【作者】 余颖聪；

【导师】 戴宁；

【作者基本信息】 浙江大学 ， 内科学， 2009， 博士

【摘要】 背景:肠易激综合征(IBS)是常见的胃肠道功能性疾病,指一组腹痛或腹部不适伴排便习惯改变、粪便性状异常等临床表现的症候群。IBS的发病机理尚不清楚,许多研究正在深入中。然而,在IBS的诊治实践和研究中,有三个问题一直困扰着我们:IBS是什么?IBS的诊治研究该如何发展?IBS到底该怎么诊治?目的:澄清IBS概念,探讨IBS诊治方向和相应思维,提出构建IBS诊治新体系的设想。方法:通过文献综合分析寻找IBS共性特征、明确IBS涵义;通过对消化科医师的问卷调查,了解他们对IBS诊断知识的掌握及诊治过程中的体会;结合动物研究实例和临床研究文献,对研究中的不确定因素和导向思维进行分析;提出IBS诊治应对策略。结果:1.以症状为基础的IBS诊断具有主观性和随意性。IBS患者临床表现多样,受生物、心理、社会三方面的因素影响,并处于动态变化中。部分临床医师对IBS知识欠缺,诊断标准在临床应用受限。2.大部分IBS动物研究试图通过建立模型查找病因和弄清发病机制、建立和验证假说,其结果的不确定性和由于这些结果导致出新的不确定问题,使研究结论无所适从。大量基于对症治疗评价分析和推论IBS发病因素及诊治研究结果同样五花八门,使研究者更感困惑、诊断途径和治疗办法变得杂乱,使人难以取舍。IBS的诊治研究较多地受传统医学思维的束缚。3.IBS患者症状及就医行为受生物、心理、社会等多种因素影响,新的IBS诊治体系需要结合上述多方面考虑。结论:1.IBS可能是一种由生物、心理、社会因素综合作用导致机体和精神受到损伤性刺激的过度反应,表现为腹痛与排便异常为主症伴有躯体多部位不适的一种动态变化的状态,目前没有器质性病变的依据。为了反映IBS症状的多样性和动态性,建议将“肠易激综合征”改称为“易激状态”,即“Irritable State(IS)”2.由于IBS受生物、心理、社会因素的综合影响,其诊治研究的方向应寻找生物-心理-社会等多方面的平衡。除了传统的医学思维外,还需要有整体思维和右脑思维的应用,而叙述医学可能会成为诊治IBS的新手段。3.对IBS患者的诊治,需要建立一个完善的诊疗体系,该体系除了医学诊疗系统外,还应包括医患沟通和互勉系统、个体化防治和评价系统、诊治保障系统和社会支撑系统五大系统有机结合的诊疗平台。更多还原

【Abstract】 Backgrounds: Irritable bowel syndrome (IBS) is a common gastrointestinal disorder characterized by recurrent abdominal pain or discomfort associated with altered bowel movements. However, its pathophysiology remains elusive, and more and more studies have been performed. While we still feel confused in IBS related practice and research, and three questions linger in our minds: What is IBS? What direction should the studies pertaining to IBS develop to? What’s the best way to diagnose and treat IBS?Objectives: To clarify the concept of IBS, and suggest the direction for the IBS-related research and the medical paradigms, design a new system of diagnosis and treatment for IBS.Methods: By reviewing the literature, we tried to find the common characterization of IBS and to clarify its definition. Questionnaires were performed to determine the gastroenterologists’ knowledge about IBS and their perceptions when dealing with IBS patients. We also analyzed the uncertainty in our animal experiments and related articles, and discussed the paradigms we should have. A management strategy concerning the diagnosis and treatment of IBS was suggested.Results: 1. The symptom-based diagnosis of IBS is subjective and casual. IBS patients present multiple symptoms, which are affected by biopsychosocial factors and in a dynamic situation. Some physicians have limited knowledge of IBS, which restricts the practice of the criteria.2. The majority of the animal studies focus on the establishment of models, detection of the pathophysiology and verifying the hypothesis. However, the uncertainties lie among and produced by the results are confusing. The results of clinical researches usually present diversity as well since they based on the retrospective epidemiological studies and trials to improve symptoms. It is hard to make a clinical decision. It seems that the traditional paradigm plays a dominant role in IBS studies.3. Since the patient’s symptoms and medical seeking behaviors are influenced by biopsychosocial factors, the new system of diagnosis and treatment of IBS should take all the aspects into account.Conclusions:1. IBS is characterized by abdominal pain and altered bowel movement, associated with discomfort from other organs. It may be a response to both physical and psychological stresses composed by biopsychosocial factors. No pathological abnormality is found till now. In order to be consistent with the dynamic and comprehensive characterization of clinical presentations, we suggest that the name "irritable bowel syndrone" change to be "Irritable State (IS) ".2. IBS is influenced by biopsychosocial factors, the direction for IBS-related researches should focus on the balance of the biopsychosocial impact. Correspondingly, we should not limit to the traditional medical paradigms. Comprehensive and the right brain paradigms are even more needed, and narrative medicine may become a new approach in managing IBS.3. A management system is needed to diagnose and treat IBS, which includes not only the medical diagnosis and treatment system, but also communication and incentive system, tailored prevention, therapy and appraisement system, guarantee system and social support system.更多还原