1、功能性消化不良(functional dyspepsia FD ),浙江大学医学院附属邵逸夫医院消化科 戴宁,消化不良的定义,指源于胃十二指肠区域的症状，有上腹痛，烧灼、餐后饱胀、早饱及其它，如上腹气胀、恶心、呕吐和嗳气,上腹痛,位于胸骨剑突下与脐水平以上、两侧锁骨中线之间区域的疼痛Epigastric pain refers to a subjective, intense and unpleasant sensation in the epigastrium, which can lead patients to believe that some tissue damage is occ
2、urring,消化不良的流行病学,我国广东：18.9%，女性多见 内科门诊约11.1%，消化内科达52.9% 每年消化不良新发病例约占人群的1%-6%多数长期慢性、反复发作约1/2的患者会就医 促使就诊的因素：症状和对疾病的担忧,Tack J, et al. In Rome III: FGID. 2006 Chen minhu, et al. Jour Chin Inter Med;1998,消化不良的分型,器质性消化不良 organic dyspepsia （存在器质性、系统性或代谢异常）,功能性消化不良 functional dyspepsia（无器质性、系统性或代谢异常),消化不良,病理
3、生理 - Statement 13,Pathogenesis of functional dyspepsia is multifactorial.FD的发病机理是多因素的,J Neurogastroenterol Motil 2012;18:150-168,发病机理,动力障碍 内脏高敏 心理因素 胃酸 Hp 感染后 遗传因素 食物和生活方式,病理生理,胃十二指肠动力紊乱、内脏高敏是FD主要病理生理机制,FD的胃十二指肠动力障碍 胃排空延缓 胃容受功能受损 胃内食物异常分布 胃窦动力低弱 胃电节律紊乱 MMC频率减少 餐后胃底收缩过度,病理生理 - Statement 16,Psychosoci
4、al factors may play a role in functional dyspepsia.心理社会因素在FD中可能起作用。,Hojo M,Miwa H, et al. J Gastroenter Hepatol 2004,病理生理 - Statement 17,Gastric acid may be responsible for the symptoms in a subset of patients with functional dyspepsia.胃酸可能对一部分FD患者的症状起作用。,89.5,10.5,- 酸灌注诱发症状- PPI治疗反应,病理生理 - Statemen
5、t 18,H. pylori may play a role in pathogenesis of functional dyspepsia.Hp在FD的发病机制中可能起作用。,FD的Hp阳性率：39-87%根除Hp对FD的影响？ - FD相对危险度下降10% - 荟萃分析：改善FD症状 OR=3.61 - 对动力和感知影响？,Jin X, Li YM. Systematic review and meta-analysis from Chinese literature: the association between Helicobacter pylori eradication and
6、improvement of functional dyspepsia. Helicobacter 2007;12:541-546.,Jin X, et al: Helicobacter 2007,病理生理 - Statement 19,Post-infectious functional dyspepsia occurs in a subset of patients.感染后FD可发生于某些患者。,病理生理 - Statement 20,Genetic factors may be involved in pathogenesis in a subset of patients with f
7、unctional dyspepsia.某些类别的FD患者的发病机制可能与遗传因子有关。,- G-P 3 subunit 825 基因 与GI症状有关- 日本有报道结果不一- 亚洲资料有限,Candidate Genotypes: FD,GNB3 (825 CC 基因型)GNB3 (TT 纯和基因型)GNB3 (825T 等位基因)SNPs (单核苷酸多态性 )HTR2AMAGI2IL -9IL4R,病理生理 - Statement 21,Dietary factors and lifestyle may be involved in the pathogenesis of functiona
8、l dyspepsia.食物因素和生活方式可能涉及FD的发病机制。,94.7,5.3,某些食物引起症状可能因内脏高敏 胃肠激素,致病因素遗传易感性急性感染心理因素.,病理生理机制胃容受性舒张功能受损胃排空延迟内脏高敏感十二指肠高敏感小肠动力异常中枢神经功能异常,症状模式餐后不适综合征 (PDS)上腹痛综合征 (EPS)症状严重程度病态行为.,FD的发病机制,出现以下一种或多种症状 餐后饱胀感 早饱上腹痛上腹烧灼感无能解释引起上述症状的器质、系统和代谢性疾病证据症状出现在诊断前6个月，且近3个月有症状,功能性消化不良 (Functional Dyspepsia),Tack et al., Gas
9、troenterology 2006; 130(5):1466-79.,Rome III,警报征象表现,无有意减轻体重进行性吞咽困难反复或持续呕吐消化道出血证据贫血发热家族胃癌病史新近出现的消化不良症状 40 y (UGI恶性肿瘤高发区),4. 治疗 8条 - Statement 第22-29,治疗总原则药物治疗 - Hp根除 - 抑酸治疗 - 促动力剂 - 草药治疗 - 抗抑郁焦虑药特殊食物,J Neurogastroenterol Motil 2012;18:150-168,治疗 - Statement 22,An integrated approach addressing physio
10、logical, biological, psychological and social factors is recommended for all FD patients.对所有的FD患者应采取针对生理、生物、精神和社会因素的整体方法。,J Neurogastroenterol Motil 2012;18:150-168,FD 与饮食,十二指肠内灌注脂肪会导致FD病人出现症状，而健康志愿者没有少量油腻会引起胃胀气、饱胀和恶心症状；相比碳水化合物，等热量的高脂肪食物会引起更多的FD症状上腹饱胀和胃胀气与摄入的脂肪量直接相关,治疗 - Statement 23,Where socio-eco
11、nomic conditions allow, H. pylori testing and eradication should be part of the management strategy for all patients in Asia who present with dyspepsia.如果社会经济情况许可，Hp试验和根除应是亚洲有消化不良患者的治疗方案的一部分。,58.0,42.0,- 有利于预防胃癌、降低溃疡病复发荟萃显示对Hp阳性的FD有益建议进一步证实,治疗 - Statement 24,Proton pump inhibitors are effective for
12、controlling symptoms in patients with functional dyspepsia, although supportive data from Asia are lacking.PPI对控制FD患者的症状有效，虽然尚缺乏来自亚洲的支持资料。,7 trial (2387 PPI pts, 1338 Placebo pts symptoms relief 40.3% and 32.7%, p0.001),7 trials sym relief2387 PPI pts 40.3%1338 Plac pts 32.7%*不同于西方亚洲需要进一步证实,治疗 - Sta
13、tement 26,Prokinetics may provide symptom relief in some functional dyspepsia patients. 促动力剂有可能减轻有些FD患者症状。,两项 荟萃分析证明有利：24RCT n=3178 比plac高10%27RCT n=3435 比plac高30%需在亚洲进一步证实,治疗 - statement 28,Anti-depressant and anxiolytic agents have a role in the management of functional dyspepsia, despite the limi
14、ted evidence.尽管证据有限，抗抑郁焦虑药物对治疗FD有一定的作用。,- 非药物心理治疗- 抗抑郁药治疗研究有限- 可能要验证,Uninvestigated Chronic Dyspepsia for 3 months or longer,Alarm feature,Organic dyspepsia,Functional dyspepsia,功能性消化不良诊断流程,Exclude evident causes of Dyspepsia by history, eg,drugs,Empitical treatment,Non-invasive test for H.pylori an
15、d treatment,No response After 4 weeks,No response After 4 weeks,Upper endoscopy,Endoscopc finding(s) that can explain the symptom (s),no,yes,yes,no,If clinically indicated: stool parasites and occultblood, blood chemistry and /or abdominal imaging (s),Result (s) that can explainThe symptom (s),yes,n
16、o,亚洲共识, 2011,Functional Dyspepsia,功能性消化不良治疗流程,H.Pylori test and eradication,If not done before,Dietary modifications,Predominant symptom (s),Postprandial fullness, early satiation,Upper abdominal bloating, nausea, vomiting or belching,Prokinetic agentWith or without PPI,PPI with or without prokinetic agent,Epigatric pain or burning,Response after 4-8 weeks,Response after 4-8 weeks,Try anti-depressant or anxiolytic agentTry herbal medication,Refer to spescialists,Try to discontinue oron demand treatment,yes,yes,no,no,亚洲共识, 2011,
