143.irritable bowel syndrome (guideline 2012)

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Transcript of 143.irritable bowel syndrome (guideline 2012)

Page 1: 143.irritable bowel syndrome (guideline 2012)
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1§”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012

§”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª(·π«∑“߇«™ªØ‘∫—µ‘)

2012

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¡“§¡ª√– “∑∑“߇¥‘πÕ“À“√·≈–°“√‡§≈◊ËÕπ‰À« (‰∑¬)

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2 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012

§”·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∑’ËPENTAGON ADVERTISING LTD., PART.566/124 ´Õ¬°‘®æ“π‘™ ∂ππæ√–√“¡ 4 ·¢«ß¡À“æƒ≤“√“¡ ‡¢µ∫“ß√—° °√ÿ߇∑æœ 10500566/124 Soi Kijpanich, Rama 4 Rd., Bangrak, Bangkok 10500Tel : 235-6038, 633-3762 Fax 633-0334Email: [email protected]

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3§”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012

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∑’Ëæ∫ºŸâªÉ«¬¥â«¬ªí≠À“π’ȇ¢â“„®·≈– approach §π‰¢â‰¥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”

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4 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012

§”π”

Irritable Bowel Syndrome (IBS) ‡ªìπ°≈ÿà¡Õ“°“√∑’Ëæ∫∫àÕ¬„π∑“߇«™ªØ‘∫—µ‘ºŸâªÉ«¬ IBS ¡’Õ“°“√§≈⓬°—∫‚√§Õ◊Ë𠇙àπ dyspepsia ∑âÕ߇ ’¬ ·≈–∑âÕߺŸ° À√◊Õ IBSÕ“®‡°‘¥√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àπdyspepsia ®ÿ¥¡ÿàßÀ¡“¬¢Õß guideline π’È §◊Õ ‡ªìπ°“√„ÀâÕߧ姫“¡√Ÿâ‡°’ˬ«°—∫ IBS·π«∑“ß„π°“√µ√«®§âπ·≈–°“√√—°…“∑’ˇÀ¡“– ¡µ“¡ ¿“«–·≈–¢âÕ¡Ÿ≈∑’Ë¡’Õ¬Ÿà„πªí®®ÿ∫—π

§”·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

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5§”·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« (‰∑¬) 3§”π” ª√–∏“π°“√®—¥∑” Guideline for Management of Irritable Bowel Syndrome 4§”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 6Definition 6¢âÕ √ÿª∑’Ë 1. 6¢âÕ √ÿª∑’Ë 2. 6¢âÕ √ÿª∑’Ë 3. 7Overlapping syndrome 8¢âÕ √ÿª∑’Ë 4. 8Pathophysiology 10¢âÕ √ÿª∑’Ë 5. 10¢âÕ √ÿª∑’Ë 6. 11¢âÕ √ÿª∑’Ë 7. 11Clinical evaluation 13¢âÕ √ÿª∑’Ë 8. 13¢âÕ √ÿª∑’Ë 9. 13¢âÕ √ÿª∑’Ë 10. 14¢âÕ √ÿª∑’Ë 11. 15¢âÕ √ÿª∑’Ë 12. 15¢âÕ √ÿª∑’Ë 13. 15¢âÕ √ÿª∑’Ë 14. 16¢âÕ √ÿª∑’Ë 15. 16Non-pharmacological treatment 18¢âÕ √ÿª∑’Ë 16. 18¢âÕ √ÿª∑’Ë 17. 18¢âÕ √ÿª∑’Ë 18. 19¢âÕ √ÿª∑’Ë 19. 19¢âÕ √ÿª∑’Ë 20. 20Pharmacological treatment 24¢âÕ √ÿª∑’Ë 21. 24¢âÕ √ÿª∑’Ë 22. 26Psychiatric problems „π IBS 29¢âÕ √ÿª∑’Ë 23. 29¢âÕ √ÿª∑’Ë 24. 30IBS Guideline 31√“¬π“¡ºŸâ‡¢â“√à«¡ª√–™ÿ¡ —¡¡π“æ‘®“√≥“ IBS Guideline 32

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7§”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012

2.2 ¡’Õ“°“√ª«¥∑âÕßÀ√◊Õ‰¡à ∫“¬„π∑âÕß¡“°°«à“À√◊Õ‡∑à“°—∫ 3 «—πµàÕ‡¥◊Õπ„π3 ‡¥◊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≈’ˬπ·ª≈ߢÕß

§«“¡∂’Ë¢Õß°“√∂à“¬Õÿ®®“√–2.2.3 Õ“°“√ª«¥∑âÕßÀ√◊Õ‰¡à ∫“¬„π∑âÕ߇°‘¥√à«¡°—∫°“√‡ª≈’ˬπ·ª≈ߢÕß

≈—°…≥–§«“¡·¢ÁßÀ√◊Õ‡À≈«¢ÕßÕÿ®®“√–‡°≥±å°“√«‘π‘®©—¬ Rome III ‡ªìπ∑’ˬա√—∫„πªí®®ÿ∫—π „™â‡ªìπ·π«∑“ßÀπ÷Ëß„π°“√

™à«¬«‘π‘®©—¬‚√§≈”‰ â·ª√ª√«π ·≈–„™â‡ªìπ·π«∑“ß„π°“√«‘®—¬

¢âÕ √ÿª∑’Ë 3.ºŸâªÉ«¬‚√§≈”‰ â·ª√ª√«πÕ“®¡’Õ“°“√∑âÕ߇ ’¬‡ªìπÕ“°“√‡¥àπ ∑âÕߺŸ°‡ªìπ

Õ“°“√‡¥àπ ∑âÕߺŸ° ≈—∫°—∫∑âÕ߇ ’¬ À√◊Õ‰¡à “¡“√∂®–®—¥≈—°…≥–°“√¢—∫∂à“¬¢ÕߺŸâªÉ«¬‰¥â‡≈¬°Á‰¥â

‚√§≈”‰ â·ª√ª√«π ·∫à߉¥â‡ªìπ 4 ™π‘¥ (subtype) ‰¥â·°à1. ≈”‰ â·ª√ª√«π ™π‘¥∑âÕ߇ ’¬‡¥àπ (diarrhea predominate IBS or

IBS-D) ºŸâªÉ«¬µâÕß¡’Õ“°“√∑âÕ߇ ’¬ ‰¡àπâÕ¬°«à“√âÕ¬≈– 25 ¢Õß°“√¢—∫∂à“¬ ·≈–µâÕß¡’Õ“°“√∑âÕߺŸ°‰¡à‡°‘π√âÕ¬≈– 25 ¢Õß°“√¢—∫∂à“¬

2. ≈”‰ â·ª√ª√«π ™π‘¥∑âÕߺŸ°‡¥àπ (constipation predominate IBS orIBS-C) ºŸâªÉ«¬µâÕß¡’Õ“°“√∑âÕߺŸ° ‰¡àπâÕ¬°«à“√âÕ¬≈– 25 ¢Õß°“√¢—∫∂à“¬ ·≈–µâÕß¡’Õ“°“√∑âÕ߇ ’¬‰¡à‡°‘π√âÕ¬≈– 25 ¢Õß°“√¢—∫∂à“¬

3. ≈”‰ â·ª√ª√«π ™π‘¥∑âÕ߇ ’¬ ≈—∫∑âÕߺŸ° (mixed IBS À√◊Õ IBS-M)ºŸâªÉ«¬µâÕß¡’Õ“°“√∑âÕ߇ ’¬ ≈—∫∑âÕߺŸ° Õ¬à“ß≈–‰¡àπâÕ¬°«à“√âÕ¬≈– 25 ¢Õß°“√¢—∫∂à“¬

4. ≈”‰ â·ª√ª√«π™π‘¥‰¡à™—¥‡®π (undetermined IBS À√◊Õ IBS-U) ºŸâªÉ«¬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.

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8 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012

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“πº‘¥ª°µ‘ (dyspepsia) ·≈–‚√§∑âÕߺŸ°‰¥â∫àÕ¬ ®“°°“√»÷°…“¥â«¬·∫∫ Õ∫∂“¡Õ“°“√°√¥‰À≈¬âÕπ dyspepsia ≈”‰ â·ª√ª√«π Õ“°“√∑âÕߺŸ° ·≈–Õ“°“√∑âÕ߇¥‘π „πª√–™“°√ 657 §π æ∫«à“¡’§«“¡™ÿ° (prevalence) „πª√–™“°√∑’Ë¡’Õ“°“√‡À≈à“π’ÈÕ¬à“ßπâÕ¬ 2 Õ“°“√∑’Ë√âÕ¬≈– 4-9 ·≈–§«“¡™ÿ°„πª√–™“°√∑’Ë¡’Õ¬à“ßπâÕ¬ 3 °≈ÿà¡Õ“°“√¢÷Èπ‰ª∑’Ë√âÕ¬≈– 1-41 ‚¥¬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°≈—∫°—πºŸâ∑’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¬·≈⫬—ß¡’Õ“°“√À√◊Õ‚√§∑“߇¥‘πÕ“À“√Õ◊ËπÊ √«¡∑—ÈßÕ“°“√ functional disorders Õ◊ËπÊπÕ°√–∫∫∑“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≈–√“¬

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9§”·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 symp-tom 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 thegeneral 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 inirritable 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 withother conditions. Curr Gastroenterol Rep 2005;7:264-271.

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6 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012

§”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘)

«—µ∂ÿª√– ߧå¢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≈“¬¡“°¢÷Èπ

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“°“√‰¥âºŸâªÉ«¬≈”‰ 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’È2.1 Õ“°“√ª«¥∑âÕßÀ√◊Õ‰¡à ∫“¬„π∑âÕ߇ªìπ‡«≈“¡“π“πÕ¬à“ßπâÕ¬ 6 ‡¥◊Õπ

π—∫µ—Èß·µà‡√‘Ë¡¡’Õ“°“√

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10 §”·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∑’Ë∑√“∫°—π™—¥‡®π æ∫«à“°≈‰°„π°“√

‡°‘¥‚√§≈”‰ 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¬◊ËÕ∫ÿº‘«≈”‰ â (gut inflammation)

§«“¡º‘¥ª°µ‘¢Õß·∫§∑’‡√’¬ª√–®”∂‘Ëπ„π≈”‰ â ·≈–§«“¡º‘¥ª°µ‘¢Õß°“√µÕ∫ πÕß

√–À«à“ß ¡Õß·≈–≈”‰ â (brain-gut interaction)

°“√»÷°…“«‘®—¬æ∫«à“ §π∑’ˇªìπ‚√§≈”‰ â·ª√ª√«π¡’°“√‡§≈◊ËÕπ‰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„πºŸâªÉ«¬≈”‰ 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“√∑’˵Õ∫ πÕßµàÕ∑—Èß°“√°√–µÿâπ∑“ß°≈ (mechanical stimulation) À√◊Õ∑“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‘

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11§”·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“√

ºŸâªÉ«¬∑’ˇªìπ‚√§≈”‰ â·ª√ª√«πÕ“®¡’Õ“°“√°”‡√‘∫¢÷Èπ®“°ªí®®—¬À≈“¬Õ¬à“ß ‡™àπ¡’°“√»÷°…“æ∫«à“Õ“À“√∫“ß™π‘¥ “¡“√∂°√–µÿâπ„À⺟âªÉ«¬‚√§≈”‰ â·ª√ª√«π¡’Õ“°“√¡“°¢÷Èπ‰¥â ‡™àπ Õ“À“√¡—π Õ“À“√∑’˺≈‘µ·°ä „π≈”‰ â¡“°º‘¥ª°µ‘ ‡™àπ °≈ÿà¡fructose ÀÕ¡ °√–‡∑’¬¡ ÷Ëß “¡“√∂°√–µÿâπ„À⇰‘¥Õ“°“√¡“°¢÷È𠬓∫“ßÕ¬à“ß∑’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°√–µÿâπ„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“ßʇ™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 (malab-

sorption 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‘¥‡™◊ÈÕ„π∑“߇¥‘πÕ“À“√ ‡™àπ °“√µ‘¥‡™◊ÈÕ Giardia lamblia‡ªìπ«—≥‚√§„π≈”‰ â‡≈Á° à«πª≈“¬À√◊Õ≈”‰ â„À≠à À√◊Õ°“√¥Ÿ¥´÷¡πÈ”µ“≈·≈Á°‚∑ ‰¡à ¡∫Ÿ√≥å ÷ËßÕ“®∑”„À⇰‘¥Õ“°“√Õ◊¥·πàπ∑âÕß ª«¥∑âÕß À√◊Õ∑âÕ߇ ’¬ §≈⓬‚√§≈”‰ â

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·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 “¡“√∂∑”„À⺟âªÉ«¬¡’Õ“°“√ª«¥∂à“¬·µà∂à“¬‰¡à ÿ¥ À√◊Õ°√–µÿâπ„À⇰‘¥Õ“°“√Õ◊¥·πàπ∑âÕß ª«¥∑âÕß ÷Ë߇ªìπÕ“°“√¢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¥‘πÕ“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∑âÕߧ≈⓬ÊÕ“°“√≈”‰ â·ª√ª√«π‰¥â ¥—ßπ—ÈπºŸâªÉ«¬∑’Ë¡’Õ“°“√≈”‰ â·ª√ª√«π §«√ —°ª√–«—µ‘µ√«®√à“ß°“¬À√◊Õ àßµ√«®∑“ßÀâÕߪؑ∫—µ‘°“√‡∫◊ÈÕßµâ𠇙àπ stool examination, CBC,ESR ‡æ◊ËÕª√–‡¡‘π«à“ºŸâªÉ«¬¡’‚Õ°“ ‡ªìπ‚√§∑’Ë°≈à“«¡“À√◊Õ‰¡à

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13§”·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◊ËπÊ §«√æ‘®“√≥“µ“¡§«“¡‡À¡“– ¡¢ÕߺŸâªÉ«¬ ºŸâªÉ«¬‚√§≈”‰ â·ª√ª√«π

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‘Ë¡‡µ‘¡ ‡π◊ËÕß®“°º≈¢Õß°“√ ◊∫§âπ‡æ‘Ë¡‡µ‘¡‰¡à‰¥âæ∫‚√§·µ°µà“ß°—∫°≈ÿࡪ√–™“°√ª°µ‘ ¡’‡æ’¬ß∫“ß·π«∑“ß°“√¥Ÿ·≈√—°…“(guidelines)1 ∑’Ë·π–π”°“√ ◊∫§âπ‡∫◊ÈÕßµâπ∫“ßÕ¬à“ß«à“Õ“®¡’§«“¡®”‡ªìπ ”À√—∫ºŸâªÉ«¬‚√§π’È2-4 ‚¥¬ºŸâªÉ«¬‰¡à§«√®–¡’Õ“°“√·≈–Õ“°“√· ¥ß‡µ◊Õπ (alarm features)3, 5

„πºŸâªÉ«¬∫“ß√“¬ °“√ ◊∫§âπ Õ“∑‘ complete blood count (CBC), stoolexamination, ESR, C-reactive protein ‡ªìπµâπÕ“®¡’§«“¡®”‡ªìπ4 ”À√—∫°“√ ◊∫§âπ‡∫◊ÈÕßµâπ∑’Ë¡’‚√§∑’˧≈⓬§≈÷ß°—∫‚√§π’È Õ“∑‘ °“√µ√«®Õÿ®®“√–‡æ◊ËÕ«‘π‘®©—¬‚√§æ¬“∏‘≈”‰ 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“°“√‡∫◊ÈÕßµâπ∑’Ëπà“ ß —¬«à“®–‡ªìπ‚√§Õ◊Ëπ ·π–π”„Àâµ√«®‡æ‘Ë¡‡µ‘¡À√◊Õª√÷°…“·æ∑¬åºŸâ‡™’ˬ«™“≠‚√§≈”‰ â·ª√ª√«π “¡“√∂∑’Ë®–æ∫Õ“°“√„π¥â“πÕ◊Ëπ Ê πÕ°‡Àπ◊ÕÕ“°“√∑“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.ºŸâªÉ«¬∑’Ë¡’Õ“°“√ª«¥∑âÕßÀ√◊Õ‰¡à ∫“¬„π∑âÕ߇√◊ÈÕ√—ß∑ÿ°√“¬ ·æ∑¬åºŸâ¥Ÿ·≈§«√

Õ∫∂“¡§«“¡ —¡æ—π∏å¢ÕßÕ“°“√ª«¥∑âÕß/‰¡à ∫“¬„π∑âÕß°—∫°“√‡ª≈’ˬπ·ª≈ß

¢Õߧ«“¡∂’Ë¢Õß°“√∂à“¬Õÿ®®“√–·≈–≈—°…≥–¢ÕßÕÿ®®“√–

◊∫‡π◊ËÕß®“°‚√§≈”‰ â·ª√ª√«π‡ªìπ‚√§∑’Ë„Àâ°“√«‘π‘®©—¬‚¥¬Õ“»—¬Õ“°“√ª«¥∑âÕßÀ√◊Õ‰¡à ∫“¬„π∑âÕ߇√◊ÈÕ√—ß√à«¡°—∫¡’°“√¢—∫∂à“¬∑’ˇª≈’ˬπ·ª≈߉ª À√◊ÕÕ“°“√ª«¥∑âÕß

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14 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012

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®®“√–·≈–≈—°…≥–¢ÕßÕÿ®®“√–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·√ß10.2 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‰ª10.4 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 ∑’ˉ¡à “¡“√∂Õ∏‘∫“¬

‰¥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

‡ªìπµâπ10.8 ¡’‰¢â10.9 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°√≥’∑’˺ŸâªÉ«¬¡’≈—°…≥–‡µ◊Õπ·π–π”«à“§«√µ√«®‡æ‘Ë¡‡µ‘¡À√◊Õª√÷°…“·æ∑¬åºŸâ‡™’ˬ«™“≠

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15§”·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

°“√»÷°…“¢Õß Cash ·≈–§≥–7 æ∫«à“ºŸâªÉ«¬‚√§≈”‰ 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“ºŸâªÉ«¬‡æ»À≠‘ß¡’·π«‚πâ¡À¬ÿ¥ß“π¡“°°«à“ ¡’ªí≠À“°“√πÕπ(sleep disturbance) ¡“°°«à“ºŸâªÉ«¬™“¬ à«π°“√»÷°…“¢Õß Rey ·≈–§≥–9 °Áæ∫«à“„πºŸâªÉ«¬‚√§≈”‰ 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®®“√–„πºŸâªÉ«¬≈”‰ â·ª√ª√«π¡’ª√–‚¬™πå„π°“√°”Àπ¥

·π«∑“ß°“√ ◊∫§âπÀ“ “‡Àµÿ¢ÕßÕ“°“√ („π°√≥’∑’Ë¡’¢âÕ∫àß™’È) ·≈–·π«∑“ß°“√

„À⬓√—°…“

·π–π”„Àâ ◊∫§âπ‡æ‘Ë¡‡µ‘¡„πºŸâªÉ«¬‚√§≈”‰ â·ª√ª√«πµ“¡™π‘¥¢Õß‚√§π’È3, 10 ‚¥¬‡©æ“–™π‘¥∑’ˇªìπ·∫∫∑âÕ߇ ’¬‡¥àπ „Àâ√–«—ß‚√§°≈ÿà¡∑’ËÕ“®¡’Õ“°“√∑âÕ߇ ’¬‡√◊ÈÕ√—߉¥â ‡™àπgiardiasis, tropical sprue, hyperthyroidism, inflammatory bowel disease(IBD) ‡ªìπµâπ

‡ªÑ“À¡“¬¢Õß°“√√—°…“ºŸâªÉ«¬‚√§≈”‰ â·ª√ª√«π§◊Õ ≈¥Õ“°“√·≈–‡æ‘Ë¡§ÿ≥¿“æ™’«‘µ¢ÕߺŸâªÉ«¬3, 5 ¥—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

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16 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012

¡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¬“´÷Ëߪ√–°Õ∫‰ª¥â«¬¬“ antispasmodics, loperamide ·≈–alosetron ‡ªìπµâπ

¢âÕ √ÿª∑’Ë 14.°“√µ√«®∑“ßÀâÕߪؑ∫—µ‘°“√·≈–°“√µ√«®æ‘‡»…∑’Ë¡’ª√–‚¬™πå„π°“√·¬°‚√§

Õ◊Ëπ∑’Ë∑”„À⇰‘¥Õ“°“√§≈⓬Փ°“√¢Õß‚√§≈”‰ â·ª√ª√«π ‰¥â·°à

14.1 °“√µ√«®æ◊Èπ∞“π CBC, ESR, stool exam14.2 °“√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-breathtest ”À√—∫ small bowel bacterial overgrowth, lactose malabsorption, gastro-intestinal transit study ·≈– anorectal function tests

14.3 °“√µ√«®Õ◊ËπÊ ‡™àπ thyroid function tests, serum cortisol, serumcalcium, electrolytes ‡ªìπµâπ

°“√µ√«®‡æ‘Ë¡‡µ‘¡∑“ßÀâÕߪؑ∫—µ‘°“√π—Èπ®–¡’ª√–‚¬™πå„πºŸâªÉ«¬‚√§≈”‰ â·ª√ª√«π‚¥¬‡©æ“–∂â“¡’≈—°…≥–‡µ◊Õπ ‚¥¬®–¡’·π«∑“ß°“√ ◊∫§âπµ“¡≈—°…≥–¢Õß™π‘¥¢Õß‚√§≈”‰ â·ª√ª√«π∑’˺ŸâªÉ«¬π—Èπ¡’ªí≠À“3 ”À√—∫ Asian guideline ·π–π”«à“∂â“√—°…“ºŸâªÉ«¬‰ª 12 —ª¥“Àå·≈â« ºŸâªÉ«¬¬—ߧߡ’Õ“°“√‰¡à¥’¢÷Èπ·π–π”«à“ §«√ àßµàÕºŸâªÉ«¬ª√÷°…“·æ∑¬å‡©æ“–∑“ß‚√§√–∫∫∑“߇¥‘πÕ“À“√

¢âÕ √ÿª∑’Ë 15.ºŸâªÉ«¬‚√§≈”‰ 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

°“√√—°…“ºŸâªÉ«¬‚√§ IBS3, 11 π’È·∫àß°“√¥Ÿ·≈‡ªìπ 3 √–¥—∫§◊Õ „π°“√¥Ÿ·≈ºŸâªÉ«¬∑’Ë¡’Õ“°“√‰¡à¡“° „ÀℙⰓ√ª√—∫‡ª≈’ˬπ惵‘°√√¡ (life style modifications)°“√À≈’°‡≈’ˬßÕ“À“√À√◊Õ°“√‡ª≈’ˬπ™π‘¥¢ÕßÕ“À“√ Õ∏‘∫“¬°“√«‘π‘®©—¬·≈–°“√¥”‡π‘π

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17§”·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“ßµàÕ‡π◊ËÕßµ≈Õ¥®πæ‘®“√≥“ª√÷°…“∑“ß®‘µ‡«™∑—Èß°“√„™â¬“·≈–®‘µ∫”∫—¥‡æ‘Ë¡

”À√—∫·æ∑¬å∑—Ë«‰ª°“√√—°…“„πºŸâªÉ«¬∑’Ë¡’Õ“°“√‡≈Á°πâÕ¬®π∂÷ߪ“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

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2. Svendsen JH, Munck LK, Andersen JR. Irritable bowel syndrome: prognosis anddiagnostic 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 JGastroenterol 2009;104 Suppl 1:S1-35.

4. Spiller R, Aziz Q, Creed F, et al. Guidelines on the irritable bowel syndrome: mechanisms andpractical 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 inirritable 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 syndromepatients: 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 RomeII-based survey in an apparent healthy adult Chinese population in Taiwan. Aliment PharmacolTher 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.

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18 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012

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·≈√—°…“ºŸâªÉ«¬≈”‰ â·ª√ª√«π∑’Ë¡’Õ“°“√‰¡à√∫°«π§ÿ≥¿“æ™’«‘µ ¡’‡ªÑ“À¡“¬∑’Ë ”§—≠§◊Õ √â“ߧ«“¡¡—Ëπ„®·≈–§≈“¬§«“¡«‘µ°°—ß«≈¢ÕߺŸâªÉ«¬ ‘Ëß·√°µâÕßÕ∏‘∫“¬„À⺟âªÉ«¬∑√“∫∂÷ß natural history ¢Õß‚√§«à“‚√§≈”‰ â·ª√ª√«π ‡ªìπ‚√§∑’ˉ¡à√⓬·√߉¡à¡’¿“«–·∑√°´âÕπ∑’Ë®–∑”„À⇠’¬™’«‘µ ·µà¡’°“√¥”‡π‘π‚√§∑’ˇ√◊ÈÕ√—ß ¡—°‡ªìπÊ À“¬Ê·¡â‰¥â√—∫°“√√—°…“ À≈—ß°“√√—°…“∂⓺ŸâªÉ«¬Õ“°“√‰¡à¥’¢÷Èπ®–¬‘Ëß∑”„À⺟âªÉ«¬«‘µ°°—ß«≈¡“°§◊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“°“√∑’Ëπ”ºŸâªÉ«¬¡“æ∫·æ∑¬å‡À¡◊Õπ°—π ·æ∑¬åµâÕß´—°ª√–«—µ‘·≈–µ√«®√à“ß°“¬Õ¬à“ß≈–‡Õ’¬¥ ·≈–∑”°“√ ◊∫§âπÕ¬à“߇À¡“– ¡°àÕπ∑’Ë®–„Àâ°“√«‘π‘®©—¬«à“‡ªìπ‚√§≈”‰ â·ª√ª√«π √«¡∑—Èß®–µâÕߧâπÀ“Õ¬à“߇µÁ¡∑’Ë«à“‰¡àæ∫¡’≈—°…≥–‡µ◊Õπ (alarm symptoms) ÷Ëß∫àß™’È«à“Õ“®®–¡’‚√§√⓬·√߇™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√– ߧå¢Õß°“√

√—°…“πÕ°®“° √â“ߧ«“¡¡—Ëπ„®·≈–§≈“¬§«“¡«‘µ°°—ß«≈„À⺟âªÉ«¬·≈â« §«√„Àâ

°“√√—°…“‡æ◊ËÕ∫√√‡∑“Õ“°“√¢ÕߺŸâªÉ«¬§«√‡√‘Ë¡µâπ¥â«¬°“√·π–π”„Àâª√—∫‡ª≈’ˬπ

°“√ªØ‘∫—µ‘µ—«„π°“√¥”‡π‘π™’«‘µª√–®”«—π (life style modifications)

°“√√—°…“‡æ◊ËÕ∫√√‡∑“Õ“°“√¢ÕߺŸâªÉ«¬§«√‡√‘Ë¡µâπ¥â«¬°“√·π–π”„Àâª√—∫‡ª≈’ˬπ°“√ªØ‘∫—µ‘µ—«„π°“√¥”‡π‘π™’«‘µª√–®”«—π (life style modifications) ‡™àπ°“√√—∫ª√–∑“πÕ“À“√ ™π‘¥¢ÕßÕ“À“√ ¬“ §«“¡‡§√’¬¥ À≈’°‡≈’Ë¬ß ‘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“®∑”„ÀâÕ“°“√¥’¢÷Èπ„πºŸâªÉ«¬∫“ß√“¬·≈–™à«¬≈¥§«“¡∂’Ë„π°“√°≈—∫‡ªìπ´È”‰¥â¥â«¬6

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19§”·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«“¡¡—Ëπ„®·°àºŸâªÉ«¬ ·≈– ”§—≠µàÕº≈ ”‡√Á®¢Õß°“√√—°…“ºŸâªÉ«¬‚√§≈”‰ â·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◊ËÕß®“°‚√§≈”‰ â·ª√ª√«π¡’°“√¥”‡π‘π‚√§∑’ˇ√◊ÈÕ√—ß ¡—°‡ªìπÊÀ“¬Ê ºŸâªÉ«¬®”‡ªìπµâÕ߉¥â√—∫°“√¥Ÿ·≈√—°…“µ‘¥µàÕ°—π√–¬–¬“«·≈–µâÕ߉¥â√—∫§«“¡√à«¡¡◊ÕÕ¬à“ߥ’®“°ºŸâªÉ«¬Õ’°¥â«¬ ¥—ßπ—Èπ‡¡◊ËÕºŸâªÉ«¬¡’§«“¡‡™◊ËÕ∂◊Õ·≈–§«“¡¡—Ëπ„®„πµ—«·æ∑¬å·≈â« ºŸâªÉ«¬®–√Ÿâ ÷°«à“·æ∑¬å‡ªìπ∑’Ëæ÷Ë߉¥âµ≈Õ¥‡«≈“∑”„À⺟âªÉ«¬§≈“¬§«“¡«‘µ°°—ß«≈≈ßÕ“®™à«¬∑”„ÀâÕ“°“√¥’¢÷Èπ ·¡âºŸâªÉ«¬®–¬—ߧߡ’Õ“°“√Õ¬Ÿà∫â“߉¡àÀ“¬¢“¥ ·µàºŸâªÉ«¬®–¡’§«“¡∑ÿ°¢å∑√¡“π‡°’Ë¬«°—∫‚√§≈¥πâÕ¬≈ß6-9

¢âÕ √ÿª∑’Ë 19.°“√´—°ª√–«—µ‘惵‘°√√¡°“√√—∫ª√–∑“πÕ“À“√·≈–‡§√◊ËÕߥ◊Ë¡ √«¡∂÷ߧ”·π–π”

‡°’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‡ªìπ¡“°¢÷Èπ10 ¡’°“√»÷°…“∑’ˇªìπ systematic review ÷Ëß à«π„À≠à‡ªìπ°“√»÷°…“·∫∫uncontrolled æ∫«à“ °“√À≈’°‡≈’ˬßÕ“À“√∑’Ë®–∑”„Àâ¡’Õ“°“√‡æ‘Ë¡¢÷Èπ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫ placebo ºŸâªÉ«¬®–¡’Õ“°“√¥’¢÷Èπ√âÕ¬≈– 12.5-67 ÷Ë߉¡à “¡“√∂ √ÿª‰¥â«à“‡ªìπplacebo effect À√◊Õ‰¡à11 ¡’°“√»÷°…“∑’ˇªìπ randomized control trial (RCT) æ∫«à“°“√À≈’°‡≈’ˬßÕ“À“√∑’Ë®–∑”„Àâ¡’Õ“°“√‡æ‘Ë¡¢÷Èπ´÷Ë߬◊π¬—π‚¥¬°“√µ√«®æ∫ IgG antibodyµàÕÕ“À“√™π‘¥π—Èπ ∑”„À⺟âªÉ«¬¡’Õ“°“√¥’¢÷ÈπÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫ sham diet ‚¥¬¡’ number needed to treat (NNT) ‡∑à“°—∫ 2.512 „πªí®®ÿ∫—π¬—߉¡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‘∑—Ë«‰ª Õ¬à“߉√°Áµ“¡°“√·π–π”„ÀâÀ≈’°‡≈’ˬßÕ“À“√∑’Ë®–∑”„Àâ¡’Õ“°“√‡æ‘Ë¡¢÷Èπ‡™àπÕ“À“√√ ®—¥ Õ“À“√¡—π ¢ÕߥÕß ·Õ≈°ÕŒÕ≈å∑ÿ°™π‘¥ °“·ø πȔ՗¥≈¡ ‡ªìπµâπ

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20 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012

∂◊Õ«à“¡’ª√–‚¬™πå‚¥¬Õ“®∑”„ÀâÕ“°“√¢ÕߺŸâªÉ«¬¥’¢÷Èπ‰¥â πÕ°®“°π’È°“√°‘πÕ“À“√§«√°‘π∑’≈–πâÕ¬·µà°‘π„Àâ∫àÕ¬¢÷Èπ ‰¡à§«√°‘π®πÕ‘Ë¡¡“° ‡æ√“–«à“®–°√–µÿâπ„Àâ¡’Õ“°“√ª«¥∑âÕß·≈–∑âÕ߇ ’¬‰¥âßà“¬

¢âÕ √ÿª∑’Ë 20.°“√√—°…“‚¥¬‰¡à„™â¬“∑’ËÕ“®¡’ª√–‚¬™πå„πºŸâªÉ«¬≈”‰ 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„πºŸâªÉ«¬‚√§≈”‰ â·ª√ª√«π‰¥â·°à

20.1 °“√„™â educational self-help guidebook ‡ªìπ°“√„Àâ°“√»÷°…“·°àºŸâªÉ«¬„Àâ¡’§«“¡√Ÿâ‡°’ˬ«°—∫‚√§∑—Èß„π¥â“π欓∏‘°”‡π‘¥ °“√«‘π‘®©—¬·≈–°“√√—°…“µ≈Õ¥®π‡¢â“„®≈—°…≥–°“√¥”‡π‘π‚√§·≈–·π«∑“ß„π°“√ª√—∫‡ª≈’ˬπ°“√ªØ‘∫—µ‘µ—«∑’ˇÀ¡“– ¡‡æ◊ËÕ≈¥Õ“°“√∑’Ë∑”„À⺟âªÉ«¬∑ÿ°¢å∑√¡“π ¡’°“√»÷°…“∑’ˇªìπ RCT ‚¥¬ª√–‡¡‘πº≈≈—æ∏å§◊Õ symptom score, perception of improvement ·≈– primarycare 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-helpguidebook 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 ¡’°“√»÷°…“∑’ˇªìπ systematicreview ·≈– meta-analysis ∑’Ë· ¥ß«à“ psychological therapy ÷Ëߪ√–°Õ∫¥â«¬cognitive behavioral therapy (CBT), dynamic psychotherapy ·≈– hypno-therapy ∑”„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 ‰¥âª√–‚¬™πå∑”„À⺟âªÉ«¬Õ“°“√¥’¢÷ÈπÕ¬à“ß™—¥‡®π ¡’°“√»÷°…“∑’ˇªìπ single-blinded study‡ª√’¬∫‡∑’¬∫ CBT °—∫ patient education alone æ∫«à“ CBT ∑”„À⺟âªÉ«¬Õ“°“√¥’¢÷Èπ√âÕ¬≈– 73 ÷Ë߉¥âº≈¥’°«à“ education group ÷Ë߉¥âº≈√âÕ¬≈– 41.3 Õ¬à“ß¡’π—¬ ”§—≠

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21§”·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 systematicreview 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÷ËߢÕß欓∏‘ √’√–«‘∑¬“¢Õß IBS §◊Õ¡’°“√‡ª≈’ˬπ·ª≈ߢÕß intestinal microbiota º‘¥ª°µ‘‰ª®“°‡¥‘¡ ‚¥¬‡°‘¥§«“¡‰¡à ¡¥ÿ≈¬å¢Õßintestinal microbiota ‡™àπ ¡’°“√≈¥≈ߢÕß Lactobacilli ·≈– Bifidobacteria ÷Ë߇ªìπ·∫§∑’‡√’¬∑’Ë¥’‡°‘¥ª√–‚¬™πåµàÕ√à“ß°“¬¢≥–‡¥’¬«°—π¡’·∫§∑’‡√’¬∑’ˉ¡à¥’‡æ‘Ë¡¢÷Èπ‡™àπClostridia ·≈– Enterobacteriaceae ‡ªìπµâπ 𔉪 Ÿà¿“«– dysbiosis, elevatedluminal gas production ·≈– immune activation ¥—ßπ—Èπ‡ªÑ“À¡“¬Àπ÷ËߢÕß°“√√—°…“ IBS ®÷ß¡ÿà߉ª∑’Ë°“√·°â‰¢§«“¡º‘¥ª°µ‘¢Õß intestinal microbiota ¡’°“√»÷°…“∑’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 IBSsymptoms, abdominal pain ·≈– flatulence ¥’¢÷ÈπÕ¬à“ß¡’π—¬ ”§—≠·≈–ª√–‚¬™πå∑’ˉ¥â‡ªìπ strain-specific ·≈– symptom-specific ”À√—∫ probiotic ∑’ˇªì𠓬æ—π∏ÿ凥’ˬ« À≈—°∞“π∑’Ë¥’∑’Ë ÿ¥§◊Õ Bifidobacteria infantis √Õß≈߉ª§◊Õ Lacto-bacillus planetarium à«π probiotic ∑’ˇªì𠓬æ—π∏ÿåº ¡‡™àπ E.coli-Nisle +Streptococcus faecalis ‡π◊ËÕß®“°¡’ªí®®—¬À≈“¬Õ¬à“߇™àπ strain selection, optimumdosage, mode of action,† safety ·≈– long-term tolerability ´÷Ëß¡’º≈µàÕº≈¢Õß°“√√—°…“®÷߬—߉¡à “¡“√∂°”Àπ¥„Àâ probiotics ‡ªìπ general recommenda-tion „π°“√√—°…“ºŸâªÉ«¬ IBS ‰¥â

20.4 “√ ¡ÿπ‰æ√ ®“°°“√»÷°…“‚¥¬ Cochrane systematic review 75RCTs ¡’ºŸâªÉ«¬√«¡ 7,957 √“¬ æ∫«à“¡’ “√ ¡ÿπ‰æ√∫“ßÕ¬à“ßÕ“®∑”„ÀâÕ“°“√¢ÕߺŸâªÉ«¬‚√§≈”‰ â·ª√ª√«π¥’¢÷Èπ‰¥â26 ¡’°“√»÷°…“∑’ˇªìπ RCT ·∫∫ multicenter ‚¥¬»÷°…“µ”√—∫ ¡ÿπ‰æ√™◊ËÕ Iberogast ´÷Ëߪ√–°Õ∫¥â«¬ ¡ÿπ‰æ√À≈“¬™π‘¥ æ∫«à“∑”„ÀâÕ“°“√¢ÕߺŸâªÉ«¬‚√§≈”‰ â·ª√ª√«π¥’¢÷ÈπÕ¬à“ß¡’π—¬ ”§—≠‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫¬“À≈Õ°‚¥¬ºŸâªÉ«¬∑𬓉¥â¥’·≈–‰¥âº≈¥’‰¡à«à“®–¡’ predominant symptom ·∫∫„¥27 Õ¬à“߉√°Áµ“¡°“√ª√–‡¡‘πª√–‚¬™πå∑’Ë·∑â®√‘ߢÕß ¡ÿπ‰æ√Õ“®‰¥âº≈‰¡à·πàπÕπ ‡π◊ËÕß®“°

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22 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012

°“√»÷°…“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«à“°“√Ωí߇¢Á¡‰¥âª√–‚¬™πå„π°“√√—°…“‚√§≈”‰ â·ª√ª√«π ‡π◊ËÕß®“°º≈°“√√—°…“¡’∑—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 therapyBiofeedback 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, balloonexpulsion 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 treat-

ments for irritable bowel syndrome: a European perspective. Aliment Pharmacol Ther 2006;24:183- 205.

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4. Ford AC, Talley NJ, Veldhuyzen van Zanten SJ, Vakil NB, Simel DL, Moayyedi P. Will thehistory and physical examination help establish that irritable bowel syndrome is causing mypatientûs lower gastrointestinal symptoms? JAMA 2008;300:1793-805.

5. Cash BD, Schemed P, Chey WD. The utility of diagnostic tests in irritable bowel syndromepatients: a systematic review. Am J Gastroenterol 2002;97:2812-9.

6. American Gastroenterological Association. AGA medical position statement: Irritable bowelsyndrome. Gastroenterology 2002;123:2105-7.

7. Manning AP, Thompson WG, Heaton KW, et al. Towards positive diagnosis of the irritable bowel. BrMed J 1978;277:653-4.

8. Owens DM, Nelson DK, Talley NJ. The irritable bowel syndrome: long-term prognosis and thephysician-patient interaction. Ann Intern Med 1995;122:107-12.

9. Spiegel BMR, Nalibo7 B, Mayer E, et al. The effectiveness of a model physician-patientrelationship versus usual care in irritable bowel syndrome: a andomized controlled trial. Gastro-enterology 2006;130:A773.

10. Simren M, Mansson A, Langkilde AM, et al. Food-related gastrointestinal symptoms in theirritable bowel syndrome. Digestion 2001;63:108-15.

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11. Park MI, Camilleri M. Is there a role of food allergy in irritable bowel syndrome and functionaldyspepsia? A systematic review. NeurogastroenterolMotil 2006;18:595-607.

12. Atkinson W, Sheldon T, Shaath N, Whorwell PJ. Food elimination based on IgG antibodies inirritable 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 TaskForce on Irritable Bowel Syndrome. An evidence-based position statement on the managementof 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 interventionsin 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 bowelsyndrome with other disorders: what are the causes and implications? Gastroenterology2002;122:1140-56.

16. Miller AR, North CS, Clouse RE, Wetzel RD, Spitznagel EL, Alpers DH. The association ofirritable 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 irritablebowel 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 bowelsyndrome: 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 ofirritable bowel syndrome. Cochrane Database Syst Rev 2007 (4) CD005110.

20. Drossman D, Toner B, Whitehead W, et al. Cognitive-behavioral therapy vs. education anddesipramine vs. placebo for moderate to severe functional bowel disorders. Gastroenterology2003; 125:19-31.

21. Tan G, Hammond D, Gurrala J. Hypnosis and irritable bowel syndrome: a review of efficacy andmechanism 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 trialsand 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 Gastroenterol2008;14:2650-61.

24. Brenner DM, Moeller MJ, Chey WD, Schoenfeld PS. The utility of probiotics in the treatment ofIBS; 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: asystematic review. Gut 2010;59:325-32.

26. Liu J, Yang M, Liu Y, Wei M, Grimsgaard S. Herbal medicines for treatment of irritable bowelsyndrome. Cochrane Database Syst Rev 2006 ;(1):CD004116.

27. Madisch A, Holtmann G, Plein K, Hotz J. Treatment of irritable bowel syndrome with herbalpreparations: results of a double-blind, randomized, placebo-controlled, multi-centre trial. Ali-ment Pharmacol Ther 2004;19:271-279.

28. Patcharatrakul T, Gonlachanvit S. Outcome of biofeedback therapy in dyssynergic defecationpatients with and without irritable bowel syndrome. J Clin Gastroenterol 2011; 45(7):593-598.

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24 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012

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) ·≈–¬“∑’ËÕÕ°ƒ∑∏‘Ϻà“π√–∫∫

serotonin À√◊Õ 5-HT receptor

°“√√—°…“≈”‰ â·ª√ª√«πªí®®ÿ∫—π¬—߇πâπ∑’Ë°“√√—°…“µ“¡Õ“°“√‡ªìπÀ≈—° à«π¬“∑’ËÕÕ°ƒ∑∏‘Ϻà“π serotonin receptors π—Èπ°Á “¡“√∂„™â‰¥âµ“¡¢âÕ∫àß™’È

21.1. °“√√—°…“Õ“°“√ª«¥∑âÕß “¡“√∂„™â¬“∑’Ë≈¥Õ“°“√ª«¥‡°√Áß(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‡ÀÁπª√–‚¬™πå·≈â«°Áµ“¡1

πÕ°®“°π—Èπ¡’¬“∑’Ë¢÷Èπ∑–‡∫’¬π„πª√–‡∑»Õ’° ‡™àπ Trimebutine ( ÷Ë߇ªìπ opioidantagononist), pinaverium (Dicetel) ·≈– dicyclomine (dicycloverine)·µà°Á‰¡à¡’À≈—°∞“π«à“¡’ª√–‚¬™πåÕ¬à“ß™—¥‡®π Õ¬à“߉√°Áµ“¡¡’ºŸâªÉ«¬∫“ß√“¬∑’˵Õ∫ πÕßµàÕ°“√√—°…“‡™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 ¬—߉¡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-HT

3 antagonists ‡™àπ alosetron, ramosetron

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25§”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012

Alosetron ¬“¬—߉¡à‰¥â¢÷Èπ∑–‡∫’¬π„πª√–‡∑»‰∑¬ ·¡âæ∫«à“‰¥âº≈¥’¡“°·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—Èπ ·≈–‡©æ“–„π À√—∞Õ‡¡√‘°“ª√–‡∑»‡¥’¬« ≈à“ ÿ¥æ∫«à“ ºŸâªÉ«¬°≈ÿà¡π’È “¡“√∂„™â¬“„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“ºŸâªÉ«¬Õ“®¡’°“√µ‘¥‡™◊ÈÕ·Ωß À√◊Õ‡ªìπ°“√ª√—∫ ‘Ëß·«¥≈âÕ¡®ÿ≈™’æ„π≈”‰ â À√◊ÕºŸâªÉ«¬Õ“®¡’small intestinal bacterial overgrowth À√◊Õ tropical sprue Õ¬Ÿà

¬“ªØ‘™’«π–∑’Ë¡’°“√»÷°…“ªí®®ÿ∫—π¡’‡æ’¬ß¢π“π‡¥’¬« §◊Õ Rifaximin ‡¡◊ËÕªï 2011¡’°“√»÷°…“ 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“√„Àâº≈¥’„π√“¬∑’ˉ¥â√—∫„¬Õ“À“√µàÕ«—ππâÕ¬°«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“°ºŸâªÉ«¬‰¡à‰¥âµâÕß°“√„¬Õ“À“√‡æ‘Ë¡¢÷Èπ°«à“∑’˧«√‰¥â °Á¡—°¡’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°Áæ∫«à“‰¥âº≈¥’°«à“ Õ“°“√¢â“߇§’¬ßπâÕ¬°«à“ lactulose11

Lubiprostone ÷Ëßæ∫«à“°“√„™â·¡â„π√–¬–¬“«°Á‰¥âº≈¥’ ª≈Õ¥¿—¬ ·≈–ºŸâªÉ«¬∑π°“√√—°…“‰¥â¥’ ¬“ºà“π°“√√—∫√Õß®“° US FDA ·≈â«·≈–‡ªìπ‡æ’¬ß¢π“π‡¥’¬«∑’Ë

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√—∫√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 agonistTegaserod ‡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 ÷Ëß„Àâº≈¥’·≈–ª≈Õ¥¿—¬ ¢≥–π’È¡’¢âÕ¡Ÿ≈«à“‰¥âº≈¥’„πºŸâªÉ«¬ IBS-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·≈–®“° systematicreview18 æ∫«à“‰¡à‰¥âº≈¥’°«à“ placebo

Mosapride ‡∑à“∑’Ë ◊∫§âπ‰¥â¡’‡æ’¬ß°“√»÷°…“‡¥’¬«19 ‡ªìπ°“√»÷°…“·∫∫‡ªî¥„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)

ºŸâªÉ«¬≈”‰ â·ª√ª√«π∑’ˉ¡à¡’Õ“°“√¢Õß°√¥‰À≈¬âÕπÀ√◊Õ°√–‡æ“–Õ“À“√∑”ß“πº‘¥ª°µ‘ (ª«¥· ∫∑âÕß∫√‘‡«≥≈‘Èπªïò) °“√„™â¬“√–ß—∫°“√À≈—Ëß°√¥¡’∫∑∫“∑πâÕ¬

®“°°“√ ◊∫§âπ æ∫«à“22.1. ‰¡à¡’°“√»÷°…“∂÷ß∫∑∫“∑¢Õ߬“√–ß—∫°“√À≈—Ëß°√¥ ‰¡à«à“®–‡ªìπ H2-

receptor 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·≈–

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27§”·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¡‘ ·≈–¡—°¡’ psychiatriccomorbidity16 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 thetreatment 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 functionalgastrointestinal 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 - Adouble-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;79:1272-5.

5. Nicandro JP, Shin P, Chuang E. Evaluation of treatment continuation with alosetron by IBS-Dseverity 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 withirritable bowel syndrome with diarrhea: a multicenter, randomized clinical trial, compared withmebeverine. Neurogastroenterol Motil 2011;23:1098-104.

7. PimentelM, Lembo A, Chey WD, et al. Rifaximin Therapy for Patients with Irritable BowelSyndrome without Constipation. New Engl J Med 2011;364:22-32.

8. Francis CY, Whorwell PJ. Bran and irritable bowel syndrome: time for reappraisal. Lancet1994;344:39-40.

9. Prior A, Whorwell PJ. Double blind study of ispaghula in irritable bowel syndrome. Gut1987;28:1510-13.

10. Bijkerk CJ, Muris JWM, Knottnerus JA, Hoes AW, De Wit NJ. Systematic review: the role ofdifferent types of fibre in the treatment of irritable bowel syndrome. Aliment Pharmacol Ther2004;19:245-51.

11. Attar A, Lemann M, Ferguson A, et al. Comparison of a low dose polyethylene glycol electro-lyte 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 out-comes with lubiprostone for up to 52 weeks in patients with irritable bowel syndrome withconstipation. Aliment Pharmacol Ther 2012;35:587-99.

13. Evans BW, Clark WK, Moore DJ, Whorwell PJ. Tegaserod for the treatment of irritable bowelsyndrome and chronic constipation. Cochrane Database Syst Rev 2007:CD003960.

14. Wensel TM, Luthin DR. Linaclotide: a novel approach to the treatment of irritable bowel syn-drome. Ann Pharmacother 2011;45:1535-43.

15. Suzuki H, Hibi T. Overlap syndrome of functional dyspepsia and irritable bowel syndrome - areboth diseases mutually exclusive? J Neurogastroenterol Motil 2011;17:360-5.

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28 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012

16. Piacentino D, Cantarini R, Alfonsi M, et al. Psychopathological features of irritable bowelsyndrome patients with and without functional dyspepsia: a cross sectional study. BMCGastroenterol 2011;11:94.

17. Van Outryve M, Milo R, Toussaint J, Van Eeghem P. çProkinetic-treatment of constipation-predominant irritable bowel syndrome: a placebo-controlled study of cisapride. J Clin Gastroenterol1991;13:49-57.

18. Ford AC, Brandt LJ, Young C, Chey WD, Foxx-Orenstein AE, Moayyedi P. Efficacy of 5-HT3antagonists and 5-HT4 agonists in irritable bowel syndrome: systematic review and meta-analy-sis. Am J Gastroenterol 2009;104:1831-43.

19. Nakamura M, Ohmiya N, Miyahara R, et al. Are symptomatic changes in irritable bowel syn-drome correlated with the capsule endoscopy transit time? A pilot study using the 5-HT4 recep-tor agonist mosapride. Hepatogastroenterology 2011;58:453-8.

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29§”·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

´÷Ëß»÷°…“„πª√–™“°√∑—Ë«‰ª∑’ËŒàÕß°ß®”π«π 2,005 √“¬ æ∫«à“ºŸâªÉ«¬∑’Ë¡’ general anxietydisorder (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“ºŸâªÉ«¬∑’Ë¡’ somatic symptom score 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∑’Ë¡“ª√÷°…“·æ∑¬å®–¡’Õ—µ√“°“√æ∫ anxiety ‰¥â Ÿß°«à“ºŸâªÉ«¬ IBS ∑’ˉ¡à‰¥â¡“æ∫·æ∑¬å„π√“¬ß“π¢Õß Gros ·≈–§≥–4 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-compulsivedisorder ¡’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‡«™·µàºŸâªÉ«¬ IBS ¡’‚Õ°“ ∑’Ë®–æ∫§«“¡º‘¥ª°µ‘

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30 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012

∑“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 associatedwith generalized anxiety disorder: a community study. Aliment Pharmacol Ther 2009;30:643-51.

2. Choung RS, Locke R, Zinsmeistr AR, Schleck CD, Talley NJ. Psychosocial distress and somaticsymptoms in community subjects with irritable bowel syndrome: a psychological component isthe 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 ofirritable bowel syndrome across the anxiety disorders and depression. J Anxiety Disorders2009;23:290-6.

5. Creed F, Tomenson B, Guthrie E, et al. The relationship between somatization and outcome inpatients 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 bowelsyndrome and comorbid depression. Clin Ther 2010;32:1221-33.

¢âÕ √ÿª∑’Ë 24.°“√ «π≈â“ß≈”‰ âÕ“®∑”„ÀâÕ“°“√≈”‰ â·ª√ª√«π¥’¢÷Èπ™—Ë«§√“« ·µàº≈¥’À√◊Õ

º≈‡ ’¬√–¬–¬“«¬—߉¡à¡’¢âÕ¡Ÿ≈∑“ß°“√·æ∑¬å™—¥‡®π

„πºŸâªÉ«¬≈”‰ â·ª√ª√«π∑’Ë¡’Õ“°“√∑âÕߺŸ°‡ªìπª√–®”°“√ «π≈â“ß≈”‰ âÕ“®∑”„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≈”‰ ≡àπà“®–‰¥âª√–‚¬™πå„¥ Ê

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31§”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012

No alarm features

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32 §”·π–𔇰’ˬ«°—∫‚√§≈”‰ â·ª√ª√«π ”À√—∫·æ∑¬å∑—Ë«‰ª (·π«∑“߇«™ªØ‘∫—µ‘) 2012

𓬷æ∑¬å°‘µµ‘ ®—π∑√å‡≈‘»ƒ∑∏‘Ï ‚√ß欓∫“≈»√’π§√‘π∑√å ¢Õπ·°àπ

·æ∑¬åÀ≠‘ß®‘π¥“√—µπå ‡®’¬‡®…Ø“°ÿ≈ ‚√ß欓∫“≈æ√–¡ß°ÿƇ°≈â“ °√ÿ߇∑æ¡À“π§√

·æ∑¬åÀ≠‘ß‚©¡»√’ ‚¶…‘µ™—¬«—≤πå ‚√ß欓∫“≈√“¡“∏‘∫¥’ °√ÿ߇∑æ¡À“π§√

·æ∑¬åÀ≠‘ß∞π‘ “ æ—™√µ√–°Ÿ≈ ‚√ß欓∫“≈®ÿÓ≈ß°√≥å °√ÿ߇∑æ¡À“π§√

𓬷æ∑¬å∏‡π» ®—¥«—≤π°ÿ≈ ‚√ß欓∫“≈ ¡‡¥Á®æ√–∫√¡√“™‡∑«’ ≥ »√’√“™“ ™≈∫ÿ√’

𓬷æ∑¬å∏‡π» ™‘µ“æπ“√—°…å ‚√ß欓∫“≈¡À“√“™π§√‡™’¬ß„À¡à ‡™’¬ß„À¡à

𓬷æ∑¬åπæ«ÿ≤‘ °’√µ‘°√≥å ÿ¿—§ ‚√ß欓∫“≈ ¡‡¥Á®æ√–∫√¡√“™‡∑«’ ≥ »√’√“™“ ™≈∫ÿ√’

·æ∑¬åÀ≠‘ßπ‘»“ ‡πµ‘π“∂ ÿπ∑√ ‚√ß欓∫“≈ ߢ≈“π§√‘π∑√å ߢ≈“

𓬷æ∑¬å∫—≠™“ ‚Õ«“∑Ó√æ√ ‚√ß欓∫“≈ ߢ≈“π§√‘π∑√å ߢ≈“

·æ∑¬åÀ≠‘ß∫ÿ…∫“ «‘«—≤π凫§‘π ‚√ß欓∫“≈®ÿÓ≈ß°√≥å °√ÿ߇∑æ¡À“π§√

·æ∑¬åÀ≠‘ß¡≥±‘√“ ¡≥’√—µπ–æ√ ‚√ß欓∫“≈»‘√‘√“™ °√ÿ߇∑æ¡À“π§√

𓬷æ∑¬å√—∞°√ «‘‰≈™π¡å ‚√ß欓∫“≈∏√√¡»“ µ√å °√ÿ߇∑æ¡À“π§√

·æ∑¬åÀ≠‘ß«√πÿ™ ®ß»√’ «— ¥‘Ï ‚√ß欓∫“≈®ÿÓ≈ß°√≥å °√ÿ߇∑æ¡À“π§√

·æ∑¬åÀ≠‘ß«√¡π ‡®’¬¡»√’æß…å ‚√ß欓∫“≈æÿ∑∏™‘π√“™ æ‘…≥ÿ‚≈°

𓬷æ∑¬å«“π‘™ ªî¬π‘√—π¥√å ‚√ß欓∫“≈æ√–¡ß°ÿƇ°≈â“ °√ÿ߇∑æ¡À“π§√

·æ∑¬åÀ≠‘ß«‚√™“ ¡À“™—¬ ‚√ß欓∫“≈®ÿÓ≈ß°√≥å °√ÿ߇∑æ¡À“π§√

𓬷æ∑¬å»µ«√√… ∑Õß «— ¥‘Ï ‚√ß欓∫“≈¡À“√“™π§√‡™’¬ß„À¡à ‡™’¬ß„À¡à

𓬷æ∑¬å»√—≥¬å «√√≥¿“ π’ ‚√ß欓∫“≈ √√æ ‘∑∏‘ª√– ߧå Õÿ∫≈√“™∏“π’

𓬷æ∑¬å»ÿ¿™—¬ »√’»‘√‘√ÿàß ‚√ß欓∫“≈æ≠“‰∑ »√’√“™“ ™≈∫ÿ√’

𓬷æ∑¬å ¡™“¬ ≈’≈“°ÿ»≈«ß»å ‚√ß欓∫“≈»‘√‘√“™ °√ÿ߇∑æ¡À“π§√

𓬷æ∑¬å ¬“¡ »‘√‘π∏√ªí≠≠“ ‚√ß欓∫“≈√“™«‘∂’ °√ÿ߇∑æ¡À“π§√

𓬷æ∑¬å ‘π Õπÿ√“…Æ√å ‚√ß欓∫“≈∫”√ÿß√“…Æ√å °√ÿ߇∑æ¡À“π§√

·æ∑¬åÀ≠‘ß ÿæ√ µ√’æß…å°√ÿ≥“ ‚√ß欓∫“≈√“¡“∏‘∫¥’ °√ÿ߇∑æ¡À“π§√

𓬷æ∑¬å ÿ√‘¬– ®—°°–æ“° ‚√ß欓∫“≈√“¡“∏‘∫¥’ °√ÿ߇∑æ¡À“π§√

𓬷æ∑¬å ÿ‡∑æ °≈™“≠«‘∑¬å ‚√ß欓∫“≈®ÿÓ≈ß°√≥å °√ÿ߇∑æ¡À“π§√

𓬷æ∑¬åÕÿ¥¡ §™‘π∑√ ‚√ß欓∫“≈»‘√‘√“™ °√ÿ߇∑æ¡À“π§√

√“¬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

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