Functional gastrointestinal disorders (??????)

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Functional gastrointestinal disorders(??????)

• Yu Baoping (???)

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FGIDs including
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Rome III Functional Gastrointestinal Disorders
(adult)

• A. Functional esophageal disorders
• A1. Functional heartburn
• A2. Functional chest pain of presumed
  esophageal origin
• A3. Functional dysphagia
• A4. Globus
• B. Functional gastroduodenal disorders
• B1. Functional dyspepsia
• B1a. Postprandial distress syndrome
• B1b. Epigastric pain syndrome
• B2. Belching disorders
• B2a. Aerophagia
• B2b. Unspecified excessive belching
• B3. Nausea and vomiting disorders
• B3a. Chronic idiopathic nausea
• B3b. Functional vomiting
• B3c. Cyclic vomiting syndrome
• B4. Rumination syndrome in adults
• C. Functional bowel disorders
• C1. Irritable bowel syndrome

• C4. Functional diarrhea
• C5. Unspecified functional bowel disorder
• D. Functional abdominal pain syndrome
• E. Functional gallbladder and Sphincter of Oddi
  (SO) disorders
• E1. Functional gallbladder disorder
• E2. Functional biliary SO disorder
• E3. Functional pancreatic SO disorder
• F. Functional anorectal disorders
• F1. Functional fecal incontinence
• F2. Functional anorectal pain
• F3. Functional defecation disorders

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FGID???III????(??)

• A. ??????
• A1. ?????
• A2. ?????????
• A3. ???????
• A4. ???
• B. ?????????
• B1. ???????
• B2. ??????
• B3. ?????????
• B4. ???????
• C. ?????
• C1. ??????
• C2. ?????
• C3. ?????
• C4. ?????
• C5. ?????????

• D. ????????
• E. ???Oddi???????
• E1. ??????
• E2. ??Oddi???????
• E3. ??Oddi???????
• F. ????????
• F1. ???????
• F2. ?????????
• F3. ???????

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Rome III Functional Gastrointestinal Disorders
(children and adolescents)

• G. Functional disorders neonates and toddlers
• G1. Infant regurgitation
• G2. Infant rumination syndrome
• G3. Cyclic vomiting syndrome
• G4. Infant colic
• G5. Functional diarrhea
• G6. Infant dyschezia
• G7. Functional constipation

• H. Functional disorders children and adolescents
• H1. Vomiting and aerophagia
• H1a. Adolescent rumination syndrome
• H1b. Cyclic vomiting syndrome
• H1c. Aerophagia
• H2. Abdominal pain-related functional
  gastrointestinal disorders
• H2a. Functional dyspepsia
• H2b. Irritable bowel syndrome
• H2c. Abdominal migraine(???)
• H2d. Childhood functional bdominal pain
• H2d1. Childhood functional abdominal pain
  syndrome
• H3. Constipation and incontinence

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FGID???III????(??)

• G. ???????????
• G1. ????
• G2. ???????
• G3. ????????
• G4. ????
• G5. ?????
• G6. ??????
• G7. ?????
• H. ???????????
• H1. ??????
• H1a. ????????
• H1b. ????????
• H1c. ???

• H2. ???????????
• H2a. ???????
• H2b. ??????
• H2c. ?????
• H2d. ???????
• H2d1.??????????
• H3. ?????
• H3a. ?????
• H3b. ????????

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Pathophysiology of FGIDs

• Genetic Predispositions
• Early Family Environment
• Psychosocial Factors
• Abnormal Motility
• Visceral Hypersensitivity
• Inflammation
• Bacterial Flora

• Brain-Gut Interactions via the CNS-ENS
• -Bidirectional hardwiring of brain-gut axis
• -Stress and postinfectious FGID
• -Brain imaging
• -Brain-gut peptides.

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Brain-Gut Axis
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Biopsychosocial Conceptualization
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FGID?????????

• FGID?????????
• FD?IBS???????????FGID?2??????,???????????
• ??????????????????????????????FD????
• ???????????IBS?????

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??-???????????

• ????????,FD?IBS?????????????????????????????????
  ???????????????????
• ????,?????????????????????????,???????????????????
  ????
• ??-???????-????????????

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?????????

• ??????,FD????????????????????????????
• IBS???????????????????
• ??????????????,????????????FD?IBS?????

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?????????

• FGID????????????????????,?????????????
• ?????????????????????????,???????????????????????
• ??????????,??????????,??????????
• ???????????????????,????????????????

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5-???(5-HT)???????????????

• ??????????????????,????(enkaphalins)????P
  ???????????????(CCK)?????(neurokinin)?????????????
  (corticotropin-releasing factor, CRF)?
• ??5-HT???????????,???????????????????????
• 95?5-HT??????,????????,??CRF?5-HT????????????????
  ??

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?????????

• ?1/3?IBS?FD???????????????????????,?????????????
  ????????????????
• IBS?????????????,?????????????
• ?????????????????

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• Functional dyspepsia ,FD
• (???????)

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Case

• An 28-year-old men was referred to our unit with
  a history of recurrent epigastric pain and
  vomiting. These episodes started 12 months prior
  to the visit in our unit and recurred every one
  to two weeks. Abdominal pain was relieved by
  vomiting. He had been suffering also from nausea,
  occasional episodes of regurgitation, and loss of
  appetite. In the patients laboratory studies did
  not reveal signs of malnutrition or inflammation
  and upper gastrointestinal x-ray examination
  with barium was negative for mucosal pattern and
  transit furthermore, the endoscopy excluded
  focal mucosal lesions of the esophagus,
  stomach, and duodenum, as well as Helicobacter
  pylori infection.

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Question to Consider

• Case Study ? What is the diagnosis of the
• patients? Why?
• ? How should the case be
• evaluated and
  treated?

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(No Transcript)
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Etiology and Pathogenesis
Functional Dyspepsia (FD)
Helicobacter pylori
Functional Dysoeosia (FD)
Chronic inflammation
Gastrointestinal dyskinesis
psycho- social psychic factor
gastric acid
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????????????????????
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Gastric Antrum?duodenum asynchronism
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delayed gastric emptying of dyspepsia

• solid

RefA.J.P.M.???,L.M.A.???,??????
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Clinical manifestation of Gastric Emptying delayed
superior belly expend
nausea?vomiting
belching
satiety
upper abdominal pain after meal
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clinical manifestation

• upper abdominal pain
• superior belly expend
• Satiety
• Belching
• Nausea
• Vomiting
• mainly one or a group of symptoms
• variety of symptoms in the development of
  disease

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Dyspeptic symptoms and their definitions

• Symptom
  Definition
• Epigastric pain Epigastric 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
• patient as
  pain.
• Epigastric burning Burning refers to an
  unpleasant subjective sensation of heat.
• Postprandial fullness An unpleasant sensation
  like the prolonged persistence of food
• in the
  stomach
• Early 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
  sensation of appetite during food ingestion.

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Diagnosis

• Diagnostic Criteria for Functional Dyspepsia(The
  Rome III)
• Must include
• 1. One or more of
• a. Bothersome postprandial fullness
• b. Early satiation
• c. Epigastric pain
• d. Epigastric burning
• AND
• 2. No evidence of structural disease
  (including at upper
• endoscopy) that is likely to explain the
  symptoms
• Criteria fulfilled for the last 3 months with
  symptom onset
• at least 6 months before diagnosis

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??III(2006)?FD?????

• ????????????????????????(?4?????1?),??????????????
  ?????
• ??????????6???????????

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Subtyping FD

• The Rome II
• B1. Functional dyspepsia
• B1a. Ulcer-like dyspepsia
• B1b. Dysmotility-like
• dyspepsia
• B1c. Unspecified (non-
• specific) dyspepsia

• The Rome III
• B1. Functional dyspepsia
• B1a. Postprandial
• distress syndrome
• (PDS)
• B1b. Epigastric pain
• syndrome (EPS)

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Diagnostic Criteria for PostprandialDistress
Syndrome (PDS)

• Must include one or both of the following
• 1. Bothersome postprandial fullness, occurring
  after ordinary sized meals, at least several
  times per week
• 2. Early satiation that prevents finishing a
• regular meal, at least several times per week
• Criteria fulfilled for the last 3 months with
  symptom onsetat least 6 months before diagnosis
• Supportive criteria
• 1. Upper abdominal bloating or postprandial
  nausea
• or excessive belching can be present
• 2. EPS may coexist

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???????(PDS)

• ?????1??2?,?
• 1. ?????????????????,
• ??????
• ????????????????,?
• ?????
• ??????????????,??
• ???,??????EPS

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Diagnostic Criteria for Epigastric PainSyndrome
(PDS)

• Must include all of the following
• 1. Pain or burning localized to the epigastrium
  of at least moderate severity at least once per
  week
• 2. The pain is intermittent
• 3. Not generalized or localized to other
  abdominalor chest regions
• 4. Not relieved by defecation or passage of
  flatus
• 5. Not fulfilling criteria for gallbladder
  andsphincter of Oddi disorders
• Criteria fulfilled for the last 3 months with
  symptom onsetat least 6 months before diagnosis
• Supportive criteria
• 1. The pain may be of a burning quality but
  withouta retrosternal component
• 2. The pain is commonly induced or relieved by
  ingestion of a meal but may occur while fasting
• 3. Postprandial distress syndrome

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???????(EPS)

• ???????,?
• 1. ????????????????,????1?
• 2. ??????
• 3. ??????????????/????
• 4. ?????????
• 5. ??????Oddi????????????
• ??????????,????????,???????????,??????????,???????
  ?PDS

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Differential Diagnosis(????)

• ???????????,?????????????????????,??????????
• FD???????

• Patients with dyspepsia may have underlying
  structural disease e.g peptic ulcer disease,
  reflux oesophagitis, gastritis, cancer.However,
  the majority of dyspeptic patients have no
  structural disease. Most of them have problems
  with the functioning of the organs e.g stomach,
  colon.Patients with gastointestinal symptoms
  with no underlying structural disease is said to
  be suffering from Functional Dyspepsia (FD)

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Therapy

• General treatment
• Reassurance and explanation represent the first
  manageme-
• nt step and may be sufficient in many
  patients
• Stopping smoking and ceasing consumption of
  coffee, alcohol, or NSAIDs
• ???????????????????

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pharmacotherapy

• Acid suppression is safe and remains first-line
  therapy in the absence of Hpylori infection
• A Cochrane meta-analysis reported an 8 pooled
  relative-risk reduction with eradication of H
  pylori
• Prokinetic drugs like metoclopramide(???),
  domperidone, and cisapride appear efficacious in
  functional dyspepsia
• antidepressants

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? ? ? ? ? ? ? ? ?
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Irritable bowel syndrome, IBS(??????)

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Case Study

• A 28-year-old woman presents with a 7-month
  history of recurrent pain in the left lower
  abdominal quadrant, bloating with abdominal
  distention, and frequent, loose stools. She
  reports having had similar but milder symptoms
  since childhood. She spends long times in the
  bathroom because she is worried about
  uncontrollable discomfort and fecal soiling if
  she does not completely empty her bowels before
  leaving the house. She feels anxious and fatigued
  and is frustrated that her previous physician did
  not seem to take her distress seriously. Physical
  examination is unremarkable except for tenderness
  over the left lower quadrant. How should the case
  be evaluated and treated?

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• IBS is a functional bowel disorder in which
  abdominal pain or discomfort is associated with
  disordered defecation or a change in bowel habit,
  but without a structural or known biochemical
  cause to explain the disorders

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Epidemiology

• Throughout the world, about 1020 of adults and
  adolescents have symptoms consistent with IBS,
  and most studies find a female predominance.
• IBS symptoms come and go over time, often overlap
  with other functional disorders, impair quality
  of life, and result in high health care costs

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Etiologyirritable bowel syndrome

• Abnormality of the gastrointestinal dynamic
• visceral hypersensitivity
• social psychology and mental factor
• Inflammation

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clinical manifestation

• Symptoms of Irritable Bowel Syndrome can
  include
• Constipation
• diarrhea (sometimes one alternating with the
  other)
• abdominal pains (often relieved by passing a
  bowel motion)
• abdominal bloating
• Headaches/backache
• Poor appetite/weight loss
• Fatigue and Sleeplessness
• Anxiety or Depression
• These symptoms can occur in any combination or
  individually

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Diagnosis

• Diagnostic Criteria for Irritable Bowel Syndrome
  (The Rome III)
• Recurrent abdominal pain or discomfort at least
  3 days per month in
• the last 3 Months associated with 2 or more of
  the following
• 1. Improvement with defecation
• 2. Onset associated with a change in frequency
  of stool
• 3. Onset associated with a change in form
  (appearance) of stool
• Criteria fulfilled for the last 3 months with
  symptom onset at least 6 months prior to
  diagnosis.

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??III?IBS?????

• ??????????????,??3?????????3?,????2??2???
• ???????
• ????????????
• ?????????(??)??
• ???????????????6???????????
• ??????????????,???????????????????????????????2?

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IBS subtping

• The Rome II
• Irritable bowel syndrome
• (IBS)
• diarrhea-predominant pattern
• constipation-predominant pattern
• diarrhea- constipation alterative pattern

• The Rome III
• Irritable bowel syndrome (IBS)
• IBS with constipation (IBS-C)
• IBS with diarrhea (IBS-D )
• Mixed IBS (IBS-M)
• Unsubtyped IBS

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??III?IBS??4???

• IBS???(IBS-C)??????(gt25???????????,?lt25???????)
  
• IBS???(IBS-D)??????(gt25???????,?lt25???????????)
  
• IBS???(IBS-M)??????????(?????????????gt25)
• IBS???(IBS-U)???????3??????

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Two-dimensional display of the 4 possible IBS
subtypes according to bowel form at a particular
in time (George F. Longstreth et al. Functional
Bowel Disorders. Gastroenterology
20061301480-1491)
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Differential Diagnosis(????)

• Abdominal aches
• Diarrhoea
• Constipation
• organic diseases

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Therapy

• Management depends on a
• confident diagnosis, explanation
• of why symptoms occur, and
• suggestions for coping with them
• ????????,????,??????
• ???????????,???????? ????

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general treatment(????)

• counseling, individualor /group interactions,
  establishing of a therapeutic relationship,
  Education about healthy life style behaviors,
  reassurance that the symptoms are not due to a
  life-threatening disease
• Specialists patients are more likely to have
  severe sy-
• mptoms, depression, anxiety, panic, or other
  psychosocial disorders that require special
  treatment
• Patients should have regular, unhurried meals

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Drug therapy

• directed toward the dominant symptoms
• Spasmolytics(???)
• ---pinaverium bromide(50mg once,tid)
• Antidiarrhoeal drug(???)
• Catharsis purgation(???)
• Propulsives and sensory regulation
  drug(?????
• ????)---a partial 5-HT4 agonist
  tegaserod(????)
• Antidepressive Agents(????)
• Others
• Cognitivebehavioral therapy, standard
  psychotherapy,
• and hypnotherapy may help selected IBS
  patients

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IBS????
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Thanks!