2016年 · 第36卷第05期

refractory gastro-esophageal reflux disease (RGERD) refers to only partial or no remission of GERD symptoms after conventional PPI treatment, and its incidence is between 10% and 40%.

The prevalence rate of chronic constipation is 3.6% ~12.9% in the general population in China, and the prevalence rate is as high as 11.5% in the elderly population. Its etiology is complex, and most adult patients are caused by functional diseases. Through dietary adjustment, dietary fiber supplementation, and oral laxatives, most patients' symptoms can be relieved, but some patients are still ineffective to conventional drug treatment, and the symptoms of constipation persist, which seriously affects their daily life, which belongs to refractory constipation (refractory constipation)^[1]。 At present, there is still a lack of uniform criteria for judging refractory constipation. Bassotti and Blandizzi^[2]It is proposed that patients with refractory constipation should meet the diagnostic criteria of functional constipation, lack of alarm signs suggesting organic disease (i.e., organic disease can be ruled out), and treatment with high-fiber diet and laxatives (such as polyethylene glycol or other osmotic laxatives) is ineffective. At present, there is no uniform definition standard for judging the course of treatment that laxative treatment is ineffective. So far, there are still few relevant epidemiology, pathophysiology, diagnosis and treatment standards, and the treatment of refractory constipation has become one of the difficult clinical problems faced by gastroenterology.

rifaximin is an antibiotic acting locally in the intestine. It is hardly absorbed into the blood, is not metabolized by the liver and kidney, and has few adverse reactions. In 1987, the drug was approved by the US FDA for the treatment of traveler's diarrhea and the prevention of hepatic encephalopathy. In 2006, Sharara et al.^[1]Through a randomized double-blind controlled human trial, it was found that rifaximin has obvious curative effect on patients with functional abdominal distension including IBS. Many clinical studies have since proved that rifaximin can significantly improve the overall symptoms of patients in the treatment of non-constipation IBS., the curative effect can be maintained for a long time, and the safety is good. In May 2015, rifaximin, an old drug, was approved by the US FDA for the treatment of non-constipation IBS.

IBS is a common functional bowel disease. Because different subtypes can overlap and convert, IBS is mainly treated according to symptoms such as diarrhea, constipation and abdominal pain. The etiology and pathogenesis of IBS are not well understood, but may involve abnormal visceral sensitivity, abnormal brain-intestinal axis function, abnormal intestinal motility, intestinal bacterial overgrowth, intestinal immune dysfunction and other aspects. At present, there is still a lack of specific drugs for the treatment of IBS. In addition to traditional drug therapy, more and more new drugs have been used in clinical research or treatment. Now, we will make a brief introduction of several major drugs recently studied.

IBS is a group of common clinical syndromes with abdominal pain, abdominal distension, abdominal discomfort and changes in defecation habits as the main symptoms. In 2003, China formulated the consensus opinion on the diagnosis and treatment of IBS, and revised it in 2007. In recent years, there has been a new understanding of the diagnosis and treatment of IBS at home and abroad, especially the clinical practice and research of IBS by Chinese scholars has been deepened, and many Chinese people have obtained information. Therefore, it is necessary to update the IBS consensus opinion in China in combination with the research data of China and the latest international consensus opinion. This consensus opinion is divided into four parts: definition and epidemiology, etiology and pathogenesis, diagnosis and treatment, with a total of 28 articles.

IBS is a functional gastrointestinal disease with a high global incidence^[1,2,3], with abdominal pain and/or abdominal discomfort with altered defecation habits and fecal traits as the main clinical features, but lacking evidence of morphological and biochemical abnormalities that could explain the symptoms^[4]。 Abdominal pain is often the main troubling symptom and reason for seeing a doctor in IBS, especially in patients with diarrhoeal IBS, who are prone to bowel symptoms when stressed, on business or long-distance travel. Therefore, analgesics with rapid onset and good curative effect will be good news for IBS patients, but there is still a lack of safe and effective similar drugs. selective calcium channel blocker (SCCB) mainly improves gastrointestinal motility abnormalities by blocking the voltage-dependent calcium channels (L-type calcium channels) of intestinal smooth muscle cells, thus relieving abdominal pain, abdominal distension and other symptoms. At present, otyronium bromide and pivonium bromide are mainly used in clinical practice, all of which are quaternary ammonium salt derivatives of SCCB. After oral administration, they mainly relieve spasm directly through the intestine. Studies showed a significantly higher abdominal pain relief rate (55.3%) for IBS with otyronium than placebo (39.9%)^[5]； Pivelonium bromide can also effectively relieve abdominal pain, abdominal distension, abnormal defecation and other symptoms in IBS patients in a short course of treatment^[6]。 Whether these two drugs are equally effective for abdominal pain and other symptoms in patients with diarrhoeal IBS, and whether the other can be switched when one of the drugs is ineffective, it is unknown. Based on this, this study aims to compare and observe the efficacy and safety of otyronium bromide and pivelonium bromide in the short-term treatment of diarrhoeal IBS, and provide a theoretical basis for SCCB in the treatment of IBS.

IBS is a functional bowel disease with abdominal pain or abdominal discomfort accompanied by changes in defecation habits and traits as the main clinical manifestation. IBS accounts for about 25% of patients attending gastroenterology clinic^[1]Consume a lot of medical resources. The etiology of IBS is still unclear, and social and psychological factors such as diet and lifestyle habits, negative life events and stress are considered to be related to the onset of IBS.

transient internal anal sphincter relaxations (TASR) refer to the transient relaxation of the internal anal sphincter that occurs spontaneously when there is no defecation and the rectum is not receiving external stimulation. Since TASR was clearly described in the 1980s^[1]rectoanal inhibitory reflex (RAIR) was considered to have the same sampling reflex significance as the rectoanal inhibitory reflex (RAIR), involved in anal control. Sun et al.^[2]It was found that the incidence of TASR was higher in patients with anal incontinence; Farouk et al.^[3]It was found that the incidence of TASR in patients with suspected stool leakage was not different from that in healthy people, and when about half of TASR occurred, the subjects could sense exhaust or defecation; Carrington et al.^[4]It was also found that TASR in healthy people was more likely to occur after meals, and 56% were accompanied by transient rectal sensations, such as exhaust sensations. The above contradictions in understanding fully show that the research on TASR is insufficient. In this study, we retrospectively analyzed the status of TASR in patients undergoing recto-anal manometry, aiming to understand the pattern of TASR in common colorectal and anal diseases, and to explore its mechanism and possible pathophysiological significance.

A 52-year-old female was admitted to the hospital on 28 April 2015 due to abdominal distension for more than 20 days and hematemesis for 1 day. Abdominal distension occurred without obvious trigger more than 20 days ago, and no diagnosis and treatment were given. 1 day ago, hematemesis occurred due to motion sickness and hyperemesis, vomiting 50 mL of bright red blood. Twenty-one years ago, he underwent repair surgery for a ruptured right liver caused by a car accident, and denied a history of hepatitis, alcoholism and hepatotoxic drugs. Physical examination at admission: blood pressure 117/75 mmHg (1 mmHg =0.133 kPa), body temperature 37.7 ℃, heart rate 64 beats/min, breathing 20 beats/min; There were no abnormalities in the heart and lungs, abdominal swelling, no tenderness, varicose veins in the abdominal wall, and positive mobile voicing. Blood routine: WBC count was 5.1×10⁹/L, RBC count is 3.2×10¹²/L, Hb is 100 g/L, PLT count is 134×10⁹/L. Biochemical examination: 47 U/L for ALT, 46 U/L for AST and 38.3 g/L for albumin. Blood viral hepatitis markers were negative. Fecal occult blood test (+ + +). Emergency gastroscopy showed moderate esophageal varices (Figure 1), there was a mucosal tear about 3 cm long in the direction of the cardia at 5 o'clock, with fresh bleeding, which was clipped with a Boston metal titanium clip and injected with lauromacrol 10 mL to stop the bleeding, seeFigure 2。 Abdominal ultrasound examination showed that the inner diameter of the main portal vein was 1.4 cm, the branches were tortuous and dilated, about 2.0 cm wide, the spleen was too large (about 4.4 cm thick), and a large amount of fluid accumulated in the abdominal cavity. Enhanced CT scan of the upper abdomen showed hepatic arterioportal fistulas (HAPF), which showed that the portal vein and artery were developed almost simultaneously in the arterial phase, and the main trunk and left and right branches of the portal vein were obviously thickened, with the right branch of the portal vein as the focus. The posterior and lower segments of the right liver were irregular in shape, and the spleen was larger, seeFigure 3、Figure 4。 The diagnosis was HAPF, cardia mucosal tear with hemorrhage, and liver rupture after surgery. After multidisciplinary discussion, the diagnosis of HAPF was confirmed and embolization was proposed. On May 7, 2015, digital subtraction angiography (DSA) was performed in the catheterization laboratory. The celiac trunk angiography showed huge HAPF. The blood supply artery originated from the direct branch of the celiac trunk, which was thick and twisted, and the portal vein, superior mesenteric vein, inferior mesenteric vein and splenic vein were reverse filling. After the microcatheter superselectively entered the fistula supply artery, the angiography showed that the fistula was large, with fast flow rate and huge flow, and the fistula was located at the distal end, seeFigure 5。 Therefore, a controllable coil was used for embolization first. During the release of the first coil, the distal end was flushed into the portal vein many times, and the fistula was anchored after many adjustments. Then, the proximal end of the fistula was densely embolized with a microcoil. Post-embolization angiography showed good occlusion of the fistula, and no premature development of the portal vein was seen, seeFigure 6Superior mesenteric arteriography showed development of the main portal vein, showing hepatic blood flow. The patient was in stable condition and recovered well after surgery, and was discharged 4 days after surgery. One week later, Doppler ultrasound revealed no dilatation of the portal vein, no reverse blood flow, and ascites disappeared; No esophageal varices were found on gastroscopy, the wound of cardia tear healed well, and no embolism-related complications occurred, suggesting that HAPF was cured.

Anorectal motility disorders mainly include pelvic floor synergistic dysfunction disorders such as defecation disorders, perineal descent syndrome and puborectal muscle contradiction syndrome. This kind of disease has complex pathogenesis and diverse symptoms, which seriously reduces the quality of life of patients and brings a huge medical burden to society. Anorectal manometry is an important anorectal physiological detection technology, which has a good guiding role in the diagnosis and treatment of anorectal motility disorders. It was initially used to screen children with Hirschprung disease (HD), and later gradually expanded to diagnose and treat various pelvic floor dysfunction diseases. In recent years, high resolution anorectal manometry (HRAM) has been increasingly used in clinical practice. The characteristics of HRAM and its application in anorectal motility disorders are reviewed.

IBS is a common functional gastrointestinal disease in gastroenterology clinic, which seriously affects the quality of life of patients. The main clinical manifestation is abdominal pain or abdominal discomfort with changes in defecation habits^[1], whose pathogenesis has not been fully elucidated, and evidence of abnormalities in morphological or biochemical markers that could explain symptoms is lacking^[2,3]。 About 11% of the world's population suffers from the disease^[4]。 At present, the treatment of IBS mainly includes psychological and social life intervention, dietary structure adjustment, intestinal flora adjustment and drug therapy, but the efficacy of these methods is not satisfactory.