11

Functional Functional Disordes of Disordes of

Digestive SystemDigestive System

22

Functional disorders

no structural, biochemical, or infectious etiology has been found

33

Functional Disordersof Digestive System (FDDS)

are are reported by 25% of the adult population female predominance > 2:1 among patients

presenting to a physician < 50% of patients with FDDS apply to the

physicians 75% of patients try to treat themselves

44

Functional Disordersof Digestive System (FDDS)

EEsophageal sophageal GastroduodenalGastroduodenal Intestinal Intestinal Functional abdominal painFunctional abdominal pain Biliary Biliary dyskinesia Anorectal disorders Anorectal disorders Noncardiac chest pain Nonulcer dyspepsia Pediatric FDDSPediatric FDDS

55

Aetiology Aetiology

Disordered motor or sensory function of the GI tract

Altered visceral sensation

66

EEsophageal sophageal Functional Functional DisordersDisorders

77

EEsophageal sophageal FDFD

61,7% of men and 63,6% of women suffer 61,7% of men and 63,6% of women suffer 77from from heartburnheartburn..

Gastroesophageal Reflux DiseaseGastroesophageal Reflux Disease (GERD): (GERD): 40-60%40-60% of adult population. of adult population.

EsophagitisEsophagitis is revealed is revealed in in 45-80% 45-80% of patients of patients with GERDwith GERD

88

Pathogenesis of GERDPathogenesis of GERD Decreasing of Antireflux BDecreasing of Antireflux Barrierarrier:: - Pressure decreasing in the lower esophageal - Pressure decreasing in the lower esophageal

sphincter sphincter - Increasing of spontaneous relaxation episodes of - Increasing of spontaneous relaxation episodes of

the lower esophageal sphincter the lower esophageal sphincter - Complete / incomplete destruction of the lower - Complete / incomplete destruction of the lower

esophageal sphincter esophageal sphincter Esophageal Clearance Decreasing:Esophageal Clearance Decreasing: - Chemical- Chemical - V- Volumetric – olumetric – due to due to oppression oppression of the secondary of the secondary

peristalsis and wall tonus diminishing of the peristalsis and wall tonus diminishing of the thoracic part of the esophagusthoracic part of the esophagus

99

Pathogenesis of GERDPathogenesis of GERD

Damage Damage propertiesproperties of refluctant of refluctant Stomach emptying disorders Stomach emptying disorders Abdominal pressure increasingAbdominal pressure increasing Connective tissue disorders (hiatal hernia) Connective tissue disorders (hiatal hernia)

1010

Diagnosis of GERDDiagnosis of GERD

EndoscopyEndoscopy ManometryManometry pHpH--metrymetry X-rayX-ray

1111

TreatmentTreatment

““Life style / modus” normalization (eating 4-6 Life style / modus” normalization (eating 4-6 times a day)times a day)

Diet (to eat suitable food)Diet (to eat suitable food) AntacidsAntacids ProkineticsProkinetics

1212

Stomach Functional Stomach Functional DisordersDisorders

1313

Stomach FDStomach FD

Functional dyspepsyFunctional dyspepsy AerophagyAerophagy Functional vomitingFunctional vomiting

1414

Functional dyspepsyFunctional dyspepsy Ulcer-like Ulcer-like

epigastric pain (fasting or night) stopped epigastric pain (fasting or night) stopped by antacids by antacids

DyskineticDyskinetic

early satiety, nausea, abdominal early satiety, nausea, abdominal distension just after eating of distension just after eating of small small amountamount of the food of the food

1515

Pathogenesis of Stomach Functional Pathogenesis of Stomach Functional Dyspepsy (SFD)Dyspepsy (SFD)

Decreasing of Decreasing of gastric motor activitygastric motor activity (antral (antral part) - gastroparesispart) - gastroparesis

Stomach Stomach dysrhythmiadysrhythmias (tachygastria, s (tachygastria, bradygastria)bradygastria)

Antrocardial and antroduodenal coordination Antrocardial and antroduodenal coordination disturbance disturbance

Duodenogastric refluxDuodenogastric reflux Stomach proximal part relaxation disturbanceStomach proximal part relaxation disturbance Visceral hVisceral hypersensitizationypersensitization of the stomach of the stomach

wall to distension wall to distension

1616

Investigation dataInvestigation data

Light epigastric pain in palpation without Light epigastric pain in palpation without anterior abdominal wall tensionanterior abdominal wall tension

1717

Differential diagnosis withDifferential diagnosis with

UlcerUlcer GallstonesGallstones Chronic pancreatitisChronic pancreatitis TumoursTumours

1818

Treatment of SFDTreatment of SFD

““Life style / modus” normalization Life style / modus” normalization (eating 4-6 times a day)(eating 4-6 times a day)

PPsychotherapysychotherapy / / PPsychosychopharmacopharmacotherapytherapy

Prokinetics /normokineticsProkinetics /normokinetics SpasmolyticsSpasmolytics H2-histamine blockersH2-histamine blockers

1919

IRRITABLE BOWEL SYNDROME

(IBS)

2020

IBSIBS

is characterized by abdominal pain and altered bowel habits, including diarrhea, constipation, or alternating diarrhea and constipation

Symptoms are typically intermittent but may be continuous

Symptoms should be present for at least 3 months before a diagnosis of IBS is considered

2121

IBSIBS

55 –– 1919 % % in men in men 1414 –– 2424 % % in womenin women Men / women = Men / women = 1,51,5 :: 2,52,5 DDisease incidenceisease incidence peak = 30 - 40 y.o. peak = 30 - 40 y.o.

2222

IBSIBS

18921892 y. - “ y. - “mucous colitismucous colitis” – English ” – English doctor W. Oslerdoctor W. Osler..

19291929 y.- y.- ““Irritable bowel” - S. Jordan S. Jordan andand E. KiferE. Kifer

Russian doctor Russian doctor А.В. Фролькис А.В. Фролькис (A.V.Frolkis) – “(A.V.Frolkis) – “dyskinesia of colondyskinesia of colon””

IRRITABLE BOWEL SYNDROME - now

2323

Manning criteria

abdominal pain or discomfort that is relieved by defecation or associated with a change in stool frequency or consistency,

abdominal distention, sensation of incomplete evacuation, passage of mucus (in faeces)

2424

Roman criteriaRoman criteria

Diagnostic criteria for IBS that incorporate the Manning criteria have been established to standardize research and may be useful in clinical practice - римские критерии синдрома раздраженной кишки

2525

2626

2727

IBSIBS

PredominancePredominance of of diarrheadiarrhea PredominancePredominance of of constipationconstipation PredominancePredominance of of abdominal pain and abdominal pain and

distensiondistension

2828

IBS: IBS: PredominancePredominance of of diarrheadiarrhea

Liquid stool 2 – 4 times a day, morning, Liquid stool 2 – 4 times a day, morning, agter breakfast, mucous and remnants of agter breakfast, mucous and remnants of undigested food in the feces undigested food in the feces

Feeling to make a defecation urgently / Feeling to make a defecation urgently / promptly promptly

Absence of diarrhea during night, but Absence of diarrhea during night, but ““Morning alarm-clockMorning alarm-clock””

Feces weight < 100 g.Feces weight < 100 g.

2929

IBS: IBS: PredominancePredominance of of constipationconstipation

Absence of defecation during > 3 Absence of defecation during > 3 days.days.

AAlternation lternation of diarrhea and of diarrhea and constipationconstipation

Feeling of incomplete evacuationFeeling of incomplete evacuation ( ( lumpy/hard, tape-like or pencil-like)lumpy/hard, tape-like or pencil-like)

3030

IBS: IBS: PredominancePredominance of of abdominal abdominal pain and distensionpain and distension

CCramp-like, spasmodicramp-like, spasmodic abdominal pain abdominal pain Pain Pain increases beforeincreases before defecation and defecation and decreases decreases

afterafter one one Pain occurs after eatingPain occurs after eating MeteorismMeteorism Abdominal tenderness, often in the left /right

lower quadrant in palpation or along all parts of bowel

3131

““Alarm” signs – Alarm” signs – exclusionexclusion criteria of IBS criteria of IBS

Constant abdominal pain, increasing after Constant abdominal pain, increasing after defecationdefecation

Night pain, diarrhea and other sympromsNight pain, diarrhea and other symproms Causeless weight lossCauseless weight loss Onset of the “IBS” at age > 50 y.Onset of the “IBS” at age > 50 y. Oncological diseases of bowel in relativesOncological diseases of bowel in relatives Fever > 37,4Fever > 37,4OOCC

3232

““Alarm” signs – Alarm” signs – exclusionexclusion criteria of IBS criteria of IBS

Hepato-, spleno-, thyroidmegalyHepato-, spleno-, thyroidmegaly AnemiaAnemia Increasing of WBC and ESRIncreasing of WBC and ESR Blood in fecesBlood in feces Deviationa in biochemical blood Deviationa in biochemical blood

analysisanalysis

3333

ObligatoryObligatory lab lab teststests

Common blood test (RBC,WBC, ESR,...)Common blood test (RBC,WBC, ESR,...) UrinalysisUrinalysis CoprogrammCoprogramm Feces culture (Feces culture (dysbacteriosisdysbacteriosis)) Occult blood in fecesOccult blood in feces Blood: total bilirubin, AST, ALT, GGTP, Blood: total bilirubin, AST, ALT, GGTP,

alc.phosphatase, markers of intestine alc.phosphatase, markers of intestine infections, immunnoglobulinsinfections, immunnoglobulins

Intestine hormones in case of severe diarrhea Intestine hormones in case of severe diarrhea

3434

ObligatoryObligatory instrumental instrumental investigationsinvestigations

ProctosigmoidoscopyProctosigmoidoscopy IrrigoscopyIrrigoscopy Endoscopy with biopsy of distant part of the Endoscopy with biopsy of distant part of the

duodenumduodenum X-ray examination of the stomach and small X-ray examination of the stomach and small

intestineintestine Colonoscopy with biopsyColonoscopy with biopsy Abdominal SonographyAbdominal Sonography

3535

ObligatoryObligatory instrumental instrumental investigationsinvestigations

pH-metrypH-metry Sphincteromanometry (in case of Sphincteromanometry (in case of

constipation)constipation) Electromyography of pelvic musclesElectromyography of pelvic muscles EnterographyEnterography Consultation of psychologist, Consultation of psychologist,

gynecologists, urologistsgynecologists, urologists

3636

Treatment of IBS with Treatment of IBS with diarrhea diarrhea predominancepredominance

Diet – 4 (B)Diet – 4 (B) Dietary modifications PsychotherapyPsychotherapy LoperamideLoperamide - motility regulation - motility regulation CholestyramineCholestyramine SmectaSmecta – – adsorbentadsorbent, coating drug, coating drug Probiotics – Probiotics – Linex, Hylak-forteLinex, Hylak-forte

3737

Treatment of IBS with Treatment of IBS with constipation constipation predominancepredominance

WheatWheat--branbran ( (отруби)отруби) ForlaxForlax Motilium, CisaprideMotilium, Cisapride Probiotics – Probiotics – Linex, Hylak-forteLinex, Hylak-forte

3838

Treatment of IBS with Treatment of IBS with pain pain predominancepredominance

Antispasmodics: Antispasmodics: Meteospasmyl, Meteospasmyl, Duspatalin, SpasmomenDuspatalin, Spasmomen

AntidepressantsAntidepressants

3939

Biliary Biliary dyskinesia

4040

Biliary Biliary dyskinesia

Motility and secretory Motility and secretory discoordination of gallbladder and discoordination of gallbladder and sphincters of extrahepatic bile ductssphincters of extrahepatic bile ducts

4141

Biliary Biliary dyskinesia

80% of children with GI problem80% of children with GI problem There are no finding of adultsThere are no finding of adults Men : women = appr. 1: 3Men : women = appr. 1: 3

4242

Classification Classification

PrimaryPrimary Secondary Secondary

Motility disturbance forms:Motility disturbance forms: Hypertonic-hyperkineticHypertonic-hyperkinetic Hypotonic-hypokineticHypotonic-hypokinetic MixedMixed

- - Oddi’s sphincterOddi’s sphincter dysfunction dysfunction - gallbladder dysfunction - gallbladder dysfunction

4343

Aetiology and pathogenesisAetiology and pathogenesis

Parasympathetic or sympathetic Parasympathetic or sympathetic tonus predominance leads to tonus predominance leads to hypertonic or hypotonic dyskinesia hypertonic or hypotonic dyskinesia

In duodenal disorders – In duodenal disorders – cholecystokinin production cholecystokinin production disturbancedisturbance

4444

Screening testsScreening tests

Liver functional testsLiver functional tests Pancreatic enzymes in the blood and Pancreatic enzymes in the blood and

urineurine SonographySonography Esophagogastroduodenoscopy Esophagogastroduodenoscopy

4545

SpecializeSpecialized testsd tests

Sonography with GB and Sonography with GB and Oddi’s Oddi’s sphinctersphincter function estimationfunction estimation

ERCPG with ERCPG with Oddi’s sphincterOddi’s sphincter manometrymanometry

Isotope scanning Isotope scanning 9999Tc of the liver and Tc of the liver and bilebile

Drug-tests with cholecystokininDrug-tests with cholecystokinin

4646

Primary causesPrimary causes of GB evacuation of GB evacuation disturbancedisturbance

GB smooth muscles disturbance GB smooth muscles disturbance (decreasind of muscle weight or (decreasind of muscle weight or sensitivity to neurohumoral stimulus)sensitivity to neurohumoral stimulus)

Function discoordination between Function discoordination between GB and choledochGB and choledoch

4747

Secondary causesSecondary causes of GB evacuation of GB evacuation disturbancedisturbance

Hormonal disorders – pregnancy, Hormonal disorders – pregnancy, hormonal treatment (somatostatin) hormonal treatment (somatostatin)

Post-surgeon conditions (vagotomy, Post-surgeon conditions (vagotomy, stomach resection,…)stomach resection,…)

Diseases – diabetes mellitus, liver Diseases – diabetes mellitus, liver cirrhosis,…cirrhosis,…

GBS and cholecystitisGBS and cholecystitis

4848

Clinical featuresClinical features

Hypertonic-hyperkineticHypertonic-hyperkinetic dyskinesia – dyskinesia – short, colic pain in the right short, colic pain in the right hypochondrium, some times a dayhypochondrium, some times a day

Hypotonic-hypokineticHypotonic-hypokinetic dyskinesiadyskinesia - - constant, dull, long lasting pain in the right constant, dull, long lasting pain in the right hypochondrium with nausea and hypochondrium with nausea and bitterbitter / air / air eructationeructation

4949

X-ray and Lab criteria of X-ray and Lab criteria of Hypertonic-hyperkineticHypertonic-hyperkinetic dyskinesia dyskinesia

CholecystographyCholecystography: :

- small GB- small GB

- prolongated bile evacuation- prolongated bile evacuation

- GB hypercontracton after Boyden test meal- GB hypercontracton after Boyden test meal Duodenal TubageDuodenal Tubage: :

- small amount of B-portion (GB bile) < 30 ml- small amount of B-portion (GB bile) < 30 ml

- prolongated bile evacuation from GB > 30 min- prolongated bile evacuation from GB > 30 min

- - apparentapparent GB answer to irritation GB answer to irritation

5050

X-ray and Lab criteria of X-ray and Lab criteria of

Hypotonic-hypokineticHypotonic-hypokinetic dyskinesia dyskinesia

CholecystographyCholecystography: : - large GB- large GB - prolongated bile evacuation - prolongated bile evacuation - GB hypocontracton after Boyden test meal < - GB hypocontracton after Boyden test meal <

½ of previous volume½ of previous volume Duodenal TubageDuodenal Tubage: : - large amount of B-portion (GB bile) > 60 ml- large amount of B-portion (GB bile) > 60 ml - prolongated bile evacuation from GB > 60 - prolongated bile evacuation from GB > 60

minmin - low GB answer to irritation- low GB answer to irritation

5151

Treatment of Treatment of Hypertonic-hyperkineticHypertonic-hyperkinetic dyskinesia dyskinesia

Low-fat diet (Low-fat diet (№ № 5)5)

AntispasmodicsAntispasmodics

5252

Treatment of Treatment of Hypotonic-hypokineticHypotonic-hypokinetic dyskinesia dyskinesia

Vegetable fat, eggs, fruits, branVegetable fat, eggs, fruits, bran Physical exercisesPhysical exercises ProkineticsProkinetics Cholecystokinetics (MgSOCholecystokinetics (MgSO44, xylite, , xylite,

Hepabene,…)Hepabene,…)