腸易激綜合征的新概念課件

腸易激綜合征的新概念

Newestconceptsinirritablebowelsyndrome

IBS腸易激綜合征的新概念

Newestconceptsin舊概念：

過敏性結(jié)腸炎易激結(jié)腸或黏液性結(jié)腸炎

舊概念：

新概念：一種以腹痛或腹部不適伴排便習(xí)慣改變?yōu)樘卣鞯墓δ苄阅c病

…agroupoffunctionalboweldisordersinwhichdiscomfortorpainisassociatedwithdefecationorachangeinbowelhabit,andwithfeaturesofdisordereddefecation.新概念：一種以腹痛或腹部不適伴排便習(xí)慣改變?yōu)樘卣鞯墓υ摬∪狈山忉尠Y狀的形態(tài)學(xué)改變和生化異常

該病缺乏可解釋癥狀的形態(tài)學(xué)改變和生化異常

PsychologicdisturbancerelatestopatientswhoseephysiciansPsychosocialfactorsinfluencehealthcareseekingIBSNon-patientsnormalIBSpatientsPsychologicdisturbanceIBS-PsychosocialPsychologicdisturbancerelate流行病學(xué)研究西方國家患病率5---24%

美國人群10-20%

就診率30％$80億

國內(nèi)北京潘國宗7.26％廣州陳旻湖5.6％就診率22.4％

流行病學(xué)研究WhatcausesIBS?WhatcausesIBS?DevelopmentofIBSpathophysiology

｛

inflammation5-HTmediatedhypersensitivityandgutmotility

Brain-gutinteractionVisceralhypersensitivityAbnormalmotorfunction195019601970198019902000AbnormalnetworkregulationOfnerve-immune-endocrineIBSmolecularbiology…….DevelopmentofIBSIBS發(fā)病機制的認識臨床癥狀

腹痛、不適大便異常，流行病學(xué)等第一階段IBS發(fā)病機制的認識臨床癥狀I(lǐng)BS發(fā)病機制的認識臨床癥狀運動異常感覺異常社會心理致病腹痛、不適壓力、電活動大便異常，敏感性、5-HT流行病學(xué)等炎癥、腦腸交流第一階段第二階段IBS發(fā)病機制的認識臨床癥狀VisceralHypersensitivity

hyperalgesiaallodyniaEndogenousModulation.cortex.BrainstemEndorgansensitivity

.silent

nociceptorsSpinalHyperexcitability.NitricoxideActivationLong-termHyperalgesia.toniccorticalregulation.NeuroplasticityEndogenousEndorgansensitivitIBS發(fā)病機制的認識臨床癥狀運動異常感覺異常社會心理致病腹痛、不適壓力、電活動大便異常，敏感性、5-HT流行病學(xué)等炎癥、腦腸交流第一階段第二階段IBS發(fā)病機制的認識臨床癥狀Serotonin(5-HT)inthehumangut

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

Colonictone↓↑Sensation↑?Secretion↑

Serotonin(5-HT)inthehumangIBS發(fā)病機制的認識臨床癥狀運動異常感覺異常社會心理致病腹痛、不適壓力、電活動大便異常，敏感性、5-HT流行病學(xué)等炎癥、腦腸交流第一階段第二階段IBS發(fā)病機制的認識臨床癥狀PsychologicdistressYoungerageDurationofabdominalpainDurationofdiarrheaFemalesFactorsPredictingGISymptomsIBS-PostInfectiousPsychologicYoungerageDuratioIBS發(fā)病機制的認識臨床癥狀運動異常感覺異常社會心理致病腹痛、不適壓力、電活動大便異常，敏感性、5-HT流行病學(xué)等炎癥、腦腸交流第一階段第二階段IBS發(fā)病機制的認識臨床癥狀Mechanosensitive

afferentSensitizedspinalcircuitsDorsalrootganglionRepeatedstimulationMechanosensitive

afferentSensDescendingVisceralPainPathwayThalamusPAGLocuscoeruleusAmygdalaColonSerotonergicNoradrenergicCaudalraphenucleusOpioidergicRostralventralmedullaDescendingVisceralPainPathw腸易激綜合征的新概念課件MotilitySecretionBloodFlowInflammationSightSoundSmellSomatosensoryCognitionAffectViscerosensoryInputIntegrationEffectMotilitySightCognitionViscerosIBS發(fā)病機制的認識臨床癥狀運動異常分子生物學(xué)階段感覺異常網(wǎng)絡(luò)調(diào)控社會心理致病腹痛、不適壓力、電活動大便異常，炎癥、敏感性流行病學(xué)等5-HT、腦腸交流第一階段第二階段第三階段一氧化氮5－HT及受體多巴胺及受體胃腸道激素及受體細胞因子及受體細胞信號轉(zhuǎn)導(dǎo)蛋白離子及離子通道

●●●IBS發(fā)病機制的認識臨床癥狀ExtracellularnetworkregulationNervecellsImmunecellsEndocrinecellsCytokine,receptor,peptide,5-HTExtracellularnetworkregulatiHowtodevelopinaperson?Howtodevelopinaperson?PredisposingfactorsPsycho-PhysiologicaltriggersConcurrentmodifiersBrain-gutdysregulationEarlylifeGeneticvulnerability,EnviromnentegillnessBehaviorreinforcement,abusePredisposingPsycho-ConcurrentPredisposingfactorsPsycho-PhysiologicaltriggersConcurrentmodifiersBrain-gutdysregulationEarlylifeGeneticEnvironmentChronicthreat&prolongedeffortfulcopingEntericInfection/Inflammation/toxins↑↓PredisposingPsycho-ConcurrentPredisposingfactorsPsycho-PhysiologicaltriggersConcurrentmodifiersBrain-gutdysregulationEarlylifeGeneticEnvironmentChronicthreat&prolongedeffortfulcopingEntericInfection/Inflammation/toxins↓Stress-responseneuromodulationPost-infectiveneuromodulationPersonality,emotionalSupport,age,gender,SleepdysfunctionLifeeventstress,Foodallergens,Alteredbowelflora↑PredisposingPsycho-ConcurrentPredisposingfactorsPsycho-PhysiologicaltriggersConcurrentmodifiersBrain-gutdysregulationEarlylifeEntericinfectionInflammation,trauma↓Stress-responseneuromodulationPost-infectiveneuromodulationPersonality,emotionalSupport,age,gender,SleepdysfunctionLifeeventstress,Foodallergens,Alteredbowelflora↑Prolongedthreat&effortfulcopingCNSENSCorticalArousal(anxiety))VisceralhypersensitivityGIsymptomsEIsymptomsIBSDysmotilityAlteredEpithelialpermeabilityPredisposingPsycho-ConcurrentHowtodiagnose？Howtodiagnose？診斷

以癥狀為基礎(chǔ)診斷以癥狀為基礎(chǔ)診斷標(biāo)準(zhǔn)Manning標(biāo)準(zhǔn)1978年RomeI1992年RomeII1999年RomeIII2006年?2003年三月廣州首屆全國IBS會議決定采用國際認同的RomeII診斷標(biāo)準(zhǔn)診斷標(biāo)準(zhǔn)Manning標(biāo)準(zhǔn)1RomeICriteriaRomeIICriteria●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)passageofmucusbloatingorfeelingofabdominaldistentionRomeICriteriaRomeITheRomeIIcriteriaatleast12weeks,whichneednotbeconsecutive,inthepast12months,ofabdominaldiscomfortorpainthathastwoofthreefeaturesRelievedbydefecationonsetassociatedwithchangeinfrequencyonsetassociatedwithchangeinform(appearance)And/orAnd/orTheRomeIIcriteriaatlea支持IBS診斷的癥狀累積大便頻率異常（異常定義為排便每天多于三次及每周少于三次）大便性狀異常（粗、硬便或稀、水便）排便過程異常（摒力、便急或排便不急感）粘液便氣脹或腹脹感功能性腸病的診斷均假設(shè)癥狀沒有結(jié)構(gòu)性和生化性解釋支持IBS診斷的癥狀累積大便頻率異常（異常定義為排便每天多于該診斷的體現(xiàn)的幾個重要原則診斷應(yīng)建立在排除器質(zhì)性疾病的基礎(chǔ)上IBS屬于腸道功能性疾病強調(diào)腹痛或腹部不適與排便的關(guān)系，體現(xiàn)IBS作為一個特定的癥候群有別于其他腸道功能行疾病（如功能性腹瀉、功能性便秘、功能性腹痛等）該診斷標(biāo)準(zhǔn)將判斷的時間延長至12個月，規(guī)定其間至少有12周時間有癥狀，但可以不連續(xù)，反應(yīng)了本病慢性、反復(fù)發(fā)作的特點，可使器質(zhì)性疾病特別是腸道腫瘤的漏診幾率降低該診斷標(biāo)準(zhǔn)在必備條件中沒有對排便次數(shù)和糞便性狀作硬性規(guī)定，只強調(diào)腹痛或腹部不適伴有排便次數(shù)和糞便性狀的改變，可使更多病例得到診斷，提高診斷的敏感性。該診斷的體現(xiàn)的幾個重要原則診斷應(yīng)建立在排除器質(zhì)性疾病的基礎(chǔ)上表現(xiàn)分型分型依據(jù)的癥狀：

①每周排便<3次；②每天排便>3次；

③塊狀或硬便；④稀爛便或水樣便；

⑤排便費力；⑥排便急迫感。表現(xiàn)分型分型依據(jù)的癥狀：表現(xiàn)分型●分型依據(jù)的癥狀：

①每周排便<3次；②每天排便>3次；

③塊狀或硬便；④稀爛便或水樣便；

⑤排便費力；⑥排便急迫感?！癖忝貫橹餍突颌佗邰蓓椫兄豁椈蛞陨?，而無②④⑥項①③⑤項中之二項或以上，可伴有②④⑥中之一項表現(xiàn)分型●分型依據(jù)的癥狀：●便秘為主型或①③⑤項中之表現(xiàn)分型●分型依據(jù)的癥狀：①每周排便<3次；②每天排便>3次；③塊狀或硬便；④稀爛便或水樣便；⑤排便費力；⑥排便急迫感。●腹瀉為主型②④⑥項中之一項或以上，而無①③⑤項或②④⑥項中之二項或以上，可伴有①⑤中一項，但無③項表現(xiàn)分型●分型依據(jù)的癥狀：●腹瀉為主型②④⑥項表現(xiàn)分型●分型依據(jù)的癥狀：①每周排便<3次；②每天排便>3次；③塊狀或硬便；④稀爛便或水樣便；⑤排便費力；⑥排便急迫感?！窀篂a便秘交替型①②③④⑤⑥表現(xiàn)分型●分型依據(jù)的癥狀：●腹瀉便秘交替型①②③④診斷流程

問診＋查體

發(fā)熱、消瘦、便血、腹部包塊診斷流程發(fā)熱、消瘦、便血、腹部包塊診斷流程

問診＋查體

有無

發(fā)熱、消瘦、便血、腹部包塊徹底檢查近期排便習(xí)慣改變、腫瘤家族史、>40歲診斷流程有診斷流程

問診＋查體

有無

發(fā)熱、消瘦、便血、腹部包塊徹底檢查近期排便習(xí)慣改變、腫瘤家族史、>40歲

腸鏡或鋇灌腸

大便常規(guī)＋OB是

否診斷流程有Whatisthebestmanagementapproach?Whatisthebestmanagementap治療

個體化、綜合治療治療個體化、治療原則AcomprehensivemulticomponentapproachTreatmentprogramisbasedondominantsymptomandtheirseverity,andonpsychosocialfactors,andetiologicalfactors治療原則AcomprehensivemulticompoDrugsfordominantinIBSAbdominalpainAntispasmodicsTricyclicAntidepressantsSSRI

Diarrhea

ConstipationFiberOsmoticlaxativesTegaserodPEGsolutionLoperamideCholestyramineDiphenoxylateDrugsfordominantinIBSAbdom治療原則AcomprehensivemulticomponentapproachTreatmentprogramisbasedondominantsymptomandtheirseverity,andonpsychosocialfactors,andetiologicalfactors治療原則Acomprehensivemulticompo

MildLifestyleanddietarymodificationSevereRealisticgoalsAntidepressantsReferralforpainmanagementModerateGutactingagentsPsychologic(motility/sensation)treatmentsAllTherapeuticrelationship/continuityofcareeducation/reassurance

治療原則AcomprehensivemulticomponentapproachTreatmentprogramisbasedondominantsymptomandtheirseverity,andonpsychosocialfactors,andetiologicalfactors治療原則Acomprehensivemulticompo心理治療Whatcanwedo?Howtodo?心理治療Whatcanwedo?心理治療

第一層次：一般性心理治療或支持性心理治療（supportivepsychotherapy）第二層次：心理治療干預(yù)(psychotherapeuticintervention)心理治療第一層次：一般性心理治療或支持性心理治療（suDefinition

Pathogenesis

Diagnosis

TreatmentDefinition

Pathogenesis

Diagno謝謝謝謝腸易激綜合征的新概念

Newestconceptsinirritablebowelsyndrome

IBS腸易激綜合征的新概念

Newestconceptsin舊概念：

過敏性結(jié)腸炎易激結(jié)腸或黏液性結(jié)腸炎

舊概念：

新概念：一種以腹痛或腹部不適伴排便習(xí)慣改變?yōu)樘卣鞯墓δ苄阅c病

…agroupoffunctionalboweldisordersinwhichdiscomfortorpainisassociatedwithdefecationorachangeinbowelhabit,andwithfeaturesofdisordereddefecation.新概念：一種以腹痛或腹部不適伴排便習(xí)慣改變?yōu)樘卣鞯墓υ摬∪狈山忉尠Y狀的形態(tài)學(xué)改變和生化異常

該病缺乏可解釋癥狀的形態(tài)學(xué)改變和生化異常

PsychologicdisturbancerelatestopatientswhoseephysiciansPsychosocialfactorsinfluencehealthcareseekingIBSNon-patientsnormalIBSpatientsPsychologicdisturbanceIBS-PsychosocialPsychologicdisturbancerelate流行病學(xué)研究西方國家患病率5---24%

美國人群10-20%

就診率30％$80億

國內(nèi)北京潘國宗7.26％廣州陳旻湖5.6％就診率22.4％

流行病學(xué)研究WhatcausesIBS?WhatcausesIBS?DevelopmentofIBSpathophysiology

｛

inflammation5-HTmediatedhypersensitivityandgutmotility

Brain-gutinteractionVisceralhypersensitivityAbnormalmotorfunction195019601970198019902000AbnormalnetworkregulationOfnerve-immune-endocrineIBSmolecularbiology…….DevelopmentofIBSIBS發(fā)病機制的認識臨床癥狀

腹痛、不適大便異常，流行病學(xué)等第一階段IBS發(fā)病機制的認識臨床癥狀I(lǐng)BS發(fā)病機制的認識臨床癥狀運動異常感覺異常社會心理致病腹痛、不適壓力、電活動大便異常，敏感性、5-HT流行病學(xué)等炎癥、腦腸交流第一階段第二階段IBS發(fā)病機制的認識臨床癥狀VisceralHypersensitivity

hyperalgesiaallodyniaEndogenousModulation.cortex.BrainstemEndorgansensitivity

.silent

nociceptorsSpinalHyperexcitability.NitricoxideActivationLong-termHyperalgesia.toniccorticalregulation.NeuroplasticityEndogenousEndorgansensitivitIBS發(fā)病機制的認識臨床癥狀運動異常感覺異常社會心理致病腹痛、不適壓力、電活動大便異常，敏感性、5-HT流行病學(xué)等炎癥、腦腸交流第一階段第二階段IBS發(fā)病機制的認識臨床癥狀Serotonin(5-HT)inthehumangut

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

Colonictone↓↑Sensation↑?Secretion↑

Serotonin(5-HT)inthehumangIBS發(fā)病機制的認識臨床癥狀運動異常感覺異常社會心理致病腹痛、不適壓力、電活動大便異常，敏感性、5-HT流行病學(xué)等炎癥、腦腸交流第一階段第二階段IBS發(fā)病機制的認識臨床癥狀PsychologicdistressYoungerageDurationofabdominalpainDurationofdiarrheaFemalesFactorsPredictingGISymptomsIBS-PostInfectiousPsychologicYoungerageDuratioIBS發(fā)病機制的認識臨床癥狀運動異常感覺異常社會心理致病腹痛、不適壓力、電活動大便異常，敏感性、5-HT流行病學(xué)等炎癥、腦腸交流第一階段第二階段IBS發(fā)病機制的認識臨床癥狀Mechanosensitive

afferentSensitizedspinalcircuitsDorsalrootganglionRepeatedstimulationMechanosensitive

afferentSensDescendingVisceralPainPathwayThalamusPAGLocuscoeruleusAmygdalaColonSerotonergicNoradrenergicCaudalraphenucleusOpioidergicRostralventralmedullaDescendingVisceralPainPathw腸易激綜合征的新概念課件MotilitySecretionBloodFlowInflammationSightSoundSmellSomatosensoryCognitionAffectViscerosensoryInputIntegrationEffectMotilitySightCognitionViscerosIBS發(fā)病機制的認識臨床癥狀運動異常分子生物學(xué)階段感覺異常網(wǎng)絡(luò)調(diào)控社會心理致病腹痛、不適壓力、電活動大便異常，炎癥、敏感性流行病學(xué)等5-HT、腦腸交流第一階段第二階段第三階段一氧化氮5－HT及受體多巴胺及受體胃腸道激素及受體細胞因子及受體細胞信號轉(zhuǎn)導(dǎo)蛋白離子及離子通道

●●●IBS發(fā)病機制的認識臨床癥狀ExtracellularnetworkregulationNervecellsImmunecellsEndocrinecellsCytokine,receptor,peptide,5-HTExtracellularnetworkregulatiHowtodevelopinaperson?Howtodevelopinaperson?PredisposingfactorsPsycho-PhysiologicaltriggersConcurrentmodifiersBrain-gutdysregulationEarlylifeGeneticvulnerability,EnviromnentegillnessBehaviorreinforcement,abusePredisposingPsycho-ConcurrentPredisposingfactorsPsycho-PhysiologicaltriggersConcurrentmodifiersBrain-gutdysregulationEarlylifeGeneticEnvironmentChronicthreat&prolongedeffortfulcopingEntericInfection/Inflammation/toxins↑↓PredisposingPsycho-ConcurrentPredisposingfactorsPsycho-PhysiologicaltriggersConcurrentmodifiersBrain-gutdysregulationEarlylifeGeneticEnvironmentChronicthreat&prolongedeffortfulcopingEntericInfection/Inflammation/toxins↓Stress-responseneuromodulationPost-infectiveneuromodulationPersonality,emotionalSupport,age,gender,SleepdysfunctionLifeeventstress,Foodallergens,Alteredbowelflora↑PredisposingPsycho-ConcurrentPredisposingfactorsPsycho-PhysiologicaltriggersConcurrentmodifiersBrain-gutdysregulationEarlylifeEntericinfectionInflammation,trauma↓Stress-responseneuromodulationPost-infectiveneuromodulationPersonality,emotionalSupport,age,gender,SleepdysfunctionLifeeventstress,Foodallergens,Alteredbowelflora↑Prolongedthreat&effortfulcopingCNSENSCorticalArousal(anxiety))VisceralhypersensitivityGIsymptomsEIsymptomsIBSDysmotilityAlteredEpithelialpermeabilityPredisposingPsycho-ConcurrentHowtodiagnose？Howtodiagnose？診斷

以癥狀為基礎(chǔ)診斷以癥狀為基礎(chǔ)診斷標(biāo)準(zhǔn)Manning標(biāo)準(zhǔn)1978年RomeI1992年RomeII1999年RomeIII2006年?2003年三月廣州首屆全國IBS會議決定采用國際認同的RomeII診斷標(biāo)準(zhǔn)診斷標(biāo)準(zhǔn)Manning標(biāo)準(zhǔn)1RomeICriteriaRomeIICriteria●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)passageofmucusbloatingorfeelingofabdominaldistentionRomeICriteriaRomeITheRomeIIcriteriaatleast12weeks,whichneednotbeconsecutive,inthepast12months,ofabdominaldiscomfortorpainthathastwoofthreefeaturesRelievedbydefecationonsetassociatedwithchangeinfrequencyonsetassociatedwithchangeinform(appearance)And/orAnd/orTheRomeIIcriteriaatlea支持IBS診斷的癥狀累積大便頻率異常（異常定義為排便每天多于三次及每周少于三次）大便性狀異常（粗、硬便或稀、水便）排便過程異常（摒力、便急或排便不急感）粘液便氣脹或腹脹感功能性腸病的診斷均假設(shè)癥狀沒有結(jié)構(gòu)性和生化性解釋支持IBS診斷的癥狀累積大便頻率異常（異常定義為排便每天多于該診斷的體現(xiàn)的幾個重要原則診斷應(yīng)建立在排除器質(zhì)性疾病的基礎(chǔ)上IBS屬于腸道功能性疾病強調(diào)腹痛或腹部不適與排便的關(guān)系，體現(xiàn)IBS作為一個特定的癥候群有別于其他腸道功能行疾?。ㄈ绻δ苄愿篂a、功能性便秘、功能性腹痛等）該診斷標(biāo)準(zhǔn)將判斷的時間延長至12個月，規(guī)定其間至少有12周時間有癥狀，但可以不連續(xù)，反應(yīng)了本病慢性、反復(fù)發(fā)作的特點，可使器質(zhì)性疾病特別是腸道腫瘤的漏診幾率降低該診斷標(biāo)準(zhǔn)在必備條件中沒有對排便次數(shù)和糞便性狀作硬性規(guī)定，只強調(diào)腹痛或腹部不適伴有排便次數(shù)和糞便性狀的改變，可使更多病例得到診斷，提高診斷的敏感性。該診斷的體現(xiàn)的幾個重要原則診斷應(yīng)建立在排除器質(zhì)性疾病的基礎(chǔ)上表現(xiàn)分型分型依據(jù)的癥狀：

①每周排便<3次；②每天排便>3次；

③塊狀或硬便；④稀爛便或水樣便；

⑤排便費力；⑥排便急迫感。表現(xiàn)分型分型依據(jù)的癥狀：表現(xiàn)分型●分型依據(jù)的癥狀：

①每周排便<3次；②每天排便>3次；

③塊狀或硬便；④稀爛便或水樣便；

⑤排便費力；⑥排便急迫感?！癖忝貫橹餍突颌佗邰蓓椫兄豁椈蛞陨?，而無②④⑥項①③⑤項中之二項或以上，可伴有②④⑥中之一項表現(xiàn)分型●分型依據(jù)的癥狀：●便秘為主型或①③⑤項中之表現(xiàn)分型●分型依據(jù)的癥狀：①每周排便<3次；②每天排便>3次；③塊狀或硬便；④稀爛便或水樣便；⑤排便費力；⑥排便急迫感?！窀篂a為主型②④⑥項中之一項或以上，而無①③⑤項或②④⑥項中之二項或以上，可伴有①⑤中一項，但無③項表現(xiàn)分型●分型依據(jù)的癥狀：●腹瀉為主型②④⑥項表現(xiàn)分型●分型依據(jù)的癥狀：①每周排便<3次；