2015年 · 第35卷第07期

irritable bowel syndrome (IBS) is one of the common diseases in gastroenterology clinics, but it does not attract enough attention from clinicians like organic diseases. In fact, although IBS is not an organic disease, its impact on the quality of life of patients is the same as that of many organic diseases. Some studies even found that the quality of life of IBS patients is lower than that of gastroenterological organic diseases. Gastroenterologists should understand the standardized diagnosis and treatment of IBS, and guide the clinical diagnosis and treatment according to evidence-based medical evidence.

IBS is one of the common gastrointestinal diseases and one of the common reasons for patients in gastroenterology. IBS remains an important clinical challenge in the 21st century. At present, the pathogenesis of IBS has not been fully elucidated. The clinical phenotype of IBS is diverse, and the etiology and pathogenesis are involved by many factors. IBS may be a large class of diseases that present similar clinical symptoms but have different pathophysiological mechanisms. During the past 40 years, extensive studies have been conducted on the pathophysiological mechanisms of IBS pathogenesis. Traditionally, the pathogenesis of IBS includes abnormal intestinal motility, visceral hypersensitivity, abnormal brain-intestinal axis regulation, mental and psychological disorders, etc. Recently, intestinal immune activation and intestinal microecological imbalance have been confirmed to be involved in IBS pathogenesis. Although these pathogenesis has been demonstrated in most patients with IBS, there is no clear explanation for the pathogenesis of all symptoms of IBS. The pathogenesis of IBS is the result of the interaction and interaction between the above factors. The etiology and pathogenesis of IBS are summarized.

IBS is a common functional gastrointestinal disease. Comprehensive and accurate diagnosis of IBS is the prerequisite for improving curative effect. At present, the internationally recognized diagnostic criteria of Rome III belong to the diagnostic criteria of symptoms^[1]The clinical manifestations of IBS patients in China have certain characteristics, and the exclusion of organic diseases is still the prerequisite for the diagnosis of IBS. Patients with IBS often have overlapping symptoms, combined with mental and psychological disorders, and generally decreased quality of life. Therefore, it is advocated to consider the severity of IBS from multiple dimensions to better guide treatment.

IBS is a group of diseases characterized by abdominal pain, abdominal discomfort, changes in defecation habits and/or traits, and relief after defecation. Its pathophysiological mechanisms include abnormal digestive tract sensory and/or motor function, abnormal mucosal secretion, intestinal flora imbalance and other changes. Clinical treatment is aimed at alleviating symptoms. At present, conventional treatment drugs include antispasmodic drugs, prokinetic drugs, antidiarrheal agents, laxatives, probiotics and antibiotics, etc. However, the etiology of different patients is different, and a variety of pathophysiological abnormalities can also exist in the same patient. Therefore, it is often difficult for a certain drug to correct all the abnormalities of patients. It is proposed to introduce the overall efficacy, symptom relief and safety of conventional therapeutic drugs for IBS from the perspective of evidence-based medicine.

Conventional treatment drugs for IBS include intestinal smooth muscle acting drugs (such as prokinetics and antispasmodics), digestive drugs, auxiliary laxatives (such as osmotic laxatives), and micro-ecological preparations. Unconventional drug therapy, including doctor-patient communication, central nervous system drug therapy, and non-drug therapy, is an important part of the clinical treatment of IBS, especially for refractory cases. The strategies, measures, and clinical challenges of unconventional drug treatment of IBS are briefly described below.

IBS is the most common functional gastrointestinal disease in gastroenterology clinics. According to Rome III criteria, IBS is characterized by abdominal pain or abdominal discomfort accompanied by defecation or changes in defecation habits. Combining the characteristics of IBS in Asian populations, including Chinese, IBS is defined as abdominal pain, abdominal distension or other abdominal discomfort as the main symptoms, with improvement of symptoms after defecation, often accompanied by changes in defecation habits [frequency and/or traits], and lack of organic lesions that can explain these symptoms that can be detected by routine clinical examination. At present, there are many epidemiological data about IBS, which has certain significance for the study of pathophysiological mechanism of IBS and the choice of clinical treatment methods. Now, the prevalence of IBS, risk factors, medical treatment and its influence are described.

A 38-year-old male was admitted to hospital on June 26, 2014 due to repeated abdominal distension with gingival bleeding for more than 1 year. Out-of-hospital abdominal ultrasound showed mild to moderate enhancement of hepatic parenchymal echo, portal vein diameter about 1.7 cm, gallbladder wall rough, spleen significantly enlarged, spleen thickness 6.5 cm, portal vein and splenic splenic vein obviously tortuous and dilated, suggesting portal hypertension, no exact peritoneal effusion was found. Transaminases were slightly elevated with HBV DNA of 4.73×10⁴Copies/mL, slight relief of abdominal distension 1 month after oral entecavir, HBV DNA<1×10³Copies/mL. The liver function was normal, and the symptoms worsened 1 month after self-stopping the drug, accompanied by fatigue and anorexia, no nausea, vomiting, and no skin and sclera yellowing. MRI showed: liver changes, mostly early cirrhosis, splenomegaly, portal hypertension. Physical examination after admission: No yellowing staining of skin and sclera, no swelling of superficial lymph nodes in the whole body, and no abnormalities in heart and lung. The abdomen was slightly swollen, no varicose veins, soft abdomen, tenderness in the middle and upper abdomen, no rebound pain, 4 cm under the spleen costs, no palpation under the liver costs, negative mobile voicing, and no edema in both lower limbs. HBsAg, anti-HBe and anti-HBc were all positive; HBV DNA<1×10³Copies/mL. Liver function was normal. RBC 3.55×10¹²/L, Hb 132 g/L, PLT 34×10⁹/L, AFP 2.22 μ g/L. Platelet-specific and histocompatible antibodies were weakly positive, antinuclear antibodies 1:100, and anti-RO52 (+ + +). Gastroscopy showed chronic non-atrophic gastritis with bile reflux. Hepatobiliary and pancreatic plain scan + enhanced CT showed: cirrhosis to be excluded, signs of portal hypertension; The spleen was obviously enlarged, and multiple flaky and round low-density shadows were seen in the spleen after enhancement; The wall of the gallbladder is slightly thickened and rough. The bone marrow smear showed that there were more Hyland histiocytes in the whole film; The megakaryocyte count increased, and the whole platelet was visible in small piles; The eosinophil ratio was 0.055. Bone marrow biopsy showed active bone marrow hyperplasia and no other special changes were observed. Liver biopsy showed moderate chronic viral hepatitis, G2/S2-3. Immunomarkers: HBsAg membrane (+), HBcAg (–), immunophenotype showing active virus replication status. The diagnosis was: ① chronic hepatitis B; ② Hypersplenism; ③ Essential thrombocytopenic purpura; ④ Secondary Hylan's histiocytosis. Splenectomy was performed on 8 Jul 2014. Spleen pathology showed: immunohistochemistry and special staining results considered ceroid histiocytosis. RBC 7.2×10 was repeated on 18 Jul 2014¹²/L, Hb 126 g/L, PLT 286×10⁹/L; Liver function was normal. He had no abdominal distension, no gingival bleeding, and his condition improved. He was discharged from hospital on 19 July 2014.

A 78-year-old female was admitted to the hospital on 19 July 2014 due to defecation of dark red bloody stool for 1 month. The patient began to defecate dark red paste bloody stool 1 month ago, initially 7 to 8 times/d, and then 3 times/d. After treatment with traditional Chinese medicine preparations in other hospitals, the symptoms did not improve significantly. During the course of the disease, there was no fever, chills, nausea, vomiting, chest tightness, chest pain, palpitations, abdominal pain, abdominal distension, and weight loss of about 10 kg. The patient had a previous history of hypertension. Colonoscopy before admission revealed multiple submucosal protuberances of the colorectum (multiple lipomas possible). Physical examination at admission: temperature 36.5 ℃, pulse 82 beats/min, breathing 16 beats/min, blood pressure 122/50 mmHg (1 mmHg =0.133 kPa). The patient was conscious and spirited, and the superficial lymph nodes such as supraclavicular bone and bilateral groin were not swollen. There were no other positive signs. Blood routine: WBC count was 5.2×10⁹/L, RBC count is 4.35×10¹²/L, Hb was 118 g/L, hematocrit was 0.372, and PLT count was 244×10⁹/L, neutrophils accounted for 0.620, lymphocytes accounted for 0.279, eosinophils accounted for 0.013 and monocytes accounted for 0.084. Fecal routine: occult blood test + + +, full field WBC at high power. It was 1.97 mmol/L for calcium, 178 U/L for lactate dehydrogenase, 72 U/L for alkaline phosphatase and 30.9 g/L for albumin. Female tumor indexes and complete set of coagulation examinations were normal. Colonoscopy revealed multiple submucosal protuberances in the colorectum, multiple nodular protuberances of clocked cords and multiple mucosal erosions in the ileocecal region, transverse colon, descending colon, and rectum (Figure 1)。 The ultrasound probe explored above the cecal and rectal lesions, and found that the intestinal wall was obviously thickened, in which the lamina propria of the mucosa was the main one, and partially broke through the submucosa, with the thickest part reaching 1.69 cm. The internal manifestation of the lesion was hypoechoic, seeFigure 2。 Several lymph nodes with a long diameter of about 0.8 cm were visible around the rectum. Apply biopsy forceps to open the fenestration above the rectal lesion, and then extend into the interior of the lesion to take a small amount of yellow tissue. Biopathological examination revealed a chronic inflammatory reaction of the rectum with massive lymphocyte infiltration. Immunohistochemical examination revealed rectal tissue CD3, CD20, CD79a, B-cell lymphoma-2,Bcl-2) genetically positive. Abdominal and pelvic CT (Figure 3) showed multiple segmental intestinal wall thickening of the small intestine, colon and rectum, combined with multiple lymph node enlargement of the abdominopelvic cavity, retroperitoneal cavity, bilateral hilar and mediastinum. Combined with clinical manifestations, laboratory examinations, endoscopic ultrasound, abdominal and pelvic CT and histopathological examinations, the patient was diagnosed as mantle cell lymphoma stage III group B (Ann/Arbor staging system). The patient was transferred to the hematology department for 4 courses of chemotherapy with R-CHOP regimen (monoclonal antibody to rituximid, cyclophosphamide, epirubicin, vincristine, dexamethasone). Colonoscopy 3 months after chemotherapy showed that colorectal swelling and bulging lesions were significantly reduced and reduced, and the mucosa was smooth, without erythema or erosion.Figure 4。 The patient had no obvious symptoms of blood in the stool, and his defecation basically returned to normal.

IBS is a common disease, both in the community population and clinically^[1]。 There are studies to analyze the symptomatic characteristics of IBS in community population^[2]However, there are relatively few reports on the clinical characteristics and medical treatment of IBS patients attending gastroenterology specialty clinics. Therefore, this study selected continuous IBS patients, analyzed their clinical characteristics and medical situation, to explore its possible implications.

IBS is a functional intestinal disease characterized by recurrent abdominal pain or abdominal discomfort, accompanied by changes in stool characteristics and bowel habits. At present, the prevalence of IBS in China is 5% ~10%, accounting for 25% ~50% of patients attending gastroenterology. The pathogenesis of IBS has not been fully elucidated, and it is currently believed to be related to abnormal gastrointestinal motility, visceral hypersensitivity, dysfunction of brain-intestinal axis, immune system disorders, intestinal inflammatory reaction and food intolerance. At present, there is still a lack of ideal and effective treatment for IBS. Although IBS does not affect life expectancy, it affects the quality of life of patients to varying degrees. Compared with healthy people, IBS patients are more likely to spend high medical expenses by seeking various medical help.

CD is a major type of IBD, which is characterized by chronic, recurrent and non-specific inflammatory reaction of the whole intestinal wall in the gastrointestinal tract, with leaping and segmental distribution of lesions; It can involve the whole digestive tract, but mainly involves the small intestine, terminal ileum and proximal colon. CD in the upper digestive tract such as esophagus, stomach and duodenum is rare, and the lesions are atypical. It is easy to be misdiagnosed and missed clinically^[1]。 Literature reported that the incidence of CD in esophagus was 0.3% ~2.0%, and the incidence of CD in stomach and duodenum was 0.5% ~4.0%^[2,3,4,5]。 2012, Annunziata et al.^[5]The incidence of upper gastrointestinal CD was reported to be 16%. Studies have shown that the onset of IBD is closely related to genetics and immunity, so there may be great differences in the onset characteristics of different races. Leong et al.^[6]Studies have shown that only 4% of CD patients in China are confined to the terminal ileum, and 19% of patients have upper gastrointestinal tract lesions, which can lead to an increased risk of surgery and hospitalization^[7]。

Biliary tract and duodenal obstruction are common complications of advanced biliary and pancreatic tumors^[1]。 Most patients had no indication for radical surgery. Minimally invasive combined implantation of biliary tract and duodenal stent to relieve obstruction can prolong the survival time and improve the quality of life of patients^[2,3,4], but long-term follow-up studies are rare. In this study, we followed up the efficacy of duodenal stent placement combined with biliary stent placement in different ways for malignant duodenal obstruction, and compared the endoscopic retrograde cholangiopancreatography-guided biliary stent (ERCP-BS) and percutaneous transhepatic insertion of biliary stent (PTIBS) The drainage effect of.

The prevalence rate of chronic constipation among adults in China is 4% ~6%, and it is as high as 22% among people>60 years old. About 50% of patients with chronic constipation are functional constipation (FC)^[1,2,3]。 Constipation will affect the physical and mental health and quality of life of patients to varying degrees^[4], which is more pronounced in patients with refractory FC. This study retrospectively analyzed the efficacy and adverse effects of prucapride combined with compound polyethylene glycol electrolyte powder (PEG) in the treatment of refractory FC.

Chronic constipation is one of the common diseases in gastroenterology. Epidemiological studies in different regions of China show that the prevalence rate of chronic constipation in adults is 4% ~6%, and it increases with age. The prevalence rate of chronic constipation in people over 60 years old can be as high as 22%^[1,2,3]。 Among them, the prevalence rate of women is higher than that of men, and the ratio of male to female prevalence is 1:1.22~1:4.56. It is worth noting that most patients with chronic constipation are functional, and 20% to 81% of them have functional defecation disorders^[4]。 Anorectal manometry can comprehensively evaluate the function of anorectum, which is necessary for the classification of constipation and defecation disorders, the choice of treatment plan and the evaluation of curative effect. In recent years, with the emergence of high-resolution anorectal manometry technology and the emphasis on biofeedback therapy, the diagnosis and treatment level of constipation and defecation disorders has been greatly improved. Now, the principle of anorectal manometry and its application progress in constipation and defecation disorders are introduced.

functional gastrointestinal disorder (FGID) is a group of chronic or recurrent gastrointestinal syndromes in which no organic disease, biochemical and pathophysiological abnormalities explaining the symptoms can be found upon examination^[1], mainly including IBS, functional dyspepsia, etc. FGID has a high incidence rate and large individual differences. It is a common disease in gastroenterology clinic, which often causes heavy psychological and economic burden to patients and seriously affects their quality of life. Multiple studies support the role of food intake in the mechanism of FGID occurrence. A large number of FGID patients say food intake induces symptoms^[2,3]。 Dietary intervention can relieve patients' symptoms^[4,5]。 However, the role of dietary factors in the pathogenesis of FGID remains unclarified. The research progress of dietary factors in the pathogenesis of FGID is reviewed.

functional gastrointestinal disorder (FGID) is a common disease of the digestive system, which seriously affects the quality of life of patients. FGID patients visit a doctor repeatedly, and the cost of diagnosis and treatment is high, which brings a heavy economic burden to individuals and society. In recent years, the research on FGID has been extensive and gradually deepened. Its pathogenesis is complex, which may be related to genetic, environmental, psychosocial, dietary and inflammatory factors, and its pathophysiological mechanism involves abnormal gastrointestinal motility, visceral hypersensitivity, dysfunction of brain-intestinal axis and intestinal flora imbalance^[1]。 Studies have confirmed that the pathogenesis of FGID is closely related to mental and psychological factors^[2]。 Traditional treatment methods are not effective for some patients with FGID, but psychotherapy [including cognitive behavior therapy (CBT), hypnotherapy, biofeedback therapy, relaxation therapy, etc.] has been used to treat FGID.

IBS, with abdominal pain or abdominal discomfort accompanied by abnormal defecation as the main symptom, is a common clinical gastrointestinal dysfunction disease. The incidence of IBS in Asian countries ranged from 6.5% to 10.1% and showed an increasing trend^[1]。 IBS is not a pure functional gastrointestinal disease. Visceral hypersensitivity and abnormal intestinal motility are the two basic pathophysiological changes of IBS. The potential mechanisms involve abnormal activation of intestinal immunity, low-grade inflammatory reaction of intestinal mucosa, changes of intestinal flora, disorder of intestinal mucosal barrier function, etc. All mechanisms are related to each other^[2]。 In recent years, more and more studies have shown that intestinal mucosal immune dysfunction plays a key role in the occurrence and development of IBS. The main theoretical basis is the phenotype and function of immune cells in the process of disease evolution. Among them, dendritic cell (DC) and mast cell (mast cell) are the key links of immune dysfunction^[3,4]。 The interactions between the two types of cells and their effects on IBS are summarized below.