厌食和恶病质综合征的处理
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6
继发性厌食
Secondary Anorexia
1. 2. 3. 4. 5. Fatigue 疲劳 Nausea 恶心 Malodour 恶臭 Altered taste 味觉改变 Gastric stasis, e.g. constipation 胃停滞， 例如便秘 6. Oropharyngeal pathology 口咽部疾病 7. Pain 疼痛
14
胃停滞
Gastric Stasis
胃动力药，例如：灭吐灵，吗叮林 不要同时处方胃动力药和抗毒蕈碱药，因为 后者竞争性阻断胃动力药的胆碱能末端的共同 通路。 Prokinetic drug, e.g. metoclopramide, domperidone Do not prescribe a prokinetic and an antimuscarinic drug concurrently because the latter competitively blocks the cholinergic final common pathway of the prokinetic 15
厌食和恶病质综合征的处理
Management of Anorexia and Cachexia
Robert Twycross April 2005
症状处理的学问： EEMMA
The Science of Symptom Management: EEMMA
Evaluation [assessment] 评估 Explanation 解释 Management [treatment] 治疗 Monitoring 监护 Attention to detail 注意细节
对亲属的解释 Explain to the family: • 一个濒死的病人对食物丧失兴趣是正常的 • it is normal for a dying patient to lose interest in food • 如果可能，在需要时才提供食物（使用微波炉？） • if possible, provide food when requested (use microwave oven?) 避免如下的情形发生 Situations to be on the look-out for: “他必须吃，否则他会死亡” “He must eat or he will die” “让他吃东西是我的工作” “Feeding him is my job” 12
of food is appealing but the person feels full after a few mouthfuls) 2. Primary anorexia (cachexia syndrome) or secondary anorexia 3. Physical (e.g. nauseated) or psychological (e.g. depressed)
3
症状的原因 Causes of Symptoms
癌症 cancer 治疗 treatment 衰弱 debility 并发疾病 concurrent disorder
4
在癌症晚期，症状常常由多种原因引起
In advanced cancer, symptoms often have multiple causes
非药物治疗
Non-drug treatments
作如下调整 Changes to: • 环境 • environment • 食谱和烹调方法 • diet and cooking • 使用小餐盘，盛少量食物 • small plate, small quantity of food
16
食欲刺激剂
9
胃停滞的原因
Causes of Gastric Stasis
1. 2. 3. 4. 5. 6. 7. 失动力型消化不良 Dysmotility dyspepsia 便秘 Constipation 药物，例如阿片类，抗毒蕈碱类药 Drugs, e.g. opioids, antimuscarinics 胰头癌 Cancer of head of pancreas 引起神经病变的腹膜后癌 Retroperitoneal cancer causing neuropathy 瘤旁自主性神经病变 Paraneoplastic autonomic neuropathy 脊髓压迫综合征 Spinal cord compression
17
食欲刺激剂
Appetite Stimulants
禁忌用于不伴有厌食的早饱！！ !! Contra-indicated in early satiety without associated anorexia
18
糖皮质激素
Corticosteroids
糖皮质激素和失活作用协同激活肌蛋 白的分解代谢 Corticosteroids and inactivity act synergistically to activate muscle protein catabolism
Cancer-related Proteolysis
末端共同通路：泛肽-蛋白酶体分解系统 Final common pathway: ubiquitin-proteasome proteolytic system
24
Байду номын сангаас
醋酸甲地孕酮治疗厌食-恶病质综合 醋酸甲地孕酮治疗厌食 恶病质综合 征的系统回顾
26项研究，3887例患者 Systematic Review of Megestrol Acetate in the Treatment of Anorexia-Cachexia Syndrome 26 studies, n = 3887
21
癌性恶病质
Cancer Cachexia
基于对病程认识的临床诊断： 体重减轻，肌肉萎缩，伴有早饱感的厌食，乏 力，疲劳，贫血，水肿 A clinical diagnosis based on pattern recognition : weight loss, muscle wasting, anorexia with early satiety, weakness, fatigue, anaemia, oedema
1. 厌食（对食物不感兴趣）或只有早饱感（觉得食物诱人但患 者在吃了几口以后就觉得饱胀） 2. 原发性厌食（恶病质综合征） 或 继发性厌食 3. 躯体的（例如，引起呕吐）或精神心理的（例如,感到抑郁）
1.Anorexia (not interested in food) or early satiety alone (the thought
20
恶病质
Cachexia
也与如下疾病相关 Also associated with : 1. 人类免疫缺陷病毒/获得性免疫缺陷综 合征 HIV/AIDS 2. 慢性阻塞性肺部疾患 COPD 3. 心衰 Cardiac failure 4. 肝脏疾病 Liver disease 5. 肾脏疾病 Renal disease 6. 类风湿性关节炎 Rheumatoid arthritis
在晚期癌症中常见: 症状：早饱+/- , 上腹饱胀，返酸，呃逆，嗳气，恶心， 症状： 呕吐 体征：振水音？ 体征 Common in advanced cancer: Symptoms: early satiety +/-,epigastric fullness, acid reflux, hiccup,belching, nausea, vomiting Signs: succussion splash?
22
癌性恶病质
Cancer Cachexia
• 诱导蛋白分解因子（PIF） proteolysis-inducing factor (PIF) • 其他蛋白分解因子 other proteolytic factors • 脂动员因子 lipid-mobilising factor
23
癌相关蛋白分解
Appetite Stimulants
皮质激素 ：有效期仅为数周 Corticosteroid effective for a few weeks 强的松龙 prednisolone 15-30mg q.d. 或 地塞米松 dexamethasone 2-4mg q.d. 孕激素：有效期可能为数月 Progestogen may be effective for months 例如 甲地孕酮 megesterol 160-800mg q.d.
10
评估
Evaluation
这是谁的问题？ 患者的还是亲属的？ 聆听患者的和亲属的忧虑 Whose problem is it? The patient’s or the family’s? Listen to the patient’s and the family’s fears 11
解释
Explanation
治疗
Management
1.纠正可逆转的因素 Correct the Correctable 2.非药物治疗 Non-drug treatments 3.症状性药物治疗 Symptomatic drug treatment
13
纠正可逆转的因素
Correct the Correctable
1. 2. 3. 4. 5. Fatigue: ‘small and often’ 疲劳：“少吃多餐” Nausea: anti-emetic 恶心：止吐剂 Malodour: treat cause 恶臭：治疗病因 Altered taste: add seasoning? 味觉改变：调味 Gastric stasis: prokinetic drug; treat constipation 胃停滞：胃动力药；治疗便秘 6. Oropharyngeal pathology: specific advice 口咽部疾病 ：特殊建议 7. Pain: analgesics 疼痛：镇痛剂
2
症状处理
Symptom Management
敬告！并不总是能完全缓解症状 敬告！
Warning! Cannot always relieve symptoms completely 替代目标： 替代目标：帮助患者更多地感觉到症状 受到控制从而更少地感到被疾病所压倒 Alternative aim: helping a patient to feel more in control and therefore less overwhelmed
Lopez et al. Journal of Pain and Symptom Management 2004; 27: 360-69
19
癌性恶病质综合征
Cancer Cachexia Syndrome
宿主神经内分泌、细胞因子系统与癌源性 癌源性产物之间复 宿主 癌源性 杂的相互作用引起骨骼肌和脂肪组织的分解 骨骼肌和脂肪组织的分解 Loss of skeletal muscle and fat caused by a complex interaction between host neuro-endocrine and cytokine systems, and tumour-derived products
症状的原因
Causes of Symptoms
临床诊断基于： Clinical diagnosis based on: • 可能性 • probability • 对病程的认识 • pattern recognition
5
“我没有胃口” 我没有胃口”
‘I have no appetite’
鉴别诊断 Differential diagnosis:
7
早饱感
Early Satiety
1. 2. 3. 4. Gastric stasis 胃停滞 Post-gastrectomy 胃切除术后 Massive hepatomegaly 巨大型肝肿大 Massive ascites 大量腹水
8
胃停滞（胃排空延迟） 胃停滞（胃排空延迟）
Gastric Stasis (Delayed Gastric Emptying)
继发性厌食
Secondary Anorexia
1. 2. 3. 4. 5. Fatigue 疲劳 Nausea 恶心 Malodour 恶臭 Altered taste 味觉改变 Gastric stasis, e.g. constipation 胃停滞， 例如便秘 6. Oropharyngeal pathology 口咽部疾病 7. Pain 疼痛
14
胃停滞
Gastric Stasis
胃动力药，例如：灭吐灵，吗叮林 不要同时处方胃动力药和抗毒蕈碱药，因为 后者竞争性阻断胃动力药的胆碱能末端的共同 通路。 Prokinetic drug, e.g. metoclopramide, domperidone Do not prescribe a prokinetic and an antimuscarinic drug concurrently because the latter competitively blocks the cholinergic final common pathway of the prokinetic 15
厌食和恶病质综合征的处理
Management of Anorexia and Cachexia
Robert Twycross April 2005
症状处理的学问： EEMMA
The Science of Symptom Management: EEMMA
Evaluation [assessment] 评估 Explanation 解释 Management [treatment] 治疗 Monitoring 监护 Attention to detail 注意细节
对亲属的解释 Explain to the family: • 一个濒死的病人对食物丧失兴趣是正常的 • it is normal for a dying patient to lose interest in food • 如果可能，在需要时才提供食物（使用微波炉？） • if possible, provide food when requested (use microwave oven?) 避免如下的情形发生 Situations to be on the look-out for: “他必须吃，否则他会死亡” “He must eat or he will die” “让他吃东西是我的工作” “Feeding him is my job” 12
of food is appealing but the person feels full after a few mouthfuls) 2. Primary anorexia (cachexia syndrome) or secondary anorexia 3. Physical (e.g. nauseated) or psychological (e.g. depressed)
3
症状的原因 Causes of Symptoms
癌症 cancer 治疗 treatment 衰弱 debility 并发疾病 concurrent disorder
4
在癌症晚期，症状常常由多种原因引起
In advanced cancer, symptoms often have multiple causes
非药物治疗
Non-drug treatments
作如下调整 Changes to: • 环境 • environment • 食谱和烹调方法 • diet and cooking • 使用小餐盘，盛少量食物 • small plate, small quantity of food
16
食欲刺激剂
9
胃停滞的原因
Causes of Gastric Stasis
1. 2. 3. 4. 5. 6. 7. 失动力型消化不良 Dysmotility dyspepsia 便秘 Constipation 药物，例如阿片类，抗毒蕈碱类药 Drugs, e.g. opioids, antimuscarinics 胰头癌 Cancer of head of pancreas 引起神经病变的腹膜后癌 Retroperitoneal cancer causing neuropathy 瘤旁自主性神经病变 Paraneoplastic autonomic neuropathy 脊髓压迫综合征 Spinal cord compression
17
食欲刺激剂
Appetite Stimulants
禁忌用于不伴有厌食的早饱！！ !! Contra-indicated in early satiety without associated anorexia
18
糖皮质激素
Corticosteroids
糖皮质激素和失活作用协同激活肌蛋 白的分解代谢 Corticosteroids and inactivity act synergistically to activate muscle protein catabolism
Cancer-related Proteolysis
末端共同通路：泛肽-蛋白酶体分解系统 Final common pathway: ubiquitin-proteasome proteolytic system
24
Байду номын сангаас
醋酸甲地孕酮治疗厌食-恶病质综合 醋酸甲地孕酮治疗厌食 恶病质综合 征的系统回顾
26项研究，3887例患者 Systematic Review of Megestrol Acetate in the Treatment of Anorexia-Cachexia Syndrome 26 studies, n = 3887
21
癌性恶病质
Cancer Cachexia
基于对病程认识的临床诊断： 体重减轻，肌肉萎缩，伴有早饱感的厌食，乏 力，疲劳，贫血，水肿 A clinical diagnosis based on pattern recognition : weight loss, muscle wasting, anorexia with early satiety, weakness, fatigue, anaemia, oedema
1. 厌食（对食物不感兴趣）或只有早饱感（觉得食物诱人但患 者在吃了几口以后就觉得饱胀） 2. 原发性厌食（恶病质综合征） 或 继发性厌食 3. 躯体的（例如，引起呕吐）或精神心理的（例如,感到抑郁）
1.Anorexia (not interested in food) or early satiety alone (the thought
20
恶病质
Cachexia
也与如下疾病相关 Also associated with : 1. 人类免疫缺陷病毒/获得性免疫缺陷综 合征 HIV/AIDS 2. 慢性阻塞性肺部疾患 COPD 3. 心衰 Cardiac failure 4. 肝脏疾病 Liver disease 5. 肾脏疾病 Renal disease 6. 类风湿性关节炎 Rheumatoid arthritis
在晚期癌症中常见: 症状：早饱+/- , 上腹饱胀，返酸，呃逆，嗳气，恶心， 症状： 呕吐 体征：振水音？ 体征 Common in advanced cancer: Symptoms: early satiety +/-,epigastric fullness, acid reflux, hiccup,belching, nausea, vomiting Signs: succussion splash?
22
癌性恶病质
Cancer Cachexia
• 诱导蛋白分解因子（PIF） proteolysis-inducing factor (PIF) • 其他蛋白分解因子 other proteolytic factors • 脂动员因子 lipid-mobilising factor
23
癌相关蛋白分解
Appetite Stimulants
皮质激素 ：有效期仅为数周 Corticosteroid effective for a few weeks 强的松龙 prednisolone 15-30mg q.d. 或 地塞米松 dexamethasone 2-4mg q.d. 孕激素：有效期可能为数月 Progestogen may be effective for months 例如 甲地孕酮 megesterol 160-800mg q.d.
10
评估
Evaluation
这是谁的问题？ 患者的还是亲属的？ 聆听患者的和亲属的忧虑 Whose problem is it? The patient’s or the family’s? Listen to the patient’s and the family’s fears 11
解释
Explanation
治疗
Management
1.纠正可逆转的因素 Correct the Correctable 2.非药物治疗 Non-drug treatments 3.症状性药物治疗 Symptomatic drug treatment
13
纠正可逆转的因素
Correct the Correctable
1. 2. 3. 4. 5. Fatigue: ‘small and often’ 疲劳：“少吃多餐” Nausea: anti-emetic 恶心：止吐剂 Malodour: treat cause 恶臭：治疗病因 Altered taste: add seasoning? 味觉改变：调味 Gastric stasis: prokinetic drug; treat constipation 胃停滞：胃动力药；治疗便秘 6. Oropharyngeal pathology: specific advice 口咽部疾病 ：特殊建议 7. Pain: analgesics 疼痛：镇痛剂
2
症状处理
Symptom Management
敬告！并不总是能完全缓解症状 敬告！
Warning! Cannot always relieve symptoms completely 替代目标： 替代目标：帮助患者更多地感觉到症状 受到控制从而更少地感到被疾病所压倒 Alternative aim: helping a patient to feel more in control and therefore less overwhelmed
Lopez et al. Journal of Pain and Symptom Management 2004; 27: 360-69
19
癌性恶病质综合征
Cancer Cachexia Syndrome
宿主神经内分泌、细胞因子系统与癌源性 癌源性产物之间复 宿主 癌源性 杂的相互作用引起骨骼肌和脂肪组织的分解 骨骼肌和脂肪组织的分解 Loss of skeletal muscle and fat caused by a complex interaction between host neuro-endocrine and cytokine systems, and tumour-derived products
症状的原因
Causes of Symptoms
临床诊断基于： Clinical diagnosis based on: • 可能性 • probability • 对病程的认识 • pattern recognition
5
“我没有胃口” 我没有胃口”
‘I have no appetite’
鉴别诊断 Differential diagnosis:
7
早饱感
Early Satiety
1. 2. 3. 4. Gastric stasis 胃停滞 Post-gastrectomy 胃切除术后 Massive hepatomegaly 巨大型肝肿大 Massive ascites 大量腹水
8
胃停滞（胃排空延迟） 胃停滞（胃排空延迟）
Gastric Stasis (Delayed Gastric Emptying)