厭食和惡病質(zhì)綜合征的處理

厭食和惡病質(zhì)綜合征的處理癥狀處理的學(xué)問：EEMMATheScienceofSymptom

Management:EEMMAEvaluation[assessment]評估Explanation解釋Management[treatment]治療Monitoring監(jiān)護(hù)Attentiontodetail注意細(xì)節(jié)2癥狀處理

SymptomManagement敬告！并不總是能完全緩解癥狀Warning!

Cannotalwaysrelievesymptomscompletely替代目標(biāo)：幫助患者更多地感覺到癥狀受到控制從而更少地感到被疾病所壓倒Alternativeaim:helpingapatienttofeelmoreincontrolandthereforelessoverwhelmed3

癌癥衰弱

cancer debility

治療并發(fā)疾病treatment concurrent disorder癥狀的原因

CausesofSymptoms在癌癥晚期，癥狀常常由多種原因引起Inadvancedcancer,symptomsoftenhavemultiplecauses4癥狀的原因

CausesofSymptoms

臨床診斷基于：Clinicaldiagnosisbasedon:可能性probability對病程的認(rèn)識patternrecognition

5“我沒有胃口”

‘Ihavenoappetite’鑒別診斷Differentialdiagnosis:1.厭食（對食物不感興趣）或只有早飽感（覺得食物誘人但患者在吃了幾口以后就覺得飽脹）2.原發(fā)性厭食（惡病質(zhì)綜合征）或繼發(fā)性厭食3.軀體的（例如，引起嘔吐）或精神心理的（例如,感到抑郁）

1.Anorexia(notinterestedinfood)or

earlysatiety

alone(thethoughtoffoodisappealingbutthepersonfeelsfullafterafewmouthfuls)2.Primaryanorexia(cachexiasyndrome)orsecondaryanorexia3.Physical(e.g.nauseated)orpsychological(e.g.depressed)6繼發(fā)性厭食

SecondaryAnorexiaFatigue疲勞Nausea惡心Malodour惡臭Alteredtaste味覺改變Gastricstasis,e.g.constipation胃停滯，

例如便秘Oropharyngealpathology口咽部疾病Pain疼痛7早飽感

EarlySatiety

Gastricstasis胃停滯Post-gastrectomy胃切除術(shù)后Massivehepatomegaly

巨大型肝腫大Massiveascites

大量腹水8胃停滯（胃排空延遲）

GastricStasis(DelayedGastricEmptying)在晚期癌癥中常見:癥狀：早飽+/-,上腹飽脹，返酸，呃逆，噯氣，惡心，嘔吐體征：振水音？Commoninadvancedcancer:Symptoms:earlysatiety+/-,epigastricfullness,acidreflux,hiccup,belching,nausea,vomitingSigns:succussionsplash9胃停滯的原因

CausesofGastricStasis

失動力型消化不良Dysmotilitydyspepsia

便秘Constipation藥物，例如阿片類，抗毒蕈堿類藥Drugs,e.g.opioids,antimuscarinics胰頭癌Cancerofheadofpancreas引起神經(jīng)病變的腹膜后癌Retroperitonealcancercausingneuropathy瘤旁自主性神經(jīng)病變Paraneoplasticautonomicneuropathy脊髓壓迫綜合征Spinalcordcompression10評估

Evaluation這是誰的問題？患者的還是親屬的？聆聽患者的和親屬的憂慮WhoseproblemisitThepatient’sorthefamily’sListentothepatient’sandthefamily’sfears11解釋

Explanation對親屬的解釋Explaintothefamily:一個瀕死的病人對食物喪失興趣是正常的itisnormalforadyingpatienttoloseinterestinfood如果可能，在需要時才提供食物（使用微波爐？）ifpossible,providefoodwhenrequested

(usemicrowaveoven)避免如下的情形發(fā)生Situationstobeonthelook-outfor:“他必須吃，否則他會死亡”“Hemusteatorhewilldie”“讓他吃東西是我的工作”“Feedinghimismyjob”

12治療

Management1.糾正可逆轉(zhuǎn)的因素CorrecttheCorrectable2.非藥物治療Non-drugtreatments3.癥狀性藥物治療Symptomaticdrugtreatment13糾正可逆轉(zhuǎn)的因素

CorrecttheCorrectableFatigue:‘smallandoften’疲勞：“少吃多餐”Nausea:anti-emetic惡心：止吐劑Malodour:treatcause惡臭：治療病因Alteredtaste:addseasoning味覺改變：調(diào)味Gastricstasis:prokineticdrug;treatconstipation胃停滯：胃動力藥；治療便秘Oropharyngealpathology:specificadvice口咽部疾?。禾厥饨ㄗhPain:analgesics疼痛：鎮(zhèn)痛劑14胃停滯

GastricStasis

胃動力藥，例如：滅吐靈，嗎叮林不要同時處方胃動力藥和抗毒蕈堿藥，因?yàn)楹笳吒偁幮宰钄辔竸恿λ幍哪憠A能末端的共同通路。Prokineticdrug,e.g.metoclopramide,domperidoneDonotprescribeaprokineticandananti-muscarinicdrugconcurrentlybecausethelattercompetitivelyblocksthecholinergicfinalcommonpathwayoftheprokinetic15非藥物治療

Non-drugtreatments作如下調(diào)整Changesto:環(huán)境environment食譜和烹調(diào)方法dietandcooking使用小餐盤，盛少量食物smallplate,smallquantityoffood16食欲刺激劑

AppetiteStimulants皮質(zhì)激素：有效期僅為數(shù)周Corticosteroid

effectiveforafewweeks強(qiáng)的松龍prednisolone15-30mgq.d.或地塞米松dexamethasone2-4mg

q.d.孕激素：有效期可能為數(shù)月Progestogen

maybeeffectiveformonths例如甲地孕酮megesterol

160-800mg

q.d.

17食欲刺激劑

AppetiteStimulants禁忌用于不伴有厭食的早飽??！!!Contra-indicatedinearlysatietywithoutassociatedanorexia18糖皮質(zhì)激素

Corticosteroids糖皮質(zhì)激素和失活作用協(xié)同激活肌蛋白的分解代謝Corticosteroidsandinactivityactsynergisticallytoactivatemuscle

proteincatabolism

19癌性惡病質(zhì)綜合征

CancerCachexiaSyndrome宿主神經(jīng)內(nèi)分泌、細(xì)胞因子系統(tǒng)與癌源性產(chǎn)物之間復(fù)雜的相互作用引起骨骼肌和脂肪組織的分解Lossofskeletalmuscleandfatcausedbyacomplexinteractionbetweenhostneuro-endocrineandcytokinesystems,andtumour-derivedproducts20惡病質(zhì)

Cachexia也與如下疾病相關(guān)Alsoassociatedwith:人類免疫缺陷病毒/獲得性免疫缺陷綜合征HIV/AIDS慢性阻塞性肺部疾患COPD心衰Cardiacfailure肝臟疾病Liverdisease腎臟疾病Renaldisease類風(fēng)濕性關(guān)節(jié)炎Rheumatoidarthritis21癌性惡病質(zhì)

CancerCachexia基于對病程認(rèn)識的臨床診斷：體重減輕，肌肉萎縮，伴有早飽感的厭食，乏力，疲勞，貧血，水腫Aclinicaldiagnosisbasedonpatternrecognition: weightloss,musclewasting,anorexiawithearlysatiety,weakness,fatigue,anaemia,oedema22癌性惡病質(zhì)

CancerCachexia誘導(dǎo)蛋白分解因子（PIF）proteolysis-inducingfactor(PIF)其他蛋白分解因子otherproteolyticfactors脂動員因子lipid-mobilisingfactor23癌相關(guān)蛋白分解

Cancer-relatedProteolysis末端共同通路：泛肽-蛋白酶體分解系統(tǒng)Finalcommonpathway:ubiquitin-proteasomeproteolyticsystem24

醋酸甲地孕酮治療厭食-惡病質(zhì)綜合征的系統(tǒng)回顧

26項(xiàng)研究，3887例患者

SystematicReviewofMegestrolAcetateintheTreatmentofAnorexia-CachexiaSyndrome26studies,n=3887Lopezetal.JournalofPainandSymptomManagement2004;27:360-6925

甲地孕酮的系統(tǒng)回顧

SystematicReviewofMegestrol

目標(biāo)是End-pointswere:增加食欲increaseinappetite增加體重weightgain,增加生存質(zhì)量increasedqualityoflife與實(shí)質(zhì)體重增加無關(guān)！Nothingaboutincreaseinlean-bodymass!Lopezetal.JPSM2004;27:360-6926魚油中的EPA

EPAinFishOilEPA[廿炭五烯酸]減緩蛋白的分解代謝EPA[eicosa-penta-enoicacid]attenuatesproteincatabolism27晚期癌癥的人工營養(yǎng)和水化

ArtificialNutritionandHydrationinAdvancedCancer生理上好的感覺還是生理上的無效？Physiologicalgoodsenseorphysiologicalfutility28晚期癌癥的人工營養(yǎng)和水化

ArtificialNutritionandHydrationinAdvancedCancer權(quán)衡受益與負(fù)擔(dān)Considerbenefitsandburdens:1.頭頸部癌：由于嚴(yán)重吞咽困難而饑餓的患者Head&neckcancer:patientstarvingbecauseofseveredysphagia2.逼近死亡：喪失興趣和/或惡病質(zhì)的患者Definitelyclosetodeath:patientdisinteresteda