肠易激综合征的新概念课件

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,肠易激综合征的新概念,Newest concepts in irritable bowel syndromeIBS,肠易激综合征的新概念Newest concepts in,旧概念,：,过敏性结肠炎,易激结肠,或黏液性结肠炎,旧概念：,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.,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,该病缺乏可解释症状的形态学改变和生化异常,该病缺乏可解释症状的形态学改变和生化异常,Psychologic disturbance relates,to patients who see physicians,Psychosocial factors influence,health care seeking,IBS Non-patients,normal,IBS patients,Psychologic,disturbance,IBS - Psychosocial,Psychologic disturbance relate,流行病学研究,西方国家 患病率,5-24%,美国 人群,10-20%,就诊率,30,$80,亿,国内,北京 潘国宗,7.26,广州 陈旻湖,5.6,就诊率,22.4,流行病学研究,What causes IBS ?,What causes IBS ?,Development of IBS pathophysiology,inflammation,5-HT mediated hypersensitivity,and gut motility,Brain-gut interaction,Visceral hypersensitivity,Abnormal motor function,1950 1960 1970 1980 1990 2000,Abnormal network regulation,Of nerve-immune-endocrine,IBS molecular biology,.,Development of IBS,IBS,发病机制的认识,临床症状,腹痛、不适,大便异常，,流行病学等,第一阶段,IBS发病机制的认识临床症状,IBS,发病机制的认识,临床症状 运动异常,感觉异常,社会心理致病,腹痛、不适 压力、电活动,大便异常，,敏感性,、,5-HT,流行病学等,炎症,、,脑肠交流,第一阶段 第二阶段,IBS发病机制的认识临床症状,Visceral Hypersensitivity,hyperalgesia,allodynia,Endogenous,Modulation,.cortex,.Brainstem,End,organ sensitivity,.silentnociceptors,Spinal,Hyperexcitability,.Nitric oxide,Activation,Long-term,Hyperalgesia,.,tonic cortical regulation,.Neuroplasticity,EndogenousEnd organ sensitivit,IBS,发病机制的认识,临床症状 运动异常,感觉异常,社会心理致病,腹痛、不适 压力、电活动,大便异常，,敏感性,、,5-HT,流行病学等,炎症,、,脑肠交流,第一阶段 第二阶段,IBS发病机制的认识临床症状,Serotonin(5-HT) in the human gut,5-HT,1,5-HT,3,5-HT,4,Gastric accommodation ,Transit ,Colonic tone ,Sensation ?,Secretion ,Serotonin(5-HT) in the human g,IBS,发病机制的认识,临床症状 运动异常,感觉异常,社会心理致病,腹痛、不适 压力、电活动,大便异常，,敏感性,、,5-HT,流行病学等,炎症,、,脑肠交流,第一阶段 第二阶段,IBS发病机制的认识临床症状,Psychologic,distress,Younger age,Duration of abdominal pain,Duration of diarrhea,Females,Factors Predicting,GI Symptoms,IBS - Post Infectious,Psychologic Younger ageDuratio,IBS,发病机制的认识,临床症状 运动异常,感觉异常,社会心理致病,腹痛、不适 压力、电活动,大便异常，,敏感性,、,5-HT,流行病学等,炎症,、,脑肠交流,第一阶段 第二阶段,IBS发病机制的认识临床症状,Mechanosensitive afferent,Sensitized spinal circuits,Dorsal root ganglion,Repeated stimulation,Mechanosensitive afferentSens,Descending Visceral Pain Pathway,Thalamus,PAG,Locus coeruleus,Amygdala,Colon,Serotonergic,Noradrenergic,Caudal raphe nucleus,Opioidergic,Rostral ventral,medulla,Descending Visceral Pain Pathw,肠易激综合征的新概念课件,Motility,Secretion,Blood Flow,Inflammation,Sight,Sound,Smell,Somatosensory,Cognition,Affect,Viscerosensory,Input,Integration,Effect,MotilitySightCognitionVisceros,IBS,发病机制的认识,临床症状 运动异常 分子生物学阶段,感觉异常,网络调控,社会心理致病,腹痛、不适 压力、电活动,大便异常， 炎症、,敏感性,流行病学等,5-HT,、,脑肠交流,第一阶段 第二阶段 第三阶段,一氧化氮,5,HT,及受体,多巴胺及受体,胃肠道激素及受体,细胞因子及受体,细胞信号转导蛋白,离子及离子通道, ,IBS发病机制的认识临床症状,Extracellular network regulation,Nerve cells,Immune cells,Endocrine cells,Cytokine, receptor, peptide, 5-HT,Extracellular network regulati,How to develop in a person?,How to develop in a person?,Predisposing,factors,Psycho-,Physiological,triggers,Concurrent,modifiers,Brain-gut,dysregulation,Early,life,Genetic vulnerability,Enviromnent eg illness,Behavior reinforcement,abuse,Predisposing Psycho-Concurrent,Predisposing,factors,Psycho-,Physiological,triggers,Concurrent,modifiers,Brain-gut,dysregulation,Early,life,Genetic,Environment,Chronic,threat &,prolonged,effortful,coping,Enteric,Infection/,Inflammation/,toxins,Predisposing Psycho-Concurrent,Predisposing,factors,Psycho-,Physiological,triggers,Concurrent,modifiers,Brain-gut,dysregulation,Early,life,Genetic,Environment,Chronic,threat &,prolonged,effortful,coping,Enteric,Infection/,Inflammation/,toxins,Stress-response,neuromodulation,Post-infective,neuromodulation,Personality, emotional,Support, age, gender,Sleep dysfunction,Life event stress,Food allergens,Altered bowel flora,Predisposing Psycho-Concurrent,Predisposing,factors,Psycho-,Physiological,triggers,Concurrent,modifiers,Brain-gut,dysregulation,Early life,Enteric infection,Inflammation,trauma,Stress-response,neuromodulation,Post-infective,neuromodulation,Personality, emotional,Support, age, gender,Sleep dysfunction,Life event stress,Food allergens,Altered bowel flora,Prolonged threat,&effortful coping,CNS,ENS,Cortical,Arousal,(anxiety),),Visceral,hypersensitivity,GI symptoms,EI symptoms,IBS,Dysmotility,Altered,Epithelial,permeability,Predisposing Psycho-Concurrent,How to diagnose,？,How to diagnose ？,诊断,以症状为基础,诊断 以症状为基础,诊断标准,Manning,标准,1978,年,Rome I 1992,年,Rome II 1999,年,Rome III 2006,年,?,2003,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,诊断标准Manning标准 1,Rome I Criteria Rome II Criteria,at least 12 weeks, which need not be consecutive, in the past 12 months, of abdominal discomfort or pain that has two of three features,-relieved by defecation; and/or,-onset associated with a change in frequency of stool; and/or,-onset associated with a change in form(appearance) of stool,At least 3 months continuous / recurrent symptoms of the following,-Abdominal pain or discomfort that is,-associated with a change in frequency of stool and/or,-associated with a change in consistency of stool; and,Two or more of the following at least 25% of the time,altered stool frequency (3/day or 3/week),altered stool passage (straining, urgency),passage of mucus,bloating or feeling of abdominal distention,Rome I Criteria Rome I,The Rome II criteria,at least 12 weeks, which need not be consecutive, in the past 12 months, of abdominal discomfort or pain that has two of three features,Relieved,by,defecation,onset,associated with,change in,frequency,onset,associated with,change in form,(appearance),And/or,And/or,The Rome II criteria at lea,支持,IBS,诊断的症状累积,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）,大便性状异常（粗、硬便或稀、水便）,排便过程异常（摒力、便急或排便不急感）,粘液便,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释,支持IBS诊断的症状累积大便频率异常（异常定义为排便每天多于,该诊断的体现的几个重要原则,诊断应建立在,排除器质性疾病,的基础上,IBS,属于肠道,功能性,疾病,强调腹痛或腹部不适与排便的关系,，体现,IBS,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、功能性腹痛等）,该诊断标准将判断的时间延长至,12,个月，规定其间至少有,12,周时间有症状，但可以不连续，反应了本病慢性、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,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粪便性状的改变，可使更多病例得到诊断，提高,诊断的敏感性,。,该诊断的体现的几个重要原则诊断应建立在排除器质性疾病的基础上,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。,表现分型分型依据的症状：,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。,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,表现分型分型依据的症状： 便秘为主型或 项中之,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。,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,表现分型分型依据的症状： 腹泻为主型 项,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。,腹泻便秘交替型, ,表现分型分型依据的症状： 腹泻便秘交替型 ,诊断流程,问诊查体,发热、消瘦、便血、腹部包块,诊断流程 发热、消瘦、便血、腹部包块,诊断流程,问诊查体,有 无,发热、消瘦、便血、腹部包块,彻底检查,近期排便习惯改变、肿瘤家族史、,40,岁,诊断流程 有,诊断流程,问诊查体,有 无,发热、消瘦、便血、腹部包块,彻底检查,近期排便习惯改变、肿瘤家族史、,40,岁,肠镜或钡灌肠,大便常规,OB,是,否,诊断流程 有,What is the best management approach?,What is the best management ap,治疗,个体化、综合治疗,治疗 个体化、,治疗原则,A comprehensive multicomponent approach,Treatment program is based on,dominant symptom,and their,severity, and on,psychosocial factors, and etiological factors,治疗原则A comprehensive multicompo,Drugs for dominant in IBS,Abdominal,pain,Antispasmodics,Tricyclic,Antidepressants,SSRI,Diarrhea,Constipation,Fiber,Osmotic laxatives,Tegaserod,PEG solution,Loperamide,Cholestyramine,Diphenoxylate,Drugs for dominant in IBSAbdom,治疗原则,A comprehensive multicomponent approach,Treatment program is based on,dominant symptom,and their,severity, and on,psychosocial factors, and etiological factors,治疗原则A comprehensive multicompo,Mild Lifestyle and dietary modification,Severe Realistic goals,Antidepressants,Referral for pain management,Moderate Gut acting agents Psychologic,(motility/sensation) treatments,All,Therapeutic relationship/continuity of care education/reassurance,治疗原则,A comprehensive multicomponent approach,Treatment program is based on,dominant symptom,and their,severity, and on,psychosocial factors, and etiological factors,治疗原则A comprehensive multicompo,心理治疗,What can we do?,How to do?,心理治疗 What can we do?,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),心理治疗 第一层次：一般性心理治疗或支持性心理治疗（su,DefinitionPathogenesisDiagnosisTreatment,DefinitionPathogenesisDiagno,谢谢,谢谢,