolerancePrevalenceDairy Intolerance(includes Lactose intolerance)75%3 in 4 peopleYeast sensitivity(eg.Candida infections)33%1 in 3 peopleGluten sensitivity(Wheat intolerance)15%1 in 7 peopleFructose or Sugar sensitivity35%1 in 3

44、peopleFood allergy1%1 in 100 peoplehttp:/ presentationsnAbdominal discomfort or pain nDisordered defecationIBS pain is associated with defecation or a change in bowel function and can occur throughout the abdomen:Upper abdomen pain is often associated with bloating and may worsen after meals.Crampin

45、g can occur around the belly button and through the lower abdomen.Lower abdomen pain is most likely to be eased by a bowel movement.Common descriptions of IBS pain are:lTwingy,crampy lStitch-like lSharp and stabbing lConstant abdominal aching lTenderness when abdomen is touched lBloating discomfort

46、The severity of IBS pain can also be very changeable.Pain can range from mild to unbearable and be constant.Hard stoolsLoose stoolsROME III subclassificationnIBS-CONSTIPATIONl25%of stools are hard and lumpyl25%of stools are loose and wateryl25%of stools are loose and wateryl25%of stools are hard and

47、 lumpyIBS-Untyped lInsufficient abnormality of stool consistency to meet criteria for IBS-C,D,or MAlarm symptoms and signsnAge 40nUnintentional weight lossnFamily history of GI malignancynSevere unrelenting large volume diarrheanHematocheziaEndoscopyDiagnosisC1.Irritable Bowel SyndromeDiagnostic cri

48、terion*Recurrent abdominal pain or discomfort*at least 3 days/month in the last 3 months associated with two or more of the following:.Improvement with defecation.Onset associated with a change in frequency of stool.Onset associated with a change in form(appearance)of stool*Criterion fulfilled for t

49、he last 3 months with symptom onsetat least 6 months prior to diagnosis*“Discomfort”means an uncomfortable sensation not described as pain.nRome III criteriaTreatmentnEducation and Psychological supportnDietary modificationsnDrug therapyEducation and Psychological supportnMost patients(70%)respond t

50、o psychological supportnClearly convey“You have IBS”nThis is a chronic diseasenThere is help with management but no known curenThis disease will not shorten your life span or lead to any other complicating illnessIt can be hard to know which foods may be trigger foods for GI upset and IBS.Just as ev