惱人的腸躁症文明病-高點醫護網
高點醫護網

篇名
惱人的腸躁症文明病
說明
觀念剖析
  大腸激躁症是一種常見的腸道功能性障礙疾病,診斷主要以症狀為主,2006年公布最新IBS的Rome III Criteria。疾病以慢性腹痛、腹脹、排便習慣改變是主要臨床表現。IBS不易診斷,不易治療,也無法治癒。主要是藥物、飲食與行為治療三者結合。

  之前我們曾經談過腸躁症的基礎知識,今天讓我們深入了解一下大腸激躁症的臨床表現、診斷標準、鑑別診斷,以及如何治療。這很重要,現代人由於生活壓力大,常常會感覺肚子不舒服,到處都感到不對勁,去找了醫生,做了很多檢查,最後的報告結果都是正常兩字。這時,也許,你的病患就是得了大腸激躁症。大腸激躁症患者有何表現呢?我們如何去治療呢?
臨床表現
  IBS患者主要臨床表現是慢性腹痛或腹部不適感、腹瀉或便秘、排便習慣改變等,腹痛常因排便或肛門排氣而得到舒解(The primary symptoms of IBS are abdominal pain or discomfort in association with frequent diarrhea or constipation, a change in bowel habits),有時會有裏急後重(tenesmus)的情況。IBS患者腸道的構造是正常的,但蠕動功能失調和臟器敏感性增強。前者造成腹瀉或便秘,後者使得腸道即使存在少量大便或氣體,也可能會造成腹痛或腹部不適。因此,必須詳細檢查後,先排除器質性病變後才能下IBS診斷。
診斷
  1999年世界第7屆歐洲聯合消化醫學週訂出IBS診斷準則(Rome II Criteria),目前已為世界各國採用。
  1. 過去一年內有3個月或3個月以上連續或再發的腹痛或腹部不適症狀,且合併下列至少兩種情況:
    (1) 排便後症狀改善;
    (2) 排便次數改變;
    (3) 大便軟硬度改變。
  2. 過去一年內有3個月或3個月以上,至少有25%的天數出現至少兩種下列症狀:
    (1) 排便次數改變(一天三次以上或一星期少於三次);
    (2) 大便形態改變(硬塊或水、稀狀);
    (3) 排便情況改變(須用力、有急迫感、裡急後重感);
    (4) 糞便伴有黏液;
    (5) 腹脹感。
  1和2都要符合,才能診斷為IBS。在2006年Rome III Criteria 公佈,有三點與Rome II Criteria有差異:
(1) introduction of a frequency threshold of symptoms needed to meet criteria (ie, 3 or more days per month in the last 3 months);
(2) duration of symptoms (reduced to more than 6 months) before one can make a firm diagnosis;
(3) refining the subtyping of IBS;
Rome III Diagnostic Criteria for IBS
At least 3 months, with onset at least 6 months previously of recurrent abdominal pain or discomfort associated with 2 or more of the following:

(1) Improvement with defecation; and/or;
(2) Onset associated with a change in frequency of stool; and/or;
(3) Onset associated with a change in form (appearance) of stool
每年至少3個月,且每個月至少有3天以上有反覆發作腹部不適或疼痛,且合併下列3種情況的2種:
(1) 排便後症狀改善;
(2) 排便次數改變;
(3) 大便軟硬改變
【註】 Manning Criteria:
(1) 解便後腹痛減輕;
(2) 開始腹痛時,大便變軟;
(3) 開始腹痛時,解便次數較頻繁;
(4) 腹脹;
(5) 解出黏液;
(6) 感覺大便解不乾淨。
鑑別診斷
  診斷IBS是一種排他診斷,所以並沒有特殊性實驗室檢查項目或影像學檢查,一般須認真除外寄生蟲感染、乳糖耐受不良、腸道細菌過度生長、或其他腹腔疾病。但若有以下情況(red flag)則需謹慎鑑別,如胃腸出血、貧血、有意義的體重減輕、夜間症狀(Such "red flag" symptoms may include weight loss, gastrointestinal bleeding, anemia, or nocturnal symptoms)、持續腹瀉、症狀遷延或持續、大便有血液(需除外痔瘡,31%IBS患者有痔瘡問題)、近期使用抗生素、大腸癌家族史、初次發作年齡大於50歲等 (There is no specific laboratory or imaging test that can be performed to diagnose irritable bowel syndrome. Diagnosis of IBS involves excluding conditions that produce IBS-like symptoms, and then following a procedure to categorize the patients symptoms. Ruling out parasitic infections, lactose intolerance, small intestinal bacterial overgrowth and celiac disease is recommended for all patients before a diagnosis of irritable bowel syndrome is made. In patients over 50 years old it is recommended that they undergo a screening colonoscope. As many as 31% of IBS patients have blood in their stool many possibly from hemorrhoidal bleeding)。
檢查項目
  實驗室檢查或影像學檢查以除外一些疾病(Investigations are performed to exclude other conditions):
  1. 糞便檢查與培養(Stool microscopy and culture):to exclude infectious conditions;
  2. 血液檢查:Full blood examination, Liver function tests, ESR, serological testing for coeliac disease;
  3. 腹部ultrasound:to exclude gallstones and other biliary tract diseases;
  4. 內視鏡與切片(Endoscopy and biopsies):to exclude peptic ulcer disease, coeliac disease, inflammatory bowel disease, malignancies;
  5. Hydrogen breath testing:to exclude fructose and lactose malabsorption;
治療
  IBS是一種良性、慢性的腸道功能疾病,不易診斷,也不易治療,也無法治癒。所以,加強患者的認知及心理建設,培養良好的醫患關係是治療IBS非常重要的一環。對於IBS治療主要以藥物、飲食與行為治療三者結合,即調整生活型態、調整飲食、解除精神心理負擔、藥物改善症狀(Although there is no cure for IBS, there are treatments that attempt to relieve symptoms, including dietary adjustments, medication and psychological interventions. Patient education and a good doctor-patient relationship are also important)。

一、飲食治療:
  減少油脂及乳製品的攝取。避免甜味劑,如山梨醇、果醣。若便秘,則多攝取蔬果纖維;若腹瀉,則限制纖維的攝取,避免食用生食與煮熟蔬果。

二、藥物:
  1. 便秘(laxatives in constipation-predominant IBS):
    可用樂可舒(Bisacodyl)、仙賽落(sennoside)、篦麻子油(castor oil)、氧化鎂;第三型血清張力素激動劑(5-HT3 agonist) Tegaserod (Zelnorm),可促進腸道蠕動(Serotonin stimulates the gut motility) 但也會增加嚴重心血管病的風險(an increased risk of serious cardiovascular adverse events)。
  2. 腹瀉(antidiarrheals in diarrhea-predominant IBS):
    止瀉藥優腹寧(Loperamide),抗痙攣藥特良高朗(mepenzolate bromide)、Buscopan;第三型血清張力素拮抗劑(5-HT3antagonist):可降低腸道感覺神經對外界刺激的痛閥值,減少腸道內容物通過的速度。藥物有Ondansetron(Zofran)、Tropisetron(Navoban)、Granisetron(Kytril)。由於藥物對dopamine不具拮抗作用,因此,不會引起錐體外症候群。主要不良反應是頭痛。Alosetron與 cilansetron兩藥會引起 ischemic colitis 以及嚴重便秘,所以不建議使用了。
  3. 第二型多巴胺拮抗劑(Dopamine-2 antagonist),如Domperidone、Metoclopramide:
    可以減輕腹脹與腹痛,減少便秘(Domperidone, a dopamine receptor blocker and a parasympathomimetic, has been shown to reduce bloating and abdominal pain as a result of an accelerated colon transit time and reduced faecal load, that is a relief from hidden constipation; defecation was similarly improved)。
  4. P物質拮抗劑(substance P antagonist):如Spantide、Spiroquinazoline、Capsaicin。
  5. 抗憂鬱及抗焦慮藥、肌肉鬆弛劑;
  6. 抗生素:
    根據研究,服用2週的Rifaximin (Xifaxan)抗生素,有助於緩解IBS患者腹脹的症狀,且可持續到停藥後10週以上(Recent studies have suggested that rifaximin can be used as an effective treatment for abdominal bloating and flatulence, giving more credibility to the potential role of bacterial overgrowth in some patients with IBS)。
三、行為治療
  1. 建立良好的醫患關係,教育病患充分瞭解IBS,包括learning about foods to avoid, causes of IBS, medications, coping strategies, and psychological factors related to IBS等方面。
  2. 認知行為治療(Cognitive behavioural therapy)與疾病共存策略:對某些IBS患者(如症狀較嚴重者),心理治療可以改善症狀(For some patients psychological therapies may help with symptoms)。Cognitive behavioural therapy and hypnosis被認為最有效的治療模式(Hypnosis can improve mental wellbeing and cognitive behavioural therapy can provide psychological coping strategies for dealing with distressing symptoms as well as help suppress thoughts and behaviours that increase the symptoms of irritable bowel syndrome);放鬆療法也有治療的效果(Relaxation therapy has also been found to be helpful)。
  3. 修正生活型態,減少壓力、焦慮,注意飲食的選擇。
四、另類醫學
  由於西醫治療方式無法滿足所有IBS患者,有50%IBS患者轉而選擇其他方式(Due to often unsatisfactory results from medical treatments for IBS up to 50 percent of people turn to complementary alternative medicine),據說療效不錯。
  1. Probiotics:每天口服10 billion to 100 billion益生菌對於治療IBS是有效的。研究指出,Bifidobacteria infantis 效果最佳。
  2. Herbal remedies:研究指出,服用Enteric coated peppermint oil 膠囊可改善大人與小孩IBS症狀。另外,多種藥材萃取的Iberogast 也用於治療胃痙攣、消化不良的用途。
  3. Yoga:其中拜日式(Suryanamaskar)功能,歷來為Yoga們重視。因為在傳統的Yoga理論提出,在黎明和黃昏時刻,天地正好處於陰陽交合之際,空氣中充滿生命的能量(普拉那),在這兩個時段練習Suryanamaskar,有助於能量循環(energy circulation)及減輕壓力(relieve stress)。
結論
  大部分的IBS患者從年輕時就開始有此症狀,常反復發作,其症狀遷延許久,不但影響其生活品質,也浪費不少醫療資源,增加社會的醫療成本(Researchers have reported that the high prevalence of IBS, in conjunction with increased costs, produces a disease with a high social cost. It is also regarded as a chronic illness and can dramatically affect the quality of a sufferers life)。
關鍵詞
腸躁症、IBS、腸道功能性障礙、大腸激躁症、胃腸出血、肌肉鬆弛劑、臨床醫學資訊館


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