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研究生:詹宜學
研究生(外文):Yi-Hsueh Chan
論文名稱:糖尿病患者胃排空時間與臨床症狀表現之相關性
論文名稱(外文):Investigation of gastric emptying and upper gastrointestinal manifestation among patients with diabetes mellitus
指導教授:吳明賢吳明賢引用關係
口試委員:劉俊人曾屏輝
口試日期:2019-06-28
學位類別:碩士
校院名稱:國立臺灣大學
系所名稱:臨床醫學研究所
學門:醫藥衛生學門
學類:醫學學類
論文種類:學術論文
論文出版年:2019
畢業學年度:107
語文別:中文
論文頁數:29
中文關鍵詞:糖尿病胃排空胃輕癱血糖併發症
DOI:10.6342/NTU201901831
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研究背景
腸胃道的活動主要由以下幾種機制調控,腸道內的生理刺激誘發調節功能,進而幫助消化,消化的機制也會因感覺的傳入而被刺激。糖尿病的病人會因血糖控制不好而出現併發症,如果造成神經病變,胃及小腸的感覺與運動功能皆會受到影響。人在禁食空腹時,胃會收縮與放鬆以便食物的堆積,開始進食以後,胃便會開始再收縮,造成胃排空的機轉。若是神經傳導功能受損便有可能影響胃排空,造成嘔吐,胃漲等症狀。糖尿病的神經病變會影響腸胃道的蠕動,這可能導致多種症狀,如腹瀉,便秘,腸脹氣和腹痛,感覺神經的受損也會造成腸胃道的異常感覺。
高血糖已經被認為是造成胃排空遲緩的主要原因之一,雖然急性的高血糖和慢性的高血糖會造成胃排空遲緩,然而,胃排空遲緩與impaired glycemiccontrol 或hypoglycemia in diabetes 之間的關係依然不明。
似乎糖尿病病人因血糖控制不好而造成的腸胃道症狀與胃排空遲緩有相關性。2016 年一群印度學者去研究比較胃排空遲緩與腸胃道症狀在糖尿病病人中的相關性,再進一步去分析比較與HbA1c,BMI,性別,年齡,腎病變之間的相關性,結論發現胃排空遲緩與低血糖,大小血管病變有關,HbA1c,BMI 可當其預測因子。
胃排空遲緩的人在胃鏡下容易看見剩餘的食物,同時兩者之間的嚴重度是相關的,造成胃排空遲緩的原因可以簡單分為阻塞性與非阻塞性,排除掉阻塞性的因素,藥物,神經病變,都是造成胃排空遲緩的原因。

研究目的
糖尿病患者因血糖控制不好,常見併發症包含神經受損,視網膜病變,腎病變以及胃輕癱。其中消化系統症狀如腹脹、胃內容物逆流,反胃、便秘、腹瀉及失禁也常為糖尿病患者到門診尋求治療原因。病人往往接受胃鏡檢查後針對胃鏡結果開始治療仍然沒有改善。糖尿病患者常見胃腸蠕動功能異常,此研究目的在於探討胃蠕動功能與病人血糖控制及臨床症狀表現之間的關係。

研究對象
西元2017年1月至西元2019年2月在台北馬偕醫院接受過胃排空測定患者,排除3 個月內未接受過胃鏡檢查,有胃潰瘍,胃接受過手術的病人。將患者分做有糖尿病(實驗組)及沒有糖尿病(控制組)兩群,分析病人胃排空結果,胃鏡檢查結果,血糖,血脂肪,過去病史,用藥歷史(會影響胃腸蠕動之藥物)與臨床症狀。(圖1)

研究方法
Gastric emptying time 胃排空測定,為馬偕醫院核子醫學科本來就有的檢查。檢查患者喝下約30 克即溶燕麥,內加少量造影劑,接受照影檢查。藉此檢查判斷患者胃排空功能。檢查所使用造影劑,對身體不會造成不良反應,也沒有過敏反應。除建議檢查後一週內物出國,兩天內勿接觸孕婦小孩,不會造成患者傷害。
糖尿病的定義:根據American Diabetes Association Criteria 飯前空腹血糖大於 126mg/dl, 或糖化血色素 (HbA1c) 大於6.5%。

研究結果
第一部分:共28 位病人符合本研究,13 位病人沒有糖尿病,15 位病人為糖尿病患者,平均年齡比為43 歲比55 歲,女性比為9 比3,胃鏡檢查與臨床症狀表現無明顯差異,胃排空時間於糖尿病患者明顯高於非糖尿病患者。(表1)
第二部分:進一步討論15 位糖尿病患者,4 位符合胃排空延遲,2 位符合胃排空加速,9 位為正常胃排空。年紀,性別,臨床症狀皆無明顯差異。糖化血色素分別為12%,7.5%,7.9%。(表2)

討論
所有病人中,被排除掉的一位病人符合胃排空遲緩,本身因為嚴重胃食道逆流接受過胃底折疊術治療。可見胃排空遲緩與手術及胃食道逆流之關聯性。四位被排除的病人有消化性潰瘍,符合正常胃排空。胃潰瘍是否會影響為排空能進一步探討。一位非糖尿病51 歲女性患者,過去沒用藥或過去病史,符合胃排空遲緩緩,原因不明。其餘符合胃排空遲緩之患者,皆為糖尿病患,平均糖化血色素12%,一位還因糖尿病身經病變接受過截肢手術,可見血糖控制不良與糖尿病神經病變及胃排空遲緩的相關性。所有患者中有兩位符合胃排空加速,皆為糖尿病患,與我們認知糖尿病造成胃輕癱大相徑庭,探討者兩位患者,臨床表現卻又如同胃輕癱之患者。為何有如此表現,可見血糖對於神經的影響應可以有更多討論。本研究因為個數量不夠,需要更多的個數量來進一步的統計分析。

結論
血糖控制越差的病人越容易造成胃排空功能遲緩,使病人常感到腸胃道不適。糖尿病患者也可能造成胃排空加速而感到腸胃道不適。胃排空檢查結果,血糖控制情形與病人臨床症狀表現未發現相關性,需要更多的數據與個數來做更進一步的統計分析。
The patient who have diabetes mellitus with poor control usually suffered from many complications such as retinopathy, neuropathy and cardiovascular disease. Gastrointestinal symptoms like abdominal fullness, gastroesophageal reflux disease, constipation and diarrhea had high occurance rates in patient with poor sugar control. Gastroparesis is a chronic syndrome caused by delayed gastric emptying in the absence of mechanical obstruction and is accompanied by symptoms such as post prandial fullness, bloating, nausea, vomiting and easy satiety. Therefore, we arranged gastric emptying scintigraphy for the people with diabetes mellitus. We discuss association of gastric emptying time and gastrointestinal manifestations among people with diabetes mellitus.
The patient has history of diabetes mellitus. The patients suffered from upper gastrointestinal symptom who visited to our gastrointestinal outpatient clinic. We arranged ultrasonography and upper gastrointestinal endoscopy examination. Past medical and family history are collected. Blood examination such as fasting glucose, HbA1C, cholesterol and triglyceride are collected. We arrange gastric emptying scintigraphy for the patients who had done endoscopy examination and still suffered from upper gastrointestinal symptom even received treatment. The patients collected from January 2017 to February 2019. This is a single center retrospective study.
Total seven patients exclude from the study. One patient do not arranged upper endoscopy examination. Four patients upper endoscopy reveal peptic ulcer disease. One patient suffered from GERD for long times and received fundoplication surgery. One patient is obesity and post bariatric surgery. There are twenty eight patients include in the study. Thirteen patients are not diabetes mellitus patients. One of the patient without DM have delayed gastric emptying time. Twelve patients have normal gastric emptying time. Fifteen patients have diabetes mellitus. Four of the patient with DM have delayed gastric emptying time. Two of the DM patients have rapid gastric emptying time. The other patients with DM have normal gastric emptying time.
The patients with diabetes mellitus under poor control may suffered delayed gastric emptying. Some diabetes also have rapid gastric emptying. However, the clinical symptoms among delayed and rapid gastric emptying are not different. We assumed that diabetes neuropathy may affect not only motor neuron but also sensor neuron. The relations between gastric emptying (rapid and delayed), sugar control and clinical symptom are still not clear, which need more cases and studies to discuss.
序言與謝辭………………………………………………………………….……….1
中文摘要………………………………………………………….…………........2,3,4
英文摘要……………………………………………………………………….…..5,6
論文內容
第一章Introduction…………………………….……………………….…10,11,12
第二章 Methods and material ……………………………………………….13,14,15
第三章 Result ………………………………….……….……………………....16,17
第四章 Discussion …………………………………………….……..……...18,19,20
第五章 Conclusion …………………………………………….……………….….21
參考文獻……………………………………………………………….22,23,24,25,26
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