(2) (3) ( ) (5) 腸躁症的週邊機轉 (6) 1. ( ) () ( ) 2. ( ) (brain-gut axis ) 3. ( ) (1,7) 1. 腸內刺激物 (irritants): (irritants) ( ) (xylitol) (gluten) (gluten-sens

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家庭醫業 1 2 3 簡介 irritable bowel syndrome, IBS 10-20% (1) NEJM 2012 10 systemic review 腸躁症的臨床分類及診斷標準 (IBS-C)(IBS-D) (IBS-M) (IBS-U) (2) (1978, Manning criteria) (3) 1.

1 家庭醫業簡介 irritable bowel syndrome, IBS 10-20% (1) NEJM systemic review 腸躁症的臨床分類及診斷標準 (IBS-C)(IBS-D) (IBS-M) (IBS-U) (2) (1978, Manning criteria) (3) 1. (Onset of pain linked to more frequent 1 台北榮民總醫院家庭醫學部住院醫師 2 台北榮民總醫院家庭醫學部住院醫師 3 台北榮民總醫院家庭醫學部部主任 IBS, irritable bowel syndrome bowel movements) 2. (Looser stools associated with onset of pain) 3. (Pain relieved by passage of stool) 4. (Noticeable abdominal bloating) 5. (Diarrhea with mucus more than 25% of the time) 6. (Sensation of incomplete evacuation more than 25% of the time) 2006 Rome III criteria (Rome III Criteria, 2006) (4) () (1) 2 家庭醫學與基層醫療第一期

2 (2) (3) ( ) (5) 腸躁症的週邊機轉 (6) 1. ( ) () ( ) 2. ( ) (brain-gut axis ) 3. ( ) (1,7) 1. 腸內刺激物 (irritants): (irritants) ( ) (xylitol) (gluten) (gluten-sensitive enteropathy Celiac disease) (8) (enteroendocrine cell) 5- ( 5-hydroxytryptamine, 5-HT, serotonin) 家庭醫學與基層醫療第ㄧ期 3

3 (fermentable oligosaccharides ) (disaccharides) (monosaccharides) (Polyols 梨 ) FODMAPS diet (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) low FODMAPS diet (9) (bile acid) (10) 25-30% (11) (Firmicutes bacteria) (Bacteroidetes bacteria) (Clostridia) (Bifidobacterium) (12) 5-HT(serotonin) (tyramine)(dopamine) (phenylethylamine) (monosodium glutamate) serotonin serotonin (13) 治療考量方向 (psychological support) (cognitivebehavioral therapy) (relaxation therapy) 藥物治療 serotonin 4 家庭醫學與基層醫療第一期

4 serotonin (enteric neurons) serotonin 5-HT1P 5-HT3 5-HT4 5-HT3 receptor antagonist 5-HT4 receptor agonist (14) (5, 14) 1. 抗痙攣藥物 (antispasmodics) (5) 2. 抗憂鬱劑 (antidepressants) (selective serotonin reuptake inhibitors, SSRIs) SSRI (15, 16) 1. (antidiarrheals) (loperamide, diphenoxylate) (5-HT3 receptor) Loperamide 5-HT3 Ondansetron, Granisetron Ramosetron (5-HT4 receptor) Tegaserod 家庭醫學與基層醫療第ㄧ期 5

5 Lubiprostone 1. (osmotic laxatives) lactulose polyethylene glycol Lactulose 2. tegaserod FDA tegaserod (17) 3. (chloride channel activator) Lubiprostone 4. FDA Linaclotide Linaclotide (guanylate cyclase-c agonist) GC-C(guanylate cyclase-c), 5. (fiber) 結語 10-20% 參考資料 1. Camilleri M: Peripheral Mechanisms in Irritable Bowel Syndrome. N Engl J Med 2012; 367: Yao X, Yang YS, Cui LH et al.: Subtypes of irritable bowel syndrome on Rome III criteria: a multicenter study.gastroenterol Hepatol Apr;27: Manning AP, Thompson WG, Heaton KW, Morris AF: Towards positive diagnosis of the irritable bowel. Br Med J. 1978;2: Drossman DA: The Functional Gastrointestinal Disorders and the Rome III Process. Gastroenterology 2006;130: Mayer EA: Irritable Bowel Syndrome. N Engl J Med 2008;358: Spiller R, Aziz Q, Creed F, et al.: Guidelines on 6 家庭醫學與基層醫療第一期

6 圖一腸躁症的診斷流程圖反覆的腹痛或不適, 伴隨著排便習慣或型態的改變是否符合 Rome Criteria 否是依症狀做更進一步檢查評估警訊 (warning signs): 直腸出血 / 貧血 / 體重下降 / 發燒有大腸癌家族史 /50 歲之後才有第一次症狀症狀在臨床上有巨大的變化否是乳麋瀉的血清學檢驗陰性陽性進一步評估 ( 如血液常規, 生化檢查, 甲狀腺促素釋素, 糞便潛血反應及寄生蟲檢查 ) 不一定需進一步評估對於乳麋瀉的全面性評估大腸鏡及其他診斷性工具陰性陰性診斷為大腸激躁症資料來源 : 參考資料 5 家庭醫學與基層醫療第ㄧ期 7

7 the irritable bowel syndrome: mechanisms and practical management. Gut 2007; 56: Hungin APS, Whorwell PJ, Tack J, Mearin F: The prevalence, patterns and impact of irritable bowel syndrome: an international survey of subjects. Aliment Pharmacol Ther 2003;17: Fukumoto S, Tatewaki M, Yamada T et al.: Shortchain fatty acids stimulate colonic transit via intraluminal 5-HT release in rats. Am J Physiol Regul Integr Comp Physiol 2003;284: Shepherd SJ, Parker FC, Muir JG, Gibson PR: Dietary triggers of abdominal symptoms in patients with irritable bowel syndrome: randomized, placebo-controlled evidence. Clin Gastroenterol Hepatol 2008;6: Wedlake L, A Hern R, Russell D et al.: Systematic review: the prevalence of idiopathic bile acid malabsorption as diagnosed by SeHCAT scanning in patients with diarrhoeapredominant irritable bowel syndrome. Aliment Pharmacol Ther 2009;30: Jeffery IB, O Toole PW, Ohman L et al.: An irritable bowel syndrome subtype defined by species-specific alterations in faecal microbiota. Gut 2012;61: Parkes GC, Rayment NB, Hudspith BN et al.: Distinct microbial populations exist in the mucosa-associated microbiota of sub-groups of irritable bowel syndrome. Neurogastroenterol Motil 2012;24: Gershon MD, Tack J: The serotonin signaling system: from basic understanding to drug development for functional GI disorders. Gastroenterology 2007;132: Camilleri M: Pharmacology of the new treatments for lower gastrointestinalmotility disorders and irritable bowel syndrome. Clin Pharmacol Ther 2012;91: Tack J, Broekaert D, Fischler B et al.: A controlled crossover study of the selective serotonin reuptake inhibitor citalopram in irritable bowel syndrome. Gut 2006;55: Tack J, Broekaert D, Corsetti M et al.: Influence of acute serotonin reuptake inhibition on colonic sensorimotor function in man. Aliment Pharmacol Ther 2006; 23: U.S. Food and Drug Administration: Zelnorm (tegaserod maleate) Information. May 11, Available at: DrugSafety/PostmarketDrugSafetyInformati onforpatientsandproviders/ucm htm. Accessed June 26, U.S. Food and Drug Administration: Zelnorm (tegaserod maleate) Information. Aug 31, Available at: NewsEvents/Newsroom/PressAnnouncements/ ucm htm. Accessed June 26, Thomas RH, Allmond K: Linaclotide (Linzess) for Irritable Bowel syndrome With Constipation and For Chronic Idiopathic Constipation. P T. 2013; 38: 家庭醫學與基層醫療第一期

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

Manning criteria Rome III criteria Rome III criteria IBS [3] a. (Improvement with defecation) b. (Onset associated with a change in frequency of stool 1 1 1 1 2 前言 (irritable bowel syndrome, IBS) 流行病學 14% 8.9% 50 (28.3%) (21%) (6%) 23% 40-49 14.7% 70 43.7% [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,