Manning criteria Rome III criteria Rome III criteria IBS [3] a. (Improvement with defecation) b. (Onset associated with a change in frequency of stool

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1 前言 (irritable bowel syndrome, IBS) 流行病學 14% 8.9% 50 (28.3%) (21%) (6%) 23% % % [1] 50% 7% 病理機轉 (microflora) [2] 1 高雄醫學大學學士後醫學系 2 彰化基督教醫院家庭醫學科 Irritable Bowel Syndrome, Diarrhea, Constipation 診斷標準 116 家庭醫學與基層醫療第四期

2 Manning criteria Rome III criteria Rome III criteria IBS [3] a. (Improvement with defecation) b. (Onset associated with a change in frequency of stool) c. (Onset associated with a change in form / appearance of stool) IBS (crampy pain) IBSIBS (1) (2) (3) (4) (5) (6) (7) (8) IBS (celiac disease) (9) IBS IBS (pellet like) (hard/lumpy stool) IBS (loose/watery) IBS 診斷工具 IBS IBS a. IBS 1. IBS Gastroenterology [4] IBS IgA IBS Arch Intern Med [5] IBS IgA( IgA to tissue transglutaminase) 家庭醫學與基層醫療第四期 117

3 (osmotic) (secretory) ( ) 50 (microscopic colitis) b. IBS 1. X 2. 鑑別診斷 IBS ( ) (carcinoid) IBS 治療 a g40~50g [6] (soluble fiber) (insoluble fiber) FODMAPs fermentable oligo-, di-, and mono-saccharides and polyols [7] [8] Lactobacillus rhamnosus GG (LGG) Bifidobacterium B. infantis, B. breve, B. longum [9] 2. (psychological therapies) [ (hypnotherapy)] [10] 118 家庭醫學與基層醫療第四期

4 (multi-component psychological therapy) (dynamic psychotherapy) IBS IBS IBS (mindfulness) b. 1. (FDA) rifaximin IBS 2. (antispasmodics) IBS (spasm) dicyclomine IBS (anticholinergic) 3. Loperamide (opioid) 4. (antidepressants) IBS IBS (visceral pain) (TCA) (SSRI) IBS ( TCA ) 5. 5-HT3 (alosteron, ramosetron) 5-HT3 alosteron 5-HT3 IBS (ischemic colitis) FDA FDA alosteron IBS 0.5mg 2 4 1mg 2 4 Ramosetron 5-HT3 IBS5 g (prosecretory agents) i. Linaclotide Guanylin (bicarbonate) Linaclotide guanylin IBS ii. Lubiprostone Lubiprostone 2 (CIC-2) IBS [11] 家庭醫學與基層醫療第四期 119

5 表一 IBS 症狀分型及其藥物治療方式疾病分型藥物分類藥物劑量與治療時間症狀改善 IBS-D 抗生素 Rifaximin 550 mg 每天 2 次吃 14 天 TCA Amitriptyline 10 mg 每晚睡前吃 8 週 5-HT3 antagonist Alosteron 0.5mg 每天 2 次吃 4 週 1mg 每天 2 次吃 4 週整體症狀腹脹糞便黏稠度腹脹整體症狀糞便黏稠度排便不完全 IBS-All: 整體症狀腹痛降低腸道內臟疼痛和腸道運動 Ramosetron 5μg 每天 1 次吃 12 週糞便黏稠度止瀉劑 Loperamide 2 mg 每晚睡前最高劑量 6mg 吃 5 週整體症狀腹痛糞便黏稠度排便頻率急便 IBS-C SSRI 促分泌劑 Fluoxetine 20mg 每天吃 12 週腹脹糞便黏稠度排便頻率 Lubiprostone 24 μg 每天 2 次吃 12 週整體症狀腹脹糞便黏稠度 Linaclotide 290 μg 每天 1 次吃 12 週整體症狀腹痛腹脹糞便黏稠度排便頻率 Trimipramine 50 mg 每晚睡前或 10mg 每天早上 + 40mg 每天晚上整體症狀糞便黏稠度排便不完全 IBS-All TCA SSRI Desipramine 50mg 每晚睡前吃 1 週 100mg 每晚睡前吃 1 週 150mg 每晚睡前吃 4 週整體症狀排便頻率 IBS-D: 腹痛 Doxepin 75mg 每晚睡前吃 6 週整體症狀腹痛排便不完全 Citalopram 20mg 每天吃 3 週 40mg 每天吃 3 週 Paroxetine CR 12.5 mg 調至 50mg 每天吃 2 週整體症狀腹脹急便排便不完全備註 : 此表為各項藥物安慰劑對照研究之臨床結果, 若有研究結果在某項症狀改善不一致者則視為無效資料來源 : 參考資料 11 結語 Rome III criteria 120 家庭醫學與基層醫療第四期

6 loperamide TCA SSRI 參考資料 1. Chang HC, Yen AM, Fann JC et al: Irritable bowel syndrome and the incidence of colorectal neoplasia: a prospective cohort study with community-based screened population in Taiwan. Br J Cancer 2015; 112: Catanzaro R, Occhipinti S, Calabrese F et al: Irritable bowel syndrome: new findings in pathophysiological and therapeutic field. Minerva Gastroenterol Dietol. 2014; 60: Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC: Functional bowel disorders. Gastroenterology. 2006; 130: Cash BD, Rubenstein JH, Young PE et al: The prevalence of celiac disease among patients with nonconstipated irritable bowel syndrome is similar to controls. Gastroenterology 2011; 141: Ford AC, Chey WD, Talley NJ et al: Yield of diagnostic tests for celiac disease in individuals with symptoms suggestive of irritable bowel syndrome: systematic review and meta-analysis. Arch Intern Med 2009; 169: Heizer WD, Southern S, Mcgovern S: The Role of Diet in Symptoms of Irritable Bowel Syndrome in Adults: A Narrative Review. J Am Diet Assoc 2009;109: Halmos EP, Power VA, Shepherd SJ, Gibson PR, Muir JG: A Diet Low in FODMAPs Reduces Symptoms of Irritable Bowel Syndrome; Gastroenterol 2014; 146: Johannesson E, Simrén M, Strid H, Bajor A, Sadik R: Physical Activity Improves Symptoms in Irritable Bowel Syndrome: A Randomized Controlled Trial. Am J Gastroenterol 2011; 106: Ortiz-Lucas M, Tobias A, Saz P, Sebastián JJ: Effect of probiotic species on irritable bowel syndrome symptoms: Abring up to date metaanalysis. Rev Esp Enferm Dig 2013; 105: Ford AC, Moayyedi P, Lacy BE et al: American College of Gastroenterology Monograph on the Management of Irritable Bowel Syndrome and Chronic Idiopathic Constipation. Am J Gastroenterol 2014; 109:S2-S Trinkley KE, Nahata MC: Medication Management of Irritable Bowel Syndrome. Digestion 2014; 89: 家庭醫學與基層醫療第四期 121

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