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    浅谈功能性消化不良

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    时间:2019-09-11

    浅谈功能性消化不良

      【中图分类号】R473 【文献标识码】B 【文章编号】1005-0019(2019)15--01

      消化不良以上腹部烧灼感、疼痛、餐后饱胀、早饱为主要表现。根据消化不良的发病原因,可将其分为器质性消化不良和功能性消化不良。通过内镜、腹部超声等检查,发现器质性病变(如溃疡、反流行食管炎、胰胆疾病、肿瘤性消化道疾病等)的,称为器质性消化不良。排除器质性疾病的消化不良,称为功能性消化不良。功能性消化不良主要与胃十二指肠功能为乱为主,引起上腹部烧灼感、疼痛、餐后饱胀、早饱等一种或多种症状,是常见的一种功能性疾病,起病缓慢、病程长,呈持续性或反复发作。在普通人群中发病率比例较高,尤其在老年人中更易多见。功能性消化不良虽不是致命性疾病,但可明显降低患者的生活质量,增加患者的经济负担。

      1 功能性消化不良流行病学

      功能性消化不良全球分布。各地区、各民族发病率有较大差异。在亚洲,发达国家发病率小于发展中国家。在中国功能性消化不良的患病率调查报道各不相同。中国的发病率比亚洲发达国家发病率高。部分调查研究认为女性发病率高于男性。从青少年到老年年龄段人群均可发生功能性消化不良。教育水平、职业的不同,功能性消化不良的发病率也不同[1]。

      2 功能性消化不良发病机制

      功能性消化不良病因不清,可能与不良饮食习惯、不良生活习惯、睡眠异常和精神社会因素等因素有关。精神社会因素与功能性消化不良有明显相关性。功能性消化不良患者失眠、焦虑、抑郁、紧张的发生率高于正常人,儿童期时出现应激事件发生率明显高于正常人。功能性消化不良患者最常见的精神心理异常是焦虑、抑郁。具有内向、情绪不稳定、孤僻、易沮丧的学龄期儿童发病率较其他儿童高。发病机制不清、复杂,可能为动力障碍和感觉异常、胃酸分泌异常、内脏感觉过敏、胃对食物的容受性降低、幽门螺杆菌感染、精神社会因素(失眠、焦虑、抑郁、紧张、注意力不集中等)、不良的生活习惯(生冷、甜食、油腻、刺激性食物等不健康饮食)、遗传等。动力障碍主要为排空延迟、协调运动失常等。内脏感觉过敏指患者胃感觉容量低于正常人。幽门螺杆菌与功能性消化不良的关系:部分患者根治幽门螺杆菌后消化不良症状缓解,部分患者根治幽门螺杆菌后消化不良症状没有明显改善,或症状改善后再加重。功能性消化不良患者可能有家族史,有家族聚集性[1]。生冷、甜食、油腻、刺激性食物或较少摄入新鲜蔬菜水果等不健康饮食可诱发功能性消化不良。

      3 功能性消化不良诊断

      罗马Ⅲ标准将功能性消化不良分为两个亚型:上腹痛综合症、餐后不适综合症。上腹痛综合症以上腹部烧灼感、疼痛为主,餐后不适综合症以餐后饱胀、早饱为主。两型均可伴有腹胀、嗳气、恶心、呕吐等。餐后饱胀指食物存留于胃部时间过长引起不适。早饱指进食少量食物既有饱满感,不能继续进食。上腹痛指两侧锁骨中线之间,胸骨剑突下与脐水平以上部位的疼痛。上腹部烧灼感指上腹部灼热感。

      功能性消化不良为排除性诊断。诊断标准为上腹部烧灼感、疼痛、餐后饱胀、早饱等一种或多种症状,超过半年或三个月来症状持续,排便后不能缓解,排除其他器质性疾病即可诊断。后期因进食减少,患者可出现营养不良的表现。支持功能性消化不良诊断条件有1、疼痛可因进食诱发或缓解。2、可出现进食后上腹部的胀气、嗳气和恶心。3、排气排便后症状不缓解。如出现呕吐、排气排便后症状缓解要考虑其他疾病。45岁以上的患者,出现消化不良、消瘦、贫血、呕血、黑便、吞咽困难、腹部肿块、黄疸等,则必须彻底检查,找到病因。45岁以下患者,实验室检查、胃镜检查后可经验性治疗2-4周,无效再进一步检查。继发性消化不良进行病因治疗后,消化不良症状会明显减轻。

      4 功能性消化不良预防和治疗

      预防合理的饮食习惯、适当的户外锻炼和减轻心理压力和负担。建议患者三餐定时定量,尤其是年龄>60岁以上的老年人,每餐进食七分饱即可。进食量过多、进食次数增多或减少、过点进餐都可诱发功能性消化不良。不建议少量多餐,增加胃肠工作时间,不利于消化功能的调节。建议多摄入新鲜的蔬菜和水果,有利于预防功能性消化不良,尤其是学龄儿童。建议减少生冷、甜食、油腻、刺激性食物的摄入,也可较少功能性消化不良的发生。不良的睡眠习惯(睡眠时间不足、睡眠质量差或日夜颠倒引起睡眠剥夺)也是引起功能性消化不良的因素。改善患者的睡眠质量也能预防功能性消化不良的发生。围绝经期功能性消化不良患者进行健康教育和心理干预可预防和改善功能性消化不良[2]。每天坚持适量的户外运动释放患者的负面情绪,改善患者精神心理状态,增强患者免疫力,增强胃肠道功能。

      治疗主要对症处理、个体化治疗。一般治疗良好的生活习惯、健康的心理。临床治疗的目的主要是缓解症状、改善患者的生活质量、减轻患者的经济负担。目前没有根治功能性消化不良的特效药。药物治疗主要为经验治疗,抑制胃酸分泌、促胃动力、抗抑郁药等。抑制胃酸分泌药可选用质子泵抑制剂或H2受体阻断剂,用于上腹痛、有烧灼感为主要表现的患者。质子泵抑制剂主要作用机制是抑制了胃壁细胞的质子泵,使H+不能泵入到胃腔内,抑制胃酸的分泌。代表药物有奥美拉唑等。H2受体阻断剂主要作用机制是阻断了胃壁细胞上H2受体,抑制胃酸的分泌。H2受体阻断剂的代表药物有西米替丁、雷尼替丁、法莫替丁等。法莫替丁作用最强,西米替丁作用較弱。促胃动力药可选用甲氧氯普胺、多潘立酮、莫沙必利等,主要用于以餐后饱胀、早饱为表现的患者。莫沙必利的作用机制是兴奋胃肠道的5-羟色胺受体,具有促胃动力作用,增加胃肠道运动,促进胃排空、保护胃粘膜、抗炎等。乳酸菌素片调节肠道菌群,促进胃肠道有益细菌的生长繁殖,助消化,增强胃肠道功能,也可用于功能性消化不良的辅助治疗。莫沙必利和乳酸菌素片联合治疗可提高功能性消化不良的疗效[3]。精神心理因素也是引起功能性消化不良的重要因素。目前功能性消化不良发病率逐渐增高,多数病人都合并有失眠、焦虑、抑郁、紧张、注意力不集中等精神心理异常。失眠、焦虑、抑郁、紧张、注意力不集中等精神心理异常又可加重患者功能性消化不良的症状和病情,使病情进一步加重。有研究表明心理治疗、抗焦虑抑郁治疗可明显改善患者的症状,增强疗效[4]。小剂量的抗抑郁药可改善患者抑郁的负面情绪,明显缓解患者的症状,增强患者治疗的依从性、提高患者的生活质量,提高预后。抗抑郁药多选黛力新,用于明显伴有精神症状患者。中医也一直致力于功能性消化不良的治疗。中医治疗可用柴胡疏肝散、半夏泄心汤、疏肝降浊方等,中成药可用健胃消食口服液、参柴胃苏胶囊等。除口服中药外,还可用针灸、推拿、穴位埋线、穴位注射、足浴等疗法[5]。

      综上所述,功能性消化不良在我国发病率较高,目前还没有研制出根治功能性消化不良的特效药,需要进一步深入研究。我国目前正致力于中西医结合研究,希望能在功能性消化不良治疗中有突破性的进展。

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