รศ.นพ.พิศาลไม้เรียง...
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Case Problems in GI. รศ.นพ.พิศาลไม้เรียง รศ.นพ.กิตติจันทร์เสิศฤทธิ์ อ.นพ.เทพสรรค์ สีอร่ามรุ่งเรือง. Disclosure of commercial support. This lecture is support by Berlin pharmaceutical industrial company. - PowerPoint PPT PresentationTRANSCRIPT
รศ.นพ.พ�ศาลไม้�เร ยง รศ.นพ.กิ�ตต� จั�นทร�เสิ�ศฤทธิ์�� อ.นพ.เทพสิรรค์� สิ อร�าม้ร��งเร�อง
Disclosure of commercial support Disclosure of commercial support
This lecture is support by Berlin
pharmaceutical industrial company.
The speakers are free to present their
own information and their personal
view without any influence from the
company.
สิถิ�ต�โรค์ท !พบบ�อยท !เวชปฏิ�บ�ต�ท�!วไปรพ.ศร นค์ร�นทร�จั'านวนค์ร�(งและร�อยละของผู้-�ป.วยนอกิ จั'าแนกิตาม้ ICD10 10 อ�นดั�บแรกิ ป0 พศ 25.
47
ล'าดั�บ
รหั�สิโรค์
ช�!อโรค์ จั'านวนค์ร�(ง
ร�อยละ
1. I10 Essential (primary) hypertension 11,905 2.32
2. K30 Dyspepsia 9,594 1.87
3. E11 Non-insulin-dependent diabetes mellitus 8,944 1.74
4. E05 Thyrotoxicosis (Hyperthyroidism) 8,399 1.63
5. J45 Asthma 7,342 1.43
6. I05 Rheumatic mitral valve disease 6,346 1.24
7. J30 Vasomotor and allergic rhinitis 5,912 1.15
8. J06 Acute upper respiratory infections of multiple or unspecified sites
5,406 1.05
9. C22 Malignant neoplasm of liver and intrahepatic bile duct
5,377 1.05
10. H90 Conductive and sensorineural hearing loss 5,305 1.03
สิถิ�ต�โรค์ท !พบบ�อยท !เวชปฏิ�บ�ต�ท�!วไปรพ.ศร นค์ร�นทร�จั'านวนค์นและร�อยละของผู้-�ป.วยนอกิ จั'าแนกิตาม้ ICD10 10 อ�นดั�บแรกิ ป0 พศ 2547
ล'าดั�บ รหั�สิโรค์ ช�!อโรค์ จั'านวนค์ร�(ง ร�อย ละ
1. K30 Dyspepsia 3,634
2. T14 Injury of unspecified body region 2,771
3. I10 Essential (primary) hypertension 2,580
4. J06 Acute upper respiratory infections of multiple or unspecified sites
2,363
5. E05 Thyrotoxicosis (Hyperthyroidism) 2,292
6. J45 Asthma 2,083
7. J02 Acute pharyngitis 1,957
8. J30 Vasomotor and allergic rhinitis 1,702
9. A09 Diarrhoea and gastroenteritis of presumed infectious origin
1,687
10. M62 Other disorders of muscle 1,686
สิถิ�ต�โรค์ท !พบบ�อยท !เวชปฏิ�บ�ต�ท�!วไป รพ. ศ-นย�ขอนแกิ�นสิถิ�ต�ผู้-�ป.วยนอกิ จั'าแนกิตาม้ ICD10 10 อ�นดั�บแรกิ ป0 พศ 2546.
ล'าดั�บ
รหั�สิโรค์
ช�!อโรค์ รวม้ รวม้ท�(งหัม้ดั
ชาย หัญิ�ง รวม้ ร�อยละ1. I10 Essential (primary) hypertension 6,011 10,413 16,424 2.85
2. E119 Non-insulin dependent diabetes mellitus
4,870 10,290 15,160 2.63
3. J069 Acute upper respiratory infection 3,714 4,711 8,425 1.46
4. N200 Calculus of kidney 4,770 3,082 7,852 1.36
5. K30 Dyspepsia 2,525 3,859 6,384 1.11
6. H251 Senile nuclear cataract 2,036 3,010 5,046 0.88
7. K021 Caries of dentine 1,408 2,707 4,115 0.71
8. A09 Diarrhoea 1,798 2,283 4,081 0.71
9. J00 Acute nasopharyngitis (common cold)
1,833 2,186 4,019 0.70
10. S099 Unspecified injury of head 2,763 872 3,635 0.63
สิถิ�ต�โรค์ท !พบบ�อยท !เวชปฏิ�บ�ต�ท�!วไป รพ. ศ-นย�ขอนแกิ�นสิถิ�ต�ผู้-�ป.วยนอกิ จั'าแนกิตาม้ ICD10 10 อ�นดั�บแรกิ ป0 พศ 2547
ล'าดั�บ
รหั�สิโรค์
ช�!อโรค์ รวม้ รวม้ท�(งหัม้ดั
ชาย หัญิ�ง รวม้ ร�อยละ1. I10 Essential (primary) hypertension 7,624 12,809 20,433 3.54
2. E119 Non-insulin dependent diabetes mellitus
4,961 11,039 16,000 2.77
3. J069 Acute upper respiratory infection 4,230 5,639 9,869 1.71
4. H251 Senile nuclear cataract 2,796 4,181 6,977 1.21
5. N200 Calculus of kidney 4,159 2,800 6,959 1.20
6. K30 Dyspepsia 2,562 3,993 6,555 1.13
7. A09 Diarrhoea 2,520 3,185 5,705 0.99
8. J00 Acute nasopharyngitis (common cold)
1,995 2,078 4,073 0.70
9. B24 Unspecified human immunodeficiency virus (HIV) disease
1,915 1,612 3,527 0.61
10. H110 Pterygium 889 2,142 3,031 0.52
สิถิ�ต�โรค์ท !พบบ�อยท !เวชปฏิ�บ�ต�ท�!วไป รพ. ศ-นย�ขอนแกิ�นสิถิ�ต�ผู้-�ป.วยนอกิ จั'าแนกิตาม้ ICD10 10 อ�นดั�บแรกิ ป0 พศ 2548. (ค์ร3!งป0งบประม้าณ)
ล'าดั�บ
รหั�สิโรค์
ช�!อโรค์ รวม้ รวม้ท�(งหัม้ดั
ชาย หัญิ�ง รวม้ ร�อยละ1. I10 Essential (primary) hypertension 4,933 8,481 13,240 4.19
2. E119 Non-insulin dependent diabetes mellitus
3,338 6,967 10,305 3.22
3. K30 Dyspepsia 1,720 2,634 4,354 1.36
4. J069 Acute upper respiratory infection 1,858 2,440 4,298 1.34
5. H251 Senile nuclear cataract 1,468 2,271 3,739 1.17
6. N200 Calculus of kidney 2,155 1,502 3,657 1.14
7. K021 Caries extending into dentine 1,033 1,886 2,919 0.91
8. A09 Diarrhea 1,156 1,170 2,626 0.82
9. J00 Acute nasopharyngitis (common cold)
1,226 1,285 2,511 0.78
10. B24 Unspecified human immunodeficiency virus (HIV) disease
1,240 1,007 2,247 0.70
Case 1Case 1
• ชายไทยค์-� อาย� 40 ป0 อาช พ พ�อค์�า• แสิบร�อน จั�กิเสิ ยดั แน�นท�อง 3
สิ�ปดัาหั�• ไม้�สิ�ม้พ�นธิ์�กิ�บอาหัาร บางค์ร�(งม้ ลม้
บร�เวณล�(นป0! ร�วม้ดั�วย• ไม้�ม้ น'(าหัน�กิลดั อ�จัจัาระป5สิสิาวะปกิต�
ไม้�ม้ ไข�• ไม้�กิ�นเหัล�า แต�กิ�นอาหัารบางค์ร�(งไม้�
ตรงเวลา•ไม้�กิ�นยาช�ดัแกิ�ปวดั
Case 1Case 1
• Thai man, not pale, no jaundice
• No lymphadenopathy
• Lung and Heart are normal
• Abdominal soft, no distension, liver
& spleen can’t be palpable
• No signs of chronic liver disease
•สิาเหัต�ท !ค์�ดัถิ3งในผู้-�ป.วยรายน ( ?
•Clue ในกิาร
diagnosis?
แสิบร�อน จั�กิเสิ ยดั แน�นท�อง
• What is/are causes?
• Clues for diagnosis
Normal physical examination
Causes of dyspepsia
Organ Pathogenesis Disease
Stomach and
Duodenum
• Acid
• NSAID
• Helicobacter pylori
• Tumor
• Infiltration
• Gastric ulcer
• Duodenal ulcer
• Gastritis
• Duodenitis
• CA stomach
• Eosinophilic
Causes of dyspepsia
Organ Pathogenesis Disease
Stomach and
Duodenum
• Acid sensitivity
• Gastric hypersensitivity
• Duodenal hypersensitivity
• Failure of fundic relaxation
to meal
• Vagal neuropathy
• Gastric dysrhythmias
• Delayed gastric emptying /
antral hypomotility
• H.pylori
• Small bowel dysmotility
NUD
Or
Functional dyspepsia
Causes of dyspepsia
Organ Pathogenesis Disease
Liver and
biliary tract
• Infection
• Tumor
• Stone
• Hepatitis
• Liver abscess
• GS
• CBD stone
• Cholangiocarcinoma
• HCC
Causes of dyspepsia
Organ Pathogenesis Disease
Pancrease • Inflammation
• Tumor
• Pancreatitis
• Pancreatic duct stone
• CA pancrease
Diagnosis
A) Peptic ulcer - DU or GU
B) Gastroduodenitis
C) Functional dyspepsia
Functional 53.4%PUD
26.4%
Hepatobiliary 16.9%
J Med Assoc Thai 1992;75:341- 8
N = 208
combined
Functional
65.6%PUD 11.3%
CA 1.8 %
Hge & Erosion 15.4%
Hepatobiliary2.6%
N = 221
Stomach Research group 1999
N = 531N = 208
NUD 76.6%
GERD 4.75%
PU 17.11%
CA 0.19%
รพ. ศร นค์ร�นทร� 2000-2002 J Med Asso Thai 1992
Functional 53.4%PUD
26.4%
Hepatobiliary
combined
Clues on clinical evaluation
Disease Clues on clinical
1. Functional - Young patient, no alarm feature
2. Chronic peptic ulceration - NSAID used, HP-positive
serologically, smoker,
Hx of bleeding or anemia
3. Gastro-esophageal reflux - Heartburn or acid regurgitation
4. Gastric cancer - Advanced age at onset,
alarm feature such as weight loss,
HP- positive serologically
5. Biliary tract disease - Biliary type pain
Clues on clinical evaluation
Disease Clues on clinical
6. Chronic pancreatitis - Constant pain, radiates to back,
alcohol abuse, DM
7. Intestinal angina - Only postprandial pain,
afraid to eat, weight loss, smoker
8. Diabetes mellitus - Hx of DM, other DM complication
9. Drugs - Theophyllin, Iron, potassium,
digoxin, antibiotic
Dyspepsia
Uninvestigated Investigated
Organic disease Functional
Ulcer - like Dysmotility - like
Management of dyspepsia
Initial management strategies for
uninvestigated dyspepsia
1. Empirical treatment
2. Prompt endoscope
3. HP. Testing follow by eradication
treatment or endoscope
Empirical treatment
• Who should empirical treatment ?
• What is appropriate medication ?
Who should empirical treatment ?
• No alarm features
Alarm features
1. Age of onset > 40 years
2. Awakening pain
3. Significant weight loss (> 5% BW within one
month or > 10% within three months)
4. History of GI bleeding
5. Persistent vomiting
6. Dysphagia
7. Strong family history of GI malignancy
1999 Thailand Consensus SRG - GAT
8. Anemia
9. Jaundice
10. Hepatomegaly, splenomegaly,
lymphadenopathy
11. Fever
12. Abdominal mass
13. Significant abdominal distension
14. Bowel habit change
1999 Thailand Consensus SRG - GAT
Alarm features
1. New – onset dyspepsia over age 50 years old
2. Dyspepsia associated with dysphagia and / or weight loss
3. Evidence of GI bleeding
• Occult blood
• Anemia
• Hematemesis
• Hematochezia or melena
4. Using NSAID or ulcerogenic agent
5. Signs or Symptoms of UGI tract obstruction
• Early satiety
• Vomiting
6. Strong family history of GI malignancy
Prompt endoscopy : Alarm features or High – risk
American Society for Gastrointestinal Endoscopy
H.pylori Test-and-Treat Strategies
• Three direct comparative studies of early endoscopy and
H.pylori Test-and-Treat Strategies
Heaney A,1999
Lassen AT,2000
Duggan A,1998
measured dyspeptic symptom resolution
• Finding : H.pylori Test-and-Treat Strategies to be at least
as effective as prompt endoscopy in patients with no
alarm symptoms
Initial management strategies for
uninvestigated dyspepsia
a) Empirical treatment
b) Prompt endoscope
c) HP. Testing follow by eradication
treatment or endoscope
A survey of etiology of dyspepsia and prevalence of H.pylori infection in every regions of Thailand
Causes of dyspepsia H.pylori +
DU
GU
NUD
CA
79 (6.75%)
27 (2.30%)
1,062 (90.69%)
3 (0.31%)
68 (86.07%)
17 (62.96%)
528 (49.72%)
2 (66.66%)
Kachintorn U, et al.1999
N = 1,171 Overall H.pylori + ve 52.52%
Pharmacological intervention for
uninvestigated dyspepsia
• Subtype of Dyspepsia (Ulcer – like or dysmotility –
like or reflux-like dyspepsia)
• PPI were significant more effective than H2RA and
antacid
40% improved with H2RA or antacid
60% improved with PPI
The Cochrane Database of Systemic – Review 2005
This patient
• Empirical treatment
• PPI for 2 – 4 weeks
• Advise : Natural history of disease
: Life – style modification
• Follow up
Case 1
The patient was advised to modified the life style.
He was on omeprazole (20mg) 1x1
domperidone (10 mg)1x3
Simethicone 1x3
At 2 week follow up his symptoms were improved and
he was advised to continue the same treatment for 6
weeks.
Case 1
• ค์'าแนะน'าในกิารปฏิ�บ�ต�ต�ว งดัเหัล�า บ�หัร !
กิ�นอาหัารตรงเวลางดัอาหัารรสิจั�ดัหัล กิเล !ยงยาท !กิระต��นใหั�เกิ�ดั
อากิาร• กิารต�ดัตาม้กิารร�กิษา
Case 1 episode 2
•หัล�งจัากิหัย�ดัยา - 2 3 เดั�อน ม้ อากิารปวดัแสิบท�อง ถิ�ายดั'าเล9กิน�อย ไม้�กิ�นยาบ'าร�ง ซื้�(อยา omeprazole กิ�นเองตาม้ร�านขายยา 1 wk อากิารแสิบท�องไม้�ดั ข3(นจั3งม้าตรวจัซื้'(า
Case 1 episode2
• Thai man, mild pale, no jaundice
• No lymphadenopathy
• Lung & Heart normal
• Abdominal soft, not tender, liver &
spleen can’ t be palpable
• PR melena, no mass
• No signs of chronic liver disease
Recurrence dyspepsia
PU CA Gastritis
Endoscope
Biopsy• HP. Test
HP.• Pathology malignancy
Inflammatory cell
ถิ�ายดั'า Anemia
ถิ�าอาจัารย�ค์�ดัถิ3ง H.pylori
infection จัะใหั�กิารร�กิษาเลยโดัยท !ไม้�ต�องสิ�องกิล�องไดั�หัร�อไม้� หัล�งจัากิเจัาะเล�อดัพบ positive
serology test
A survey of etiology of dyspepsia and prevalence of H.pylori infection in every regions of Thailand
Causes of dyspepsia H.pylori +
DU
GU
NUD
CA
79 (6.75%)
27 (2.30%)
1,062 (90.69%)
3 (0.31%)
68 (86.07%)
17 (62.96%)
528 (49.72%)
2 (66.66%)
Kachintorn U, et al.1999
N = 1,171 Overall H.pylori + ve 52.52%
Laboratory findingsLaboratory findings
• CBC:Hct 33%, Wbc 9000 PMN 65% L 30%
Mono 3% Eos 2%
• Stool examination : no parasite ,no wbc no rbc
stool occult blood positive
ถิ�าผู้ลกิารตรวจั Rapid urease test ใหั�ผู้ล negative จัะ rule out H.pylori ไดั�หัร�อไม้� และอาจัารย�จัะร�กิษาอย�างไร
กิารว�น�จัฉั�ย H. pylori Diagnostic test
Sensitivity Specificity
Histology - 93
99 - 95 99% Urea breath test
- 13CO2
- 90
98% - 80 99% - 14CO
2 - 90
98% - 92 100%Serology 88
- 96% - 89
99% - 86Rapid urease test - 86Rapid urease test
97%97% - 86 98% - 86 98%Culture -77
94% 100%
False negative for rapid urease test
• High dose H2RA
• PPI
• Antibiotic
• Active UGI bleeding
• Pathologic findings: mild gastritis with
presence of H pylori.
First line therapy (7-14 days)
PPI or Amoxycillin 1 gm bid*
RBC + Clarithromycin + or
bid 500 mg bid Metronidazole 500 mg bid
or PPI/RBC + Amoxycillin + Metronidazole
Second line therapy (7-14 days)
PPI bid + Bismuth subsalicylate/subcitrate 120 mg qid +
Metronidazole 500 mg tid + Tetracycline 500 mg qid
HP. Eradication
Case 2Case 2
•หัญิ�งไทย โสิดั 28 ป0 อาช พ ร�บราชกิารค์ร-•จั�กิแน�นท�อง ร�วม้กิ�บถิ�ายอ�จัจัาระบ�อย 2 เดั�อน•จั�กิแน�นท�องบร�เวณล�(นป0! เล9กิน�อย ร�วม้กิ�บอากิาร
ถิ�ายอ�จัจัาระบ�อย ว�นละ - 34 ค์ร�(ง หัล�งร�บประทานอาหัาร บางค์ร�(งม้ ม้-กิปน แต�ไม้�พบเล�อดั น'(าหัน�กิไม้�ลดัหัร�อเบ�!ออาหัาร
• ไปพบแพทย� 4 ท�าน บอกิเป<นโรค์กิระเพาะ โรค์ประสิาทลงกิระเพาะ ไดั�ยากิ�นไม้�ดั ข3(น กิ�งวลว�าจัะเป<นม้ะเร9ง
• ไม้�ดั�!ม้สิ�รา กิ�นอาหัารตรงเวลา
Case 2Case 2
• A Thai woman not pale, no jaundice, No signs of hyperthyroidism, no signs of malnutrition (edema, vitamin deficiency)
• BP 120/80 torr, Pulse 75/min, BT 36.7 ๐C
• Lung & heart WNL
• Abdomen: soft ,no distension,
liver & spleen can’t be palpable
• No sign chronic liver disease
• PR normal
สิาเหัต�ท !น�าค์�ดัถิ3งในผู้-�ป.วยรายน (A) IBSB) IBDC) ParasiticD) CA colon
Case 2Case 2
A young lady with :
• Abdominal discomfort (epigastrium),
• Chronic diarrhea ( no bloody stool).
• Normal physical examination.
Chronic diarrhea
Functional Organic
Some ‘red-flag’ symptoms and signs suggesting organic gut disease
• Rectal bleeding
• Weight loss*
• Continuous diarrhea
• Constant and recent distension
• Anemia
• Fever
* Occasionally IBS patients lose weight because they food
intake to avoid meal-induced symptoms
IBSIBS
Diarrhea ConstipationAbdominal
discomfort
Distribution of abdominal pain induced by balloon inflation
Prevalence of IBS among Thai, American and British
Thai American British
Rural Urban
No of subjects 401 676 789 301
Mean age 41 31 24 NA
% women 56 31 58 55
Change bowel pattern due to 3.5 21.3 70.5 NA
stress(%)
Abdominal pain due to stress 1.8 15.5 54.1 NA
Painless diarrhea 0 3.6 4.9 4.7
Painless constipation 9.5 7.1 17.5 10.3
Spastic colon syndrome 5.7 4.3 22.3 13.6
DiagnosesDiagnoses
Most likely diagnosis is IBSIBS
Differentiate diagnoses :• Giardiasis
• Strogyloidiasis
• Lactose intolerance
• IBD
• Drugs
Some drugs commonly disturb bowel function
Drugs causing constipation
• Opiates (e.g. codeine, morphine)
• Phenothiazines (e.g. chlorpromazine)
• Tricyclic antidepressants (e.g. amitriptyline)
• 5-HT3 antagonist (e.g.
ondansetron)
• Calcium channel blockers
• Anticholinergics
• Calcium carbonate
Drugs causing diarrhea
• Misoprostol
• Cisapride
• Antacids containing magnesium hydroxide
• Herbal teas containing senna
• Alcohol
• Caffeine
Symptom criteria to exclude organic disease in patients with possible IBS
Young age group
Chronic recurrent symptoms
Mild to moderate symptoms
No signs of organic disease
Middle age
New onset of symptoms
No signs of organic
disease
Age > 50 yr
Change in
symptoms or new
onset of symptoms
Severe symptoms
Sign of organic
disease
Minimal diagnostic
work up
Limited diagnostic
work up
Full diagnostic
work up
Initial work-up in patients with suspected IBSInitial work-up in patients with suspected IBS
• History• Physical examination
(including digital examination of rectum)• CBC• Erythrocyte sedimentation rate• Occult faecal blood test • Colonic examination (discussed on an
individual basis)• Abdominal ultrasound (discussed on an
individual basis)
• CBC : Hct 40%, Wbc 8500, PMN 82%
L18%, Mono 1%, Plt 180000
• Stool exam : no parasite, no rbc
no wbc, occult blood –ve
Sigmoidoscopy : normal
Randomized , Double-Blind, Placebo-Controlled Treatment Trial for the Irritable Bowel Syndrome
Reference a
Antispasmodic agents
Bertherlot,1981, France
General Practitioner Research Group, 1976, U.K.
Kruis ,1986, Germany
Page,1981, U.S.A.
Test agent
Mebeverine
Dicyclomine
Mebeverine
Dicyclomine
Patients entered
111
29
80
97
Length oftreatment
period(wk)
8
2
16
2
Rx groups’baseline
characteristic compared?
Y
-
Y
Y
Activetreatment response
(%)
86
38
13
94
Placeboresponse
(%)
73
25
30
54
Kenneth D Klein. Gastroenterology. 1988.
Randomized , Double-Blind, Placebo-Controlled Treatment Trial for the Irritable Bowel Syndrome
Test agent
Ispaghula
Psyllium
Ispaghula
Loperamide
Reference a
Bulking agents
Arthurs, 1983, Ireland
Longstreth, 1981, U.S.A.
Prior, 1987, U.K.
Opioids
Hovdenak, 1987, Norway
Patients entered
80
77
80
60
Length oftreatment
period(wk)
4
8
12
3
Rx groups’baseline
characteristic compared?
N
Y
Y
Y
Activetreatment response
(%)
73
77
82
100
Placeboresponse
(%)
63
71
53
45
Kenneth D Klein. Gastroenterology. 1988.
Newly approved prescription treatment for IBS
• Treatment•Tegaserod maleate1
• 5 – HT4 receptor partial agonist
• Indicated for the short – term treatment of women with IBS whose primary bowel symptom is constipation
• Alosetron hydrochloride2
• 5 – HT3 receptor partial agonist
• Indicated only for women with severe diarrhea – predominant IBS who have
• Chronic IBS symptoms (generally lasting 6 months or longer)• Has anatomic or biochemical abnormalities of the GI tract excluded • Failed to respond to conventional therapy
ท�านจัะเล�อกิใช�ยาอะไรA) Imodium
B) Buscopan
C) Mebeverine
D) Psyllium
Recommendations
• Various antispasmodics can be given to
reduce pain, those with an anticholinergic
action appearing to be slightly more effective
• Tricyclic antidepressants can be beneficial for
pain, initially at a low dose, but occasionally
higher doses may be required. They are best
avoided if constipation is a major feature
Recommendations
• Patients with urgency and diarrhea can be
successfully treated with loperamide at doses of
4 - 12 mg daily. Codeine is a reasonable alternative
but more likely to cause unwanted sedation
• A small number of patients with diarrhea
predominant IBS have bile salt malabsorption and
may response to cholestyramine
Case 2 Treatment
• ใหั� Mebeverine 1x3 , Imodium 1 tab prn, Buscopan 1 tab prn
น�ดัม้าดั ข3(น ใหั�ร�กิษาใกิล�บ�าน • 6 เดั�อน ต�อม้าม้ อากิารปวดัท�องม้ากิข3(นใหัม้� นอน
ไม้�หัล�บ กิ�งวลม้ากิ ว�าจัะเป<นม้ะเร9งอ กิ โดัยม้ ล-กิของค์�ณอาเป<นม้ะเร9งล'าไสิ�ใหัญิ� ตอนอาย� 40 ป0 เม้�!อ 1 เดั�อนกิ�อน จั3งม้าตรวจัซื้'(า
• ไม้�ม้ น'(าหัน�กิลดั ไม้�ม้ ไข� ย�งกิ�นไดั�ดั ไม้�อาเจั ยน
Case 2 episode 2
•CBC normal•Stool exam normal•ค์'าแนะน'าและกิารร�กิษา
เพ�!ม้เต�ม้
Patients in English general practice with fear of cancer or other serious disease
Percentage of Percentage of patients
patients with IBS* with organic disease
(n = 76) (n = 100)
Fear of cancer 46 30 (p < 0.04)
Fear of other disease 9 10
Total with fear 55 40(p < 0.05)
FOBT vs SIGMOIDOSCOPY (FS) vs COLONOSCOPY in detection of FOBT vs SIGMOIDOSCOPY (FS) vs COLONOSCOPY in detection of colorectal cancercolorectal cancer among Chinese among Chinese
505 asymptomatic adults older than 50 years were recruited from the general public through health exhibitions. All enrolled subjects were offered FOBT and full colonoscopy under sedation.
476 (94.3%) had a complete colonoscopy were recorded. Lesions at the distal 40 cm in the left colon and rectum were taken as findings of FS.
Advanced colonic lesions* sensitivity specificity
FOBT 14.3% 79.2% FS 77.8% 83.9% Combining FOBT with FS would not significantly improve the results of FS alone.
Among the 385 subjects with a normal distal colon, 14 (3.6%) had advanced lesions in the proximal colon that would be missed by FS alone.
* Advanced colonic lesions = adenoma > or = 10 mm, villous adenoma, adenoma with moderate or severe dysplasia, or invasive cancer
Sung JJ et al Gastroenterology. 2003 Mar;124(3):608-14
Management guideline for IBS
• Listen to the patient • Explanation and reassurance • Healthy lifestyle advice • Dietary advice • Psychological considerations • Psychological treatment• Pharmacological approach
Do’s and don’ts of IBS management
Do’s• Approach the patient
empathically• Explore any hidden
agenda• Explain nature of the
disorder thoroughly
Don’ts • Discourage the patient
from seeing you again• Punish the patient• Assume psychogenic
origin of the symptoms without proper assessment
• Feel forced into repeated or needless investigations
This presentation is placed on the
website of Department of Medicine,
KKU.
http://www.med.mykku.net