Izifo ze-ulcer Peptic

Ngokuningiliziwe nge-Peptic Ugcer Ulcer

Isifo sesilonda se-Peptic yisifo esivamile sokugaya okungagcini nje kuphela esingenza ukuphila kungakhululekile, kodwa kungabuye kube nemiphumela emibi kakhulu. Izentuthuko zakamuva-ikakhulukazi ulwazi olusha mayelana nezimbangela zalo kanye nokwelapha-ziye zashintsha ukunakekelwa kwesifo se-peptic ulcer. Uma wena noma othandekayo enezifo zesilonda se-peptic, kufanele uqiniseke ukuthi uqaphela ulwazi lwakamuva kule nkinga evamile.

Kuyini Ulcer Peptic?

Isilonda sophethisi ukukhukhula kwesibonda sesisu noma i-duodenum (ingxenye yokuqala yomathumbu amancane). Lezi zilonda zibizwa ngokuthi "i-peptic" ulcers ngoba zihlobene nomsebenzi we-asidi ne-pepsin (i-enzyme ebalulekile yokugaya) kumaseli afaka isisu ne-duodenum.

Isilonda esisodwa esitholakala esiswini sithathwa ngokuthi isilonda esiswini. Uma ku-duodenum kubizwa ngokuthi i-duodenal ulcer.

• Ukudla Okuhle Nokubi Kwezilonda ZasePeptic

• Ingabe Uzibeka Kulolonda?

Izimpawu zingahlukahluka phakathi kwalezi zinhlobo ezimbili zezilonda zamapulisi futhi udokotela wakho angabathinta kancane kancane. Odokotela babona abantu abanezilonda zamapulisi njalo. Nganoma yisiphi isikhathi esithile, amaphesenti angaphezu kweyodwa emhlabeni wonke azoba nesilonda se-peptic.

Izimpawu zesilonda se-peptic zingaba nzima kakhulu. Okubi nakakhulu, lezi zilonda zingaholela ekubalulekile, mhlawumbe imiphumela esongela ukuphila. Ngenhlanhla, kubantu abaningi bangaphiliswa futhi izinkinga ezinzima zingagwenywa ngezokwelapha ezifanele kanye nezinyathelo zokuvimbela izilonda eziphindaphindiwe.

Izimpawu

Uphawu oluyinhloko lwesilonda se-peptic lungumzimba wesisu .

Iningi labantu lizochaza ukuhlunga noma ukushisa okuvame ukutholakala emgodini wesisu noma ngaphansi kwezimbambo ngakwesokudla noma kwesobunxele.

Iphethini lobuhlungu besisu lingaxhomeke endaweni yesilonda. Ngezilonda zesisu, ubuhlungu buvame ukuqhutshwa kabi ngokudla futhi, ngezikhathi ezithile, umuntu one-ulcer esiswini angase (mhlawumbe engaqondakali) abuyele ekudleni futhi aze alahlekelwe isisindo esithile.

Ngokuphambene, izilonda ze-duodenal zivame ukhiqiza ubuhlungu phakathi kokudla lapho isisu singenalutho-ubuhlungu buvame ukukhululeka ngokudla okuthile. Abantu abanesilonda se-duodenal bavame ukulahlekelwa isisindo futhi bangase banesisindo.

Uma isilonda se-peptic sibe sikhulu ngokwanele, singase siphume sibe yisitsha segazi bese sikhiqiza ukuphuma kwegazi. Odokotela bakubiza lokhu ngokuthi "i- GI ephezulu " iphuma ngegazi ngoba isakhiwo sokuphuma kwegazi sisenhla ephezulu yesimiso sesisu. Izimpawu ze-GI ezingenhla zikhishwa ngegazi futhi zingenakwenzeka ukungazinaki, njengokuhlanza igazi elibomvu elibomvu.

Ngakolunye uhlangothi, uma ukuphuma kwegazi kuhamba kancane , izimpawu zingase zibe ezicashile futhi zingase zibe nokuqala kokubuthakathaka kancane kancane (kusuka ekuphefumuleni kwegazi ), isizungu , izimpande (kusukela ngokushesha kwenhliziyo), ukuchoboza esiswini (okubangelwa igazi elihamba phambili, futhi ecasulayo, amathumbu), kanye ne- melena noma i-tarry stool (ebangelwa inqubo yokugaya ukudla egazini egazini lomathumbu).

Isilonda esiphezulu esifundeni sesisu kanye ne-duodenum (indawo ebizwa ngokuthi isiteshi se-pyloric) singabangela ukuvuvukala ngokwanele esiswini esiswini ukuze kuvezwe isithiyo esinqunyiwe. Uma kunjalo, izimpawu zingase zibandakanye ukubhuka, ukuhlambalaza okukhulu, isicanucanu, ukuhlanza nokulahlekelwa isisindo. Abantu abanezilonda zamapulisi banomqondo ophakeme kakhulu wokuthuthukisa isifo se-reflux ye-gastroesophageal (GERD) kanye nezimpawu ezihambisana nayo, ikakhulukazi ukukhwabanisa .

Ngenkathi isilonda se-peptic senza ukuba kube khona izimpawu eziningi ezihlukahlukene, inani elimangalisayo labantu abanezilonda zamapulpers (mhlawumbe amaphesenti angu-50) kungenzeka lingaboni noma yiziphi izimpawu ezithile. Ngeshwa, ngisho nezilonda zamapulisi ezingabonakali ngokuqondile izimpawu zingase zidale izinkinga ezibalulekile.

Funda kabanzi mayelana nezimpawu zezilonda ze-peptic.

Izinkinga

Uma kuphela into e-peptic ulcers eyenziwe yayiwukuthi ibangele ubuhlungu besisu, kungenzeka ukuthi ingabhekwa njengenkinga enkulu kangaka. Kodwa, njengoba sesibonile kakade, bangenza okungaphezu kwalokho!

Izinkinga ezinkulu ze-peptic isilonda sesifo kufaka phakathi:

• Ukuphuza. Lokhu kuyinkimbinkimbi ejwayelekile kunazo zonke zesifo sezilonda zesilonda. Ukuphuma kwegazi kungancipha futhi kunokucabangela noma kungaba namandla futhi ngokushesha kusongela ukuphila. Ngokuphawulekayo, isilonda esiphuza kancane esingase singabonakali singagcina sibe yingozi esiphuthumayo yezokwelapha-uma iqhubeka ishiya isitsha segazi.
• Isivimbelo se-gastric outlet. Lesi simo-ukuvinjelwa ekuhlanganiseni kwesisu kanye ne-duodenum-kungabangelwa i-peptic ulcer yesifo noma i-scarring okungapheli ngenxa yesilonda se-peptic yangaphambili. Uma ukuvinjelwa kunzima, noma uma ukuvinjelwa okulinganiselwe kungaxazululwanga ngemuva kwesikhathi esifanele sokwelashwa kwezokwelapha, ukwelashwa okuhlinzayo kungadingeka.
• I-Perforation. Uma isilonda se-peptic sigxuma ngokuphelele odongeni lwesisu noma i-duodenum, kungabangela ukuguqulwa. I-perforation ingavumela isisu se-esiswini ukuba ivule emgodini wesisu, kubangele ubuhlungu obukhulu besisu esiswini futhi ngezinye izikhathi ukushaqeka . Ukuqothulwa kwesilonda se-peptic yisimo esisongela ukuphila. Ukwelashwa kudinga ukwelapha okuhlinzekwayo.

• Izimpawu zezilonda ze-Peptic

• Yiziphi Izinhlobo Zokuhlinzwa Zama-Ulcers E-Peptic?

• I-Fistula. Isilonda se-peptic singase siphambane nesitho esiswini esiseduze futhi senze i-fistula (okungukuthi, uxhumano) phakathi kwesisu noma i-duodenum nesakhiwo esiseduze. I-fistula ingase ihlanganise ne-colon, isihlahla se-biliary, ama-pancreas, noma isitsha esikhulu segazi. Kuye ngokuthi yiziphi izakhi ezithintekayo, izimpawu zingase zihluke ekuhlanzeni izinto ezibonakalayo zibe yizicucu ezinzima, ezinkulu noma ezibulalayo. Njengoba kufana ne-perforation, ukwelapha okuhlinzekwayo kuyadingeka ekwelapheni.

Funda kabanzi ngezinkinga zezilonda ze-peptic.

Izimbangela

Ezimweni eziningi, izilonda ze-peptic zibangelwa enye yezinto ezimbili:

1. Ukutheleleka nge-bacterium ebizwa ngokuthi i- Helicobacter pylori (H. pylori)
2. Ukusetshenziswa okungapheli kwezidakamizwa ezingekho-steroidal anti-inflammatory (NSAIDS)

Ukuqaphela ukuthi ukutheleleka kukaHl pylori kunomthwalo omkhulu uma kungenjalo isifo sesilonda esiyisifo se-peptic yisinye sezimbangela ezinkulu kakhulu kwezokwelapha emashumini ambalwa eminyaka edlule. Ukutheleleka okungapheli neHl pylori kuvamile kakhulu. Kulinganiselwa ukuthi okungenani amaphesenti angu-50 kubo bonke abantu aneHl pylori emaphepheni abo asezintweni ezisenhla. Futhi kukholelwa ukuthi lokhu bekulokhu kwenzeka emlandweni wesintu.

Ukucwaninga kubonisa ukuthi uHl pylori angadlulisela abantu izilonda ezincane ngezindlela eziningana ezahlukene, kuhlanganise:

• Ukwandisa ukuvimba kwesisu esiswini
• Kubangela ukuvuvukala
• Ukunciphisa izindlela zokuvikela zesisu esiswini
• Kubangela amangqamuzana esiswini (okuyinto i-secrete acid ne-pepsin) ukukhula emgqeni we-duodenum

Ukutheleleka kwe-An H. pylori kuvame kakhulu kubantu abane-peptic ulcer isifo. Amaphesenti angaba ngu-75 wezilonda zamaphilisi ase-US ahlotshaniswa nalokhu ukutheleleka-futhi inani liphakeme ezweni elingathuthuki. Ukuqeda uHhylori kuyisici esibalulekile sokwelashwa kwesifo sezilonda zesilonda.

Ukusetshenziswa okungapheli kwama-NSAID, kufaka phakathi i-aspirin, kwandisa ingozi yezilonda ze-peptic ngama-20. Abasebenzisi be-NSAID abane-H. pylori (iqembu, futhi, elibandakanya ngaphezu kwengxenye yabo bonke abantu) linyuke ngokuphindwe kabili kwesifo se-peptic ulcer.

Ama-NSAID acatshangwa ukuthi akwandise ingozi yezilonda ze-peptic ngokuvimbela i- COX-1 receptor emkhakheni wezinsikazi ophezulu. Ukuvinjelwa kwe-COX-1 kunciphisa ukukhiqizwa kwezinhlobonhlobo ze-prostaglandins ezisebenzela ukuvikela uketshezi kwesisu kanye ne-duodenum. (I-NSAID engavimbeli i-COX-1 receptor ithuthukiswe, kodwa lezi zithole idumela elibi ngenxa yokwanda okubonakalayo ezinkingeni zenhliziyo.)

Funda kabanzi mayelana nama-NSAID nenhliziyo .

Abantu abangaphandle kweHl pylori bangahlakulela izilonda ze-peptic, ikakhulukazi uma zisebenzisa i-NSAID. Abantu abangasebenzisi ama-NSAID bangahlakulela izilonda ze-peptic, ikakhulukazi uma bane-H. pylori. Kodwa abantu abanezici zombili lezi zinto baneengozi enkulu kakhulu ye-peptic ulcer isifo.

Nakuba i-H. pylori ne-NSAID i-akhawunti ye-peptic isilonda sesilonda, kunezinye izimbangela eziningi ezikhona. Lokhu kufaka:

• Ezinye izidakamizwa (ikakhulukazi i-steroids, i- clopidogrel , i- spironolactone , ama-SSRI, i-crack cocaine, i-methamphetamine, ngisho ne- acetaminophen )
• I-Chemotherapy ne-radiation therapy
• Izicubu eziningi kuhlanganise ne- Zollinger-Ellison syndrome ne- carcinoid syndrome
• Ezinye izifo, kuhlanganise i-herpes simplex ne-cytomegalovirus
• Izifo ezivuthayo ezifana nesifo sarcoidosis nesifo sikaCrohn
• Utshwala usebenzisa
• Ukubhema
• I-arterial artery disease ethinta imishanguzo ehlinzeka ngesisu noma i-duodenum
• Isimo somsoco esibi

Naphezu kwalokho obekuzwile konke ukuphila kwakho, abukho ubufakazi bokuthi ukudla noma yiluphi uhlobo lokudla okuqondile, njengezitsha ezivundiwe, lubangela isifo sesilonda se-peptic. Ungase uthole ukuthi, ngokwakho, ukudla ukudla okunye kungaholela ekuguleni, ukugxekwa, noma ezinye izimpawu zamathumbu-futhi uma kunjalo, kufanele uzigweme. Kodwa uyawagwema ukuze uzizwe ungcono, hhayi ukuvimbela isifo sesilonda se-peptic.

Ngokufanayo, ochwepheshe manje basusa umqondo wokuthi izilonda zibangelwa ukucindezeleka okunzima noma okungapheli ngokomzwelo, njengokubhekana nomphathi ocasulayo, ngaphandle uma ukucindezeleka kukuholela ekubhemeni, ekuphuzeni, noma ngokufaka okuningi kwe-Advil.

Funda kabanzi mayelana nezimbangela zezilonda ze-peptic.

Ukuxilongwa

Ukuhlolwa kokuhlolwa kwe-peptic isilonda sesilonda kunemigomo emibili ehlukene:

1. Ukusungula ubukhona noma ukungabikho kwesilonda se-peptic
2. Ukuhlola imbangela yesilonda, uma kukhona

Uma izimpawu zakho ziba mnene, udokotela wakho angase akufake emgodini wezokwelapha ukuvimbela isisu esiswini. Uma izimpawu zakho zihamba futhi ungabuyi emuva kwalesi silinganiso esilula, lokho kungase kube konke okukuyo. Kodwa-ke, uma izimpawu zakho ziba nzima kakhulu, noma uma izimpawu zakho zibuyela emuva emva kweklasi elifushane, ngokuvamile umqondo omuhle wokwenza ucwaningo olucacile. Namuhla, lokhu kwenziwa kahle kakhulu futhi kunembile ngokunenqubo yokugcina i- endoscopy .

Njengoba i-endoscopy, i-tube eguquguqukayo ene-fiberoptic system idluliselwa phansi kwesisu futhi isisu-futhi uhlangothi lwesisu nolwe-duodenum luboniswa ngqo. I-Endoscopy iyashesha futhi inembile. Ngaphezu kwalokho, uma isilonda sisekhona, ukuqina kwayo jikelele kungahlolwa futhi kungabuye kuhlolwe nganoma yiziphi izimpawu zokulimala-lapho kwenzeka khona i-biopsy. I-biopsy nayo iyasiza kakhulu ekutholeni ukuthi uHl pylori ukhona.

Izifundo zama-ray eziphezulu ze-GI , besebenzisa i-barium egwinyekile ukudala ukungafani, zingasetshenziswa futhi ukuxilonga izilonda zamapayipi. Kodwa-ke, lokhu kuhlolwa kunembile kakhulu kunokugcina i-endoscopy, kuthatha isikhathi eside, futhi akunikezi ithuba lamabhrikhi ukuhlola ukulimala okungenzeka noma uHl pylori. Kuhlanganisa nokuvezwa kwemisebe. Ngenxa yalezi zizathu, ama-x-ray awasasetshenziselwa kaningi ukuhlolisisa isifo sesilonda.

Uma kutholakala isilonda se-peptic, kubalulekile ukuhlola ukuthi ngabe ukutheleleka ku-H. pylori kukhona nokuthi ngabe ama-NSAID angaba yisici. Lolu lwazi lubaluleke kakhulu ekunqumeni ngokuphathwa okufanele.

Indlela engcono kakhulu yokuthola i-H. pylori ine-biopsy etholakala ngesikhathi sokuphela kwe-endoscopy. Ngaphandle kwalokho, ukuhlola ukuphefumula kwe-urea kungasetshenziswa. I-H. pylori iyimfihlo ye-enzyme eyenza ukuthi urea ngokweqile-okungatholakala ekuphefumuleni. Ukuhlolwa kwegazi nokuhlolwa kwesitokisi kungasetshenziswa futhi ukuthola uHl pylori.

Ngenxa yokuthi i-NSAID (futhi ngezinye izikhathi iminye imithi) idlale indima evelele ekuthuthukiseni izilonda ze-peptic, kubalulekile ukunikeza udokotela wakho i-akhawunti ephelele yawo yonke imithi oyisebenzisayo, imithi yesiguli noma ngaphezulu.

Uma unesilonda se-peptic futhi ungenayo i-H. pylori ukutheleleka noma ukusetshenziswa kwe-NSAID, udokotela wakho angadinga ukwenza ukuhlolwa okuqhubekayo kwezokwelapha, efuna ezinye izimbangela ezingase zenzeke. Esikhathini esiningi sabantu abanesifo se-ulcer peptic, lokhu akudingekile.

Funda kabanzi mayelana nokuthola izilonda ze-peptic.

Ukwelapha

Ezimweni eziningi, izilonda ze-peptic zingaphathwa ngempumelelo ngemithi yokwelapha. Ngokuvamile, ukwelashwa kwezokwelapha kunezinto ezintathu:

1. Ukuqeda H. pylori
2. Ukunikeza ukwelashwa kweproton pump inhibitor (PPI)
3. Ukuhoxisa izici ezithinta izilonda zamapayipi

Uma ukuhlolwa kulungile ku-H. pylori, isihluthulelo sokwelapha ngempumelelo isifo sesilonda se-peptic ukususa ukutheleleka nge-antibiotics. Ngokuvamile, ama-antibiotic amabili ahlukene asetshenziselwa izinsuku eziyisikhombisa kuya kwezingu-14-ngokuvamile i-clarithromycin, i-metronidazole, kanye / noma i-amoxicillin.

Kubalulekile ukuphinda uhlolwe i-H. pylori ngemuva kwenkambo yama-antibiotics ukuze ubhale ukuthi ukutheleleka sekuphelile. Uma kungenjalo, inkambo yokwelashwa, ukusebenzisa izidakamizwa ezahlukene noma imithi ehlukile, kuyodingeka. Ukwehluleka ukuphulukisa isilonda, nezilonda eziphindaphindiwe, kuningi kakhulu kubantu abanokutheleleka ngokwanele ngeHIV pylori.

Ukuphulukiswa kwe-ulcer nakho kungakhuthazwa ngokuvimbela ukuvinjwa kwesisu esiswini. Uma kutholakala isilonda se-peptic, lokhu kufezwa ngokusebenzisa i-PPI, njenge- esomeprazole (Nexium) , i-pantoprazole (i-Prevacid), i- omeprazole (i-Prilosec) , noma i-rabeprazole (i-AcipHex). Ukwehlisa i-asidi esiswini akusizi nje kuphela isilonda ukuphulukisa kodwa futhi kwenza ama-antibiotics asebenze kangcono ngokumelene neHl pylori. Ukwelashwa kwe-PPI kuvame ukuqhubeka ngamasonto ayisishiyagalolunye kuya kwangu-12 kubantu abanezifo zesilonda esiswini.

Ngaphezu kokugwema wonke ama-NSAID, noma ubani onesilonda sesilonda kufanele ayeke ukubhema futhi anciphise utshwala okungaphezu kwesisodwa esisodwa ngosuku (uma kunjalo).

Ngemuva kokuba kuthathwe ama-antibiotic, i-H. pylori yaqeda, amaviki ayisishiyagalolunye kuya kwangu-12 we-PPI ukwelashwa, futhi isusa ama-offensive agandaganda njenge-NSAID, amathuba okuphulukisa ngokuphelele isilonda se-peptic ahle kakhulu-ngokujwayelekile ngaphezu kwamaphesenti angu-90-95. Ngaphezu kwalokho, ingozi yesilonda esiphindayo isincane kakhulu.

Kodwa-ke, uma uHh pylori engakhulumi-noma uma uqhubeka (noma uqala) usebenzisa i-NSAIDS, ukubhema, noma ukudlala uphuzo oludakayo-kukhona ithuba elihle kakhulu ukuthi lesi silonda ngeke siphume noma singabuyela.

Ochwepheshe abaningi batusa ukuphindaphinda i-endoscopy ngemuva kokwelashwa kwesilonda esiswini sokuqinisekisa ukuthi ukuphulukisa sekuphelile. Izilonda zesikhumba esiswini ngezikhathi ezithile zakha esakhiweni somdlavuza wesisu- futhi kungabalulekile ukubona ngeso lengqondo indawo ngemuva kokwelashwa ukuqinisekisa ukuthi isayithi eliphulukisiwe livamile. Ngokuvamile akudingekile ukuphinda i-endoscopy ngemuva kokwelashwa kwesilonda se-duodenal.

Isilonda esiphezulu esingapheli ngemva kwamasonto angu-12 we-PPI ukwelashwa kubizwa ngokuthi i-"refractory" ulcer. Uma unesilonda esiphezulu phezu kwesinye isifundo sezinyanga ezingu-12 se-PPI therapy:

• Kungenzeka ukuthi ube nesinye i-endoscopy ene-biopsies eyengeziwe, efuna ukutheleleka kwe-H. pylori esele isetshenziswe, futhi uqinisekise ukuthi ayikho uphawu lwe-malignancy.
• Kungase kudingeke ukuthi ube nesidakamizwa esiphezulu sezokwelapha esibheka izimbangela ezingavamile zezifo zesifo sezilonda.
• Kufanele ulindele udokotela wakho ukuba ahlole kabanzi ngemikhuba yakho mayelana nokusetshenziswa kwe-NSAID, ukubhema, ukuphuza, nokunye ukusetshenziswa kwezidakamizwa.

Konke lokhu kuyadingeka. Ukuthola indlela yokwelapha isilonda esibonakalayo kubaluleke kakhulu, ngoba abantu abanezilonda ezinqabileko bangase bakhulekele enye yezinkinga ezimbi ze-peptic ulcer.

Ngingadluli, ukwelashwa kwe-peptic isilonda sesilonda kwakujwayelekile. Kodwa-ke, kusukela ku-H. pylori itholakala ukuthi iyimbangela ebalulekile futhi evame ukuyenza-futhi njengoba izidakamizwa ezinamandla ze-PPI zakhiwa-ukuhlinzeka kuvele kungadingeki.

Ukuhlinzwa manje kuyadingeka ikakhulukazi izilonda ezibonisa ukuthi ziphikisana ngokuphelele nokwelapha, zisolakala ukuthi zinezinkinga zokugula, noma njengokwelashwa kwezinkinga ze-peptic isifo sesilonda, njengegazi elikhukhulayo, ukuvinjelwa, ukukhwabanisa noma ukubunjwa kwe-fistula.

Funda kabanzi mayelana nokuphatha izilonda ze-peptic.

Izwi elivela

Nakuba isilonda se-peptic yinkinga ebalulekile yezokwelapha engaba nemiphumela emibi, ukuthuthukiswa kokunakekelwa kwezempilo eminyakeni embalwa edlule kushintshile ngokuphelele ukwelashwa kwalesi simo nokubikezelwa kwabantu abanakho.

Uma uthola ukuthi unesifo se-peptic ulcer, uma nje usebenza nodokotela wakho ukuze uthole isizathu esiyinhloko, landela ngokwethembeka iminyango emibili kuya kweyesithathu yokwelashwa kwezokwelapha okungenzeka kubekiwe, futhi ugweme imithi-nemikhuba-wena okufanele ukugweme, kukhona ithuba elihle kakhulu ukuthi isilonda sakho sizophulukisa ngokuphelele futhi ngeke siphindele emuva.

> Imithombo:

> Lau JY, Sung J, Hill C, et al. Ukubuyekezwa Okuhlelekile Kwe-Epidemiology Yezinkinga Eziyinkimbinkimbi Zezilonda Zase-Peptic: Ingozi, Ukuphindaphindiwe, Izingozi Zengozi Nokufa. Ukugaya ukudla 2011; 84: 102.

> Leodolter A, Kulig M, Brasch H, et al. Ukuhlaziywa kwe-Meta Ukuqhathaniswa Ukuqeda, Ukuphulukisa nokuphindaphindiwe Amanani ezigulane ne-Helicobacter pylori-ehambisana ne-Gastric noma i-Duodenal ulcer. Ukudla Pharmacol Ther 2001; 15: 1949.

> Li LF, Chan RL, uLu L, et al. Ukubhema nokubhema kwezifo: Ukubambisana kwe-Causal kanye Nezindlela Zokwakheka Kwama-molecular (Ukubuyekeza). I-Int J Mol Med 2014; 34: 372.

> Umfelandawonye P, Megraud F, O'Morain CA, et al. Ukuphathwa kwe-Helicobacter Pylori Infection - Umbiko we-Maastricht IV / Florence Consensus. U-Gut 2012; 61: 646.