大腸憩室症與大腸激躁症之相關性研究

Abstract

研究背景: 大腸激躁症(irritable bowel syndrome, IBS)是常見的腸胃道功能性疾病。大腸激躁症與一些器質性的疾病於臨床表現及病生理機轉有重疊的現象。在近來的研究發現，大腸憩室症(colonic diverticulosis, CD)，特別是左側的大腸憩室症，有較高的風險會患有大腸激躁症。然而在亞洲人族群的研究中，有相衝突的結果發現，也缺乏大型前瞻性研究證實。慢性低度發炎及腸道微生物叢的改變在有症狀的大腸憩室疾病(diverticular disease, DD)的病生理機轉中扮演重要角色。近來許多研究探討使用5-ASA，抗生素或益生菌來治療慢性憩室疾病的效果。如何區分大腸激躁症與慢性有症狀的大腸憩室疾病以給予適當的治療實有其臨床上的重要性。腹痛持續大於24小時的這個臨床症狀曾被指出能鑑別大腸激躁症與有症狀的大腸憩室疾病，然而其有效性仍需要證實。 目的: 進行前瞻性研究以了解大腸激躁症與大腸憩室症之間的關聯性於台灣人族群中是否存在。驗證腹痛持續大於24小時的這個臨床症狀是否能鑑別大腸激躁症與有症狀的大腸憩室疾病。 方法: 針對於本院接受全大腸鏡檢查的病人進行收案。以問卷調查方式來診斷大腸激躁症(根據Rome III criteria) 並了解病人腹痛的特徵。比較IBS及non-IBS兩組病人間大腸憩室症(CD)的盛行率是否有差異。比較CD及non-CD兩組病人間IBS的盛行率是否有差異。比較單純只有IBS (pure IBS)及單純只有(有症狀)大腸憩室疾病(pure DD)的兩組病人間，腹痛持續大於24小時的這個臨床症狀的盛行率是否有差異。 結果: 本研究於2016年3月至11月間共收案1502人，其中119人因符合排除條件而被排除，最後有1383人進入結果分析。病人的平均年齡為55.8±13.1歲，男女比為1.58:1。收集的個案中6.6% 符合Rome III criteria中大腸激躁症(IBS)定義，17.1% 有大腸憩室症，以右側憩室症為主，佔所有憩室症中的69%。IBS及non-IBS兩組間不論是在總體(Diverticulosis, 14.3% vs 17.3%, P=0.455)、右側(RD, 8.8% vs 12.0%, P=0.359)或是左側(LD, 2.2% vs 2.6%, P=0.435)憩室症的盛行率都未達統計學上顯著差別。在IBS組中，有顯著較高的較BSRS-5 score。年輕(<65歲)的IBS族群中，有較少的大腸腺瘤(OR:0.43, P=0.012)。大腸憩室症(CD)及無大腸憩室症(non-CD)兩組間在IBS的盛行率上都無顯著差異(5.5% vs 6.8%, P=0.455)。在CD組中，年齡大是最主要的危險因子(OR:2.04,P=0.000)。喝酒(OR:1.48,P=0.037)及較高的BMI(OR:1.09, P=0.000)亦是大腸憩室症的危險因子。在所有大腸憩室憩室症(CD)病人中，有28.3% 是伴有腹痛症狀的大腸憩室疾病(DD)，有顯著較高的BSRS-5 score。在單純IBS及單純有症狀大腸憩室疾病兩組間疼痛的持續時間、嚴重度及位置均無統計上顯著差異。 結論: 台灣人族群的大腸憩室症好發於右側。我們針對台灣人族群的研究中並未在大腸憩室症(不論是左側或右側)與大腸激躁症間看到關聯性。使用腹痛超過24小時的臨床症狀來鑑別IBS與有症狀的大腸憩室疾病的論述未能得到驗證。在IBS病人中有顯著較高的心理社會壓力。在較年輕的IBS患者中，大腸腺瘤的盛行率較低。年齡(大)是大腸憩室症最主要的危險因子。喝酒及肥胖會顯著增加大腸憩室症的風險。有症狀大腸憩室疾病的族群，須注意因慢性腹痛所造成的心理影響。

Background: Irritable bowel syndrome (IBS) is a common functional GI disorder. The clinical presentation and pathophysiologic mechanisms of IBS has overlap with some organic GI disease. Recent researches showed the presence of colonic diverticulosis (CD), especially left-sided diverticulosis, was associated with higher risk of IBS. However, conflicting findings were observed in the studies conducted in Asian population. Larger prospective studies are needed to confirm the association. Low grade inflammation and alteration in gut microbiota play important role in the pathophysiologic mechanism of symptomatic diverticular disease (DD). Recent studies have focused on the use of 5-ASA, antibiotics and probiotics in treating chronic diverticular disease. It is of clinical importance to distinguish IBS and chronic symptomatic diverticular disease to define the appropriate treatment. The effectiveness of abdominal pain lasting for more than 24 hours could discriminate IBS and DD had been proposed. Further validation is needed. Objectives: We conducted prospective study to 1. clarify the association between IBS and CD in Taiwanese population; 2. Validate the effectiveness of abdominal pain lasting for more than 24 hours in differentiating IBS and DD. Methods: We enrolled patients undergoing colonoscopy in single hospital. Questionnaire was applied to identify IBS patients (according to Rome III criteria) and to collect the characteristics of abdominal pain. We compared 1. the prevalence of CD in the IBS and non-IBS groups. 2. The prevalence of the clinical symptom of abdominal pain lasting for more than 24 hours in pure (no overlap) IBS and pure DD groups. Results: We initially enrolled 1502 subjects during March 2016 to November 2016 and 119 subjects met the exclusion criteria. A final total of 1383 subjects were enrolled for analysis. The mean age of the patients was 55.8±13.1 and the male to female ratio was 1.58:1. IBS was identified in 6.6% and CD was observed in 17.1% of the patients. Right-sided diverticulosis is predominant (69% of all CD). There was no statistically significant difference between the prevalence of whole CD (14.3% vs 17.3%, P=0.455), right-sided CD(8.8% vs 12.0%, P=0.359) and left-sided CD(2.2% vs 2.6%, P=0.435) in IBS and non-IBS groups. Significantly higher BSRS-5 score was observed in the IBS group. In younger (age<65) IBS patients, the prevalence of colonic adenoma was lower (OR:0.43, P=0.012). There was no significant difference between the prevalence of IBS in CD and non-CD groups (5.5% vs 6.8%, P=0.455). Older age was the most important risk factor for CD (OR:2.04,P=0.000). Alcohol consumption (OR:1.48,P=0.037) and higher BMI (OR:1.09, P=0.000) also increased the risk of CD. Within the whole diverticulosis group, abdominal pain was complained in 28.3% of the patients. Higher BSRS-5 score was observed in this subgroup (symptomatic diverticular disease). The pain duration, severity and location could not differentiate pure IBS and pure symptomatic DD in our study. Conclusions: In Taiwaness population, right-sided diverticulosis is predominant. The association between colonic diveticulosis and IBS was not observed in our study. The effectiveness of abdominal pain lasting for more than 24 hours in differentiating IBS and DD also could not be validated. IBS patients had higher psychosocial stress. Younger IBS patients had lower adenoma prevalence. Older age is the most important risk factor of CD. Alcohol consumption and obesity increased the risk of CD. Patients with symptomatic diverticular disease had higher psychosocial stress.