厌食与恶病质综合征处理.ppt

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1、厌食与食与恶病病质综合征合征处理理病症处理的学问：病症处理的学问：EEMMAThe Science of Symptom Management:EEMMAEvaluation assessment 评估Explanation 解释Management treatment 治疗Monitoring 监护Attention to detail 注意细节2021/11/142病症处理病症处理Symptom Management敬告！并不总是能完全缓解病症敬告！并不总是能完全缓解病症Warning!Cannot always relieve symptoms completely 替代目标：帮助患者更

2、多地感觉到病症替代目标：帮助患者更多地感觉到病症受到控制从而更少地感到被疾病所压倒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 overwhelmed2021/11/143癌症 衰弱cancer debility治疗 并发疾病 treatment concurrent disorder病症的原因病症的原因 Causes of Symptoms在癌症晚期，病症常常由多种原因引起In advanced cancer,symptoms often have m

3、ultiple causes2021/11/144病症的原因病症的原因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 2021/11/145“我没有胃口我没有胃口I have no appetite鉴别诊断 Differential diagnosis: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

4、interested in food)or early satiety alone(the thought 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)2021/11/146继发性厌食继发性厌食Secondary Anorexia1.Fatigue 疲劳2.Nausea 恶心

5、3.Malodour 恶臭4.Altered taste 味觉改变5.Gastric stasis,e.g.constipation 胃停滞，例如便秘6.Oropharyngeal pathology 口咽部疾病7.Pain 疼痛2021/11/147早饱感早饱感Early Satiety 1.Gastric stasis 胃停滞2.Post-gastrectomy 胃切除术后3.Massive hepatomegaly 巨大型肝肿大 4.Massive ascites 大量腹水2021/11/148胃停滞胃排空延迟胃停滞胃排空延迟Gastric Stasis(Delayed Gastric

6、Emptying)在晚期癌症中常见:病症：早饱+/-,上腹饱胀，返酸，呃逆，嗳气，恶心，呕吐体征：振水音？Common in advanced cancer:Symptoms:early satiety+/-,epigastric fullness,acid reflux,hiccup,belching,nausea,vomitingSigns:succussion splash?2021/11/149胃停滞的原因胃停滞的原因Causes of Gastric Stasis1.失动力型消化不良 Dysmotility dyspepsia2.便秘 Constipation3.药物，例如阿片类，抗

7、毒蕈碱类药 Drugs,e.g.opioids,antimuscarinics4.胰头癌 Cancer of head of pancreas 5.引起神经病变的腹膜后癌 Retroperitoneal cancer causing neuropathy6.瘤旁自主性神经病变 Paraneoplastic autonomic neuropathy7.脊髓压迫综合征 Spinal cord compression2021/11/1410评估评估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 patients or the

8、familys?Listen to the patients and the familys fears2021/11/1411解释解释Explanation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?)防止如下的情形发生 Situations to be on the loo

9、k-out for:“他必须吃，否那么他会死亡 “He must eat or he will die “让他吃东西是我的工作 “Feeding him is my job 2021/11/1412治疗治疗Management Correct the Correctable Non-drug treatments Symptomatic drug treatment2021/11/1413纠正可逆转的因素纠正可逆转的因素Correct the Correctable1.Fatigue:small and often 疲劳：“少吃多餐2.Nausea:anti-emetic 恶心：止吐剂3.Ma

10、lodour:treat cause 恶臭：治疗病因4.Altered taste:add seasoning?味觉改变：调味5.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2021/11/1414胃停滞胃停滞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。Proki

11、netic drug,e.g.metoclopramide,domperidone Do not prescribe a prokinetic and an anti-muscarinic drug concurrently because the latter competitively blocks the cholinergic final common pathway of the prokinetic2021/11/1415非药物治疗非药物治疗Non-drug treatments作如下调整 Changes to:环境environment食谱和烹调方法diet and cookin

12、g使用小餐盘，盛少量食物small plate,small quantity of food2021/11/1416食欲刺激剂食欲刺激剂Appetite Stimulants皮质激素皮质激素：有效期仅为数周：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.202

13、1/11/1417食欲刺激剂食欲刺激剂Appetite Stimulants禁忌用于不伴有厌食的早饱！!Contra-indicated in early satiety without associated anorexia2021/11/1418糖皮质激素 Corticosteroids糖皮质激素和失活作用协同激活肌蛋糖皮质激素和失活作用协同激活肌蛋白的分解代谢白的分解代谢Corticosteroids and inactivity actsynergistically to activate muscle protein catabolism 2021/11/1419癌性恶病质综合征癌性

14、恶病质综合征 Cancer Cachexia Syndrome宿主宿主神经内分泌、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 products2021/11/1420恶病质恶病质Cachexia也与如下疾病相关 Also associated with:1.人类免疫缺陷病毒/获得性

15、免疫缺陷综合征 HIV/AIDS2.慢性阻塞性肺部疾患 COPD3.心衰 Cardiac failure4.肝脏疾病 Liver disease 5.肾脏疾病 Renal disease 6.类风湿性关节炎 Rheumatoid arthritis2021/11/1421癌性恶病质癌性恶病质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 earl

16、y satiety,weakness,fatigue,anaemia,oedema2021/11/1422癌性恶病质癌性恶病质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脂发动因子 lipid-mobilising factor2021/11/1423癌相关蛋白分解癌相关蛋白分解 Cancer-related Proteolysis末端共同通路：泛肽-蛋白酶体分解系统 Final common pathway:ubiquitin-proteasome p

17、roteolytic system2021/11/1424醋酸甲地孕酮治疗厌食醋酸甲地孕酮治疗厌食-恶病质综合恶病质综合征的系统回忆征的系统回忆 26项研究，项研究，3887例患者例患者Systematic Review of Megestrol Acetate in the Treatment of Anorexia-Cachexia Syndrome26 studies,n=3887Lopez et al.Journal of Pain and Symptom Management 2004;27:360-692021/11/1425甲地孕酮的系统回忆甲地孕酮的系统回忆Systematic

18、 Review of Megestrol 目标是 End-points were:增加食欲increase in appetite增加体重weight gain,增加生存质量 increased quality of life 与实质体重增加无关！Nothing about increase in lean-body mass!Lopez et al.JPSM 2004;27:360-692021/11/1426鱼油中的鱼油中的EPAEPA in Fish OilEPA廿炭五烯酸减缓蛋白的分解代谢EPA eicosa-penta-enoic acidattenuates protein cat

19、abolism2021/11/1427晚期癌症的人工营养和水化晚期癌症的人工营养和水化Artificial Nutrition and Hydration in Advanced Cancer生理上好的感觉还是生理上的无效？Physiological good sense orphysiological futility?2021/11/1428晚期癌症的人工营养和水化晚期癌症的人工营养和水化Artificial Nutrition and Hydration in Advanced Cancer权衡受益与负担 Consider benefits and burdens:1.头颈部癌：由于严重

20、吞咽困难而饥饿的患者 Head&neck cancer:patient starving because of severe dysphagia2.逼近死亡：丧失兴趣和/或恶病质的患者 Definitely close to death:patient disinterested and/or cachectic2021/11/1429晚期癌症的人工营养和水化晚期癌症的人工营养和水化Artificial Nutrition and Hydration in Advanced Cancer如果患者正处于严重的吞咽困难而且疾病呈局限性，请酌情人工营养和水化 If the patient is su

21、ffering from severe dysphagia and disease localised,consider artificial nutrition and hydration:鼻胃管？nasogastric tube?胃造瘘喂饲？feeding gastrostomy?2021/11/1430晚期癌症的人工营养和水化晚期癌症的人工营养和水化Artificial Nutrition and Hydration in Advanced Cancer假设患者逼近死亡，不要延长患者的濒死过程If the patient is close to death,try not to prolong the patients dying与亲属讨论其他方式以表达他们对其亲人的爱Discuss with the family other ways of showing their love to their relative 2021/11/1431对濒死患者的人工水化对濒死患者的人工水化输液输液Artificial Hydration in Patients Close to Death直肠补液？皮下输液？Rectal fluid?Subcutaneous fluid?2021/11/1432