143.irritable bowel syndrome (guideline 2012)
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143.irritable bowel syndrome (guideline 2012) 143.irritable bowel syndrome (guideline 2012) Document Transcript

  • §”·π–𔇰’ˬ«°—∫ ‚√§≈”‰ â·ª√ª√«π  ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012 ‚¥¬  ¡“§¡ª√– “∑∑“߇¥‘πÕ“À“√·≈–°“√‡§≈◊ËÕπ‰À« (‰∑¬) §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012 1
  • §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π  ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012 ‚¥¬  ¡“§¡ª√– “∑∑“߇¥‘πÕ“À“√·≈–°“√‡§≈◊ËÕπ‰À« (‰∑¬) æ‘¡æ§√—Èß∑’Ë 1 ‡¡…“¬π 2556 ®”π«π 5,000 ‡≈à¡ 32 Àπâ“  ß«π≈‘¢ ‘∑∏‘Ï æ‘¡æå∑’Ë PENTAGON ADVERTISING LTD., PART. 566/124 ´Õ¬°‘®æ“π‘™ ∂ππæ√–√“¡ 4 ·¢«ß¡À“æƒ≤“√“¡ ‡¢µ∫“ß√—° °√ÿ߇∑æœ 10500 566/124 Soi Kijpanich, Rama 4 Rd., Bangrak, Bangkok 10500 Tel : 235-6038, 633-3762 Fax 633-0334 Email: toon47@asianet.co.th 2 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012
  • §”π” Irritable Bowel Syndrome (IBS) ‡ªìπªí≠À“∑’Ëæ∫∫àÕ¬„πª√–‡∑»‰∑¬·≈– post infectious diarrhea Õ“®®–‡ªì𠓇ÀµÿÀπ÷ËߢÕß IBS ‰¥â ∑”„Àâ incidence ‡æ‘Ë¡¢÷Èπ„π∫â“π‡√“ Guideline π’È ™à«¬„Àâ·æ∑¬å∑æ∫ºŸª«¬¥â«¬ªí≠À“π’‡È ¢â“„®·≈– approach §π‰¢â ’Ë â É ‰¥â‡À¡“– ¡¢÷Èπ ¢Õ¢Õ∫§ÿ≥Õ“®“√¬å∑ÿ°∑à“π∑’Ë ≈–‡«≈“ ·≈–µ—Èß„®∑”„À≥â guideline ¥’·≈– practical ∑’Ë ÿ¥ ”À√—∫ª√–‡∑»‰∑¬ ».πæ. ‘π Õπÿ√“…Æ√å 𓬰 ¡“§¡ª√– “∑∑“߇¥‘πÕ“À“√·≈–°“√‡§≈◊ËÕπ‰À« (‰∑¬) §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012 3
  • §”π” Irritable Bowel Syndrome (IBS) ‡ªìπ°≈ÿ¡Õ“°“√∑’æ∫∫àÕ¬„π∑“߇«™ªØ‘∫µ‘ à Ë — ºŸâªÉ«¬ IBS ¡’Õ“°“√§≈⓬°—∫‚√§Õ◊Ë𠇙àπ dyspepsia ∑âÕ߇ ’¬ ·≈–∑âÕߺŸ° À√◊Õ IBS Õ“®‡°‘¥√à«¡°—π°—∫‚√§Õ◊Ë𠧫“¡√Ÿâ·≈–§«“¡‡¢â“„®‡°’ˬ«°—∫‚√§ IBS „πÀ¡Ÿà·æ∑¬å ‡«™ªØ‘∫—µ‘∑—Ë«‰ª¬—ß¡’πâÕ¬Õ¬Ÿà‚¥¬∑’˺ŸâªÉ«¬ IBS ¡—°®–‰¥â√—∫°“√«‘π‘®©—¬‡ªìπ‚√§Õ◊Ë𠇙àπ dyspepsia ®ÿ¥¡ÿàßÀ¡“¬¢Õß guideline π’È §◊Õ ‡ªìπ°“√„ÀâÕߧ姫“¡√Ÿâ‡°’ˬ«°—∫ IBS ·π«∑“ß„π°“√µ√«®§âπ·≈–°“√√—°…“∑’‡Ë À¡“– ¡µ“¡ ¿“«–·≈–¢âÕ¡Ÿ≈∑’¡Õ¬Ÿ„πªí®®ÿ∫π Ë ’ à — §”·π–π”„π guideline π’È ‡ªìπ‡æ’¬ß·π«∑“ß„π°“√¥Ÿ·≈ºŸâªÉ«¬ IBS Õ¬à“߉√ °Áµ“¡·æ∑¬å∑’Ë¥Ÿ·≈ºŸâªÉ«¬Õ“®®–∑”°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬·µ°µà“߉ª®“°§Ÿà¡◊Õπ’ȉ¥âµ“¡ §«“¡‡À¡“– ¡ ”À√—∫ºŸâªÉ«¬·µà≈–√“¬ ∫∑ √ÿªµà“ßÊ ∑’ˇ°’ˬ«°—∫ IBS „π§Ÿà¡◊Õ©∫—∫π’ȉ¥â√«∫√«¡·≈–‡¢’¬π¢÷Èπ¡“ ‚¥¬Õâ“ßÕ‘ß∂÷ߢâÕ¡Ÿ≈®“°µà“ߪ√–‡∑»‡ªìπ à«π„À≠à·≈–‡ªì𧫓¡‡ÀÁπ¢ÕߺŸâ‡™’ˬ«™“≠ „π°√≥’∑’Ë¢âÕ¡Ÿ≈‰¡à‡æ’¬ßæÕÀ√◊Õ‰¡à¡’ ‚¥¬‡©æ“–Õ¬à“߬‘ËߢâÕ¡Ÿ≈∑’ˇ°’ˬ«¢âÕß°—∫ IBS „πª√–‡∑»‰∑¬ ´÷Ëß¡’§”∂“¡À≈“¬ª√–°“√∑’ˬ—߉¡à¡’§”µÕ∫∑’Ë™—¥‡®π ·≈–§ßµâÕß ∑”°“√»÷°…“‡æ‘Ë¡‡µ‘¡‡æ◊ËÕπ”¡“„™â„π°“√®—¥∑” guideline §√—ÈßµàÕ‰ª„Àâ ¡∫Ÿ√≥嬑Ëߢ÷Èπ Guideline π’È ”‡√Á®≈ÿ≈à«ß‰¥â¥’‚¥¬§«“¡√à«¡¡◊Õ¢Õß°√√¡°“√∑’Ë√–¥¡§«“¡§‘¥ ∑—Èß„π°“√ª√–™ÿ¡§√—Èß·√° «—π∑’Ë 22 - 23 ¡°√“§¡ 2554 ·≈–§√—Èß∑’Ë Õß«—π∑’Ë 23 - 24 ¡‘∂ÿπ“¬π 2555 ®÷ߢբÕ∫§ÿ≥‡ªìπÕ¬à“ß Ÿß ‰«â ≥ ∑’Ëπ’ȥ⫬ √».πæ.∫—≠™“ ‚Õ«“∑Ó√æ√ ª√–∏“π°“√®—¥∑” guideline 4 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012
  •  “√∫—≠ §”π” 𓬰 ¡“§¡ª√– “∑∑“߇¥‘πÕ“À“√·≈–°“√‡§≈◊ËÕπ‰À« (‰∑¬) §”π” ª√–∏“π°“√®—¥∑” Guideline for Management of Irritable Bowel Syndrome §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) Definition ¢âÕ √ÿª∑’Ë 1. ¢âÕ √ÿª∑’Ë 2. ¢âÕ √ÿª∑’Ë 3. Overlapping syndrome ¢âÕ √ÿª∑’Ë 4. Pathophysiology ¢âÕ √ÿª∑’Ë 5. ¢âÕ √ÿª∑’Ë 6. ¢âÕ √ÿª∑’Ë 7. Clinical evaluation ¢âÕ √ÿª∑’Ë 8. ¢âÕ √ÿª∑’Ë 9. ¢âÕ √ÿª∑’Ë 10. ¢âÕ √ÿª∑’Ë 11. ¢âÕ √ÿª∑’Ë 12. ¢âÕ √ÿª∑’Ë 13. ¢âÕ √ÿª∑’Ë 14. ¢âÕ √ÿª∑’Ë 15. Non-pharmacological treatment ¢âÕ √ÿª∑’Ë 16. ¢âÕ √ÿª∑’Ë 17. ¢âÕ √ÿª∑’Ë 18. ¢âÕ √ÿª∑’Ë 19. ¢âÕ √ÿª∑’Ë 20. Pharmacological treatment ¢âÕ √ÿª∑’Ë 21. ¢âÕ √ÿª∑’Ë 22. Psychiatric problems „π IBS ¢âÕ √ÿª∑’Ë 23. ¢âÕ √ÿª∑’Ë 24. IBS Guideline √“¬π“¡ºŸâ‡¢â“√à«¡ª√–™ÿ¡ —¡¡π“æ‘®“√≥“ IBS Guideline §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012 3 4 6 6 6 6 7 8 8 10 10 11 11 13 13 13 14 15 15 15 16 16 18 18 18 19 19 20 24 24 26 29 29 30 31 32 5
  • 2.2 ¡’Õ“°“√ª«¥∑âÕßÀ√◊Õ‰¡à ∫“¬„π∑âÕß¡“°°«à“À√◊Õ‡∑à“°—∫ 3 «—πµàÕ‡¥◊Õπ„π 3 ‡¥◊Õπ∑’˺à“π¡“√à«¡°—∫≈—°…≥–Õ“°“√∑“ߧ≈‘π‘°Õ¬à“ßπâÕ¬ 2 „π 3 ≈—°…≥–µàÕ‰ªπ’È 2.2.1 Õ“°“√ª«¥∑âÕßÀ√◊Õ‰¡à ∫“¬„π∑âÕߥ’¢÷ÈπÀ≈—ß°“√∂à“¬Õÿ®®“√– 2.2.2 Õ“°“√ª«¥∑âÕßÀ√◊Õ‰¡à ∫“¬„π∑âÕ߇°‘¥√à«¡°—∫°“√‡ª≈’¬π·ª≈ߢÕß Ë §«“¡∂’Ë¢Õß°“√∂à“¬Õÿ®®“√– 2.2.3 Õ“°“√ª«¥∑âÕßÀ√◊Õ‰¡à ∫“¬„π∑âÕ߇°‘¥√à«¡°—∫°“√‡ª≈’¬π·ª≈ߢÕß Ë ≈—°…≥–§«“¡·¢ÁßÀ√◊Õ‡À≈«¢ÕßÕÿ®®“√– ‡°≥±å°“√«‘π®©—¬ Rome III ‡ªìπ∑’¬Õ¡√—∫„πªí®®ÿ∫π „™â‡ªìπ·π«∑“ßÀπ÷ß„π°“√ ‘ Ë — Ë ™à«¬«‘π‘®©—¬‚√§≈”‰ â·ª√ª√«π ·≈–„™â‡ªìπ·π«∑“ß„π°“√«‘®—¬ ¢âÕ √ÿª∑’Ë 3. ºŸâ ªÉ « ¬‚√§≈”‰ â·ª√ª√«πÕ“®¡’Õ“°“√∑âÕ߇ ’¬‡ªìπÕ“°“√‡¥àπ ∑âÕߺŸ°‡ªìπ Õ“°“√‡¥àπ ∑âÕߺŸ° ≈—∫°—∫∑âÕ߇ ’¬ À√◊Õ‰¡à “¡“√∂®–®—¥≈—°…≥–°“√¢—∫∂à“¬¢ÕߺŸª«¬ â É ‰¥â‡≈¬°Á‰¥â ‚√§≈”‰ â·ª√ª√«π ·∫à߉¥â‡ªìπ 4 ™π‘¥ (subtype) ‰¥â·°à 1. ≈”‰ â·ª√ª√«π ™π‘¥∑âÕ߇ ’¬‡¥àπ (diarrhea predominate IBS or IBS-D) ºŸª«¬µâÕß¡’Õ“°“√∑âÕ߇ ’¬ ‰¡àπÕ¬°«à“√âÕ¬≈– 25 ¢Õß°“√¢—∫∂à“¬ ·≈–µâÕß¡’ â É â Õ“°“√∑âÕߺŸ°‰¡à‡°‘π√âÕ¬≈– 25 ¢Õß°“√¢—∫∂à“¬ 2. ≈”‰ â·ª√ª√«π ™π‘¥∑âÕߺŸ°‡¥àπ (constipation predominate IBS or IBS-C) ºŸª«¬µâÕß¡’Õ“°“√∑âÕߺŸ° ‰¡àπÕ¬°«à“√âÕ¬≈– 25 ¢Õß°“√¢—∫∂à“¬ ·≈–µâÕß¡’ â É â Õ“°“√∑âÕ߇ ’¬‰¡à‡°‘π√âÕ¬≈– 25 ¢Õß°“√¢—∫∂à“¬ 3. ≈”‰ â·ª√ª√«π ™π‘¥∑âÕ߇ ’¬ ≈—∫∑âÕߺŸ° (mixed IBS À√◊Õ IBS-M) ºŸª«¬µâÕß¡’Õ“°“√∑âÕ߇ ’¬ ≈—∫∑âÕߺŸ° Õ¬à“ß≈–‰¡àπÕ¬°«à“√âÕ¬≈– 25 ¢Õß°“√¢—∫∂à“¬ â É â 4. ≈”‰ â·ª√ª√«π™π‘¥‰¡à™¥‡®π (undetermined IBS À√◊Õ IBS-U) ºŸª«¬ — â É µâÕß¡’Õ“°“√∑âÕ߇ ’¬ ≈—∫°—∫∑âÕߺŸ° Õ¬à“ß≈–‰¡à‡°‘π√âÕ¬≈– 25 ¢Õß°“√¢—∫∂à“¬ Reference: 1. Longstreth GF, Thompson W, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional Bowel Disorder p.487-556. In Rome III: The Functional Gastrointestinal Disorders. Drossman DA, eds. Degnon Associates, Mclean, Virginia USA 2006. §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012 7
  • Overlapping Syndrome ¢âÕ √ÿª∑’Ë 4. ‚√§≈”‰ â·ª√ª√«π “¡“√∂æ∫√à«¡°—∫‚√§°√¥‰À≈¬âÕπÀ√◊Õ°√–‡æ“–Õ“À“√ ∑”ß“πº‘¥ª°µ‘ (dyspepsia) ‰¥â ·æ∑¬åºŸâ¥Ÿ·≈§«√„Àâ°“√√—°…“√à«¡µ“¡§«“¡ ‡À¡“– ¡ ‚√§≈”‰ â·ª√ª√«π “¡“√∂æ∫√à«¡°—∫‚√§°√¥‰À≈¬âÕπ °√–‡æ“–Õ“À“√∑”ß“π º‘¥ª°µ‘ (dyspepsia) ·≈–‚√§∑âÕߺŸ°‰¥â∫Õ¬ ®“°°“√»÷°…“¥â«¬·∫∫ Õ∫∂“¡Õ“°“√ à °√¥‰À≈¬âÕπ dyspepsia ≈”‰ â·ª√ª√«π Õ“°“√∑âÕߺŸ° ·≈–Õ“°“√∑âÕ߇¥‘π „π ª√–™“°√ 657 §π æ∫«à“¡’§«“¡™ÿ° (prevalence) „πª√–™“°√∑’Ë¡’Õ“°“√‡À≈à“π’È Õ¬à“ßπâÕ¬ 2 Õ“°“√∑’√Õ¬≈– 4-9 ·≈–§«“¡™ÿ°„πª√–™“°√∑’¡Õ¬à“ßπâÕ¬ 3 °≈ÿ¡Õ“°“√ Ëâ Ë ’ à 1 ¢÷Èπ‰ª∑’Ë√âÕ¬≈– 1-4 ‚¥¬Õ’°°“√»÷°…“ ºŸâªÉ«¬ 1290 √“¬ æ∫«à“¡’§«“¡™ÿ°¢Õß≈”‰ â ·ª√ª√«π √âÕ¬≈– 12.8 ·≈– dyspepsia √âÕ¬≈– 14 ‚¥¬√âÕ¬≈– 87 ¢ÕߺŸâªÉ«¬ ≈”‰ â·ª√ª√«π ¡’Õ“°“√ dyspepsia √à«¡¥â«¬ æ∫«à“¡“°°«à“√âÕ¬≈– 50 ¢ÕߺŸâªÉ«¬ ∑—ÈßÀ¡¥¡’Õ“°“√∑’ˇª≈’ˬπ·ª≈߉ª ¿“¬À≈—ß®“° 1 ªï æ∫«à“Õ“°“√≈”‰ â·ª√ª√«π ¬—ߧßÕ¬Ÿà√âÕ¬≈– 57-74 À√◊Õ  “¡“√∂À“¬‰ª À√◊ÕÕ“®¡’Õ“°“√Õ◊Ë𠇙àπ dyspepsia ¢÷Èπ¡“·∑π‰¥â2 „πÕ’°°“√»÷°…“ æ∫«à“ √âÕ¬≈– 23-87 ¢ÕߺŸâªÉ«¬≈”‰ â·ª√ª√«π ¡’ Õ“°“√ functional dyspepsia ¥â«¬ ·≈–√âÕ¬≈– 13-87 ¢ÕߺŸâªÉ«¬ dyspepsia ¡’ Õ“°“√≈”‰ â·ª√ª√«π™—¥‡®π3  ”À√—∫Õ“°“√°√¥‰À≈¬âÕ𠇙àπ heartburn æ∫«à“ √âÕ¬≈– 47 ¢ÕߺŸâ¡’Õ“°“√π’È ¡’Õ“°“√≈”‰ â·ª√ª√«π√à«¡¥â«¬ ·≈–„π∑“ß°≈—∫°—π ºŸâ∑’Ë¡’Õ“°“√≈”‰ â·ª√ª√«π°Áæ∫«à“¡’Õ“°“√°√¥‰À≈¬âÕπ‰¥â√âÕ¬≈– 46.54 πÕ°®“°Õ“°“√¥—ß°≈à“«¢â“ßµâπ∑’Ëæ∫√à«¡°—∫Õ“°“√≈”‰ â·ª√ª√«π‰¥â∫àÕ¬·≈â« ¬—ß¡’Õ“°“√À√◊Õ‚√§∑“߇¥‘πÕ“À“√Õ◊ËπÊ √«¡∑—ÈßÕ“°“√ functional disorders Õ◊ËπÊ πÕ°√–∫∫∑“߇¥‘πÕ“À“√Õ’°À≈“¬™π‘¥ ∑’Ëæ∫√à«¡‰¥â∫àÕ¬„πºŸâªÉ«¬≈”‰ â·ª√ª√«πÕ’° ¥â«¬‡™àπ°—π5 ‡π◊ËÕß®“° “¡“√∂æ∫Õ“°“√‡À≈à“π’ȉ¥âÀ≈“¬°≈ÿà¡Õ“°“√„πºŸâªÉ«¬√“¬‡¥’¬«°—π ·æ∑¬åºŸâ¥Ÿ·≈§«√„Àâ°“√√—°…“√à«¡µ“¡§«“¡‡À¡“– ¡„πºŸâªÉ«¬·µà≈–√“¬ 8 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012
  • References: 1. Locke GR, Zinsmeister AR, Fett SL, Melton LJ, Talley NJ. Overlap of gastrointestinal symptom complexes in a US community. Neurogastroenterol Motil 2002;17:29-34. 2. Agreus L, Svardsudd K, Nyren O, Tibblin G. Irritable bowel syndrome and dyspepsia in the general population: Overlap and lack of stability over time. Gastroenterology 1995;109:671-680. 3. Whitehead WE, Palsson OS, Levy RR, Feld AD, Turner M, Von Korff M . Comorbidity in irritable bowel syndrome. Am J Gastroenterol 2007;102:2767-2776. 4. Kennedy TM, Jones RH, Hungin AP, Oûflanagan H, Kelly P. Irritabale Bowel Syndrome, Gastro-oesophageal reflux, and bronchial responsiveness in the general population. Gut 1998; 43:770-774 5. Frissora CL and Koch KL. Symptom overlap and comorbidity of irritable bowel syndrome with other conditions. Curr Gastroenterol Rep 2005;7:264-271. §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012 9
  • §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π  ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) «—µ∂ÿª√– ß§å¢Õߧ”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π 1. ‡æ◊ËÕ‡ √‘¡ √â“ߧ«“¡√Ÿâ‡°’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π„Àâ°—∫·æ∑¬å∑—Ë«‰ª„Àâ ·æ√àÀ≈“¬¡“°¢÷π È 2. ‡æ◊ËÕ‡ªìπ·π«∑“ß„π°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§≈”‰ â·ª√ª√«π„Àâ‡À¡“– ¡ ·≈–¡’ª√– ‘∑∏‘¿“æ 3. ‡æ◊ËÕ„Àâ°“√„™â∑√—欓°√∑“ß°“√·æ∑¬å·≈–§ÿ≥¿“æ™’«‘µ¥’¢÷Èπ ≈¥§à“„™â®à“¬ „π°“√¥Ÿ·≈ºŸâªÉ«¬‚√§≈”‰ â·ª√ª√«π §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª Definition ¢âÕ √ÿª∑’Ë 1. 𑬓¡ ‚√§≈”‰ â·ª√ª√«π ‡ªìπ°≈ÿà¡Õ“°“√∑’ˇ°‘¥®“°°“√∑”ß“π¢Õß∑“ß ‡¥‘πÕ“À“√º‘¥ª°µ‘ ‚¥¬¡’Õ“°“√ª«¥∑âÕßÀ√◊Õ‰¡à ∫“¬„π∑âÕß∑’Ë —¡æ—π∏å°—∫°“√ ∂à“¬Õÿ®®“√–‡ªìπÕ“°“√‡¥àπ ‚¥¬‰¡àæ∫§«“¡º‘¥ª°µ‘∑“ß°“¬«‘¿“§À√◊Õ‚√§∑“ß°“¬ (organic disease) ∑’Ë “¡“√∂Õ∏‘∫“¬«à“‡ªì𠓇Àµÿ¢ÕßÕ“°“√‰¥â ºŸâªÉ«¬≈”‰ â·ª√ª√«πµâÕß¡’Õ“°“√¢â“ßµâπ‰¡àπâÕ¬°«à“ 3 ‡¥◊Õπ ¢âÕ √ÿª∑’Ë 2. ‡°≥±å°“√«‘π‘®©—¬‚√§≈”‰ â·ª√ª√«πµ“¡ Rome III ºŸâªÉ«¬µâÕß¡’Õ“°“√µ“¡ ¢âÕ 2.1 ·≈– 2.2 ¥—ßµàÕ‰ªπ’È 2.1 Õ“°“√ª«¥∑âÕßÀ√◊Õ‰¡à ∫“¬„π∑âÕ߇ªìπ‡«≈“¡“π“πÕ¬à“ßπâÕ¬ 6 ‡¥◊Õπ π—∫µ—Èß·µà‡√‘Ë¡¡’Õ“°“√ 6 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012
  • Pathophysiology ¢âÕ √ÿª∑’Ë 5.  “‡Àµÿ¢Õß‚√§≈”‰ â·ª√ª√«π¬—߉¡à‡ªìπ∑’∑√“∫°—π™—¥‡®π æ∫«à“°≈‰°„π°“√ Ë ‡°‘¥‚√§≈”‰ â·ª√ª√«π¡’À≈“¬°≈‰° ‰¥â·°à °“√‡§≈◊ËÕπ‰À«¢Õß∑“߇¥‘πÕ“À“√ º‘¥ª°µ‘ (GI dysmotility) ª√– “∑√—∫√Ÿâ§«“¡√Ÿâ ÷°„π∑“߇¥‘πÕ“À“√‰«°«à“ª°µ‘ (visceral hypersensitivity) °“√Õ—°‡ ∫¢Õ߇¬◊Õ∫ÿº«≈”‰ â (gut inflammation) Ë ‘ §«“¡º‘¥ª°µ‘¢Õß·∫§∑’‡√’¬ª√–®”∂‘π„π≈”‰ â ·≈–§«“¡º‘¥ª°µ‘¢Õß°“√µÕ∫ πÕß Ë √–À«à“ß ¡Õß·≈–≈”‰ â (brain-gut interaction) °“√»÷ ° …“«‘ ®— ¬ æ∫«à “ §π∑’Ë ‡ ªì π‚√§≈”‰ â · ª√ª√«π¡’ ° “√‡§≈◊Ë Õ π‰À«¢Õß ∑“߇¥‘πÕ“À“√º‘¥ª°µ‘ ‡™àπ ¡’°“√»÷°…“æ∫«à“°“√‡§≈◊ËÕπ‰À«¢Õß≈”‰ â‡≈Á°¡’≈—°…≥– ‡©æ“– ‡™à𠇪ìπ·∫∫ cluster À√◊Õ minute contraction ´÷Ëßæ∫‰¥â®“°°“√µ√«®¥Ÿ °“√∫’∫µ—«¢Õß≈”‰ â‡≈Á° πÕ°®“°π—Èπ¬—ßæ∫«à“°“√∫’∫µ—«∑’˺‘¥ª°µ‘¢Õß≈”‰ â ‡ ≈Á ° ‚¥¬‡©æ“–°“√∫’∫µ—«∑’Ë·√ßÊ ∑’Ë∫√‘‡«≥≈”‰ â‡≈Á° à«πª≈“¬¡’§«“¡ —¡æ—π∏å°—∫Õ“°“√ ª«¥∑âÕß„πºŸâ ªÉ « ¬≈”‰ â·ª√ª√«π ·≈–¬—ß¡’°“√»÷°…“æ∫«à“‡¡◊ËÕ°√–µÿâπ≈”‰ â„À≠à „πºŸâªÉ«¬∑’ˇªìπ≈”‰ â·ª√ª√«π ºŸâªÉ«¬®–√—∫√Ÿâ§«“¡√Ÿâ ÷°‰¥â¡“°°«à“§πª°µ‘ √«¡∂÷ß °“√°√–µÿâπ¥â«¬ “√‡§¡’ ‡™àπ °“√√—∫ª√–∑“πæ√‘° ∑’Ë¡’ à«πª√–°Õ∫¢Õß·§ª‰´´‘π °Á¡’√“¬ß“π«à“®–∑”„À⇰‘¥Õ“°“√ª«¥∑âÕß · ∫∑âÕß„πºŸâªÉ«¬‚√§≈”‰ â·ª√ª√«π∑’Ë¡’ Õ“°“√∑âÕ߇ ’¬‡¥àπ¡“°°«à“§πª°µ‘ ¥—ßπ—ÈπºŸâªÉ«¬≈”‰ â·ª√ª√«π®÷ß¡’§«“¡‰«¢Õß ∑“߇¥‘πÕ“À“√∑’µÕ∫ πÕßµàÕ∑—ß°“√°√–µÿπ∑“ß°≈ (mechanical stimulation) À√◊Õ Ë È â ∑“߇§¡’ (chemical stimulation) πÕ°®“°π—Èπ¬—ßæ∫«à“¿“«–≈”‰ â·ª√ª√«π¡’§«“¡ —¡æ—π∏å°—∫°“√¡’°“√Õ—°‡ ∫ ‡≈Á°πâÕ¬∫√‘‡«≥≈”‰ â ´÷Ëß¡’√“¬ß“π„πºŸâªÉ«¬∑’ˇªìπ≈”‰ â·ª√ª√«πÀ≈—ß°“√µ‘¥‡™◊ÈÕ¢Õß ∑“߇¥‘πÕ“À“√ (post infectious IBS) ·≈–¬—ß¡’√“¬ß“π∂÷ߧ«“¡º‘¥ª°µ‘¢Õß°“√ µÕ∫ πÕߢÕß ¡Õß„πºŸâªÉ«¬≈”‰ â·ª√ª√«π´÷Ëßµà“߉ª®“°§πª°µ‘ 10 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012
  • ¢âÕ √ÿª∑’Ë 6. ªí®®—¬∑’Ë “¡“√∂°√–µÿâπ„À⺟âªÉ«¬‚√§≈”‰ â·ª√ª√«π¡’Õ“°“√°”‡√‘∫‰¥â·°à Õ“À“√∫“ß™π‘¥ ¬“∫“ß™π‘¥ §«“¡‡§√’¬¥∑—Èß∑“ß°“¬·≈–®‘µ„® °“√µ‘¥‡™◊ÈÕ„π ∑“߇¥‘πÕ“À“√·≈–πÕ°∑“߇¥‘πÕ“À“√ ºŸª«¬∑’‡Ë ªìπ‚√§≈”‰ â·ª√ª√«πÕ“®¡’Õ“°“√°”‡√‘∫¢÷π®“°ªí®®—¬À≈“¬Õ¬à“ß ‡™àπ â É È ¡’ ° “√»÷ ° …“æ∫«à “ Õ“À“√∫“ß™π‘ ¥  “¡“√∂°√–µÿâ π„Àâ ºŸâ ªÉ « ¬‚√§≈”‰ â · ª√ª√«π¡’ Õ“°“√¡“°¢÷Èπ‰¥â ‡™àπ Õ“À“√¡—π Õ“À“√∑’˺≈‘µ·°ä „π≈”‰ â¡“°º‘¥ª°µ‘ ‡™àπ °≈ÿà¡ fructose ÀÕ¡ °√–‡∑’¬¡ ´÷ß “¡“√∂°√–µÿπ„À⇰‘¥Õ“°“√¡“°¢÷𠬓∫“ßÕ¬à“ß∑’√–§“¬ Ë â È Ë ‡§◊ÕßµàÕ∑“߇¥‘πÕ“À“√Õ“®®–∑”„À⇰‘¥Õ“°“√§≈⓬‚√§≈”‰ â·ª√ª√«π ‡™àπ Õ“°“√ ª«¥∑âÕß Õ◊¥·πàπ∑âÕß À√◊Õ§«“¡‡§√’¬¥∑“ߥâ“π√à“ß°“¬·≈–®‘µ„®°Á ° √–µÿâ π„Àâ ∑“߇¥‘πÕ“À“√¡’§«“¡‰«µàÕ°“√√—∫√Ÿâ§«“¡√Ÿâ ÷°√«¡∂÷ß∫’∫µ—«º‘¥ª°µ‘‰¥â πÕ°®“°π—Èπ°“√µ‘¥‡™◊ÈÕ∑—Èß„π∑“߇¥‘πÕ“À“√·≈–πÕ°∑“߇¥‘πÕ“À“√ “¡“√∂ °√–µÿâπ„À⇰‘¥°“√°”‡√‘∫¢Õß‚√§≈”‰ â·ª√ª√«π‰¥â ¥—ßπ—Èπ°“√À≈’°‡≈’Ë¬ßªí®®—¬µà“ßÊ ‡™àπ Õ“À“√ ¬“ ·≈–§«“¡‡§√’¬¥ Õ“® “¡“√∂∑”„À⺟âªÉ«¬‡°‘¥Õ“°“√°”‡√‘∫‰¥âπâÕ¬≈ß ®÷ߧ«√·π–π”„ÀâÀ≈’°‡≈’Ë¬ßªí®®—¬¥—ß°≈à“«„πºŸâªÉ«¬∑ÿ°√“¬ ¢âÕ √ÿª∑’Ë 7. ‚√§∑“߇¥‘πÕ“À“√∑’Ë∑”„Àâ¡’Õ“°“√‡À¡◊Õπ‚√§≈”‰ â·ª√ª√«π∑’Ëæ∫‰¥â„π ª√–‡∑»‰∑¬‰¥â·°à °“√µ‘¥‡™◊ÈÕ„π∑“߇¥‘πÕ“À“√ ¿“«–°“√¥Ÿ¥´÷¡πÈ”µ“≈·≈Á°‚∑  ‰¡à ¡∫Ÿ√≥å (lactose malabsorption) °“√¥Ÿ¥´÷¡ “√Õ“À“√∫°æ√àÕß (malabsorption syndrome) ¡’·∫§∑’‡√’¬„π≈”‰ â‡≈Á°¡“°°«à“ª°µ‘ (small intestinal bacterial overgrowth) °≈â“¡‡π◊ÈÕÀŸ√Ÿ¥∑«“√Àπ—°∑”ß“π‰¡àª√– “π°—∫°“√‡∫àß (anismus) ≈”‰ âÕ—°‡ ∫‡√◊ÈÕ√—ß (inflammatory bowel disease) ·≈–¡–‡√Áß ¢Õß∑“߇¥‘πÕ“À“√ ‡ªìπµâπ ‚√§∑“߇¥‘πÕ“À“√∑’ËÕ“®∑”„À⇰‘¥Õ“°“√§≈⓬‚√§≈”‰ â·ª√ª√«π∑’Ëæ∫‰¥â ∫àÕ¬„πª√–‡∑»‰∑¬‰¥â·°à °“√µ‘¥‡™◊Õ„π∑“߇¥‘πÕ“À“√ ‡™àπ °“√µ‘¥‡™◊Õ Giardia lamblia È È ‡ªì π «— ≥‚√§„π≈”‰ â‡≈Á° à«πª≈“¬À√◊Õ≈”‰ â„À≠à À√◊Õ°“√¥Ÿ¥´÷¡πÈ”µ“≈·≈Á°‚∑  ‰¡à ¡∫Ÿ√≥å ´÷ßÕ“®∑”„À⇰‘¥Õ“°“√Õ◊¥·πàπ∑âÕß ª«¥∑âÕß À√◊Õ∑âÕ߇ ’¬ §≈⓬‚√§≈”‰ â Ë §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012 11
  • ·ª√ª√«π‰¥â °“√¥Ÿ¥´÷¡ “√Õ“À“√∫°æ√àÕß ‡π◊ËÕß®“° “‡Àµÿ„¥Ê °Áµ“¡ ‡™àπ ®“° µ—∫ÕàÕπ∑”ß“πº‘¥ª°µ‘∑”„À⇰‘¥°“√¥Ÿ¥´÷¡‰¢¡—π‰¡à ¡∫Ÿ√≥å (fat malabsorption) °ÁÕ“®∑”„À⇰‘¥Õ“°“√∂à“¬º‘¥ª°µ‘ Õ◊¥·πàπ∑âÕß ‡À¡◊Õπ‚√§≈”‰ â·ª√ª√«π‰¥â ¿“«– ·∫§∑’ ‡ √’ ¬„π≈”‰ â‡≈Á°¡“°°«à“ª°µ‘ ∑”„À⇰‘¥Õ“°“√∑âÕ߇ ’¬ Õ◊¥∑âÕß √à«¡°—∫ ª«¥∑âÕߧ≈⓬‚√§≈”‰ â·ª√ª√«π™π‘¥∑âÕ߇ ’¬ πÕ°®“°π—Èπ°“√¡’°≈â“¡‡π◊ÈÕÀŸ√Ÿ¥ ∑«“√Àπ—°∑”ß“π‰¡à —¡æ—π∏å°—∫·√߇∫àß À√◊Õ anismus °Á “¡“√∂∑”„Àâ ºŸâ ªÉ « ¬¡’ Õ“°“√ª«¥∂à“¬·µà∂à“¬‰¡à ÿ¥ À√◊Õ°√–µÿâπ„À⇰‘¥Õ“°“√Õ◊¥·πàπ∑âÕß ª«¥∑âÕß´÷Ë߇ªìπ Õ“°“√¢Õß≈”‰ â·ª√ª√«π‡ªìπ¡“°¢÷Èπ‰¥â ‚√§≈”‰ âÕ—°‡ ∫ À√◊Õ inflammatory bowel disease  “¡“√∂∑”„À⇰‘¥ Õ“°“√ª«¥∑âÕß ∂à“¬‡À≈« §≈⓬‚√§≈”‰ â·ª√ª√«π‰¥â‡™àπ°—π  à«π¡–‡√ÁߢÕß∑“߇¥‘π Õ“À“√√–¬–·√°¡—°‰¡à∑”„À⇰‘¥Õ“°“√ ·µà‡¡◊ËÕ¡’¢π“¥¢Õß¡–‡√Áß„À≠à¢÷ÈπÀ√◊Õ‡ªìπ∑’Ë ∫√‘‡«≥∑«“√Àπ—° Õ“®∑”„À⇰‘¥Õ“°“√∂à“¬º‘¥ª°µ‘ À√◊ÕÕ“°“√ª«¥∑âÕß ·πàπ∑âÕß §≈⓬ÊÕ“°“√≈”‰ â·ª√ª√«π‰¥â ¥—ßπ—πºŸª«¬∑’¡Õ“°“√≈”‰ â·ª√ª√«π §«√´—°ª√–«—µ‘ È â É Ë ’ µ√«®√à“ß°“¬À√◊Õ àßµ√«®∑“ßÀâÕߪؑ∫µ°“√‡∫◊Õßµâ𠇙àπ stool examination, CBC, — ‘ È ESR ‡æ◊ËÕª√–‡¡‘π«à“ºŸâªÉ«¬¡’‚Õ°“ ‡ªìπ‚√§∑’Ë°≈à“«¡“À√◊Õ‰¡à 12 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012
  • Clinical evaluation ¢âÕ √ÿª∑’Ë 8. °“√«‘π‘®©—¬‚√§≈”‰ â·ª√ª√«πÕ“»—¬≈—°…≥–Õ“°“√·≈–Õ“°“√· ¥ß¢Õß ºŸâªÉ«¬∑“ߧ≈‘π‘°‡ªìπÀ≈—°  à«π°“√µ√«®∑“ßÀâÕߪؑ∫—µ‘°“√‡∫◊ÈÕßµâπ·≈–°“√µ√«® 摇»…Õ◊πÊ §«√æ‘®“√≥“µ“¡§«“¡‡À¡“– ¡¢ÕߺŸª«¬ ºŸª«¬‚√§≈”‰ â·ª√ª√«π Ë â É â É Õ“®®–¡’Õ“°“√Õ◊ËπÊ πÕ°‡Àπ◊Õ®“°Õ“°“√¥â“π∑“߇¥‘πÕ“À“√‰¥â ‚√§≈”‰ â·ª√ª√«π‡ªìπ‚√§∑’Ë«‘π‘®©—¬‚¥¬Õ“»—¬ª√–«—µ‘ Õ“°“√ ·≈–Õ“°“√· ¥ß ‡ªìπÀ≈—° ‰¡à¡§«“¡®”‡ªìπµâÕß∑”°“√ ◊∫§âπ‡æ‘¡‡µ‘¡ ‡π◊Õß®“°º≈¢Õß°“√ ◊∫§âπ‡æ‘¡ ’ Ë Ë Ë ‡µ‘¡‰¡à‰¥âæ∫‚√§·µ°µà“ß°—∫°≈ÿࡪ√–™“°√ª°µ‘ ¡’‡æ’¬ß∫“ß·π«∑“ß°“√¥Ÿ·≈√—°…“ Ë È â É (guidelines)1∑’·π–π”°“√ ◊∫§âπ‡∫◊Õßµâπ∫“ßÕ¬à“ß«à“Õ“®¡’§«“¡®”‡ªìπ ”À√—∫ºŸª«¬ 2-4 ‚√§π’È ‚¥¬ºŸâªÉ«¬‰¡à§«√®–¡’Õ“°“√·≈–Õ“°“√· ¥ß‡µ◊Õπ (alarm features)3, 5 „πºŸâªÉ«¬∫“ß√“¬ °“√ ◊∫§âπ Õ“∑‘ complete blood count (CBC), stool examination, ESR, C-reactive protein ‡ªìπµâπÕ“®¡’§«“¡®”‡ªìπ4  ”À√—∫°“√  ◊∫§âπ‡∫◊ÈÕßµâπ∑’Ë¡’‚√§∑’˧≈⓬§≈÷ß°—∫‚√§π’È Õ“∑‘ °“√µ√«®Õÿ®®“√–‡æ◊ËÕ«‘π‘®©—¬‚√§ 欓∏‘≈”‰ â„πºŸâªÉ«¬∑’Ë¡’Õ“°“√‚√§≈”‰ â·ª√ª√«π™π‘¥∑’Ë¡’Õ“°“√∑âÕ߇ ’¬‡¥àπÀ√◊Õ ¡’Õ“°“√ ≈—∫∑—Èß∑âÕߺŸ°·≈–∑âÕ߇ ’¬·≈–·∫∫º ¡‡¥àπ3, 6  ”À√—∫ºŸâªÉ«¬∑’Ë¡’Õ“°“√ ‡∫◊È Õ ßµâ π ∑’Ë πà “  ß — ¬ «à “ ®–‡ªì π‚√§Õ◊Ëπ ·π–π”„Àâ µ √«®‡æ‘Ë ¡ ‡µ‘ ¡ À√◊ Õ ª√÷ ° …“·æ∑¬å ºŸâ ‡ ™’Ë ¬«™“≠‚√§≈”‰ â·ª√ª√«π  “¡“√∂∑’Ë®–æ∫Õ“°“√„π¥â“πÕ◊Ëπ Ê πÕ°‡Àπ◊Õ Õ“°“√∑“߇¥‘πÕ“À“√√à«¡‰¥â ‡™àπ ÕàÕπ‡æ≈’¬, πÕπ‰¡àÀ≈—∫, fibromyalgia, ª«¥À≈—ß, ªí  “«–∫àÕ¬ ·≈–¡’Õ“°“√‡®Á∫ª«¥¢≥–¡’‡æ» —¡æ—π∏å (dyspareunia), §«“¡‡§√’¬¥, ´÷¡‡»√â“ ·≈–¡’ somatization ¢âÕ √ÿª∑’Ë 9. ºŸª«¬∑’¡Õ“°“√ª«¥∑âÕßÀ√◊Õ‰¡à ∫“¬„π∑âÕ߇√◊Õ√—ß∑ÿ°√“¬ ·æ∑¬åº¥·≈§«√ â É Ë ’ È Ÿâ Ÿ  Õ∫∂“¡§«“¡ —¡æ—π∏å¢ÕßÕ“°“√ª«¥∑âÕß/‰¡à ∫“¬„π∑âÕß°—∫°“√‡ª≈’ˬπ·ª≈ß ¢Õߧ«“¡∂’Ë¢Õß°“√∂à“¬Õÿ®®“√–·≈–≈—°…≥–¢ÕßÕÿ®®“√–  ◊∫‡π◊Õß®“°‚√§≈”‰ â·ª√ª√«π‡ªìπ‚√§∑’„Àâ°“√«‘π®©—¬‚¥¬Õ“»—¬Õ“°“√ª«¥∑âÕß Ë Ë ‘ À√◊Õ‰¡à ∫“¬„π∑âÕ߇√◊ÈÕ√—ß√à«¡°—∫¡’°“√¢—∫∂à“¬∑’ˇª≈’ˬπ·ª≈߉ª À√◊ÕÕ“°“√ª«¥∑âÕß §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012 13
  • À√◊Õ‰¡à ∫“¬„π∑âÕß∑’Ë¥’¢÷ÈπÀ≈—ß°“√∂à“¬Õÿ®®“√– ∂÷ß·¡âºŸâªÉ«¬®–¡’Õ“°“√‡©æ“–À√◊Õ®– ¡’Õ“°“√ª«¥∑âÕßÀ√◊Õ‰¡à ∫“¬„π∑âÕ߇©æ“–∫√‘‡«≥≈‘Èπªïò°Áµ“¡ ‚¥¬°“√«‘π‘®©—¬·≈– ·¬°™π‘¥¢Õß‚√§π’È¡’§«“¡®”‡ªìπµâÕß√Ÿâ§«“¡∂’Ë¢Õß°“√∂à“¬Õÿ®®“√–·≈–≈—°…≥–¢Õß Õÿ®®“√–1 ´÷Ëß®– “¡“√∂∑”„Àâ·¬°™π‘¥‡ªìπ 4 ™π‘¥ µ“¡¢âÕ √ÿª∑’Ë 3 ¢âÕ √ÿª∑’Ë 10. ºŸâªÉ«¬∑’˧«√‰¥â√—∫°“√µ√«®∑“ßÀâÕߪؑ∫—µ‘°“√À√◊Õ°“√µ√«®‡æ‘Ë¡‡µ‘¡‰¥â·°à ºŸâªÉ«¬∑’Ë¡’≈—°…≥–‡µ◊Õπ¥—ßµàÕ‰ªπ’È 10.1 ºŸâªÉ«¬∑’Ë¡’Õ“°“√√ÿπ·√ß 10.2 ºŸâªÉ«¬∑’Ë¡’πÈ”Àπ—°≈¥≈ߺ‘¥ª°µ‘ (≈¥≈ß¡“°°«à“À√◊Õ‡∑à“°—∫√âÕ¬≈– 10 „π 3 ‡¥◊Õπ) 10.3 ºŸâªÉ«¬∑’ˇ√‘Ë¡¡’Õ“°“√‡¡◊ËÕÕ“¬ÿ 50 ªï¢÷Èπ‰ª 10.4 ºŸâªÉ«¬∑’Ë¡’Õ“°“√∂à“¬‡ªìπ‡≈◊Õ¥À√◊Õ¡Ÿ°‡≈◊Õ¥ 10.5 ‚≈À‘µ®“ß®“°¢“¥∏“µÿ‡À≈Á° «‘µ“¡‘π∫’ 12 À√◊Õ‚ø‡≈µ ∑’‰¡à “¡“√∂Õ∏‘∫“¬ Ë ‰¥â®“° “‡ÀµÿÕ◊ËππÕ°∑“߇¥‘πÕ“À“√ 10.6 ºŸâªÉ«¬∑’Ë¡’Õ“°“√ª«¥À√◊Õ·πàπ∑âÕß√∫°«π¢≥–πÕπÀ≈—∫ 10.7 µ√«®√à“ß°“¬æ∫≈—°…≥–º‘¥ª°µ‘ ‡™àπ µ—∫‚µ °âÕπ„π∑âÕß ´’¥ ‡À≈◊Õß ‡ªìπµâπ 10.8 ¡’‰¢â 10.9 ª√–«—µ‘¡–‡√Áß≈”‰ â„À≠à„π§√Õ∫§√—«∑’ˇªìπ≠“µ‘ “¬µ√ß (first degree relatives) °“√Õ“»—¬≈—°…≥–¢ÕßÕ“°“√·≈–Õ“°“√· ¥ß‡µ◊Õπ„π·π«∑“ß°“√¥Ÿ·≈ºŸâªÉ«¬ ‚√§≈”‰ â·ª√ª√«π¢Õߪ√–‡∑»‰∑¬‰¥â„™â·π«∑“ß°“√¥Ÿ·≈ºŸâªÉ«¬‚√§π’È¢Õ߇Շ™’¬¡“ ª√–°Õ∫5„π°√≥’∑ºª«¬¡’≈°…≥–‡µ◊Õπ·π–π”«à“§«√µ√«®‡æ‘¡‡µ‘¡À√◊Õª√÷°…“·æ∑¬å ’Ë Ÿâ É — Ë ºŸ‡â ™’¬«™“≠ Ë 14 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012
  • ¢âÕ √ÿª∑’Ë 11. ºŸâªÉ«¬‚√§≈”‰ â·ª√ª√«π∑’ˉ¡à¡’≈—°…≥–‡µ◊Õπ¡’‚Õ°“ ‡°‘¥¡–‡√Áß≈”‰ â„À≠à ‰¡àµà“ß®“°ª√–™“°√∑—Ë«‰ª â É °“√»÷°…“¢Õß Cash ·≈–§≥–7 æ∫«à“ºŸª«¬‚√§≈”‰ â·ª√ª√«π¡’§«“¡™ÿ°¢Õß ‚√§¡–‡√Áß≈”‰ â„À≠à∑’Ë√âÕ¬≈– 0-0.51 ¢≥–∑’˧«“¡™ÿ°¢Õß‚√§π’È„πª√–™“°√∑—Ë«‰ªÕ¬Ÿà∑’Ë √âÕ¬≈– 0-6 ´÷Ë߉¡à¡’§«“¡·µ°µà“ß°—π ¢âÕ √ÿª∑’Ë 12. ‚√§≈”‰ â·ª√ª√«π‡ªìπ‚√§‡√◊ÈÕ√—ß À√◊Õ‡ªìπÊÀ“¬Ê ºŸâªÉ«¬¡—°¡’Õ“¬ÿ¬◊𬓫 ‰¡àµà“ß®“°ª√–™“°√∑—Ë«‰ª ·µà®–¡’§ÿ≥¿“æ™’«‘µ∑’Ë¥âÕ¬°«à“ °“√»÷°…“À≈“¬°“√»÷°…“8, 9 æ∫«à“ºŸâªÉ«¬‚√§≈”‰ â·ª√ª√«π¡’§ÿ≥¿“æ™’«‘µ∑’Ë ¥âÕ¬°«à“ª√–™“°√∑—Ë«‰ª Õ“∑‘ °“√»÷°…“¢Õß Lu ·≈–§≥–8 „πºŸâªÉ«¬™“«®’π∑’ˇªìπ ‚√§≈”‰ â·ª√ª√«π æ∫«à“ºŸª«¬‡æ»À≠‘ß¡’·π«‚πâ¡À¬ÿ¥ß“π¡“°°«à“ ¡’ª≠À“°“√πÕπ â É í (sleep disturbance) ¡“°°«à“ºŸâªÉ«¬™“¬  à«π°“√»÷°…“¢Õß Rey ·≈–§≥–9 °Áæ∫ «à “„πºŸâ ªÉ « ¬‚√§≈”‰ â·ª√ª√«π∑’˪√÷°…“·æ∑¬å ·≈–∑’ˉ¡à‰¥âª√÷°…“·æ∑¬å≈â«π¡’ §ÿ≥¿“æ™’«‘µ∑’Ë¥âÕ¬°«à“°≈ÿà¡∑’ˉ¡à¡’‚√§ ¢âÕ √ÿª∑’Ë 13. ≈—°…≥–°“√∂à“¬Õÿ®®“√–„πºŸª«¬≈”‰ â·ª√ª√«π¡’ª√–‚¬™πå„π°“√°”Àπ¥ â É ·π«∑“ß°“√ ◊∫§âπÀ“ “‡Àµÿ¢ÕßÕ“°“√ („π°√≥’∑’Ë¡’¢âÕ∫àß™’È) ·≈–·π«∑“ß°“√ „À⬓√—°…“ ·π–π”„Àâ ∫§âπ‡æ‘¡‡µ‘¡„πºŸª«¬‚√§≈”‰ â·ª√ª√«πµ“¡™π‘¥¢Õß‚√§π’3, 10 ‚¥¬ ◊ Ë â É È ‡©æ“–™π‘¥∑’‡Ë ªìπ·∫∫∑âÕ߇ ’¬‡¥àπ „Àâ√–«—ß‚√§°≈ÿ¡∑’Õ“®¡’Õ“°“√∑âÕ߇ ’¬‡√◊Õ√—߉¥â ‡™àπ à Ë È giardiasis, tropical sprue, hyperthyroidism, inflammatory bowel disease (IBD) ‡ªìπµâπ ‡ªÑ“À¡“¬¢Õß°“√√—°…“ºŸª«¬‚√§≈”‰ â·ª√ª√«π§◊Õ ≈¥Õ“°“√·≈–‡æ‘¡§ÿ≥¿“æ â É Ë 3, 5 ™’«‘µ¢ÕߺŸâªÉ«¬ ¥—ßπ—Èπ°“√®”·π°ºŸâªÉ«¬‚√§π’ȇªìπ 4 ™π‘¥§◊Õ ≈”‰ â·ª√ª√«π ™π‘¥ ∑âÕ߇ ’¬‡¥àπ, ≈”‰ â·ª√ª√«π ™π‘¥∑âÕߺŸ°‡¥àπ, ≈”‰ â·ª√ª√«π ™π‘¥∑âÕ߇ ’¬ ≈—∫ ∑âÕߺŸ° (IBS-M), ≈”‰ â·ª√ª√«π™π‘¥‰¡à™—¥‡®π (IBS-U) ®–∑”„Àâ°“√√—°…“´÷Ëß §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012 15
  • ¡ÿà߇πâπ∑’˵âÕß°“√≈¥Õ“°“√¢ÕߺŸâªÉ«¬‡ªìπÀ≈—° ∑”‰¥â –¥«°·≈–ßà“¬µàÕ°“√®—¥¬“Õ’° √«¡‰ª∂÷ß∑”„Àâ°“√»÷°…“«‘®—¬‚√§π’ȇªìπ‰ª„π·π«∑“߇¥’¬«°—πÕ’°¥â«¬‡™àπ ºŸâªÉ«¬∑’Ë¡’ Õ“°“√∑âÕ߇ ’¬‡¥àπÕ“®„™â¬“´÷ߪ√–°Õ∫‰ª¥â«¬¬“ antispasmodics, loperamide ·≈– Ë alosetron ‡ªìπµâπ ¢âÕ √ÿª∑’Ë 14. °“√µ√«®∑“ßÀâÕߪؑ∫µ°“√·≈–°“√µ√«®æ‘‡»…∑’¡ª√–‚¬™πå„π°“√·¬°‚√§ — ‘ Ë ’ Õ◊Ëπ∑’Ë∑”„À⇰‘¥Õ“°“√§≈⓬Փ°“√¢Õß‚√§≈”‰ â·ª√ª√«π ‰¥â·°à 14.1 °“√µ√«®æ◊Èπ∞“π CBC, ESR, stool exam 14.2 °“√µ√«®æ‘‡»…√–∫∫∑“߇¥‘πÕ“À“√ ‰¥â·°à barium enema, upper GI study with small bowel follow through, gastroscopy, sigmoidoscopy, colonoscopy, ultrasono-graphy À√◊Õ CT scan ¢Õß™àÕß∑âÕß, πà“®–∑” H2-breath test  ”À√—∫ small bowel bacterial overgrowth, lactose malabsorption, gastrointestinal transit study ·≈– anorectal function tests 14.3 °“√µ√«®Õ◊ËπÊ ‡™àπ thyroid function tests, serum cortisol, serum calcium, electrolytes ‡ªìπµâπ °“√µ√«®‡æ‘Ë ¡ ‡µ‘ ¡ ∑“ßÀâ Õ ßªØ‘ ∫— µ‘ ° “√π—È π ®–¡’ ª √–‚¬™πå „ πºŸâ ªÉ « ¬‚√§≈”‰ â ·ª√ª√«π‚¥¬‡©æ“–∂â“¡’≈—°…≥–‡µ◊Õπ ‚¥¬®–¡’·π«∑“ß°“√ ◊∫§âπµ“¡≈—°…≥–¢Õß ™π‘¥¢Õß‚√§≈”‰ â·ª√ª√«π∑’ºª«¬π—π¡’ª≠À“3  ”À√—∫ Asian guideline ·π–π”«à“ Ë Ÿâ É È í ∂â“√—°…“ºŸâªÉ«¬‰ª 12  —ª¥“Àå·≈â« ºŸâªÉ«¬¬—ߧߡ’Õ“°“√‰¡à¥’¢÷Èπ·π–π”«à“ §«√ àßµàÕ ºŸâªÉ«¬ª√÷°…“·æ∑¬å‡©æ“–∑“ß‚√§√–∫∫∑“߇¥‘πÕ“À“√ ¢âÕ √ÿª∑’Ë 15. ºŸâ ªÉ « ¬‚√§≈”‰ â·ª√ª√«π∑’˧«√ àßµàÕ‰ªæ∫·æ∑¬å‡©æ“–∑“ß‚√§√–∫∫ ∑“߇¥‘πÕ“À“√ ‰¥â·°à ºŸâªÉ«¬∑’Ë¡’¢âÕ∫àß™’È„π°“√µ√«®æ‘‡»…‡æ‘Ë¡‡µ‘¡À√◊ÕºŸâªÉ«¬∑’Ë¡’ Õ“°“√√ÿπ·√ß√—°…“·≈⫉¡à “¡“√∂§«∫§ÿ¡Õ“°“√‰¥â °“√√—°…“ºŸª«¬‚√§ IBS3, 11 π’·∫àß°“√¥Ÿ·≈‡ªìπ 3 √–¥—∫§◊Õ „π°“√¥Ÿ·≈ºŸª«¬ â É È â É ∑’Ë¡’Õ“°“√‰¡à¡“° „ÀℙⰓ√ª√—∫‡ª≈’ˬπ惵‘°√√¡ (life style modifications) °“√À≈’°‡≈’¬ßÕ“À“√À√◊Õ°“√‡ª≈’¬π™π‘¥¢ÕßÕ“À“√ Õ∏‘∫“¬°“√«‘π®©—¬·≈–°“√¥”‡π‘π Ë Ë ‘ 16 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012
  • ¢Õß‚√§ ∑”„À⺟âªÉ«¬¡—Ëπ„®„πµ—«‚√§«à“‚√§π’ȉ¡à√⓬·√ß·µà‡√◊ÈÕ√—ß´÷ËßÕ“®¡’º≈„Àâ§ÿ≥¿“æ ™’«‘µ≈¥≈߉¥â ∂⓺ŸâªÉ«¬‡√‘Ë¡¡’Õ“°“√¡“°¢÷Èπ·π–π”„Àℙ⬓√—°…“µ“¡Õ“°“√·≈–™π‘¥ ¢Õß≈”‰ â·ª√ª√«π∑’˺ŸâªÉ«¬‡ªìπ √à«¡°—∫°“√√—°…“§«“¡‡§√’¬¥ µ≈Õ¥®π°“√µ‘¥µ“¡ ºŸâªÉ«¬Õ¬à“ßµàÕ‡π◊ËÕß  ”À√—∫√“¬∑’Ë¡’§«“¡√ÿπ·√ß¡“°·π–π”„Àâ¡’°“√¥Ÿ·≈√—°…“Õ¬à“ß µàÕ‡π◊ËÕßµ≈Õ¥®πæ‘®“√≥“ª√÷°…“∑“ß®‘µ‡«™∑—Èß°“√„™â¬“·≈–®‘µ∫”∫—¥‡æ‘Ë¡  ”À√— ∫ ·æ∑¬å ∑—Ë «‰ª°“√√—°…“„πºŸâ ªÉ « ¬∑’Ë ¡’ Õ “°“√‡≈Á ° πâ Õ ¬®π∂÷ ß ª“π°≈“ß  “¡“√∂∑”‰¥â  à«π„π√“¬∑’Ë¡’Õ“°“√¡“° °“√√—°…“‚¥¬·æ∑¬å‡©æ“–∑“ß‚√§√–∫∫ ∑“߇¥‘πÕ“À“√·≈–®‘µ‡«™¡’§«“¡®”‡ªìπ ‡π◊ËÕß®“°Õ“®µâÕß¡’°“√ ◊∫§âπ‡æ‘Ë¡‡µ‘¡·≈– ‡ªìπ°“√∑”„À⺟âªÉ«¬¡’§«“¡¡—Ëπ„®„π·π«∑“ß°“√√—°…“¡“°¢÷Èπ «à“‰¥â√—∫°“√¥Ÿ·≈®“° ·æ∑¬åºŸâ¡’§«“¡‡™’ˬ«™“≠„π‚√§∑’ˇªìπ „π¢≥–∑’ËÕ“°“√¬—߉¡à¥’¢÷Èπ‡∑à“∑’˧«√ References 1. Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional bowel disorders. Gastroenterology 2006;130:1480-91. 2. Svendsen JH, Munck LK, Andersen JR. Irritable bowel syndrome: prognosis and diagnostic safety. A 5-year follow-up study. Scand J Gastroenterol 1985;20:415-8. 3. Brandt LJ, Chey WD, Foxx-Orenstein AE, Schiller LR, Schoenfeld PS, Spiegel BM, et al. An evidence-based position statement on the management of irritable bowel syndrome. Am J Gastroenterol 2009;104 Suppl 1:S1-35. 4. Spiller R, Aziz Q, Creed F, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut 2007;56:1770-98. 5. Gwee KA, Bak YT, Ghoshal UC, et al. Asian consensus on irritable bowel syndrome. J Gastroenterol Hepatol 2010;25:1189-205. 6. Tungtrongchitr A, Manatsathit S, Kositchaiwat C, et al. Blastocystis hominis infection in irritable bowel syndrome patients. Southeast Asian J Trop Med Public Health 2004;35: 705-10. 7. Cash BD, Schoenfeld P, Chey WD. The utility of diagnostic tests in irritable bowel syndrome patients: a systematic review. Am J Gastroenterol 2002;97:2812-9. 8. Lu CL, Chang FY, Lang HC, Chen CY, Luo JC, Lee SD. Gender difference on the symptoms, health-seeking behaviour, social impact and sleep quality in irritable bowel syndrome: a Rome II-based survey in an apparent healthy adult Chinese population in Taiwan. Aliment Pharmacol Ther 2005;21:1497-505. 9. Rey E, Garcia-Alonso MO, Moreno-Ortega M, Alvarez-Sanchez A, Diaz-Rubio M. Determinants of quality of life in irritable bowel syndrome. J Clin Gastroenterol 2008;42: 1003-9. 10. Mayer EA. Clinical practice. Irritable bowel syndrome. N Engl J Med 2008;358:1692-9. 11. Drossman DA, Camilleri M, Mayer EA, Whitehead WE.. AGA technical review on irritable bowel syndrome. Gastroentero-logy 2002;123:2108-31. §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012 17
  • Non-pharmacological Treatment ¢âÕ √ÿª∑’Ë 16. ºŸâªÉ«¬≈”‰ â·ª√ª√«π∑’Ë¡’Õ“°“√‰¡à√∫°«π§ÿ≥¿“æ™’«‘µ °“√¥Ÿ·≈√—°…“¡’ ‡ªÑ“À¡“¬‡æ◊ËÕ √â“ߧ«“¡¡—Ëπ„®·≈–§≈“¬§«“¡«‘µ°°—ß«≈¢ÕߺŸâªÉ«¬ °“√¥Ÿ·≈√—°…“ºŸª«¬≈”‰ â·ª√ª√«π∑’¡Õ“°“√‰¡à√∫°«π§ÿ≥¿“æ™’«µ ¡’‡ªÑ“À¡“¬ â É Ë ’ ‘ ∑’ ”§—≠§◊Õ √â“ߧ«“¡¡—π„®·≈–§≈“¬§«“¡«‘µ°°—ß«≈¢ÕߺŸª«¬  ‘ß·√°µâÕßÕ∏‘∫“¬ Ë Ë â É Ë „À⺟âªÉ«¬∑√“∫∂÷ß natural history ¢Õß‚√§«à“‚√§≈”‰ â·ª√ª√«π ‡ªìπ‚√§∑’ˉ¡à√⓬·√ß ‰¡à¡’¿“«–·∑√°´âÕπ∑’Ë®–∑”„À⇠’¬™’«‘µ ·µà¡’°“√¥”‡π‘π‚√§∑’ˇ√◊ÈÕ√—ß ¡—°‡ªìπÊ À“¬Ê ·¡â‰¥â√∫°“√√—°…“ À≈—ß°“√√—°…“∂⓺Ÿª«¬Õ“°“√‰¡à¥¢π®–¬‘ß∑”„À⺪«¬«‘µ°°—ß«≈¡“° — â É ’ ÷È Ë Ÿâ É §◊Õ°≈—«‡ªìπ¡–‡√Áß≈”‰ â ·æ∑¬åµâÕßÕ∏‘∫“¬‡æ◊ËÕ √â“ߧ«“¡¡—Ëπ„®„À⺟âªÉ«¬«à“‚√§≈”‰ â ·ª√ª√«π‰¡à„™à‚√§¡–‡√Áß·≈–®–‰¡à°≈“¬‡ªìπ¡–‡√Áß ·¡â®–¡’Õ“°“√∑’π”ºŸª«¬¡“æ∫·æ∑¬å Ë â É ‡À¡◊Õπ°—π ·æ∑¬åµÕß´—°ª√–«—µ·≈–µ√«®√à“ß°“¬Õ¬à“ß≈–‡Õ’¬¥ ·≈–∑”°“√ ◊∫§âπÕ¬à“ß â ‘ ‡À¡“– ¡°àÕπ∑’Ë®–„Àâ°“√«‘π‘®©—¬«à“‡ªìπ‚√§≈”‰ â·ª√ª√«π √«¡∑—Èß®–µâÕߧâπÀ“Õ¬à“ß ‡µÁ¡∑’Ë«à“‰¡àæ∫¡’≈—°…≥–‡µ◊Õπ (alarm symptoms) ´÷Ëß∫àß™’È«à“Õ“®®–¡’‚√§√⓬·√ß ‡™àπ¡–‡√Áß≈”‰ â√à«¡¥â«¬ ‡æ◊ËÕ¬◊π¬—π„À⺟âªÉ«¬¡—Ëπ„®«à“‰¡à¡’‚√§√⓬·√ß1-5 ¢âÕ √ÿª∑’Ë 17. ºŸâªÉ«¬≈”‰ â·ª√ª√«π∑’Ë¡’Õ“°“√√∫°«π§ÿ≥¿“æ™’«‘µ «—µ∂ÿª√– ß§å¢Õß°“√ √—°…“πÕ°®“° √â“ߧ«“¡¡—Ëπ„®·≈–§≈“¬§«“¡«‘µ°°—ß«≈„À⺟âªÉ«¬·≈â« §«√„Àâ °“√√—°…“‡æ◊ËÕ∫√√‡∑“Õ“°“√¢ÕߺŸâªÉ«¬§«√‡√‘Ë¡µâπ¥â«¬°“√·π–π”„Àâª√—∫‡ª≈’Ë¬π °“√ªØ‘∫—µ‘µ—«„π°“√¥”‡π‘π™’«‘µª√–®”«—π (life style modifications) °“√√—°…“‡æ◊Õ∫√√‡∑“Õ“°“√¢ÕߺŸª«¬§«√‡√‘¡µâπ¥â«¬°“√·π–π”„Àâª√—∫‡ª≈’¬π Ë â É Ë Ë °“√ªØ‘ ∫— µ‘ µ— «„π°“√¥”‡π‘π™’«‘µª√–®”«—π (life style modifications) ‡™àπ °“√√—∫ª√–∑“πÕ“À“√ ™π‘¥¢ÕßÕ“À“√ ¬“ §«“¡‡§√’¬¥ À≈’°‡≈’ˬߠ‘Ëß∑’Ë∑”„À⺟âªÉ«¬¡’ Õ“°“√¡“°¢÷Èπ‡ªìπµâπ ·¡â‰¡à¡’À≈—°∞“π∑“ß«‘∑¬“»“ µ√å∑’Ë π—∫ πÿπ«à“°“√ª√—∫ ‡ª≈’ˬπ°“√ªØ‘∫—µ‘µ—«¡’ª√–‚¬™πå„π°“√√—°…“ ·µà°“√·π–π”„Àâª√—∫‡ª≈’ˬπ°“√ªØ‘∫—µ‘ µ— « Õ“®∑”„Àâ Õ “°“√¥’ ¢÷È π„πºŸâ ªÉ « ¬∫“ß√“¬·≈–™à « ¬≈¥§«“¡∂’Ë „ π°“√°≈— ∫ ‡ªì π ´È” ‰¥â¥«¬6 â 18 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012
  • ¢âÕ √ÿª∑’Ë 18. °“√„Àâ°“√«‘π‘®©—¬‚√§‡™‘ß∫«°·≈–°“√¡’§«“¡ —¡æ—π∏å∑’Ë¥’√–À«à“ß·æ∑¬å ·≈–ºŸâªÉ«¬¡’§«“¡ ”§—≠µàÕº≈ ”‡√Á®¢Õß°“√√—°…“ºŸâªÉ«¬‚√§≈”‰ â·ª√ª√«π °“√µ√–Àπ—°∂÷ß·≈–«‘π‘®©—¬‚√§≈”‰ â·ª√ª√«π¥â«¬§«“¡¡—Ëπ„®‡ªìπ ‘Ëß ”§—≠∑’Ë ·æ∑¬å®– √â“ߧ«“¡¡—π„®·°àºª«¬ ·≈– ”§—≠µàÕº≈ ”‡√Á®¢Õß°“√√—°…“ºŸª«¬‚√§≈”‰ â Ë Ÿâ É â É ·ª√ª√«π ‡¡◊ËÕºŸâªÉ«¬¡’§«“¡¡—Ëπ„®„π°“√¥Ÿ·≈√—°…“¢Õß·æ∑¬å®– àߺ≈„À⇰‘¥§«“¡  —¡æ—π∏å∑’Ë¥’√–À«à“ß·æ∑¬å·≈–ºŸâªÉ«¬ ´÷Ëß®–¡’§«“¡ ”§—≠µàÕº≈ ”‡√Á®¢Õß°“√√—°…“ ‡π◊Õß®“°‚√§≈”‰ â·ª√ª√«π¡’°“√¥”‡π‘π‚√§∑’‡Ë √◊Õ√—ß ¡—°‡ªìπÊÀ“¬Ê ºŸª«¬®”‡ªìπµâÕß Ë È â É ‰¥â√—∫°“√¥Ÿ·≈√—°…“µ‘¥µàÕ°—π√–¬–¬“«·≈–µâÕ߉¥â√—∫§«“¡√à«¡¡◊ÕÕ¬à“ߥ’®“°ºŸâªÉ«¬ Õ’°¥â«¬ ¥—ßπ—π‡¡◊ÕºŸª«¬¡’§«“¡‡™◊Õ∂◊Õ·≈–§«“¡¡—π„®„πµ—«·æ∑¬å·≈â« ºŸª«¬®–√Ÿ °«à“ È Ë â É Ë Ë â É â ÷ ·æ∑¬å‡ªìπ∑’æ߉¥âµ≈Õ¥‡«≈“∑”„À⺪«¬§≈“¬§«“¡«‘µ°°—ß«≈≈ßÕ“®™à«¬∑”„ÀâÕ“°“√ Ë ÷Ë Ÿâ É ¥’¢π ·¡âºª«¬®–¬—ߧߡ’Õ“°“√Õ¬Ÿ∫“߉¡àÀ“¬¢“¥·µàºª«¬®–¡’§«“¡∑ÿ°¢å∑√¡“π‡°’¬«°—∫ ÷È Ÿâ É à â Ÿâ É Ë 6-9 ‚√§≈¥πâÕ¬≈ß ¢âÕ √ÿª∑’Ë 19. °“√´—°ª√–«—µæƒµ‘°√√¡°“√√—∫ª√–∑“πÕ“À“√·≈–‡§√◊Õߥ◊¡ √«¡∂÷ߧ”·π–π” ‘ Ë Ë ‡°’ˬ«°—∫°“√√—∫ª√–∑“πÕ“À“√·≈–‡§√◊ËÕߥ◊Ë¡ ¡’ª√–‚¬™πå„π°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ ≈”‰ â·ª√ª√«π ºŸâªÉ«¬ à«π„À≠à√Ÿâ ÷°«à“Õ“À“√∫“ßÕ¬à“ß∑”„ÀâÕ“°“√¢Õß‚√§≈”‰ â·ª√ª√«π Ë ‡ªìπ¡“°¢÷π10 ¡’°“√»÷°…“∑’‡Ë ªìπ systematic review ´÷ß à«π„À≠à‡ªìπ°“√»÷°…“·∫∫ È uncontrolled æ∫«à“ °“√À≈’°‡≈’ˬßÕ“À“√∑’Ë®–∑”„Àâ¡’Õ“°“√‡æ‘Ë¡¢÷Èπ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫ °—∫ placebo ºŸâªÉ«¬®–¡’Õ“°“√¥’¢÷Èπ√âÕ¬≈– 12.5-67 ´÷߉¡à “¡“√∂ √ÿª‰¥â«“‡ªìπ Ë à 11 placebo effect À√◊Õ‰¡à ¡’°“√»÷°…“∑’‡Ë ªìπ randomized control trial (RCT) æ∫«à“ °“√À≈’°‡≈’¬ßÕ“À“√∑’®–∑”„Àâ¡Õ“°“√‡æ‘¡¢÷π´÷߬◊π¬—π‚¥¬°“√µ√«®æ∫ IgG antibody Ë Ë ’ Ë È Ë µàÕÕ“À“√™π‘¥π—π ∑”„À⺪«¬¡’Õ“°“√¥’¢πÕ¬à“ß¡’π¬ ”§—≠∑“ß ∂‘µ‡‘ ¡◊Õ‡ª√’¬∫‡∑’¬∫ È Ÿâ É ÷È — Ë °—∫ sham diet ‚¥¬¡’ number needed to treat (NNT) ‡∑à“°—∫ 2.512 „πªí®®ÿ∫—π ¬—ß‰¡à¡’À≈—°∞“π∑’Ë¥’‡æ’¬ßæÕ∑’Ë®–· ¥ß∂÷ߪ√– ‘∑∏‘¿“æ¢Õß°“√À≈’°‡≈’ˬßÕ“À“√∑’Ë®– ∑”„À⺟âªÉ«¬¡’Õ“°“√‡æ‘Ë¡¢÷Èπ13 ®÷߬—߉¡à·π–π”„Àâµ√«®À“ IgG antibody ‡ªìπ routine „π‡«™ªØ‘∫µ∑«‰ª Õ¬à“߉√°Áµ“¡°“√·π–π”„ÀâÀ≈’°‡≈’¬ßÕ“À“√∑’®–∑”„Àâ¡Õ“°“√‡æ‘¡¢÷π — ‘ —Ë Ë Ë ’ Ë È ‡™àπÕ“À“√√ ®—¥ Õ“À“√¡—π ¢ÕߥÕß ·Õ≈°ÕŒÕ≈å∑°™π‘¥ °“·ø πȔ՗¥≈¡ ‡ªìπµâπ ÿ §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012 19
  • ∂◊Õ«à“¡’ª√–‚¬™πå‚¥¬Õ“®∑”„ÀâÕ“°“√¢ÕߺŸª«¬¥’¢π‰¥â πÕ°®“°π’°“√°‘πÕ“À“√§«√°‘π â É ÷È È ∑’≈–πâÕ¬·µà°π„Àâ∫Õ¬¢÷π ‰¡à§«√°‘π®πÕ‘¡¡“° ‡æ√“–«à“®–°√–µÿπ„Àâ¡Õ“°“√ª«¥∑âÕß ‘ à È Ë â ’ ·≈–∑âÕ߇ ’¬‰¥âßà“¬ ¢âÕ √ÿª∑’Ë 20. °“√√—°…“‚¥¬‰¡à „ ™â ¬ “∑’Ë Õ “®¡’ ª √–‚¬™πå „ πºŸâ ªÉ « ¬≈”‰ â·ª√ª√«π‰¥â · °à °“√„™â educational self-help guidebook, psychological therapy, °“√√—°…“ ¥â«¬ “√ ¡ÿπ‰æ√ °“√Ωí߇¢Á¡ ·≈– biofeedback therapy °“√√—°…“‚¥¬‰¡à„™â¬“ (non-drug therapy) ∑’ËÕ“®¡’ª√–‚¬™πå „ πºŸâ ªÉ « ¬ ‚√§≈”‰ â·ª√ª√«π‰¥â·°à 20.1 °“√„™â educational self-help guidebook ‡ªìπ°“√„Àâ°“√»÷°…“·°à ºŸâ ªÉ « ¬„Àâ ¡’ § «“¡√Ÿâ ‡ °’Ë ¬ «°— ∫‚√§∑—È ß„π¥â“π欓∏‘°”‡π‘¥ °“√«‘π‘®©—¬·≈–°“√√—°…“ µ≈Õ¥®π‡¢â“„®≈—°…≥–°“√¥”‡π‘π‚√§·≈–·π«∑“ß„π°“√ª√—∫‡ª≈’ˬπ°“√ªØ‘∫—µ‘µ—«∑’Ë ‡À¡“– ¡‡æ◊ËÕ≈¥Õ“°“√∑’Ë∑”„À⺟âªÉ«¬∑ÿ°¢å∑√¡“π ¡’°“√»÷°…“∑’ˇªìπ RCT ‚¥¬ ª√–‡¡‘πº≈≈—æ∏å§◊Õ symptom score, perception of improvement ·≈– primary care consultation rates º≈°“√»÷°…“∑’ËÀπ÷Ëߪïæ∫«à“„π°≈ÿà¡ self-help guidebook ¡’ºŸâªÉ«¬¡“æ∫·æ∑¬å≈¥≈ßπâÕ¬°«à“ control group 1.56 §√—ÈßµàÕªïÕ¬à“ß¡’π—¬ ”§—≠ (95% CI, 1.15-1.98) À√◊Õ≈¥≈ß√âÕ¬≈– 60 πÕ°®“°π’Èæ∫«à“„π°≈ÿà¡ self-help guidebook ºŸâªÉ«¬√“¬ß“π perceived improvement ¡“°°«à“‚¥¬¡’ mean effect ‡∑à“°—∫ 0.51 (95% CI, 0.23-0.79)14 20.2 Psychological therapy ‡π◊ËÕß®“°ºŸâªÉ«¬‚√§≈”‰ â·ª√ª√«π¡—°¡’¿“«– anxiety, depression ·≈– somatization √à«¡¥â«¬15,16 ¡’°“√»÷°…“∑’‡Ë ªìπ systematic review ·≈– meta-analysis ∑’Ë· ¥ß«à“ psychological therapy ´÷Ëߪ√–°Õ∫¥â«¬ cognitive behavioral therapy (CBT), dynamic psychotherapy ·≈– hypnotherapy ∑”„Àâ global IBS symptoms ¥’¢÷ÈπÕ¬à“ß¡’π—¬ ”§—≠‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫ °—∫°“√√—°…“µ“¡ª°µ‘17-19 ‚¥¬ CBT ‡ªìπ·π«∑“ß°“√√—°…“∑’Ë¡’°“√»÷°…“¡“°∑’Ë ÿ¥ ‚¥¬‡©æ“–¡’°“√»÷°…“∑’Ë„À≠à·≈–¡’§ÿ≥¿“æ ŸßÀπ÷Ëß°“√»÷°…“∑’Ë· ¥ß«à“ CBT ‰¥â ª√–‚¬™πå∑”„À⺪«¬Õ“°“√¥’¢πÕ¬à“ß™—¥‡®π ¡’°“√»÷°…“∑’‡Ë ªìπ single-blinded study Ÿâ É ÷È ‡ª√’¬∫‡∑’¬∫ CBT °—∫ patient education alone æ∫«à“ CBT ∑”„À⺟âªÉ«¬Õ“°“√ ¥’¢π√âÕ¬≈– 73 ´÷߉¥âº≈¥’°«à“ education group ´÷߉¥âº≈√âÕ¬≈– 41.3 Õ¬à“ß¡’π¬ ”§—≠ ÷È Ë Ë — 20 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012
  • ∑“ß ∂‘µ‘ (NNT= 3.2)20  ”À√—∫ hypnotherapy ¡’°“√»÷°…“∑’ˇªìπ systematic review ª√–°Õ∫¥â«¬ 6 °“√»÷°…“∑’Ë¡’ control ·≈– 8 °“√»÷°…“∑’ˉ¡à¡’ control ¡’ ºŸâªÉ«¬√«¡ 644 √“¬ æ∫«à“√âÕ¬≈– 80 ¡’ global IBS symptoms ¥’¢÷Èπ ‚¥¬‡©æ“– ºŸâªÉ«¬ typical IBS ®–µÕ∫ πÕ߉¥â¥’  à«πºŸâªÉ«¬™“¬∑’Ë¡’∑âÕ߇ ’¬‡ªìπÕ“°“√‡¥àπ ·≈–ºŸâªÉ«¬ IBS ∑’Ë¡’ atypical symptoms À√◊Õ¡’ comorbid psychopathology ¡—°‰¡à§àÕ¬µÕ∫ πÕßµàÕ°“√√—°…“21 20.3 Probiotics22-25 °≈‰°Àπ÷ߢÕß欓∏‘ √’√–«‘∑¬“¢Õß IBS §◊Õ¡’°“√‡ª≈’¬π Ë Ë ·ª≈ߢÕß intestinal microbiota º‘¥ª°µ‘‰ª®“°‡¥‘¡ ‚¥¬‡°‘¥§«“¡‰¡à ¡¥ÿ≈¬å¢Õß intestinal microbiota ‡™àπ ¡’°“√≈¥≈ߢÕß Lactobacilli ·≈– Bifidobacteria ´÷Ëß ‡ªìπ·∫§∑’‡√’¬∑’Ë¥’‡°‘¥ª√–‚¬™πåµàÕ√à“ß°“¬¢≥–‡¥’¬«°—π¡’·∫§∑’‡√’¬∑’ˉ¡à¥’‡æ‘Ë¡¢÷Èπ‡™àπ Clostridia ·≈– Enterobacteriaceae ‡ªìπµâπ 𔉪 Ÿà¿“«– dysbiosis, elevated luminal gas production ·≈– immune activation ¥—ßπ—Èπ‡ªÑ“À¡“¬Àπ÷ËߢÕß°“√ √—°…“ IBS ®÷ß¡ÿ߉ª∑’°“√·°â‰¢§«“¡º‘¥ª°µ‘¢Õß intestinal microbiota ¡’°“√»÷°…“ à Ë ∑’ˇªìπ systematic review 3 °“√»÷°…“ (2 °“√»÷°…“‡ªìπºŸâªÉ«¬ºŸâ„À≠àÕ¬à“߇¥’¬«, 1 °“√»÷°…“‡ªìπºŸâ„À≠à·≈–‡¥Á°)2-4 æ∫«à“ probiotics ∑”„À⺟âªÉ«¬¡’ global IBS symptoms, abdominal pain ·≈– flatulence ¥’¢÷ÈπÕ¬à“ß¡’π—¬ ”§—≠·≈–ª√–‚¬™πå ∑’ˉ¥â‡ªìπ strain-specific ·≈– symptom-specific  ”À√—∫ probiotic ∑’ˇªìπ  “¬æ—π∏ÿ凥’ˬ« À≈—°∞“π∑’Ë¥’∑’Ë ÿ¥§◊Õ Bifidobacteria infantis √Õß≈߉ª§◊Õ Lactobacillus planetarium  à«π probiotic ∑’ˇªì𠓬æ—π∏ÿ庠¡‡™àπ E.coli-Nisle + Streptococcus faecalis ‡π◊Õß®“°¡’ª®®—¬À≈“¬Õ¬à“߇™àπ strain selection, optimum Ë í dosage, mode of action,† safety ·≈– long-term tolerability ´÷Ëß¡’º≈µàÕ º≈¢Õß°“√√—°…“®÷߬—߉¡à “¡“√∂°”Àπ¥„Àâ probiotics ‡ªìπ general recommendation „π°“√√—°…“ºŸâªÉ«¬ IBS ‰¥â 20.4  “√ ¡ÿπ‰æ√ ®“°°“√»÷°…“‚¥¬ Cochrane systematic review 75 RCTs ¡’ºŸâªÉ«¬√«¡ 7,957 √“¬ æ∫«à“¡’ “√ ¡ÿπ‰æ√∫“ßÕ¬à“ßÕ“®∑”„ÀâÕ“°“√¢Õß ºŸâªÉ«¬‚√§≈”‰ â·ª√ª√«π¥’¢÷Èπ‰¥â26 ¡’°“√»÷°…“∑’ˇªìπ RCT ·∫∫ multicenter ‚¥¬ »÷°…“µ”√—∫ ¡ÿπ‰æ√™◊ËÕ Iberogast ´÷Ëߪ√–°Õ∫¥â«¬ ¡ÿπ‰æ√À≈“¬™π‘¥ æ∫«à“∑”„Àâ Õ“°“√¢ÕߺŸª«¬‚√§≈”‰ â·ª√ª√«π¥’¢πÕ¬à“ß¡’π¬ ”§—≠‡¡◊Õ‡ª√’¬∫‡∑’¬∫°—∫¬“À≈Õ° â É ÷È — Ë ‚¥¬ºŸª«¬∑𬓉¥â¥·≈–‰¥âº≈¥’‰¡à«“®–¡’ predominant symptom ·∫∫„¥27 Õ¬à“߉√ â É ’ à °Áµ“¡°“√ª√–‡¡‘πª√–‚¬™πå∑’Ë·∑â®√‘ߢÕß ¡ÿπ‰æ√Õ“®‰¥âº≈‰¡à·πàπÕπ ‡π◊ËÕß®“° §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012 21
  • °“√»÷°…“µà“ßÊ ¡’§«“¡À≈“°À≈“¬¢Õß®”π«π·≈–™π‘¥ ¡ÿπ‰æ√∑’Ë„™â·≈–µâÕߧ”π÷ß ∂÷ßæ‘…®“°§«“¡‰¡à∫√‘ ÿ∑∏‘Ï„π ¡ÿπ‰æ√π—ÈπÊ ¥â«¬´÷Ëß∑”„À⇪ìπ¢âÕ®”°—¥¢Õß ¡ÿπ‰æ√ ∑’Ë®–π”¡“„™â„À⇰‘¥ª√–‚¬™πå„π°“√√—°…“13 20.5 °“√Ωí߇¢Á¡ ®“°°“√»÷°…“∑’ˇªìπ systematic review æ∫«à“‰¡à “¡“√∂  √ÿª‰¥â«“°“√Ωí߇¢Á¡‰¥âª√–‚¬™πå„π°“√√—°…“‚√§≈”‰ â·ª√ª√«π ‡π◊Õß®“°º≈°“√√—°…“ à Ë ¡’∑—Èß∑’Ë∑”„ÀâÕ“°“√¥’¢÷Èπ·≈–‰¡à¥’¢÷Èπ ®÷ßµâÕß°“√°“√»÷°…“‡æ‘Ë¡‡µ‘¡Õ’°¡“°°àÕπ∑’Ë®– ·π–π”°“√Ωí߇¢Á¡„À⇪ìπÀπ÷Ëß„π·π«∑“ß°“√√—°…“13 20.6 Biofeedback therapy Biofeedback therapy28 À√◊Õ°“√Ωñ°‡∫àßÕÿ®®“√– ¡’√“¬ß“π«à“¡’ª√–‚¬™πå„π ºŸâªÉ«¬≈”‰ â·ª√ª√«π™π‘¥∑âÕߺŸ°‡¥àπ∑’Ë¡’ªí≠À“‡∫à߉¡à∂Ÿ°«‘∏’ (anismus) √à«¡¥â«¬ ‚¥¬æ∫«à“∂⓺ŸâªÉ«¬ “¡“√∂Ωñ°‡∫àß®π “¡“√∂‡∫àßÕÿ®®“√–‰¥â∂Ÿ°«‘∏’ Õ“°“√ª«¥·πàπ ∑âÕß®“°≈”‰ â·ª√ª√«π®–¥’¢÷Èπ  —¡æ—π∏å°—∫°“√§≈“¬µ—«¢ÕßÀŸ√Ÿ¥∑«“√Àπ—°¢≥–‡∫àß ∑’Ë¥’¢÷Èπ ¥—ßπ—ÈπºŸâªÉ«¬≈”‰ â·ª√ª√«π™π‘¥∑âÕߺŸ°‡¥àπ∑’Ë¡’Õ“°“√√∫°«π¡“°À√◊Õ¥◊ÈÕµàÕ °“√√—°…“ °“√µ√«®°“√∑”ß“π¢Õß∑«“√Àπ—° ‡™àπ anorectal manometry, balloon expulsion test À√◊Õ defecogram ‡æ◊ËÕ§âπÀ“¿“«–‡∫à߉¡à∂Ÿ°«‘∏’ (anismus) ·≈– „Àâ°“√√—°…“‚¥¬«‘∏’ biofeedback ®÷ßπà“®–¡’ª√–‚¬™πåµàÕºŸâªÉ«¬ References : 1. Brandt LJ, Bjorkman D, Fennerty MB, et al. Systematic review on the management of irritable bowel syndrome in North America. Am J Gastroenterol 2002;97 (Suppl 11):S7- 26. 2. Tack J, Fried M, Houghton LA, Spicak J, Fisher G. Systematic review: the efficacy of treatments for irritable bowel syndrome: a European perspective. Aliment Pharmacol Ther 2006;24:183 - 205. 3. Hammer J, Eslick GD, Howell SC, Altiparmak E, Talley NJ. Diagnostic yield of alarm features in irritable bowel syndrome and functional dyspepsia. Gut 2004;53:666-72. 4. Ford AC, Talley NJ, Veldhuyzen van Zanten SJ, Vakil NB, Simel DL, Moayyedi P. Will the history and physical examination help establish that irritable bowel syndrome is causing my patientûs lower gastrointestinal symptoms? JAMA 2008;300:1793-805. 5. Cash BD, Schemed P, Chey WD. The utility of diagnostic tests in irritable bowel syndrome patients: a systematic review. Am J Gastroenterol 2002;97:2812-9. 6. American Gastroenterological Association. AGA medical position statement: Irritable bowel syndrome. Gastroenterology 2002;123:2105-7. 7. Manning AP, Thompson WG, Heaton KW, et al. Towards positive diagnosis of the irritable bowel. Br Med J 1978;277:653-4. 8. Owens DM, Nelson DK, Talley NJ. The irritable bowel syndrome: long-term prognosis and the physician-patient interaction. Ann Intern Med 1995;122:107-12. 9. Spiegel BMR, Nalibo7 B, Mayer E, et al. The effectiveness of a model physician-patient relationship versus usual care in irritable bowel syndrome: a andomized controlled trial. Gastroenterology 2006;130:A773. 10. Simren M, Mansson A, Langkilde AM, et al. Food-related gastrointestinal symptoms in the irritable bowel syndrome. Digestion 2001;63:108-15. 22 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012
  • 11. Park MI, Camilleri M. Is there a role of food allergy in irritable bowel syndrome and functional dyspepsia? A systematic review. NeurogastroenterolMotil 2006;18:595-607. 12. Atkinson W, Sheldon T, Shaath N, Whorwell PJ. Food elimination based on IgG antibodies in irritable bowel syndrome: a randomized controlled trial. Gut 2004;53:1459-64. 13. Brandt LJ, Chey WD, Foxx-Orenstein AE, et al. American College of Gastroenterology Task Force on Irritable Bowel Syndrome. An evidence-based position statement on the management of irritable bowel syndrome. Am J Gastroenterol. 2009;104 Suppl 1:S1-35. 14. Robinson A , Lee V, Kennedy A , et al. A randomized controlled trial of self-help interventions in patients with a primary care diagnosis of irritable bowel syndrome. Gut 2006;55:643-648. 15. Whitehead WE, Palsson O, Jones KR.. Systematic review of the comorbidity of irritable bowel syndrome with other disorders: what are the causes and implications? Gastroenterology 2002;122:1140-56. 16. Miller AR, North CS, Clouse RE, Wetzel RD, Spitznagel EL, Alpers DH. The association of irritable bowel syndrome and somatization disorder. Ann Clin Psychiatry 2001;13:25-30. 17. Lackner JM, Mesmer C, Morley S, Dowzer C, Hamilton S. Psychological treatments for irritable bowel syndrome: a systematic review and meta-analysis .J Consult Clin Psychol 2004;72: 1100-13. 18. Ford A, Talley N, Schoenfeld P, et al. Efficacy of psychological therapies in irritable bowel syndrome: systematic and meta-analysis. Am J Gastroenterol 2008;103 (Suppl 1):S477. 19. Webb AN, Kukuruzovic RH, Catto-Smith AG, Sawyer SM. Hypnotherapy for treatment of irritable bowel syndrome. Cochrane Database Syst Rev 2007 (4) CD005110. 20. Drossman D, Toner B, Whitehead W, et al. Cognitive-behavioral therapy vs. education and desipramine vs. placebo for moderate to severe functional bowel disorders. Gastroenterology 2003; 125:19-31. 21. Tan G, Hammond D, Gurrala J. Hypnosis and irritable bowel syndrome: a review of efficacy and mechanism of action. Am J Clin Hypnosis 2005;47:161-178. 22. Whelan K. Probiotics and prebiotics in the management of IBS: a review of recent clinical trials and systematic reviews. Curr Opin Clin Nutr Care 2011;14:531-7. 23. McFarland LV, Dubin S. Meta-analysis of probiotics for the treatment of IBS. World J Gastroenterol 2008;14:2650-61. 24. Brenner DM, Moeller MJ, Chey WD, Schoenfeld PS. The utility of probiotics in the treatment of IBS; a systematic review. Am J Gastroenterol 2009;104:1033-49. 25. Moayyedi P, Ford AC, Talley NJ, et al. The efficacy of probiotics in the treatment of IBS: a systematic review. Gut 2010;59:325-32. 26. Liu J, Yang M, Liu Y, Wei M, Grimsgaard S. Herbal medicines for treatment of irritable bowel syndrome. Cochrane Database Syst Rev 2006 ;(1):CD004116. 27. Madisch A, Holtmann G, Plein K, Hotz J. Treatment of irritable bowel syndrome with herbal preparations: results of a double-blind, randomized, placebo-controlled, multi-centre trial. Aliment Pharmacol Ther 2004;19:271-279. 28. Patcharatrakul T, Gonlachanvit S. Outcome of biofeedback therapy in dyssynergic defecation patients with and without irritable bowel syndrome. J Clin Gastroenterol 2011; 45(7):593-598. §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012 23
  • Pharmacological Treatment ¢âÕ √ÿª∑’Ë 21. ¬“∑’Ë¡’ª√–‚¬™πå„π°“√√—°…“ºŸâªÉ«¬‚√§≈”‰ â·ª√ª√«π‰¥â·°à antispasmodics, fiber, anti-diarrheal, laxatives, antibiotics, probiotics, lubiprostone, linaclotide, anti-depressants (TCA and SSRI) ·≈–¬“∑’ÕÕ°ƒ∑∏‘º“π√–∫∫ Ë Ï à serotonin À√◊Õ 5-HT receptor °“√√—°…“≈”‰ â·ª√ª√«πªí®®ÿ∫π¬—߇πâπ∑’°“√√—°…“µ“¡Õ“°“√‡ªìπÀ≈—°  à«π¬“ — Ë ∑’ËÕÕ°ƒ∑∏‘Ϻà“π serotonin receptors π—Èπ°Á “¡“√∂„™â‰¥âµ“¡¢âÕ∫àß™’È 21.1. °“√√— ° …“Õ“°“√ª«¥∑â Õ ß  “¡“√∂„™â ¬ “∑’Ë ≈ ¥Õ“°“√ª«¥‡°√Á ß (antispasmodics) ‰¥â ‰¡à«à“®–‡ªìπ hyoscine, mebeverine ·µà‡π◊ËÕß®“°¬“‡À≈à“π’È ¡’®”Àπà“¬¡“π“π·≈â« °“√»÷°…“∑’ˇ§¬∑”‡¡◊ËÕπ“π·≈â«π—Èπ ¡—°¡’¢π“¥‡≈Á° ‰¡à ¡∫Ÿ√≥å „π‡™‘ß RCT ·≈–Õ“®¡’ publication bias ·¡â¡’ºŸâ∑” meta-analysis · ¥ß„Àâ‡ÀÁπ ª√–‚¬™πå·≈â«°Áµ“¡1 πÕ°®“°π—π¡’¬“∑’¢π∑–‡∫’¬π„πª√–‡∑»Õ’° ‡™àπ Trimebutine (´÷߇ªìπ opioid È Ë ÷È Ë antagononist), pinaverium (Dicetel) ·≈– dicyclomine (dicycloverine) ·µà°‰¡à¡À≈—°∞“π«à“¡’ª√–‚¬™πåÕ¬à“ß™—¥‡®π Õ¬à“߉√°Áµ“¡¡’ºª«¬∫“ß√“¬∑’µÕ∫ πÕß Á ’ Ÿâ É Ë µàÕ°“√√—°…“‡™àπ°—π  à«π¬“ ‡™àπ alverine (Spasmonal), fenoverine (Spasmopriv) ‡§¬¡’ ®”Àπà“¬„πª√–‡∑» ·µàªí®®ÿ∫—π‰¥â∂Õπ∑–‡∫’¬π‰ª·≈â« ¬“∑’Ë¡’º≈µàÕ pain modulation °Á‡≈◊Õ°„™â‰¥â ‡™àπ tricyclic antidepressant ·≈– SSRI2 ·µà¬“°≈ÿà¡ GABA analogue ‡™àπ gabapentin ·≈– pregabalin ¬—ß ‰¡à¡’°“√»÷°…“„π IBS 21.2. °“√√—°…“Õ“°“√∑âÕ߇ ’¬ ‡≈◊Õ°„™â¬“µàÕ‰ªπ’ȉ¥â Antidiarrheal drugs ‡™à𠬓º ¡ diphenoxylate À√◊Õ loperamide ‚¥¬¬“ “¡“√∂≈¥§«“¡∂’Ë ∑”„Àâª√‘¡“≥Õÿ®®“√–, ≈—°…≥–Õÿ®®“√–¥’¢÷Èπ‰¥â ·µà‰¡à¡’º≈ µàÕÕ“°“√ª«¥∑âÕß ·≈– global assessment ¥’¢÷ÈππâÕ¬3,4  à«π codeine ‰¡à·π–π”„Àâ„™â‡æ√“–𔉪 Ÿà abuse ‰¥â 5-HT3 antagonists ‡™àπ alosetron, ramosetron ● ● ● 24 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012
  • Alosetron ¬“¬—߉¡à ‰ ¥â ¢÷È π ∑–‡∫’ ¬ π„πª√–‡∑»‰∑¬ ·¡âæ∫«à“‰¥â º ≈¥’ ¡ “° ·µà‡π◊ËÕß®“°æ∫º≈¢â“߇§’¬ß§◊Õ ischemic colitis ·≈–¡’∫“ß√“¬‡ ’¬™’«‘µ ºŸâº≈‘µ®÷ß ®”°—¥„Àâ·æ∑¬å —Ëß„™â‡©æ“–°√≥’¡’¢âÕ∫àß™’È·≈–ºŸâªÉ«¬∑√“∫º≈¢â“߇§’¬ß·≈–¬‘π¬Õ¡„™â ‡∑à“π—π ·≈–‡©æ“–„π À√—∞Õ‡¡√‘°“ª√–‡∑»‡¥’¬« ≈à“ ÿ¥æ∫«à“ ºŸª«¬°≈ÿ¡π’ “¡“√∂„™â¬“ È â É à È „π√–¬–¬“«‰¥âÕ¬à“߉¥âº≈·≈–ª≈Õ¥¿—¬5 Ramosetron ¢÷Èπ∑–‡∫’¬π„πª√–‡∑»·≈â« æ∫«à“‰¥âº≈¥’¡“°„πºŸâªÉ«¬™“¬ ·≈– °”≈—ß¡’°“√»÷°…“„π«ß°«â“ßµàÕ‰ª6 °“√„™â¬“ªØ‘™’«π–Õ“®¡’ª√–‚¬™πå„π°“√√—°…“ IBS-D ‰¥â ‚¥¬¡’ ¡¡µ‘∞“π«à“ ºŸª«¬Õ“®¡’°“√µ‘¥‡™◊Õ·ΩßÀ√◊Õ‡ªìπ°“√ª√—∫ ‘ß·«¥≈âÕ¡®ÿ≈™’æ„π≈”‰ â À√◊ÕºŸª«¬Õ“®¡’ â É È Ë â É small intestinal bacterial overgrowth À√◊Õ tropical sprue Õ¬Ÿà ¬“ªØ‘™«π–∑’¡°“√»÷°…“ªí®®ÿ∫π¡’‡æ’¬ß¢π“π‡¥’¬« §◊Õ Rifaximin ‡¡◊Õªï 2011 ’ Ë ’ — Ë ¡’°“√»÷°…“ phase III ∑’Ë· ¥ß„Àâ‡ÀÁπ«à“ Rifaximin ‰¥âº≈¥’„πºŸâªÉ«¬ non IBS-C ‚¥¬∑”„ÀâÕ“°“√√«¡¥’¢÷È𠪫¥∑âÕß ∑âÕßÕ◊¥¥’¢÷Èπ µ≈Õ¥®π≈—°…≥–Õÿ®®“√–∑’ˇÀ≈« ‡ªìππÈ”°Á¥’¢÷Èπ¥â«¬7 21.3. °“√√—°…“Õ“°“√∑âÕߺŸ° ‡≈◊Õ°„™â¬“µàÕ‰ªπ’ȉ¥â Fiber „¬Õ“À“√„Àâ º ≈¥’ „ π√“¬∑’Ë ‰ ¥â √— ∫„¬Õ“À“√µà Õ «— π πâ Õ ¬°«à “ ‡°≥±å À√◊Õ°≈ÿà¡∑’˵âÕß°“√„¬Õ“À“√¡“°°«à“Õ—µ√“‡©≈’ˬ À√◊ÕºŸâ∑’Ë√—∫ª√–∑“π„¬Õ“À“√‰¡à  ¡Ë”‡ ¡Õ8-10 Õ¬à“߉√°Áµ“¡À“°ºŸª«¬‰¡à‰¥âµÕß°“√„¬Õ“À“√‡æ‘¡¢÷π°«à“∑’§«√‰¥â °Á¡°¡’ â É â Ë È Ë — Õ“°“√¢â“߇§’¬ß‡™àπ ∑âÕßÕ◊¥ ¡’≈¡„π∑âÕß À“°‡ªìπ‰ª‰¥â§«√‰¥â√—∫„¬Õ“À“√„π√Ÿª·∫∫ ∏√√¡™“µ‘ ‡™àπ®“°º—° º≈‰¡â ¡“°°«à“„π√Ÿª∑’Ë¢÷Èπ∑–‡∫’¬π‡ªìπ¬“À√◊Õº≈‘µ¿—≥±å‡ √‘¡ Õ“À“√ Laxatives ‰¡à¡À≈—°∞“π‡™‘ßª√–®—°…å„π°“√„™â¬“ conventional laxatives ’ (‡™àπ magnesium salt, lactulose, bisacodyl, senna) „πºŸâªÉ«¬ IBS ·µàæ∫«à“ ¡’°“√„™â¬“°≈ÿà¡π’ÈÕ¬à“ß°«â“ߢ«“ß ·≈–‡ªìπ∑’ˬա√—∫∑—Èß„πºŸâªÉ«¬·≈–·æ∑¬å  à«π polyethylene glycol ¡’°“√»÷°…“¢π“¥‡≈Á° ·µà°æ∫«à“‰¥âº≈¥’°«à“ Õ“°“√ Á 11 ¢â“߇§’¬ßπâÕ¬°«à“ lactulose Lubiprostone ´÷ßæ∫«à“°“√„™â·¡â„π√–¬–¬“«°Á‰¥âº≈¥’ ª≈Õ¥¿—¬ ·≈–ºŸª«¬ Ë â É ∑π°“√√—°…“‰¥â¥’ ¬“ºà“π°“√√—∫√Õß®“° US FDA ·≈â«·≈–‡ªìπ‡æ’¬ß¢π“π‡¥’¬«∑’Ë ● ● ● §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012 25
  • √—∫√Õß„Àâ„™â„π IBS-C ‰¥â∑—Ë«‰ª‰¡à¡’¢âÕ®”°—¥À√◊Õ¢âÕ∫àß™’ȇ©æ“– ¢≥–π’È√Õ¢÷Èπ∑–‡∫’¬π „πª√–‡∑»‰∑¬12 5-HT4 agonist Tegaserod ‡ªì𬓰≈ÿà¡π’È∑’ˇ§¬¢÷Èπ∑–‡∫’¬π„πª√–‡∑» ·≈–æ‘ Ÿ®πå«à“‰¥âº≈¥’ ª≈Õ¥¿—¬ ·µàµàÕ¡“ºŸâº≈‘µ·≈–®”Àπà“¬¢Õ¬°‡≈‘°‰¡à®”Àπà“¬ ®“°∑’Ë¡’°“√»÷°…“ ∑∫∑«πºŸâªÉ«¬∑’ˇ¢â“√à«¡°“√∑¥ Õ∫∑“ߧ≈‘π‘°®”π«π¡“°æ∫«à“ºŸâ∑’ˉ¥â√—∫¬“¡’Õ—µ√“ ‡°‘¥¿“«–·∑√°´âÕπ·≈–Õ—µ√“µ“¬®“°‚√§À—«„®·≈– stroke ¡“°°«à“13 Prucalopride ¬“π’È¢÷Èπ∑–‡∫’¬π·≈â«∑—Èß„π·≈–µà“ߪ√–‡∑»‡æ◊ËÕ„™â√—°…“ chronic constipation ´÷ß„Àâº≈¥’·≈–ª≈Õ¥¿—¬ ¢≥–π’¡¢Õ¡Ÿ≈«à“‰¥âº≈¥’„πºŸª«¬ IBSË È ’ â â É C ·µà¬—߉¡à‰¥â¢÷Èπ∑–‡∫’¬π°“√√—°…“„π¢âÕ∫àß™’Èπ’È Linaclotide ªí®®ÿ∫—π¢÷Èπ∑–‡∫’¬π„π À√—∞Õ‡¡√‘°“‡æ◊ËÕ√—°…“ IBS-C ·≈â«14 ·µà¬—߉¡à¡’„™â„πª√–‡∑»‰∑¬ Cisapride ªí®®ÿ∫—πºŸâº≈‘µ¬“µâπµ”√—∫∂Õπ∑–‡∫’¬π‰ªπ“π·≈â« „πª√–‡∑» ¡’®”Àπà“¬‡ªì𬓠generic ‡∑à“π—Èπ °“√»÷°…“º≈¢Õß cisapride „π IBS-C ¡’‰¡à¡“° ¡’‡æ’¬ß°“√»÷°…“‡¥’¬«∑’Ëæ∫«à“¥’°«à“ placebo17 ·µàÀ≈—ß®“°π—Èπ·≈–®“° systematic review18 æ∫«à“‰¡à‰¥âº≈¥’°«à“ placebo Mosapride ‡∑à“∑’ ∫§âπ‰¥â¡‡’ 撬߰“√»÷°…“‡¥’¬«19 ‡ªìπ°“√»÷°…“·∫∫‡ªî¥ Ë ◊ „πºŸâªÉ«¬ 10 √“¬ æ∫«à“™à«¬„ÀâÕ“°“√‚¥¬√«¡¥’¢÷Èπ‰¥â ● ● ● ● ● ¢âÕ √ÿª∑’Ë 22. ‰¡à¡’¢âÕ∫àß™’È„π°“√„™â¬“≈¥°√¥„πºŸâªÉ«¬≈”‰ â·ª√ª√«π∑’ˉ¡à¡’Õ“°“√¢Õß °√¥‰À≈¬âÕπÀ√◊Õ°√–‡æ“–Õ“À“√∑”ß“πº‘¥ª°µ‘ (ª«¥· ∫∑âÕß∫√‘‡«≥≈‘Èπªïò) ºŸâ ªÉ « ¬≈”‰ â · ª√ª√«π∑’Ë ‰ ¡à ¡’ Õ “°“√¢Õß°√¥‰À≈¬âÕπÀ√◊Õ°√–‡æ“–Õ“À“√ ∑”ß“πº‘¥ª°µ‘ (ª«¥· ∫∑âÕß∫√‘‡«≥≈‘πªï) °“√„™â¬“√–ß—∫°“√À≈—ß°√¥¡’∫∑∫“∑πâÕ¬ È ò Ë ®“°°“√ ◊∫§âπ æ∫«à“ 22.1. ‰¡à¡’°“√»÷°…“∂÷ß∫∑∫“∑¢Õ߬“√–ß—∫°“√À≈—Ëß°√¥ ‰¡à«à“®–‡ªìπ H2receptor antagonist À√◊Õ PPI „πºŸâªÉ«¬≈”‰ â·ª√ª√«π‡≈¬ 22.2. Õ¬à “ ߉√°Áµ“¡ æ∫«à“ºŸâªÉ«¬Õ“®¡’Õ“°“√¢Õß∑—Èß≈”‰ â·ª√ª√«π·≈– 26 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012
  • ‚√§°√¥‰À≈¬âÕπÀ√◊Õ functional dyspepsia ‡À≈◊ËÕ¡´âÕπ‰¥â„π¢≥–‡¥’¬«°—π ‚¥¬ ¡’§«“¡™ÿ°Õ¬Ÿà√“« 11-27 %15 ºŸâªÉ«¬¡—°¡’Õ“°“√¡“°°«à“ºŸâ∑’Ë¡’¿“«–Àπ÷Ëß¿“«–„¥ ‡æ’¬ßÕ¬à“߇¥’¬« ®÷ßæ∫‰¥â¡“°„π ∂“π欓∫“≈√–¥—∫µµ‘¬¿Ÿ¡‘ ·≈–¡—°¡’ psychiatric comorbidity16 Õ—πÕ“®‰¥â√∫ª√–‚¬™π宓°°“√ª√–‡¡‘π·≈–√—°…“∑“ß®‘µ‡«™  à«πÕ“°“√ — ¢Õß·µà≈–¿“«–·π–π”„Àâ√—°…“·¬°®“°°—π Reference 1. Poynard T, Regimbeau C, Benhamou Y. Meta-analysis of smooth musclerelaxants in the treatment of irritable bowel syndrome. Aliment Pharmacol Ther 2001;15:355-61. 2. Jackson JL, OûMalley PG, Tomkins G, Balden E, Santoro J, Kroenke K. Treatment of functional gastrointestinal disorders with antidepressant medications: a meta-analysis. Am J Med 2000; 108:65-72. 3. Lavo B, Stenstam M, Nielsen A-L. Loperamide in treatment of irritable bowel syndrome - A double-blind placebo controlled study. Scand J Gastroenterol Suppl 1987;22:77-80. 4. Palmer KR, Corbett CL, Holdsworth CD. Double-blind cross-over study comparing loperamide, codeine and diphenoxylate in the treatment of chronic diarrhea. Gastroenterology 1980;79:12725. 5. Nicandro JP, Shin P, Chuang E. Evaluation of treatment continuation with alosetron by IBS-D severity criteria. Curr Med Res Opin 2012;28:449-56. 6. Lee KJ, Kim NY , Kwon JK , et al. Efficacy of ramosetron in the treatment of male patients with irritable bowel syndrome with diarrhea: a multicenter, randomized clinical trial, compared with mebeverine. Neurogastroenterol Motil 2011;23:1098-104. 7. PimentelM, Lembo A, Chey WD, et al. Rifaximin Therapy for Patients with Irritable Bowel Syndrome without Constipation. New Engl J Med 2011;364:22-32. 8. Francis CY, Whorwell PJ. Bran and irritable bowel syndrome: time for reappraisal. Lancet 1994;344:39-40. 9. Prior A, Whorwell PJ. Double blind study of ispaghula in irritable bowel syndrome. Gut 1987;28:1510-13. 10. Bijkerk CJ, Muris JWM, Knottnerus JA, Hoes AW, De Wit NJ. Systematic review: the role of different types of fibre in the treatment of irritable bowel syndrome. Aliment Pharmacol Ther 2004;19:245-51. 11. Attar A, Lemann M, Ferguson A, et al. Comparison of a low dose polyethylene glycol electrolyte solution with lactulose for treatment of chronic constipation. Gut 1999;44:226-30. 12. Chey WD, Drossman DA, Johanson JF, Scott C, Panas RM, Ueno R. Safety and patient outcomes with lubiprostone for up to 52 weeks in patients with irritable bowel syndrome with constipation. Aliment Pharmacol Ther 2012;35:587-99. 13. Evans BW, Clark WK, Moore DJ, Whorwell PJ. Tegaserod for the treatment of irritable bowel syndrome and chronic constipation. Cochrane Database Syst Rev 2007:CD003960. 14. Wensel TM, Luthin DR. Linaclotide: a novel approach to the treatment of irritable bowel syndrome. Ann Pharmacother 2011;45:1535-43. 15. Suzuki H, Hibi T. Overlap syndrome of functional dyspepsia and irritable bowel syndrome - are both diseases mutually exclusive? J Neurogastroenterol Motil 2011;17:360-5. §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012 27
  • 16. Piacentino D, Cantarini R, Alfonsi M, et al. Psychopathological features of irritable bowel syndrome patients with and without functional dyspepsia: a cross sectional study. BMC Gastroenterol 2011;11:94. 17. Van Outryve M, Milo R, Toussaint J, Van Eeghem P. çProkinetic-treatment of constipationpredominant irritable bowel syndrome: a placebo-controlled study of cisapride. J Clin Gastroenterol 1991;13:49-57. 18. Ford AC, Brandt LJ, Young C, Chey WD, Foxx-Orenstein AE, Moayyedi P. Efficacy of 5-HT3 antagonists and 5-HT4 agonists in irritable bowel syndrome: systematic review and meta-analysis. Am J Gastroenterol 2009;104:1831-43. 19. Nakamura M, Ohmiya N, Miyahara R, et al. Are symptomatic changes in irritable bowel syndrome correlated with the capsule endoscopy transit time? A pilot study using the 5-HT4 receptor agonist mosapride. Hepatogastroenterology 2011;58:453-8. 28 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012
  • Psychiatric problems „π IBS ¢âÕ √ÿª∑’Ë 23. ¿“«–§«“¡º‘¥ª°µ‘∑“ß®‘µ‡«™ ‡™à𠇧√’¬¥ «‘µ°°—ß«≈ À√◊Õ´÷¡‡»√â“ ‡ªìπ¿“«– ∑’Ëæ∫∫àÕ¬„πºŸâªÉ«¬‚√§≈”‰ â·ª√ª√«π ·≈–§«√‰¥â√—∫°“√√—°…“Õ¬à“߇À¡“– ¡ §«“¡º‘¥ª°µ‘∑“ß®‘µ‡«™ ‡™àπ anxiety, depression ·≈– somatization „πºŸâªÉ«¬ Irritable Bowel Syndrome (IBS) ¢âÕ¡Ÿ≈¢Õß Lee ·≈–§≥–1 ´÷ß»÷°…“„πª√–™“°√∑—«‰ª∑’ŒÕß°ß®”π«π 2,005 √“¬ æ∫«à“ºŸª«¬∑’¡’ general anxiety Ë Ë Ëà â É Ë disorder (GAD) ¡’Õ—µ√“°“√æ∫ IBS ‰¥â¡“°°«à“ºŸâ∑’ˉ¡à¡’ GAD 4.7 ‡∑à“ ·≈–ºŸâªÉ«¬ IBS ¡’Õ—µ√“°“√æ∫ GAD ‰¥â¡“°°«à“ºŸâ∑’ˉ¡à¡’Õ“°“√ IBS ‰¥â∂÷ß 5 ‡∑à“ ¢âÕ¡Ÿ≈°“√»÷°…“¢Õß Choung PS ·≈–§≥–2 æ∫«à“ºŸª«¬∑’¡’ somatic symptom score â É Ë  Ÿß ¡’Õ—µ√“°“√‡°‘¥‚√§ IBS ‰¥â Ÿß°«à“ºŸâ∑’Ë¡’ somatic symptom score µË” ‰¥â∂÷ß 4 ‡∑à“ º≈°“√»÷°…“¢Õß Henningsen ·≈–§≥–3 ‚¥¬∑” meta-analysis æ∫«à“ ºŸâªÉ«¬∑’Ë¡’Õ“°“√¢Õß IBS ¡’Õ—µ√“°“√æ∫ anxiety ·≈– depression ‰¥â¡“°°«à“ ∑’Ëæ∫„π§πª°µ‘ À√◊ÕºŸâªÉ«¬∑’Ë¡’Õ“°“√‡π◊ËÕß®“°¡’ organic cause „πºŸâªÉ«¬ IBS ∑’¡“ª√÷°…“·æ∑¬å®–¡’Õµ√“°“√æ∫ anxiety ‰¥â ß°«à“ºŸª«¬ IBS ∑’‰¡à‰¥â¡“æ∫·æ∑¬å Ë — Ÿ â É Ë 4 „π√“¬ß“π¢Õß Gros ·≈–§≥– æ∫«à“ºŸâªÉ«¬ panic disorders, GAD ·≈–ºŸâªÉ«¬ ∑’Ë¡’ major depression ¡’Õ—µ√“°“√‡°‘¥Õ“°“√¢Õß IBS ‰¥â¡“°°«à“ ‚¥¬∑’˺ŸâªÉ«¬ ∑’ˇªìπ social anxiety disorder, specific phobia ·≈– obsessive-compulsive disorder ¡’Õ“°“√¢Õß IBS ‰¡àµà“ß®“°§πª°µ‘ §«“¡√ÿπ·√ß·≈–§«“¡∂’Ë¢ÕßÕ“°“√ IBS „πºŸâªÉ«¬ GAD ®–¡“°°«à“„π°≈ÿࡺŸâªÉ«¬Õ◊ËπÊ √“¬ß“π¢Õß Creed ·≈–§≥–5 æ∫«à“ºŸâªÉ«¬ IBS ∑’Ë¡’ marked somatization Õ“°“√¢Õß IBS ®–¥’¢÷Èπ‚¥¬°“√√—°…“ ¥â « ¬ psychotherapy À√◊ Õ antidepressant ¡“°°«à “ °“√√— ° …“‚¥¬«‘ ∏’ ª °µ‘ °“√»÷°…“‚¥¬ Friedrich ·≈–§≥–6 ´÷Ë߇ªìπ°“√∑” meta-analysis æ∫«à“°“√„™â¬“ antidepressant (TCA ·≈– SSRI) „π°“√√—°…“ IBS ∑’Ë¡’ depression √à«¡¥â«¬ æ∫«à“¬“ antidepressant ∫“ߢπ“πÕ“®®–∑”„ÀâÕ“°“√¢Õß IBS ¥’¢÷Èπ ‚¥¬‰¡à¡’ §«“¡ —¡æ—π∏å°—∫º≈¢Õ߬“µàÕÕ“°“√ depression ∑’ˇ°‘¥√à«¡ ‚√§ IBS ‰¡à‰¥â‡ªìπ‚√§∑“ß®‘µ‡«™·µàºª«¬ IBS ¡’‚Õ°“ ∑’®–æ∫§«“¡º‘¥ª°µ‘ Ÿâ É Ë §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012 29
  • ∑“ß®‘µ‡«™‰¥â¡“°°«à“ª√–™“°√∑—Ë«‰ª¥—ß°≈à“«¡“¢â“ßµâπ ºŸâªÉ«¬ IBS ∑’Ë¡’ªí≠À“ ∑“ß®‘µ‡«™§«√‰¥â√—∫°“√¥Ÿ·≈√—°…“√à«¡‰ª¥â«¬°—π∑—Èß Õߪí≠À“ References 1. Lee S, Wu J, Ma YL, Tsang A, Guo WJ, Sung J. Irritable bowel syndrome is strongly associated with generalized anxiety disorder: a community study. Aliment Pharmacol Ther 2009;30:64351. 2. Choung RS, Locke R, Zinsmeistr AR, Schleck CD, Talley NJ. Psychosocial distress and somatic symptoms in community subjects with irritable bowel syndrome: a psychological component is the rule. Am J Gastroenterol 2009;104:1772-9. 3. Henningsen P, Zimmermann T, Sattel H. Medically unexplained physical symptoms, anxiety, and depression: a meta-analytic review. Psychosomatic Medicine 2003;65:528-33. 4. Gros DF, Antony MM, McCabe RE, Swinson RP. Frequency and severity of the symptoms of irritable bowel syndrome across the anxiety disorders and depression. J Anxiety Disorders 2009;23:290-6. 5. Creed F, Tomenson B, Guthrie E, et al. The relationship between somatization and outcome in patients with severe irritable bowel syndrome. J of Psychosomatic Res 2008;64:613-20. 6. Friedrich M, Grady SE, Wall GC. Effects of antidepressants in patients with irritable bowel syndrome and comorbid depression. Clin Ther 2010;32:1221-33. ¢âÕ √ÿª∑’Ë 24. °“√ «π≈â“ß≈”‰ âÕ“®∑”„ÀâÕ“°“√≈”‰ â·ª√ª√«π¥’¢π™—«§√“« ·µàº≈¥’À√◊Õ ÷È Ë º≈‡ ’¬√–¬–¬“«¬—߉¡à¡’¢âÕ¡Ÿ≈∑“ß°“√·æ∑¬å™—¥‡®π „πºŸâ ªÉ « ¬≈”‰ â · ª√ª√«π∑’Ë ¡’ Õ “°“√∑â Õ ßºŸ ° ‡ªì π ª√–®”°“√ «π≈â “ ß≈”‰ â Õ“®∑”„ÀâÕ“°“√¥’¢÷Èπ™—Ë«§√“«·µà‰¡à§«√∑”‡ªìπª√–®”‡π◊ËÕß®“°‰¡à¡’¢âÕ¡Ÿ≈∑“ß°“√ ·æ∑¬å∑’Ë∫àß∫Õ°∂÷ߺ≈¥’À√◊Õº≈‡ ’¬√–¬–¬“« „πºŸâªÉ«¬≈”‰ â·ª√ª√«π∑’Ë¡’Õ“°“√§àÕπ‰ª∑“ß∑âÕ߇ ’¬°“√ «π≈â“ß≈”‰ â‰¡àπà“ ®–‰¥âª√–‚¬™πå„¥ Ê 30 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012
  • No alarm features §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012 31
  • √“¬π“¡ºŸâ‡¢â“√à«¡ª√–™ÿ¡ —¡¡π“æ‘®“√≥“ Guideline for Management of Irritable bowel syndrome §√—Èß∑’Ë 1 «—π∑’Ë 22-23 ¡°√“§¡ 2554 ≥ ‚√ß·√¡¥ÿ ‘µ ∏“π’ æ—∑¬“ ®—ßÀ«—¥™≈∫ÿ√’ §√—Èß∑’Ë 2 «—π∑’Ë 23-24 ¡‘∂ÿπ“¬π 2555 ≥ ‚√ß·√¡‡™Õ√“µ—π À—«À‘π √’ Õ√å∑·Õπ¥å ª“ ®—ßÀ«—¥ª√–®«∫§’√’¢—π∏å 𓬷æ∑¬å°‘µµ‘ ·æ∑¬åÀ≠‘ß®‘π¥“√—µπå ·æ∑¬åÀ≠‘ß‚©¡»√’ ·æ∑¬åÀ≠‘ß∞π‘ “ 𓬷æ∑¬å∏‡π» 𓬷æ∑¬å∏‡π» 𓬷æ∑¬åπæ«ÿ≤‘ ·æ∑¬åÀ≠‘ßπ‘»“ 𓬷æ∑¬å∫—≠™“ ·æ∑¬åÀ≠‘ß∫ÿ…∫“ ·æ∑¬åÀ≠‘ß¡≥±‘√“ 𓬷æ∑¬å√—∞°√ ·æ∑¬åÀ≠‘ß«√πÿ™ ·æ∑¬åÀ≠‘ß«√¡π 𓬷æ∑¬å«“π‘™ ·æ∑¬åÀ≠‘ß«‚√™“ 𓬷æ∑¬å»µ«√√… 𓬷æ∑¬å»√—≥¬å 𓬷æ∑¬å»ÿ¿™—¬ 𓬷æ∑¬å ¡™“¬ 𓬷æ∑¬å ¬“¡ 𓬷æ∑¬å ‘π ·æ∑¬åÀ≠‘ß ÿæ√ 𓬷æ∑¬å ÿ√‘¬– 𓬷æ∑¬å ÿ‡∑æ 𓬷æ∑¬åÕ¥¡ ÿ 32 ®—π∑√å‡≈‘»ƒ∑∏‘Ï ‡®’¬‡®…Ø“°ÿ≈ ‚¶…‘µ™—¬«—≤πå æ—™√µ√–°Ÿ≈ ®—¥«—≤π°ÿ≈ ™‘µ“æπ“√—°…å °’√µ‘°√≥å ÿ¿—§ ‡πµ‘π“∂ ÿπ∑√ ‚Õ«“∑Ó√æ√ «‘«—≤π凫§‘π ¡≥’√—µπ–æ√ «‘‰≈™π¡å ®ß»√’ «— ¥‘Ï ‡®’¬¡»√’æß…å ªî¬π‘√—π¥√å ¡À“™—¬ ∑Õß «— ¥‘Ï «√√≥¿“ π’ »√’»√√ß ‘ ‘ ÿà ≈’≈“°ÿ»≈«ß»å »‘√‘π∏√ªí≠≠“ Õπÿ√“…Æ√å µ√’æß…å°√ÿ≥“ ®—°°–æ“° °≈™“≠«‘∑¬å §™‘π∑√ ‚√ß欓∫“≈»√’π§√‘π∑√å ‚√ß欓∫“≈æ√–¡ß°ÿƇ°≈â“ ‚√ß欓∫“≈√“¡“∏‘∫¥’ ‚√ß欓∫“≈®ÿÓ≈ß°√≥å ‚√ß欓∫“≈ ¡‡¥Á®æ√–∫√¡√“™‡∑«’ ≥ »√’√“™“ ‚√ß欓∫“≈¡À“√“™π§√‡™’¬ß„À¡à ‚√ß欓∫“≈ ¡‡¥Á®æ√–∫√¡√“™‡∑«’ ≥ »√’√“™“ ‚√ß欓∫“≈ ß¢≈“π§√‘π∑√å ‚√ß欓∫“≈ ß¢≈“π§√‘π∑√å ‚√ß欓∫“≈®ÿÓ≈ß°√≥å ‚√ß欓∫“≈»‘√√“™ ‘ ‚√ß欓∫“≈∏√√¡»“ µ√å ‚√ß欓∫“≈®ÿÓ≈ß°√≥å ‚√ß欓∫“≈æÿ∑∏™‘π√“™ ‚√ß欓∫“≈æ√–¡ß°ÿƇ°≈â“ ‚√ß欓∫“≈®ÿÓ≈ß°√≥å ‚√ß欓∫“≈¡À“√“™π§√‡™’¬ß„À¡à ‚√ß欓∫“≈ √√æ ‘∑∏‘ª√– ß§å ‚√ß欓∫“≈æ≠“‰∑ »√’√“™“ ‚√ß欓∫“≈»‘√√“™ ‘ ‚√ß欓∫“≈√“™«‘∂’ ‚√ß欓∫“≈∫”√ÿß√“…Æ√å ‚√ß欓∫“≈√“¡“∏‘∫¥’ ‚√ß欓∫“≈√“¡“∏‘∫¥’ ‚√ß欓∫“≈®ÿÓ≈ß°√≥å ‚√ß欓∫“≈»‘√√“™ ‘ §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012 ¢Õπ·°àπ °√ÿ߇∑æ¡À“π§√ °√ÿ߇∑æ¡À“π§√ °√ÿ߇∑æ¡À“π§√ ™≈∫ÿ√’ ‡™’¬ß„À¡à ™≈∫ÿ√’  ß¢≈“  ß¢≈“ °√ÿ߇∑æ¡À“π§√ °√ÿ߇∑æ¡À“π§√ °√ÿ߇∑æ¡À“π§√ °√ÿ߇∑æ¡À“π§√ æ‘…≥ÿ‚≈° °√ÿ߇∑æ¡À“π§√ °√ÿ߇∑æ¡À“π§√ ‡™’¬ß„À¡à Õÿ∫≈√“™∏“π’ ™≈∫ÿ√’ °√ÿ߇∑æ¡À“π§√ °√ÿ߇∑æ¡À“π§√ °√ÿ߇∑æ¡À“π§√ °√ÿ߇∑æ¡À“π§√ °√ÿ߇∑æ¡À“π§√ °√ÿ߇∑æ¡À“π§√ °√ÿ߇∑æ¡À“π§√