Funksjonelle tarmlidelser

Transcription

1 Funksjonelle tarmlidelser FD IBS Funksjonelle Øsofaguslidelser Matoverfølsomhet

2 Economical Impact Functional Dyspepsia is a great economical challenge to the society The annual expenditure due to the management of patients with functional dyspepsia was estimated to 2786 Mill. SEK Nyren et al. 1984

3 Epidemiology of FD Prevalence 25% Only 1 in 4 consult medical care Helicobacter pylory infection similar to background population 17% postifectious dyspepsia genotyping

4 Funksjonell Dyspepsi (FD) ROMA III Må inkludere 1. En eller flere av a. Plagsom postprandial oppfylthet b. Tidlig metthet c. Epigastrisk smerte d. Brennende følelse i epigastriet OG 2. Ingen tegn til strukturell sykdom (inkludert ved øvre endoskopi) som kan forklare symptomene Kriteriene må være oppfylt siste 3 mnd med symptom start minst 6 mnd før diagnose

5 ROMA III

6 Dyspeptic symptoms CNS (neurotisism) Low vagal tone (RSA) Genetics Inflammation Visceral hypersensitivity (barostat, drinking test) Disturbed accomodation of prox stomach, wide antrum (ultrasound)

7 Nutrient signaling in the small intestine Nutrients in the gut trigger reflex control of gut secretory and motor function via vagal pathways. nodose ganglion vagal motor outflow NTS vagal afferents slowed gastric emptying lipids carbohydrates protein slows gastric emptying to a rate matched to the absorptive capacity of the small intestine

8 Nutrient-induced activation/modulation of upper GI vagal afferents L-Try, Phe Calcium receptor NPW GPR-7 Gaq lumen G-cell vagal afferent GLP-1 5-HT ATP CCK - Direct paracrine effects Ghrelin etc. Leptin Neuropeptide W - Modulation of function (paracrine /endocrine)

9 Pathogenesis of FD Impaired accommodation Visceral hypersensitivity to distention Delayed gastric emptying H. Pylori infection Low vagal tone Psychological factors

10

11 Gastric Accommodation Definition Gastric accommodation is a complex process that describes how the size of the gastric compartment changes in response to a meal Extragastric reflexes: Receptive relaxation Intestino-gastric reflexes Colo-gastric reflexes Intragastric reflexes: Adaptive relaxation Antro-fundic reflexes

12

13 Gastric Accommodation Normal stomach Functional dyspepsia Reflux oesophagitis

14

15 Postprandial, but not fasting, distention thresholds are related to the severity of meal-related symptoms in patients with functional dyspepsia. GASTROENTEROLOGY 2013;145:

16

17 fmri and meal-stimulated brain activity

18

19 Dyspeptic symptoms epigastric pain or discomfort nausea bloating postprandial fullness early satiety belching regurgitation vomiting heartburn anorexia

20 Subgroups of FD B1a: Ulcer-like dyspepsia Pain centered in the upper abdomen is the predominant (most bothersome) symptom B1b: Dysmotility-like dyspepsia An unpleasant or troublesome non-painful sensation (discomfort) centered in the upper abdomen is the predominant symptom; this sensation may be characterized by or associated with upper abdominal fullness, early satiety, bloating, or nausea B1c: Unspecified dyspepsia

21 Functional dyspepsia overlaps with other diseases Irritabel Bowel syndrome Gastro Oesophageal Reflux Disease Motility disorders Biliary tract dyspepsia Depression Anxiety Somatoform disorders

22 Sensitivitet 1.00 Symptomer per intragastrisk volum Kjøttsuppe Vann Nutridrink Spesifisitet AUC

23 FD 218 patients

24 Food related symptoms (Tack 2014)

25 Symptoms related to pathophysiology (Tack 14)

26

27 Pressure (cmh2o) Pressure cmh2o Balloon pressures at max distension (180ml) in FD effect of buscopan p < FD before FD after FD before Fd after 5 0 FD before Fd after

28 symptoms (VAS) Symptoms at max distension (180 ml) before buscopan 4 3 p = FD C

29 Symptoms (VAS) Symptoms (VAS) Symptoms at max distension (180ml) in FD effect of buscopan p = FD before FD after pat before pat after

30 2007

31 Treatment in FD Non-pharmacological Reassurance. It s not dangerous Regular life-style and more healthy meals Eat smaller meals! Psychotherapy Cognitive therapy Stress-coping Deep-breathing techniques Hypno-therapy Pharmacological

32

33 Treatment of functional dyspepsia Delgado-Aros, Talley 2004 Helicobacter pylori PPI and H2-antagonists Prokinetic agents Antidepressants and SSRI Psychotherapy 5-HT3 antagonists

34 Helicobacter pylori and functional dyspepsia: An unsolved issue World J Gastroenterol 2014 H. pylori eradication is associated with a 10% therapeutic gain as compared to placebo and that symptoms improvement ultimately occurs in nearly 40% of eradicated patients Meta-analysis, including data more recent studies (overall 14 trials with 2993 patients), confirmed that improvement of dyspepsia symptoms occurs more frequently after H. pylori therapy than placebo.

35 Hypnotherapy in FD Symptom change throughout the study Calvert et al., Gastroenterology 2002;123:

36 Novel therapeutic agents in neurogastroenterology: advances in the past year M. CAMILLERI 14