Colon irritable
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Este documento presenta información sobre el síndrome de intestino irritable (SII). Resume las características epidemiológicas, los criterios de diagnóstico de Roma, las alteraciones fisiopatológicas como la hipersensibilidad visceral, y los enfoques de tratamiento que incluyen modificaciones dietéticas y opciones farmacológicas.
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Colon irritable
- 1. Universidad Nacional Autónoma de México Facultad de Medicina Hospital Juárez de México Servicio de Gastroenterología Trastornos digestivos funcionales Colon irritable Ojeda Ramos Diana Jazmín 3339
- 4. “Espero doctor, que no sea Ud. uno más de esos 20 doctores incompetentes que dicen que no tengo nada y que no me encuentran nada anómalo.”
- 5. Estrés afecta función GI Dolor Sensibilidad 1960 SNC / SNE Reactividad autonómica Hipersensibilidad SII visceral Post-infeccioso Comidas Dolor / Motilidad 1950 Contracciones simultáneas 1970 1980 1990 2000 Mecanismos Motilidad Interacción Cerebro-intestino Marcadores mioeléctricos Inflamación HipersensIbilidad. visceral
- 8. Es uno de los trastornos digestivo más frecuentes en la consulta, siendo del 12% al Médico General y el 40% al gastroenterólogo Más frecuente en mujeres en una relación 3:1 30-50 años de edad Jóvenes con mayor prevalencia EPIDEMIOLOGÍA
- 9. Percepción Integración Efecto Conocimiento Estado afectivo Vista Sonido Olfato Sensib. somática Sensibilidad visceral Motilidad Secreción Flujo sang. Inflamación
- 11. Diarrea Estreñimiento Contracciones segm. no propulsivas Contracc. propulsivas Tono rectal postprandial Hipersensib. rectal Respuesta gastrocólica Camilleri, Gastroenterology 2001; 120:652
- 13. SII - Hipersensibilidad Sensibilidad del órgano •inflamación mucosa •Distensión mecánica SNC Modulación • Cortex • Vias Cerebrales Hipersensibilidad visceral Hiperalgesia Alodinia Hiperexitabilidad Medular •ON activación •otros Sensibilización • SII Post-infeccioso • Neuropatía 847
- 16. Serotonina • Las células enterocromafines (CE) segregan serotonina • La serotonina se une a receptores en los nervios que modulan las MOTILIDAD, SECRECIÓN Y SENSIBILIDAD • SERT la introduce en las células epiteliales para su inactivación Gerson MD, Rev Gasterol Dis 2003; 3:S25
- 17. SII - Fisiología - Receptores Serotonérgicos Neurona motora excitatoria ACh Contracción 5-HT3 5-HT4 5-HT1A Neurona motora Inhibitoria 5-HT1D NO, VIP Relajación
- 19. Interaccón Cerebro-Intestino Distres Psicológico Inflamación mucosa Síntomas SII Sensibilidad visceral Desencadenante Infección aguda Alteración en motilidad secreción Gwee et. al., Gut 1999; 44:400 Drossman, Gut 1999; 44:306
- 21. ANAMNESIS MANIFESTACIONES CLÍNICAS Dolor abdominal en la región baja del abdomen Inicio asociado al cambio en las defecaciones No se presenta por la noche ni interfiere con el sueño Distensión visible Meteorismo Asociados Dolor pélvico crónico Dispareunia Dispepsia Depresión Ansiedad DIAGNÓSTICO
- 22. SINTOMAS ALARMANTES ORGÁNICO Inicio agudo Edad > 40-50 años Diarrea nocturna Diarrea grave Hematoquezia Pérdida de peso Fiebre Antecedentes familiares de Ca colon, enteropatía, enf. celiaca DIAGNÓSTIC O
- 23. ESTUDIOS QUE DEBEN REALIZARSE Estudios mínimos indispensables BH,QS, función tiroidea, parásitos, sangre, enfermedad celiaca Prueba de Hidrógeno Intolerancia a la lactosa Endoscopia con biopsia Enf. Celiaca DIAGNÓSTICO
- 24. SII - Tratamiento Esquema Severo Moderado Leve Todos Metas realistas Antidepresivos Tratamiento del dolor Fármacos sobre la (motilidad/sensibilidad ) Tratamiento Psicológico Modificación de dieta y estilo de vida Buena relación / Tratamiento continuado Educación / Revaloración 667
- 25. MODIFICACIONES DIETÉTICAS Grasas Aumenta la CCK Evitar alimentos que causen distensión Leguminosos y legumbres,… Alcohol y Cafeína Dolor Fibra Acelera el transito en colon TRATAMIENTO
- 26. 1.- ANTICOLINÉRGICOS Hiosciamina sublingual 0.125 mg orales 2 veces al día Diclomina 10-20 mg orales Metoescopolamina 2.5- 5 mg 2.- ANTIDIARREICOS Loperamida 2 mg V.O. 3-4 veces al dia 3.- LAXANTES Laxantes osmóticos Leche de Mg Polietilenilglicol TRATAMIENTO FARMACOLÓGICO
- 27. 4.- PSICOTRÓPICOS Tricíclicos Amitriptilina, Imipramina, Doxepina Inhibidores de de Serotonina Ansiolíticos la recaptura Benzodiacepinas 5.AGONISTAS/ANTAGONISTAS DEL RECEPTOR DE SEROTONINA Alosentrón 6.ANTIBIOTICOS NO ABSORBIBLES Rifamixina 400 mg/8hrs/10 días 7.- PROBIÓTICOS TRATAMIENTO
Notas del editor
- Slide 1223 - Physiological Correlations of Diarrhea and Constipation Summary of changes in colorectal motor functions in patients with diarrhea- and constipation-predominant irritable bowel syndrome. In general, diarrhea is associated with an increase in propulsive contractions, tone and sensitivity; whereas, constipation is associated with reduced propulsive contractions, tonic response to the meal and a variable effect on rectal sensitivity. Camilleri, Gastroenterology 2001; 120:652
- SEROTONIN RECEPTORS AND THEIR ACTION ON INTESTINAL SMOOTH MUSCLE Serotonin in phylogenetically among the oldest of neurotransmitters. Its receptors are widely distributed throughout the brain and the peripheral nervous system including the digestive tract. Fourteen unique serotonergic receptor subtypes and their related genes are recognized currently in mammals. With the exception of the 5-HT5B receptor, all mammalian species appear to have the same set of serotonergic receptor genes. This has allowed development of a consistent molecular nomenclature for the serotonergic receptor subtypes. Thirteen of the serotonergic receptors are metabotropic receptors characterized by 7 transmembrane spanning regions. Pharmacologists used biochemical and physiological results to classify the 13 receptor subtypes into 6 subfamilies denoted as 5-HT1-6. The 5-HT1 subfamily contains 6 subtypes identified as 5-HT1A-F and the 5-HT2 subfamily as 5-HT2A-B. The 5-HT5 subfamily has 2 members and the 5-HT4, 5-HT6 and 5-HT7 subfamilies have only one member. The 14th member of the serotonergic receptor family is an ionotropic receptor identified as the 5-HT3 receptor. The 5-HT3 receptor like the nicotinic receptor for acetylcholine is a receptor-gated cation channel. Binding of 5-HT to this receptor, rather than activating intracellular metabolic pathways, opens an ionic channel that leads to depolarization of the membrane electrical potential. Unlike the other serotonergic receptor subtypes, the 5-HT3 receptor is expressed only by neurons in both the peripheral and central nervous system. The remaining 13 serotonergic receptor subtypes may be expressed by neurons, smooth muscle and other kinds of cells. The 5-HT1, 5-HT4 and 5-HT3 receptors are the main serotonergic receptor subtypes in the digestive tract. All three subtypes are expressed by neurons in the enteric nervous system. Intramural spinal and vagal sensory afferent terminals also express the 5-HT3 receptor subtype. The 5-HT4 receptor subtype is expressed both by enteric neurons and smooth muscles in the digestive tract. Smooth muscle of the esophagus and ileum of animals and of human colon express the 5-HT4 receptor. Stimulation of the various subtypes of 5-HT receptors associated with enteric neurons may lead to activation of excitatory musculomotor neurons and secretomotor neurons or to activation of inhibitory musculomotor neurons. Stimulation of excitatory musculomotor neurons will lead to muscle contraction; stimulation of inhibitory musculomotor neurons will lead to suppression of muscle contraction. Hoyer D, Clarke DE, Fozard JR, Hartig PR, Martin GR, Mylecharane EJ, Saxena PR, Humbhrey PPA. VII. International union of pharmacology classification of receptors for 5-hydroxytryptamine (serotonin). Pharmacol Rev 1994; 46:157-203. Humphrey PPA, Bountra C, Clayton N, Kozlowski K. Review article: the therapeutic potential of 5-HT3 receptor antagonists in the treatment of irritable bowel syndrome. Alimen Pharmacol Ther 1999; 13 suppl 2: 31-38. Peroutka JA, Howell TA. The molecular evolution of G protein-coupled receptors: focus 5-hydroxytryptamine receptors. Neuropharmacology 1994; 33:319-324.
- Slide 1125: Post-infectious IBS – Brain-Gut Interaction Diagram This slide provides a conceptual model to explain the possible relationship between IBS symptoms with psychological distress, mucosal inflammation, dysmotility and visceral hypersensitivity. An acute infection may trigger mucosal inflammation, dysmotility and secretion. Inflammation may also contribute to intestinal dysmotility and secretion. These two factors may then lead to visceral hypersensitivity, which in turn, may produce IBS symptoms. It is noted, however that such gut disturbances do not always lead to symptoms (broken line). In fact, most subjects in the Gwee et al. study did not have symptoms, even though they had intestinal hypersensitivity and dysmotility. Thus, it is likely that high levels of psychological distress may, through central mechanisms, enable the clinical expression of IBS symptoms by amplifying incoming visceral signals. This may occur directly via increased central perception or via its effects on gut inflammation dysmotility, secretion and visceral hypersensitivity. Drossman DA. Mind over matter in the postinfective irritable bowel. Gut 1999; 44:306-307. Gwee KA, Leong YL, Graham C, et. al. The role of psychological and biological factors in post- infective gut dysfunction. Gut 1999; 44:400-406.
- Grasas y cck ….se retrasa el vaciammiento gástrico e induce la seccreción biliar y la liberación de varias hormonas