功能性消化不良的症状谱及自然史研究
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摘要
第一部分中国FD患者的人口学资料
目的：分析中国功能性消化不良(FD)患者的人口学资料，研究FD不同亚型的差别，比较不同地区不同级别医院FD患者的精神状态和睡眠情况。方法：本研究是一项分层的多中心研究，以武汉、北京、上海、广州、西安等5个城市5家Ⅲ级甲等医院为中心，每个城市再分别选取2家Ⅱ级和I级医院（城乡各一），在共计25家医院的消化内科门诊对前来就诊的FD患者进行面对面的问卷调查，Ⅲ级、Ⅱ级和Ⅰ级医院分配的研究对象人数的比例为5:3:2。调查时间为2008年6月至2009年11月。功能性消化不良问卷调查表收集患者的一般情况、消化不良症状的程度及频率、HP感染情况，焦虑状态、抑郁状态、是否睡眠障碍等资料。患者在入组及入组后一个月、三个月、六个月、一年时均需完成功能性消化不良问卷调查表。
结果：
1.943例患者同时完成了入组及四次随访的问卷调查表，随访率达89.9%。平均年龄为42.99±11.74年，男340人，女603人，男：女=1：1.77。平均随访时间为12.24±0.59月。
2.与失访人群相比，男性(P=0.006)、饮酒者(P=0.001)、经济条件好的患者(P=0.030)、文化程度高的患者(P=0.011)以及就诊的患者(P<0.001)更容易随访。
3.943名FD患者中，404人(43%)诊断为餐后饱胀不适综合征(PDS)，134(14%)人诊断为上腹痛综合征(EPS)，剩下405人(43%)为混合型。混合组的消化不良症状评分(DSS)明显高于PDS组，P<0.001；明显高于EPS组，P<0.001；PDS组与EPS组无差别，P=0.054。
4.943名FD患者中，85人(9.0%)存在焦虑状态，61人(6.5%)存在抑郁状态，469名(49.7%)FD患者存在睡眠障碍。不同城市不同级别医院FD患者焦虑、抑郁状态、睡眠障碍的发生率存在差别。北京地区FD患者焦虑、抑郁状态、睡眠障碍发生率最高，分别为17.9%、12.2%、59.2%。Ⅲ级医院FD患者焦虑状态的发生率明显高于Ⅱ级医院(P<0.001)，Ⅲ级医院的FD患者抑郁状态的发生率明显高于I级医院(P=0.005)。
结论:混合组DSS明显高于PDS组和EPS组。不同城市不同级别医院FD患者焦虑、抑郁状态、睡眠障碍的发生率存在差别。
第二部分中国FD患者的症状谱及影响其预后的相关因素
目的：使用有效的评估工具了解FD患者的症状谱及影响其预后的相关因素。
方法：从2008年6月至2009年11月，全国武汉，北京，西安，上海及广州等五个城市共计1049例FD患者（符合Rome Ⅲ标准）纳入本研究，其中女性占65.3%，平均年龄42.80±11.64岁。功能性消化不良问卷调查表收集患者的一般情况、消化不良症状的程度及频率、HP感染情况，焦虑状态、抑郁状态、是否睡眠障碍、是否有重大精神刺激、是否受虐待、是否合并肠道症状、入组前就诊及药物治疗情况等资料。患者在入组及入组后一个月、三个月、六个月、一年时均需完成功能性消化不良问卷调查表。使用重复测量的方差分析了解FD患者在一年随访中消化不良症状的变化，运用多元线性回归方法从横向及纵向上研究影响患者症状变化的相关因素。
结果：
1.943例患者同时完成了入组及四次随访的问卷调查表，随访率达89.9%。平均随访时间为12.24±0.59个月。
2.餐后饱胀不适是FD患者的首要症状，其次是上腹痛、嗳气、上腹烧灼感，呕吐症状发生率最低。
3.在一年四次随访过程中，FD患者的消化不良总体症状严重程度（DSS）呈明显减轻趋势。（15.04±6.47vs10.46±6.68vs9.00±6.67vs7.59±6.48vs6.91±6.39, P<0.05）
4.上腹饱胀不适、早饱、上腹痛、上腹烧灼感、嗳气、恶心、呕吐及腹部膨胀等单个症状的严重程度均呈明显减轻趋势（P<0.05）。
5.单变量相关分析阐明了随访一年后FD患者的DSS与入组时相关因素的关系（纵向研究），及与随访一年时相关因素的关系（横向研究）。结果显示：从纵向研究来看，曾有受虐待史的FD患者，一年后DSS较无受虐史FD患者要低（P=0.025）。从横向研究来看，年龄(P<0.001)、饮酒(P=0.024)、焦虑状态(P<0.001)、抑郁状态(P<0.001)、睡眠障碍(P<0.001)、一年后同时合并肠道症状(P<0.001)、体重下降(P<0.001)，以及一年的随访过程中患者就诊(P<0.001)及使用促动力药(P<0.001)、胃粘膜保护剂(P<0.001)、抑酸药(P<0.001)和中药(P<0.001)均与一年后的DSS明显相关。
6.通过多元线性回归进一步分析了随访一年后FD患者的DSS与入组时相关因素的关系（纵向研究），及与随访一年时相关因素的关系（横向研究）。结果显示：从纵向比较来看，当诸多因素进入了多元线性回归模型，之前无意义的变量仍然与一年后DSS没有相关性，而之前有意义的变量如受虐待史与一年后DSS失去相关性。从横向研究来看，女性患者(P<0.001)、焦虑状态(P=0.018)、睡眠障碍(P=0.019)、体重下降(P<0.001)、一年随访过程中患者就诊(P<0.001)和使用促动力药(P=0.035)仍与一年后DSS明显相关。
结论: FD患者的消化不良症状严重程度随访一年呈下降趋势。女性、焦虑状态、睡眠障碍、体重减轻、一年随访过程中患者就诊和使用促动力药与FD患者的预后相关。
第三部分FD与其他FGIDs的重叠，症状亚群之间的转变及其影响因素
目的：以FD患者为研究对象，探讨FD与其他FGIDs之间的重叠以及经过一段时间的随访后功能性胃肠病之间的相互转换及危险因素的相关研究比较少见，尤其是依据罗马Ⅲ诊断标准的研究更是鲜有报道。因此，我们对一个较大样本量的中国的FD患者进行为期一年的随访，旨在研究FD与其他功能性胃肠病之间的重叠以及症状亚群的不稳定性。
方法：来自武汉，北京，西安，上海及广州等五个城市共计1049例FD门诊患者（年龄≥18岁）纳入本研究，要求患者在入组及入组后一个月、三个月、六个月、一年时分别完成一份功能性消化不良问卷调查表。患者的一般情况、消化道症状的程度及频率（包括上消化道和下消化道）、HP感染情况，精神因素（焦虑状态和抑郁状态）、是否睡眠障碍、是否受虐待以及是否就诊等资料均被记录。根据罗马Ⅲ诊断标准，我们分别在入组和一年随访时将FD患者分为不同的症状亚群。
结果：
1.943例FD患者同时完成了入组及四次随访的问卷调查表，随访率达89.9%。其中有324人(34.4%)在入组时同时合并有其他的功能性胃肠症状：225人(69.4%)重叠胃食管反流病（GERD），30人(9.3%)重叠肠易激综合征（IBS），23人(7.1%)重叠功能性便秘(FC)，7人(2.2%)重叠功能性腹泻（D），另有39人(12%)同时重叠两种功能性胃肠病。
2.与FD alone组相比，FD-other FGIDs重叠组具有更严重的的消化不良症状(26.72±10.46vs.19.57±8.64, P<0.001)，更容易合并焦虑状态(P=0.002)、抑郁状态(P=0.012)和睡眠障碍(P<0.001)。年老者(44.27±11.94vs.42.21±11.67, P=0.011)、重体力劳动者(P=0.001)、经济条件差的患者(P=0.011)以及HP感染者(P=0.002)更容易重叠其他的功能性胃肠病。
3.通过一年的随访研究，我们发现495人（52.5%）仍符合入组时的诊断，230人（24.4%）从一个症状亚群转变为另一个症状亚群，218人（23.1%）症状消失。
4.单因素逻辑回归分析显示：年老者（unadjusted OR：1.014，95%CI：1.0-1.027；P=0.043）、中度体力劳动者（unadjusted OR：1.593，95%CI：1.121-2.264；P=0.009）、焦虑状态（unadjusted OR：2.020，95%CI：1.194-3.417；P=0.009）、抑郁状态（unadjusted OR：1.869，95%可信区间1.010-3.458；P=0.046）和睡眠障碍（unadjustedOR：1.645，95%CI：1.2-2.257；P=0.002）与症状亚群之间相互转变行为有关。
5.通过多因素逻辑回归分析证实中度体力劳动者(adjusted OR：1.592，95%CI：1.085-2.336；P=0.018）和睡眠障碍（adjusted OR：1.644，95%CI：1.159-2.332；P=0.005）仍然是症状亚群之间相互转变行为的危险因素。同时HP感染（adjusted OR：0.628，95%CI：0.405-0.975；P=0.038）也与这一转变行为相关。
结论:临床上FD与其他功能性胃肠病重叠是很常见的。在一年的随访过程中，约有四分之一患者症状不稳定，发生症状亚群之间的相互转变。中度体力劳动、睡眠障碍和HP感染与这种症状亚群之间的转变行为相关。
Part ⅠDemographic data of Chinese patients with functional dyspepsia
Objective: To analysis the demographic data of Chinese patients with functional dyspepsia(FD), to study the differences between the three subtypes of FD, and to compare anxiety,depression and sleep disorder of FD patients from different cities and different levels ofhospitals.
Methods: This was a stratified multi-center study.5tertiary hospitals in Wuhan, Beijing,Shanghai, Guangzhou and Xi'an city were selected as center, then2secondary hospitalsand2primary hospitals were selected randomly from each city(half of urban and half ofrural). From June2008to November2009, patients with FD (Rome Ⅲ criteria) who visitedthe general gastroenterology outpatient clinic of the total25hospitals were requested tofinish a self-report questionnaire. Baseline demographic data, dyspepsia symptom data,anxiety, depression, sleep disorder, HP status were assessed using self-report questionnaires.Patients completed questionnaires at baseline and1,3,6,12-month follow-up, respectively.
Results:
1.943patients completed all of the four follow-ups，with a89.9%respond rate. The meanage was42.99±11.74years. There were340males and603females (male to female ratio1:1.77). The average duration of follow-up was12.24±0.59months.2. Compared to non-responders, males (P=0.006), alcohol users (P=0.001), those of higherdegree of education (P=0.011), those of better economic situation (P=0.030) and those who had consulted a physician (P<0.001) were significantly more likely to be successfullyfollowed up.
3. Among943FD patients,404(43%) were defined as PDS，134(14%) were defined asEPS，and405(43%) were classed as PDS and EPS overlap. The mean dyspepsia symptomscores (DSS) in PDS and EPS overlap group was significantly higher than PDS group(P<0.001), and EPS group (P<0.001). There were no significant differents between PDSgroup and EPS group (P=0.054).
4. Of the943FD patients，85(9.0%) suffered from anxiety,61(6.5%) suffered fromdepression, and469(49.7%) suffered from sleep disorder. The incidence of anxiety,depression and sleep disorders in FD patients were different between different cities anddifferent levels of hospitals. The highest were in Beijing city with17.9%for anxiety,12.2%for depression and59.2%for sleep disorder. FD patients from tertiary hospitals weresubjected to more anxiety than patients from secondary hospitals (P<0.001). FD patientsfrom tertiary hospitals were subjected to more depression than patients from primaryhospitals (P=0.005).
Conclusions: PDS and EPS overlap group had a higher DSS than PDS group and EPSgroup. The incidence of anxiety, depression and sleep disorders in FD patients differedfrom different cities and different levels of hospitals.
Part Ⅱ Fluctuation of gastrointestinal symptoms and associated factorsin Chinese patients with functional dyspepsia
Objective: To study the evolution of gastrointestinal symptoms and associated factors inChinese patients with functional dyspepsia.
Methods: From June2008to November2009, a total of1049patients with FD (65.3% females, mean age42.80±11.64y) who visited the general gastroenterology outpatientclinic in Wuhan, Beijing, Shanghai, Guangzhou, and xi’ an city of China were referred forthis study. All of the patients fulfilled the Rome Ⅲ criteria of FD. Baseline demographicdata, dyspepsia symptom data, anxiety, depression, sleep disorder and drug treatments wereassessed using self-report questionnaires. Patients completed questionnaires at baseline and1,3,6,12-month follow-up, respectively. Comparison of dyspepsia symptoms between atbaseline and at four follow-ups was explored using MANOVA of repeated measuring.Multiple linear regression was done to examine factors associated with outcome, bothlongitudinally and horizontally.
Results:
1.943patients (89.9%of the original population) completed all of the four follow-ups. Theaverage duration of follow-up was12.24±0.59months.
2. Postprandial fullness was the most common symptom in FD patients, followed byabdominal pain, belching, epigastric burning, while vomit had lowest incidence.
3. During1-y follow-up period, the mean dyspepsia symptom score (DSS) in FD patientsshowed a significant gradually reduced trend (15.04±6.47vs10.46±6.68vs9.00±6.67vs7.59±6.48vs6.91±6.39, P<0.001), and similar differences were found for all individualsymptoms (P<0.001).
4. For longitudinal associations: Univariate correlates analysis revealed that history ofabuse was associated with DSS at1-y follow-up (P=0.025), while no association werefound for other variable such as gender, age, BMI, anxiety, depression, sleep disorder,H.pylori status, DSS at baseline, and drug treatments before baseline. For horizontalassociations: Univariate correlates analysis found that age (P<0.001), alcohol consumption(P=0.024), anxiety (P<0.001), depression (P<0.001), sleep disorder (P<0.001), bowelsymptom at1-y follow-up (P<0.001), weight loss (P<0.001), consulting a physician(P<0.001), prokinetics (P<0.001), gastric mucosa protectant (P<0.001), antacids (P<0.001)and traditional Chinese medicine use during1-y follow-up period (P<0.001) were significantly associated with DSS at1-y follow-up.
5. Multiple linear regression analysis showed that gender (P<0.001), anxiety (P=0.018),sleep disorder at1-y follow-up (P=0.019), weight loss (P<0.001), consulting a physician(P<0.001) and prokinetics use during1-y follow-up period (P=0.035) were horizontallyassociated with DSS at1-y follow-up. No relationship was found longitudinally betweenDSS at1-y follow-up and patients’ characteristic at baseline.
Conclusions: During1-y follow-up period, the mean DSS in FD patients showed asignificant gradually reduced trend and similar differences were found for all individualsymptoms. Female, anxiety, and sleep disorder at1-y follow-up, weight loss, consulting aphysician and prokinetics use during1-y follow-up period are associated with outcome.
Part Ⅲ Clinical overlap and natural history of functional dyspepsia andother functional gastrointestinal disorders
Objectives: Rare studies have been performed to discuss the overlap of functionaldyspepsia (FD) and other functional gastrointestinal disorders (FGIDs) and the naturalhistory of gastrointestinal symptom based on FD patients according to Rome Ⅲ criteria.We aimed to determine not only the clinical overlap between FD and other FGIDs, but alsothe instability and variability of symptom subgroups in Chinese patients with FD.
Methods: A cohort of1049consecutive FD patients (age≥18years) seen at the generalgastroenterology outpatient clinic in Wuhan, Beijing, Shanghai, Guangzhou, and xi’ an cityof China were requested to fill out a self-report questionnaire at initial visit and1-month,3-month,6-month,1-year later, respectively. Baseline demographic data, gastrointestinalsymptoms data (including upper and lower gastrointestinal), H.pylori status, psychosocialfactors, sleep disorder, history of abuse were assessed. According to Rome Ⅲ diagnostic criteria, symptom subgroups were assigned at baseline and1-y follow-up.
Results:
1.943FD patients completed all of the four follow-ups (89.9%response rate).324(34.4%)had other FGIDs overlap at baseline, including225(69.4%) overlap withgastro-oesophageal reflux disease(GERD)，30(9.3%) overlap with irritable bowel syndrome(IBS),23(7.1%) overlap with functional constipation,7(2.2%) overlap with functionaldiarrhea(D) and39(12%) overlap with more FGIDs at the same time.
2. Comparing with FD alone group, FD-other FGIDs overlap group had higher dyspepsiascores (26.72±10.46vs19.57±8.64, P<0.001). Older age (44.27±11.94vs.42.21±11.67, P=0.011), higher physical labor (P=0.001), worse economic condition (P=0.011), H.pyloriinfection (P=0.002), anxiety (P=0.002), depression (P=0.012) and sleep disorder (P<0.001)were associated with FD-other FGIDs overlap group.
3. Following1-y follow-up,495(52.5%) remained the same symptom subgroup,230(24.4%)had transition from one symptom subgroup to another, and218(23.1%) reported nosymptom.
4. Univariate analysis revealed that older (unadjusted OR:1.014,95%confidence interval(95%CI):1.0-1.027; P=0.043), medium physical labor (unadjusted OR:1.593,95%CI:1.121-2.264; P=0.009), anxiety (unadjusted OR:2.020,95%CI:1.194-3.417; P=0.009),depression (unadjusted OR:1.869,95%CI:1.010-3.458; P=0.046) and sleep disorder(unadjusted OR:1.645,95%CI:1.2-2.257; P=0.002) significantly increased the likelihoodof transition between symptom subgroups.
5. After multivariate logistic regression analysis, medium physical labor (adjusted OR:1.592,95%CI:1.085-2.336; P=0.018) and sleep disorder (adjusted OR:1.644,95%CI:1.159-2.332; P=0.005) remained independent risk factor for transition between symptomgroups. H. pylori-positive (adjusted OR:0.628,95%CI:0.405-0.975; P=0.038）was alsoindependently associated with it.
Conclusion: Clinical overlap between FD and other FGIDs are very common. The gastrointestinal symptoms are unstable and about a quarter of patients have transition fromone symptom subgroup to another. Medium physical labor, sleep disorder and H. pyloriinfection were independent risk factors for transition between symptom groups.
目的：分析中国功能性消化不良(FD)患者的人口学资料，研究FD不同亚型的差别，比较不同地区不同级别医院FD患者的精神状态和睡眠情况。方法：本研究是一项分层的多中心研究，以武汉、北京、上海、广州、西安等5个城市5家Ⅲ级甲等医院为中心，每个城市再分别选取2家Ⅱ级和I级医院（城乡各一），在共计25家医院的消化内科门诊对前来就诊的FD患者进行面对面的问卷调查，Ⅲ级、Ⅱ级和Ⅰ级医院分配的研究对象人数的比例为5:3:2。调查时间为2008年6月至2009年11月。功能性消化不良问卷调查表收集患者的一般情况、消化不良症状的程度及频率、HP感染情况，焦虑状态、抑郁状态、是否睡眠障碍等资料。患者在入组及入组后一个月、三个月、六个月、一年时均需完成功能性消化不良问卷调查表。
结果：
1.943例患者同时完成了入组及四次随访的问卷调查表，随访率达89.9%。平均年龄为42.99±11.74年，男340人，女603人，男：女=1：1.77。平均随访时间为12.24±0.59月。
2.与失访人群相比，男性(P=0.006)、饮酒者(P=0.001)、经济条件好的患者(P=0.030)、文化程度高的患者(P=0.011)以及就诊的患者(P<0.001)更容易随访。
3.943名FD患者中，404人(43%)诊断为餐后饱胀不适综合征(PDS)，134(14%)人诊断为上腹痛综合征(EPS)，剩下405人(43%)为混合型。混合组的消化不良症状评分(DSS)明显高于PDS组，P<0.001；明显高于EPS组，P<0.001；PDS组与EPS组无差别，P=0.054。
4.943名FD患者中，85人(9.0%)存在焦虑状态，61人(6.5%)存在抑郁状态，469名(49.7%)FD患者存在睡眠障碍。不同城市不同级别医院FD患者焦虑、抑郁状态、睡眠障碍的发生率存在差别。北京地区FD患者焦虑、抑郁状态、睡眠障碍发生率最高，分别为17.9%、12.2%、59.2%。Ⅲ级医院FD患者焦虑状态的发生率明显高于Ⅱ级医院(P<0.001)，Ⅲ级医院的FD患者抑郁状态的发生率明显高于I级医院(P=0.005)。
结论:混合组DSS明显高于PDS组和EPS组。不同城市不同级别医院FD患者焦虑、抑郁状态、睡眠障碍的发生率存在差别。
第二部分中国FD患者的症状谱及影响其预后的相关因素
目的：使用有效的评估工具了解FD患者的症状谱及影响其预后的相关因素。
方法：从2008年6月至2009年11月，全国武汉，北京，西安，上海及广州等五个城市共计1049例FD患者（符合Rome Ⅲ标准）纳入本研究，其中女性占65.3%，平均年龄42.80±11.64岁。功能性消化不良问卷调查表收集患者的一般情况、消化不良症状的程度及频率、HP感染情况，焦虑状态、抑郁状态、是否睡眠障碍、是否有重大精神刺激、是否受虐待、是否合并肠道症状、入组前就诊及药物治疗情况等资料。患者在入组及入组后一个月、三个月、六个月、一年时均需完成功能性消化不良问卷调查表。使用重复测量的方差分析了解FD患者在一年随访中消化不良症状的变化，运用多元线性回归方法从横向及纵向上研究影响患者症状变化的相关因素。
结果：
1.943例患者同时完成了入组及四次随访的问卷调查表，随访率达89.9%。平均随访时间为12.24±0.59个月。
2.餐后饱胀不适是FD患者的首要症状，其次是上腹痛、嗳气、上腹烧灼感，呕吐症状发生率最低。
3.在一年四次随访过程中，FD患者的消化不良总体症状严重程度（DSS）呈明显减轻趋势。（15.04±6.47vs10.46±6.68vs9.00±6.67vs7.59±6.48vs6.91±6.39, P<0.05）
4.上腹饱胀不适、早饱、上腹痛、上腹烧灼感、嗳气、恶心、呕吐及腹部膨胀等单个症状的严重程度均呈明显减轻趋势（P<0.05）。
5.单变量相关分析阐明了随访一年后FD患者的DSS与入组时相关因素的关系（纵向研究），及与随访一年时相关因素的关系（横向研究）。结果显示：从纵向研究来看，曾有受虐待史的FD患者，一年后DSS较无受虐史FD患者要低（P=0.025）。从横向研究来看，年龄(P<0.001)、饮酒(P=0.024)、焦虑状态(P<0.001)、抑郁状态(P<0.001)、睡眠障碍(P<0.001)、一年后同时合并肠道症状(P<0.001)、体重下降(P<0.001)，以及一年的随访过程中患者就诊(P<0.001)及使用促动力药(P<0.001)、胃粘膜保护剂(P<0.001)、抑酸药(P<0.001)和中药(P<0.001)均与一年后的DSS明显相关。
6.通过多元线性回归进一步分析了随访一年后FD患者的DSS与入组时相关因素的关系（纵向研究），及与随访一年时相关因素的关系（横向研究）。结果显示：从纵向比较来看，当诸多因素进入了多元线性回归模型，之前无意义的变量仍然与一年后DSS没有相关性，而之前有意义的变量如受虐待史与一年后DSS失去相关性。从横向研究来看，女性患者(P<0.001)、焦虑状态(P=0.018)、睡眠障碍(P=0.019)、体重下降(P<0.001)、一年随访过程中患者就诊(P<0.001)和使用促动力药(P=0.035)仍与一年后DSS明显相关。
结论: FD患者的消化不良症状严重程度随访一年呈下降趋势。女性、焦虑状态、睡眠障碍、体重减轻、一年随访过程中患者就诊和使用促动力药与FD患者的预后相关。
第三部分FD与其他FGIDs的重叠，症状亚群之间的转变及其影响因素
目的：以FD患者为研究对象，探讨FD与其他FGIDs之间的重叠以及经过一段时间的随访后功能性胃肠病之间的相互转换及危险因素的相关研究比较少见，尤其是依据罗马Ⅲ诊断标准的研究更是鲜有报道。因此，我们对一个较大样本量的中国的FD患者进行为期一年的随访，旨在研究FD与其他功能性胃肠病之间的重叠以及症状亚群的不稳定性。
方法：来自武汉，北京，西安，上海及广州等五个城市共计1049例FD门诊患者（年龄≥18岁）纳入本研究，要求患者在入组及入组后一个月、三个月、六个月、一年时分别完成一份功能性消化不良问卷调查表。患者的一般情况、消化道症状的程度及频率（包括上消化道和下消化道）、HP感染情况，精神因素（焦虑状态和抑郁状态）、是否睡眠障碍、是否受虐待以及是否就诊等资料均被记录。根据罗马Ⅲ诊断标准，我们分别在入组和一年随访时将FD患者分为不同的症状亚群。
结果：
1.943例FD患者同时完成了入组及四次随访的问卷调查表，随访率达89.9%。其中有324人(34.4%)在入组时同时合并有其他的功能性胃肠症状：225人(69.4%)重叠胃食管反流病（GERD），30人(9.3%)重叠肠易激综合征（IBS），23人(7.1%)重叠功能性便秘(FC)，7人(2.2%)重叠功能性腹泻（D），另有39人(12%)同时重叠两种功能性胃肠病。
2.与FD alone组相比，FD-other FGIDs重叠组具有更严重的的消化不良症状(26.72±10.46vs.19.57±8.64, P<0.001)，更容易合并焦虑状态(P=0.002)、抑郁状态(P=0.012)和睡眠障碍(P<0.001)。年老者(44.27±11.94vs.42.21±11.67, P=0.011)、重体力劳动者(P=0.001)、经济条件差的患者(P=0.011)以及HP感染者(P=0.002)更容易重叠其他的功能性胃肠病。
3.通过一年的随访研究，我们发现495人（52.5%）仍符合入组时的诊断，230人（24.4%）从一个症状亚群转变为另一个症状亚群，218人（23.1%）症状消失。
4.单因素逻辑回归分析显示：年老者（unadjusted OR：1.014，95%CI：1.0-1.027；P=0.043）、中度体力劳动者（unadjusted OR：1.593，95%CI：1.121-2.264；P=0.009）、焦虑状态（unadjusted OR：2.020，95%CI：1.194-3.417；P=0.009）、抑郁状态（unadjusted OR：1.869，95%可信区间1.010-3.458；P=0.046）和睡眠障碍（unadjustedOR：1.645，95%CI：1.2-2.257；P=0.002）与症状亚群之间相互转变行为有关。
5.通过多因素逻辑回归分析证实中度体力劳动者(adjusted OR：1.592，95%CI：1.085-2.336；P=0.018）和睡眠障碍（adjusted OR：1.644，95%CI：1.159-2.332；P=0.005）仍然是症状亚群之间相互转变行为的危险因素。同时HP感染（adjusted OR：0.628，95%CI：0.405-0.975；P=0.038）也与这一转变行为相关。
结论:临床上FD与其他功能性胃肠病重叠是很常见的。在一年的随访过程中，约有四分之一患者症状不稳定，发生症状亚群之间的相互转变。中度体力劳动、睡眠障碍和HP感染与这种症状亚群之间的转变行为相关。
Part ⅠDemographic data of Chinese patients with functional dyspepsia
Objective: To analysis the demographic data of Chinese patients with functional dyspepsia(FD), to study the differences between the three subtypes of FD, and to compare anxiety,depression and sleep disorder of FD patients from different cities and different levels ofhospitals.
Methods: This was a stratified multi-center study.5tertiary hospitals in Wuhan, Beijing,Shanghai, Guangzhou and Xi'an city were selected as center, then2secondary hospitalsand2primary hospitals were selected randomly from each city(half of urban and half ofrural). From June2008to November2009, patients with FD (Rome Ⅲ criteria) who visitedthe general gastroenterology outpatient clinic of the total25hospitals were requested tofinish a self-report questionnaire. Baseline demographic data, dyspepsia symptom data,anxiety, depression, sleep disorder, HP status were assessed using self-report questionnaires.Patients completed questionnaires at baseline and1,3,6,12-month follow-up, respectively.
Results:
1.943patients completed all of the four follow-ups，with a89.9%respond rate. The meanage was42.99±11.74years. There were340males and603females (male to female ratio1:1.77). The average duration of follow-up was12.24±0.59months.2. Compared to non-responders, males (P=0.006), alcohol users (P=0.001), those of higherdegree of education (P=0.011), those of better economic situation (P=0.030) and those who had consulted a physician (P<0.001) were significantly more likely to be successfullyfollowed up.
3. Among943FD patients,404(43%) were defined as PDS，134(14%) were defined asEPS，and405(43%) were classed as PDS and EPS overlap. The mean dyspepsia symptomscores (DSS) in PDS and EPS overlap group was significantly higher than PDS group(P<0.001), and EPS group (P<0.001). There were no significant differents between PDSgroup and EPS group (P=0.054).
4. Of the943FD patients，85(9.0%) suffered from anxiety,61(6.5%) suffered fromdepression, and469(49.7%) suffered from sleep disorder. The incidence of anxiety,depression and sleep disorders in FD patients were different between different cities anddifferent levels of hospitals. The highest were in Beijing city with17.9%for anxiety,12.2%for depression and59.2%for sleep disorder. FD patients from tertiary hospitals weresubjected to more anxiety than patients from secondary hospitals (P<0.001). FD patientsfrom tertiary hospitals were subjected to more depression than patients from primaryhospitals (P=0.005).
Conclusions: PDS and EPS overlap group had a higher DSS than PDS group and EPSgroup. The incidence of anxiety, depression and sleep disorders in FD patients differedfrom different cities and different levels of hospitals.
Part Ⅱ Fluctuation of gastrointestinal symptoms and associated factorsin Chinese patients with functional dyspepsia
Objective: To study the evolution of gastrointestinal symptoms and associated factors inChinese patients with functional dyspepsia.
Methods: From June2008to November2009, a total of1049patients with FD (65.3% females, mean age42.80±11.64y) who visited the general gastroenterology outpatientclinic in Wuhan, Beijing, Shanghai, Guangzhou, and xi’ an city of China were referred forthis study. All of the patients fulfilled the Rome Ⅲ criteria of FD. Baseline demographicdata, dyspepsia symptom data, anxiety, depression, sleep disorder and drug treatments wereassessed using self-report questionnaires. Patients completed questionnaires at baseline and1,3,6,12-month follow-up, respectively. Comparison of dyspepsia symptoms between atbaseline and at four follow-ups was explored using MANOVA of repeated measuring.Multiple linear regression was done to examine factors associated with outcome, bothlongitudinally and horizontally.
Results:
1.943patients (89.9%of the original population) completed all of the four follow-ups. Theaverage duration of follow-up was12.24±0.59months.
2. Postprandial fullness was the most common symptom in FD patients, followed byabdominal pain, belching, epigastric burning, while vomit had lowest incidence.
3. During1-y follow-up period, the mean dyspepsia symptom score (DSS) in FD patientsshowed a significant gradually reduced trend (15.04±6.47vs10.46±6.68vs9.00±6.67vs7.59±6.48vs6.91±6.39, P<0.001), and similar differences were found for all individualsymptoms (P<0.001).
4. For longitudinal associations: Univariate correlates analysis revealed that history ofabuse was associated with DSS at1-y follow-up (P=0.025), while no association werefound for other variable such as gender, age, BMI, anxiety, depression, sleep disorder,H.pylori status, DSS at baseline, and drug treatments before baseline. For horizontalassociations: Univariate correlates analysis found that age (P<0.001), alcohol consumption(P=0.024), anxiety (P<0.001), depression (P<0.001), sleep disorder (P<0.001), bowelsymptom at1-y follow-up (P<0.001), weight loss (P<0.001), consulting a physician(P<0.001), prokinetics (P<0.001), gastric mucosa protectant (P<0.001), antacids (P<0.001)and traditional Chinese medicine use during1-y follow-up period (P<0.001) were significantly associated with DSS at1-y follow-up.
5. Multiple linear regression analysis showed that gender (P<0.001), anxiety (P=0.018),sleep disorder at1-y follow-up (P=0.019), weight loss (P<0.001), consulting a physician(P<0.001) and prokinetics use during1-y follow-up period (P=0.035) were horizontallyassociated with DSS at1-y follow-up. No relationship was found longitudinally betweenDSS at1-y follow-up and patients’ characteristic at baseline.
Conclusions: During1-y follow-up period, the mean DSS in FD patients showed asignificant gradually reduced trend and similar differences were found for all individualsymptoms. Female, anxiety, and sleep disorder at1-y follow-up, weight loss, consulting aphysician and prokinetics use during1-y follow-up period are associated with outcome.
Part Ⅲ Clinical overlap and natural history of functional dyspepsia andother functional gastrointestinal disorders
Objectives: Rare studies have been performed to discuss the overlap of functionaldyspepsia (FD) and other functional gastrointestinal disorders (FGIDs) and the naturalhistory of gastrointestinal symptom based on FD patients according to Rome Ⅲ criteria.We aimed to determine not only the clinical overlap between FD and other FGIDs, but alsothe instability and variability of symptom subgroups in Chinese patients with FD.
Methods: A cohort of1049consecutive FD patients (age≥18years) seen at the generalgastroenterology outpatient clinic in Wuhan, Beijing, Shanghai, Guangzhou, and xi’ an cityof China were requested to fill out a self-report questionnaire at initial visit and1-month,3-month,6-month,1-year later, respectively. Baseline demographic data, gastrointestinalsymptoms data (including upper and lower gastrointestinal), H.pylori status, psychosocialfactors, sleep disorder, history of abuse were assessed. According to Rome Ⅲ diagnostic criteria, symptom subgroups were assigned at baseline and1-y follow-up.
Results:
1.943FD patients completed all of the four follow-ups (89.9%response rate).324(34.4%)had other FGIDs overlap at baseline, including225(69.4%) overlap withgastro-oesophageal reflux disease(GERD)，30(9.3%) overlap with irritable bowel syndrome(IBS),23(7.1%) overlap with functional constipation,7(2.2%) overlap with functionaldiarrhea(D) and39(12%) overlap with more FGIDs at the same time.
2. Comparing with FD alone group, FD-other FGIDs overlap group had higher dyspepsiascores (26.72±10.46vs19.57±8.64, P<0.001). Older age (44.27±11.94vs.42.21±11.67, P=0.011), higher physical labor (P=0.001), worse economic condition (P=0.011), H.pyloriinfection (P=0.002), anxiety (P=0.002), depression (P=0.012) and sleep disorder (P<0.001)were associated with FD-other FGIDs overlap group.
3. Following1-y follow-up,495(52.5%) remained the same symptom subgroup,230(24.4%)had transition from one symptom subgroup to another, and218(23.1%) reported nosymptom.
4. Univariate analysis revealed that older (unadjusted OR:1.014,95%confidence interval(95%CI):1.0-1.027; P=0.043), medium physical labor (unadjusted OR:1.593,95%CI:1.121-2.264; P=0.009), anxiety (unadjusted OR:2.020,95%CI:1.194-3.417; P=0.009),depression (unadjusted OR:1.869,95%CI:1.010-3.458; P=0.046) and sleep disorder(unadjusted OR:1.645,95%CI:1.2-2.257; P=0.002) significantly increased the likelihoodof transition between symptom subgroups.
5. After multivariate logistic regression analysis, medium physical labor (adjusted OR:1.592,95%CI:1.085-2.336; P=0.018) and sleep disorder (adjusted OR:1.644,95%CI:1.159-2.332; P=0.005) remained independent risk factor for transition between symptomgroups. H. pylori-positive (adjusted OR:0.628,95%CI:0.405-0.975; P=0.038）was alsoindependently associated with it.
Conclusion: Clinical overlap between FD and other FGIDs are very common. The gastrointestinal symptoms are unstable and about a quarter of patients have transition fromone symptom subgroup to another. Medium physical labor, sleep disorder and H. pyloriinfection were independent risk factors for transition between symptom groups.
引文
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