300字范文 > 难治性抑郁症疲劳肠易激综合征和慢性疼痛|功能医学案例报道（上）

难治性抑郁症疲劳肠易激综合征和慢性疼痛|功能医学案例报道（上）

时间：2018-10-19 15:05:53

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难度：★★★☆☆ 类型：案例交流字数：3,676

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上周功能医学医生网有幸邀请到王东生主任做了一期专访，为我们分享了他的功能医学进阶历程，本期王主任将<The Permanente Journal>杂志上的案例<Refractory Depression, Fatigue, Irritable Bowel Syndrome, and Chronic Pain: A Functional Medicine Case Report>做了翻译并加以整理，分上下二期推出，希望为功能医学同仁提供复杂性疾病干预的功能医学新思路。

ABSTRACT

Introduction: Single-disorder or single-organ-system clinical practice guidelines are often of limited usefulness in guiding effective management of patients with chronic multidimensional signs and symptoms. The presence of multiple long-standing medical problems in a given patient despite intensive medical effort suggests that addressing systemic core imbalances could complement more narrowly focused approaches.

摘要

简介：单病种或单器官系统的临床实践指南在指导具有慢性多维体征和症状患者的有效治疗时，其价值往往有限。在既定患者中，尽管进行了相当强度的医疗干预，但仍然长期存在多种医学问题，这提示解决系统性核心失衡，可弥补相对局限的治疗手段。

Case Presentation: A 72-year-old man experiencing long-standing depression, fatigue, irritable bowel syndrome, and chronic pain in the context of additional refractory illnesses was assessed and treated, guided by a system-oriented approach to underlying core imbalances termed functional medicine. This patient was referred from a team of clinicians representing primary care, cardiology, gastroenterology, hematology, and psychology. Prior treatment had been unsuccessful in managing multiple chronic comorbidities. Diagnostic assessment included com-prehensive stool and nutritional/metabolic laboratory testing.

病例介绍：72岁男性，长期患有抑郁、疲劳、肠易激综合症、慢性疼痛的难治性疾病的背景下，通过功能医学系统导向的方法进行评估和治疗，解决潜在的核心失衡。这篇论文中的患者由来自初级保健、心脏病学、胃肠学、血液学和心理学的临床医师小组所转诊。先前的治疗在处理多项慢性并发疾病方面没有获得成功。诊断评估包括：粪便综合分析和营养/代谢实验室检查。

Results: The blood-, urine-, or stool-based measurements of relevant markers for multiple systemic issues, including digestion/absorption, inflammation, oxidative stress, and methylation, identied previously unrecognized root causes of his constellation of symptoms. These functional measurements guided rational recommendations for dietary choices and supplementation. The patient experienced steady and signicant improvement in his mental health, fatigue, chronic pain, and irritable bowel syndrome—as well as the unexpected resolution of his chronic idiopathic pancytopenia.

结果：基于血液、尿液或粪便的多个系统性问题的相关标志物的检测，包括消化/吸收、炎症、氧化应激和甲基化，确定了先前未被认识到的一些症状的根本原因。这些功能检测对于膳食选择和补充建议具有指导性意义。最终，患者的心理健康、疲劳、慢性疼痛和肠易激综合征得到了稳定和显著的改善，而且慢性特发性全血细胞减少症意外消退。

Conclusion: The success in this case suggests that other patients with chronic, complex, and treatment-refractory illness may benefit from a system-oriented assessment of core imbalances guided by specialized nutritional/metabolic and digestive laboratory testing.

结论：本病例的成功提示，对慢性、复杂和难治性疾病患者的治疗可能受益于以特殊的营养/代谢和消化实验室检测为指导，以系统为导向的核心失衡评估。

INTRODUCTION

Single-disorder clinical practice guidelines are often of limited usefulness in guiding effective management of patients with chronic multidimensional signs and symptoms. The presence of multiple long-standing medical problems, despite excellent medical care, suggests that new questions or perspectives may be helpful. For example, assessment of underlying key common pathways for all diseases, such as gastrointestinal dysfunction, proin ammatory imbalance, and oxidative stress, could augment the more traditional organ-system-oriented, discipline-focused approach. The organizing principle of the approach taken here, termed functional medicine, is that restoration of health requires defining and addressing seven potential core imbalances that may underlie any given disease state. These seven categories are 1) as-similation (digestion, absorption, microbiomics, respiration), 2) defense and repair (immune function, inflammation, infection), 3) energy (production, regulation), 4) biotransformation and elimination (toxicity, detoxification), 5) transport (cardiovascular and lymphatic systems), 6) communication (hormones, neurotransmitters, cytokines), and 7) structural integrity (membranes, fascia, bacterial translocation). The core belief is that imbalance in one or more of these seven common disease pathways may be the root cause of many seemingly disparate conditions.

单病种临床实践指南通常在指导患有慢性多维体征和症状患者的有效治疗方面价值有限，尽管现有医疗技术发达，但多种疾病长期存在的现象表明，新的问题或观点可能会有所帮助。例如，评估所有疾病的基本的关键共同途径，如胃肠功能障碍、促炎失衡和氧化应激，可以改进传统的以器官系统、医学分科为重的模式。这里所采用的方法原则，被称为功能医学，是指恢复健康，需要界定和解决可能构成任何特定疾病状态的七种潜在核心失衡，分别是：1）同化（消化、吸收、微生物组学、呼吸）；2）防御和修复（免疫功能、炎症、感染）；3）能量（生产、调节）；4）生物转化和消除（毒性，解毒）；5）运输（心血管和淋巴系统）；6）通讯（激素、神经递质、细胞因子）；7）结构完整性（膜、筋膜、细菌易位）。其核心理念是这七种常见生理途径中的一种或多种的失衡，可能是许多看似不同的病症的根本原因。

This case illustrates how specialized laboratory testing identified previously unrecognized physiologic and biochemical dysfunction in a complex patient. This dysfunction in several common disease pathways was both clinically relevant and inexpensively modifiable. The result was substantial clinical improvement and a markedly improved patient quality of life.

本案例说明了在复杂性疾病患者中如何通过专门的实验室检测，来识别先前未被识别的生理和生化功能障碍。在几种常见疾病的发生过程中，这种功能障碍既与临床相关，又能廉价地加以改变，其结果可以使临床问题得到改善，并能显著提高患者的生活质量。

CASE PRESENTATION

Initial Visit (February )

A 72-year-old man was referred to a board-certified internist specializing in complex, refractory illnesses in February . The patient’s primary goal, stated at his first visit, was to “walk out of the office with more hope.” He wrote that it was “very hard to function. I wake after 9 hours of sleep and still feel tired. I don’t have the emotional or physical strength to accomplish much. This is frustrating and I am on a cycle of becoming more depressed, more frustrated, and more helpless.”

In addition to chronic fatigue and depression, the patient reported 1) heartburn, frequent gas, bloating, and diarrhea alternating with constipation; 2) right lower quadrant abdominal cramping, worsening after bowel movements; and 3) wide- spread arthralgias and myalgias. See Table 1 through 6 (Tables 4 and 5 available online at: / les/15-242.pdf ), and the Sidebar: Important Medical History for a list of the patient’s medical considerations.

案例介绍

初次问诊（2月）

2月，一名72岁的男性被转诊到一名专门研究复杂难治性疾病的内科医生。患者在他第一次的问诊中提出首要目标是“能够带着更多希望走出办公室。”他表示“身体很难运转，我睡了9个小时后，醒过来仍感到疲倦，我没有足够的精神和体力来完成任何事情，这令人非常沮丧，就像被困在一个让人抑郁、沮丧、无助的循环中。

除了慢性疲劳和抑郁以外，患者还存在以下症状：

1）胃灼热、频繁胀气、腹胀、腹泻和便秘交替

2）右下腹部痉挛，排便后恶化

3）广泛的关节痛和肌痛

（见表1，表4和5见网站: / les/15-242.pdf），以及侧边栏：患者重要医学事件列表的病史

表1：患者的健康时间轴（本网站编辑翻译）

Initial Clinical Findings

Patient-reported outcome instruments (higher scores indicate worse symptoms):

Brief Fatigue Inventory: total fatigue interference score of 37/60

Brief Pain Inventory: total pain interference score 36/70

Patient Health Questionnaire-9: total score 13 (moderate depression 10-14).

初步临床发现

患者报告结果量表（分数越高表示症状越严重）：

简明疲劳量表：总疲劳干扰评分为 37/60；

简明疼痛量表：总疼痛干扰评分为 36/70；

患者健康问卷-9 ：总分13（中度抑郁10-14）。

Physical Examination

Blood pressure 118/54 mmHg, pulse 74 beat/min and regular. Body mass index, 21.6 (calculated as weight in kilograms divided by height in meters squared)

Anicteric with clear lungs and normal cardiac examination

Abdomen tender to palpation of the right upper quadrant and epigastric area

No hepatosplenomegaly

Palpation in the left lower quadrant resulted in right lower quadrant discomfort

No ascites present

No edema in extremities (cool, pale fingers with slow capillary refill)

No palmar erythema

No asterixis.

体格检查

血压118/54 mmHg；脉搏74次/分，律齐；体重指数（BMI ）21.6（体重的公斤数除以身高米数的平方）

无黄疸，肺和心脏检查正常

腹部触诊：右上腹和上腹部压痛

无肝脾肿大

左下腹部触诊致右下腹部不适

无腹水

四肢无水肿（手指冰冷，毛细血管血液回流缓慢）

无手掌红斑

无扑翼样震颤

DIAGNOSTIC ASSESSMENTS

The patient’s concern of a reduced quality of life secondary to depression, fatigue, and gastrointestinal distress was part of a remarkable medical history as a survivor of end-stage liver failure and alcoholism. However, his depression, fatigue, widespread pain, and gastrointestinal symptoms did not resolve from medical treatments of specific diagnoses and individual symptoms. A clinical decision was made to evaluate the root causes of this patient’s symptoms from a functional medicine perspective with comprehensive and structured stool and nutritional diagnostic panels. A Comprehensive Digestive Stool Analysis 2.0 (CDSA 2.0) and Nutritional Evaluation (NutrEval) from a Clinical Laboratory Improvement Amendments-certified laboratory (Genova Diagnostics, Asheville, NC) were ordered. These kits offer bundled laboratory tests that provide insight into the function and status of several of the core pathways. Additionally, given the presence of environmental stressors and a decreased sense of personal efficacy, he was referred for Resilience Training or Mindfulness-Based Stress Reduction.

诊断评估

患者经由终末期肝功能衰竭和酗酒而幸存，临床担忧在于由抑郁、疲劳和胃肠道不适继发的生活质量下降，是其显著性病史中的一部分。然而，他的抑郁、疲劳、广泛疼痛和胃肠道症状，并未从针对专科诊断和个体症状的医疗干预中得到解决。临床决策是从功能医学的角度，通过消化道粪便综合分析1,2和营养诊断系列评估该患者症状的根本原因。订购了来自获得临床实验室改进修正证书认证的实验室(Genova Diagnostics, Asheville, NC)的综合消化道分析2.0(CDSA 2.0)和营养评价(NutrEval)。这些试剂盒还捆绑了另外的实验室测试项目，提供了对几个核心通路的功能和状态的评估。此外，患者由于存在环境压力因素和个人感知能力的下降，也被转诊进行恢复训练和正念减压。

OTHER RELEVANT LABORATORY RESULTS

This patient had previously been found to be vitamin D deficient. However, he wasnot on vitamin D supplementation at his first visit and supplementation (2000 IU)was begun. In addition this patient’s dehydroepiandrosterone-sulfate (DHEAS)level was low normal and DHEA 5 mg sublingually each morning wasstarted.3

其他相关实验室结果

患者以前被发现缺乏维生素D，然而，他并没有服用维生素D补充剂，在第一次就诊时开始补充（2000IU）。此外，该患者的脱氢表雄酮-硫酸盐（DHEA-S）水平低于正常，开始每天早晨5毫克舌下含服。3

FOLLOW-UP AND OUTCOMES

The patient was evaluated four times between April and January . Witheach subsequent visit, he reported steady improvement in his mood, overall energy,and chronic pain. He was compliant with the dietary recommendations and supplements outlined in Table 3. He elected to not pursue Resilience Training orMindfulness-Based Stress Reduction.

He experienced minor episodes of dizziness with two near syncopal episodes, forwhich he was referred to his cardiologist.

后续随访

在4月至1月期间对患者进行了四次评估，每次随访，他的情绪、精力和慢性疼痛都得到了稳定的改善，患者遵循表2中列出的饮食和补充剂建议，但选择不进行恢复训练或正念减压，有过几次轻微头昏发作，其中有两次几近晕厥，为此也曾被转诊至心脏病专家。

表2：药物和营养补充剂

药物

剂量

赖诺普利/氢氯噻嗪

40 mg /25 mg /d

曲唑酮

150 mg/d

文拉法辛

225 mg/d