Повідомлення#3 » 16 вересня 2016, 10:45
1, 5. Особливоuj клінічного сенсу в виставленні діагнозу хронічний гастрит, грунтуючись на описі "набряклість і гіперемія слизової" і на висновку ендоскопіста "хронічний неерозивний гастрит" (або щось в цьому роді), немає. Дуже мало ендоскопістів "насмілюються" не описати подібну картинку, просто тому що їх (нас) так вчили. Ця картинка дуже суб'єктивна і немає критеріїв для її об'єктивізації (порівняйте - кишкова метаплазія як маркер хронічного атрофічного гастриту при морфологічному дослідженні слизової шлунка). До цього потрібно ставитися філософськи і просто враховувати цей факт у своїй клінічній практиці.
Схема, про яку Ви пишете, є діагностичним алгоритмом обстеження пацієнтів з неуточненою диспепсією.
Що ж стосується терапії функціональної диспепсії, основних її принципів, дозвольте процитувати: Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease. Отже:
TREATMENT OF FUNCTIONAL DYSPEPSIA
Regardless of the initial management strategy undertaken, a substantial proportion of patients with dyspepsia will have persistent or recurrent symptoms that require evaluation with endoscopy. The vast majority will have no significant endoscopic findings and will be given a diagnosis of functional dyspepsia. Most patients with functional dyspepsia have mild, intermittent symptoms that respond to reassurance and lifestyle modifications. Refractory symptoms, however, may be difficult to manage. Failure to improve may lead to concern that an organic cause has been missed and to repeated diagnostic testing. Treatment with placebo leads to improvement in dyspepsia and global health status in up to 80% of such patients - a finding that attests to the therapeutic value of a positive physician-patient relationship. The management ... [skipped] ... can be summarized as follows: [2]
• Careful inquiry into the patient's medical, social, and family history may uncover stresses that have led to acute symptomatic worsening or the current concern with chronic symptoms. Rule out a recent change in diet or medications as the cause of the symptoms.
• Avoid overtesting, which reflects diagnostic ambivalence and erodes the patient's confidence, unless warranted by a change in the pattern of symptoms or by objective findings.
• Establish a positive diagnosis of functional dyspepsia. Stress to the patient that functional dyspepsia is a real disease, and provide reassurance about the natural history. Discuss the pathophysiology of the symptoms, including abnormalities of gut motility, heightened visceral sensation, and the importance of the "mind-gut" interaction.
• Identify dietary, emotional, and environmental factors that may trigger symptoms. Coffee, caffeine, and ex-cessive alcohol should be avoided. In patients with meal-related bloating, nausea, or early satiety, frequent small, low-fat meals may reduce postprandial symptoms. [6] [24] [69]
• Set realistic treatment goals. Because most symptoms are chronic or recurrent, the patient must adapt lifestyle modifications and coping strategies.
• Use drugs judiciously as adjuncts to therapy, not as a "panacea. "Many patients do not need or want drug therapy once an explanation and reassurance have been given.
• Provide a follow-up visit to confirm a symptomatic response.
• Consider referral of patients with psychological or psychiatric problems, a history of physical or sexual abuse, or refractory symptoms to a psychologist or chronic pain management clinic.