Functional gastrointestinal disorders and gastrointestinal motility disorders: clinically, many patients present with gastrointestinal symptoms and no organic disease is found after a series of examinations and follow-ups. These were previously considered as so-called neurological disorders, but in recent years they are considered as functional gastrointestinal disorder (FGID). There are two important shifts in understanding, first, that gastrointestinal disorder symptoms are a biopsychosocially integrated model rather than a simplified model based on a single disease. Second, FGID is the result of dysregulation of the brain-gut axis with power and sensory abnormalities. Gastrointestinal motility disorders refer to a group of disorders related to motility disorders. Several common gastrointestinal motility disorders will be described here.
I. Gastroesophageal reflux disease
Gastroesophageal reflux disease (GERD) is caused by the dysfunction of the normal anti-reflux mechanism, so that the contents of the stomach and duodenum enter the esophagus excessively, causing reflux symptoms and damage to the esophagus and even organs outside the esophagus. About one-third of GERD patients have reflux esophagitis (RE). Patients without endoscopic reflux esophagitis are also referred to as endoscopically negative GERD.
Heartburn is seen in about 10-20% of the population in Western countries. The prevalence of GERD and reflux esophagitis in Beijing and Shanghai in China is 5.77% and 1.92%, respectively.
Clinical manifestations of GERD.
1.Reflux symptoms
2.Irritation symptoms caused by reflux
3.Symptoms of reflux esophagitis.
Reflux-induced irritation symptoms such as heartburn, chest pain, cough, breath-holding, and foreign body sensation in the throat, sputum production, hoarseness, discomfort and other symptoms outside the esophagus may sometimes not be easily diagnosed in time. Severe reflux esophagitis can develop into esophageal stricture, epithelial intestinal metaplasia of the lower esophagus, i.e. Barrett’s esophagus, and in a few patients, cancer can occur.
Second, functional dyspepsia
Functional dyspepsia (FD) is a group of common clinical syndrome with persistent or recurrent epigastric pain or discomfort, abdominal distension and other dyspeptic symptoms, and lack of objective examination abnormalities. According to the Rome II criteria, the duration of the disease is positioned at 1 year, of which at least 1/4 of the time is symptomatic.
Pathophysiology and pathogenesis of FD: Gastric dysmotility is the main basis of its pathogenesis. Patients with FD do not have increased gastric acid secretion, but the stomach is hypersensitive to chemicals such as gastric acid and hypersensitive to physical stimuli such as dilation, while vagal hypotonia or psychosomatic disorders may play a role in the pathogenesis. In addition, the role of Helicobacter pylori infection (HP) or chronic gastritis in the pathogenesis is debated.
Clinical typing of FD: It is divided into dyskinesia-like dyspepsia, ulcer-like dyspepsia, and nonspecific dyspepsia. Note that the specificity of the disorder based on symptoms alone is not strong.
Diagnosis and treatment process of FD: When a patient presents with dyspepsia with mainly upper abdominal symptoms, such as symptoms for more than 3 months, no alarm symptoms, and age below 40 years, it can be treated empirically based on the relationship between symptoms and meals, and judged as acid-related disease or power disorder-related dyspepsia. Antacids or acid suppressants can be selected to treat acid-related diseases, and prokinetic agents can be selected to treat dyspepsia related to gastric dysmotility. The consultation and treatment process is proposed. For those with poor therapeutic efficacy, further relevant morphological examinations should be performed, attention should be paid to the identification of organic dyspepsia, dynamics and visceral perception examinations should be performed if necessary, and psychological tests should be performed if necessary, etc.
Treatment principles of FD: Treatment needs to be comprehensive, possible triggering factors should be avoided, combined with the above mentioned drugs to correct pathophysiology, relieve symptoms, reduce recurrence and improve quality of life.
Third, functional constipation
Chronic constipation (chronic constipation) is a very common symptom caused by a variety of etiologies. Epidemiological survey of 2486 people aged 18-70 in Beijing showed that the prevalence of chronic constipation was 6.07%, with women significantly higher than men, accounting for 9.68% and 2.11% respectively. The combination of gastroesophageal reflux symptoms in constipated patients was 17.2%, and the combination of dyspepsia symptoms in constipated patients was as high as 43.4%. A survey of 210 patients with chronic constipation in our hospital showed that 47.1% of the patients had functional constipation.
Etiology of chronic constipation: Chronic constipation is caused by many etiologies. In addition to organic diseases of the digestive tract, endocrine or metabolic diseases, neurological diseases, and drug factors can cause constipation. Gastrointestinal and colonic motility disorders, anorectal motility disorders can all cause constipation.
Definition of functional constipation (Rome II criteria): Functional constipation can be diagnosed if a patient with chronic constipation lacks a definite cause and there is no evidence of organic disease to explain the symptoms, and if two or more of the following criteria have been present for at least three months in the past 12 months.
1, straining to pass stool
2. Lumpy or hard bowel movements
3.Incomplete defecation
4.Anorectal obstruction during defecation
5. Need to use manual defecation
6, less than 3 times a week defecation
Functional constipation is classified as slow transit constipation (STC), outlet obstructive constipation (OOC), and mixed constipation (MC).
Diagnosis of functional constipation: organic diseases such as intestinal tumors, inflammation, and strictures should be excluded. Pay attention to the presence of metabolic diseases, connective tissue diseases, endocrinopathies, neurological diseases and other etiologies, as well as pharmacological factors. Determine the type and degree of constipation (whether medication is used, impact on quality of life, and objective findings) and the presence of comorbidities of constipation, such as dyspepsia, ventral hernia, and anorectal anatomical abnormalities.
Symptom analysis is important. Anorectal finger examination, proctoscopy and abdominal plain film are important and easy examinations. Sometimes gastrointestinal passage measurement and anorectal manometry should also be chosen. To provide guidance for the development of a treatment plan.
Treatment of functional constipation: Treatment principles should be proactive and comprehensive measures and holistic treatment, paying attention to the pathophysiology causing constipation and its possible links, and rational selection of laxative drugs.
Biofeedback: For some patients with pelvic floor spasm syndrome who are not satisfied with the above treatment, biofeedback treatment can be chosen to correct the uncoordinated movement of anal sphincter and pelvic floor muscles during defecation, which is often effective.
The main indications for surgical treatment are slow-passage constipation with colonic weakness, exit obstructive constipation combined with anorectal and pelvic floor anatomical abnormalities, such as anterior rectal distension, rectal prolapse, etc. The causal relationship needs to be analyzed and the same preoperative prediction should be made.