张凤武脾胃病学术经验总结及治疗慢性萎缩性胃炎的临床研究

发布时间：2018-06-04 21:27

本文选题：脾胃病 + 健脾化瘀解毒方　；参考：《中国中医科学院》2017年博士论文

【摘要】：[目的]张凤武主任医师为第五批全国老中医药专家学术经验继承指导老师,从医40余年,治疗脾胃病的经验颇具特色。本人作为其学术经验继承人,有幸拜张老为师,通过临床跟师学习、收集总结医案、与老师访谈、检索查阅相关论文书籍等方式,梳理张凤武主任学术经验渊源,总结其有关脾胃病治疗的学术特色,从而继承发扬名老中医的临证经验。张师尤其对慢性萎缩性胃炎的诊治效果最佳,从“脾虚”、“血瘀”、“邪毒”论治慢性萎缩性胃炎,并以此为法创立“健脾化瘀解毒方”,通过临床试验研究,探讨张师健脾化瘀解毒方治疗脾虚气滞、挟瘀毒内阻证型慢性萎缩性胃炎的临床疗效。[方法]从理论研究和临床试验研究两个方面系统总结老师治疗脾胃病学术经验。1理论研究方面通过搜集文献,整理老师临证医案、医话,精读四部经典和老师学术相关的书籍,导师授业与本人侍诊,形成既符合临床真实情况又反映导师脾胃病学术观点的经验总结、学术思想。2临床试验研究方面对张凤武主任治疗慢性萎缩性胃炎的经验方(健脾化瘀解毒方)进行临床研究。本研究病例来自于2014年6月-2015年10月期间至宁夏回族自治区中医医院国医堂张凤武主任门诊的慢性萎缩性胃炎患者92例。所有患者均符合经胃镜及病理结果确诊为慢性萎缩性胃炎,中医证型为脾虚气滞、挟瘀毒内阻证。利用spss19.0软件进行随机分组,分为治疗组和对照组,每组46例。治疗组:给予张氏“健脾化瘀解毒方”;对照组给予胃复春片。两组均治疗3个月后,比较对临床综合疗效、中医症状积分、胃镜下黏膜评分、组织病理疗效、幽门螺杆菌根除率等指标变化的观察,探讨健脾化瘀解毒方治疗脾虚气滞、挟瘀毒内阻证型慢性萎缩性胃炎的临床疗效。[结果]1理论研究方面1.1张凤武主任脾胃病学术经验的渊源张师的学术经验渊源于中医古籍经典理论、历代医家及当代名医的临床经验。张师认为《内经》中关于脾胃的理论是较为全面和系统的,是后世“脾胃乃后天之本”理论的渊源。张师在临床治疗各种疾病时,除辨证施治外,总不忘以调理脾胃为根本,注意顾护胃气,体现“脾胃为后天之本”的思想。《金匮要略》中强调“四季脾旺不受邪”,脾胃健旺,后天气血生化之源充足,则正气充盛,体质强健,能抵御外邪的入侵。“治肝实脾”理论出自《金匮要略·脏腑经络先后病脉证第一》,云:“夫治未病者,见肝之病,知肝传脾,当先实脾”,本条所论,在临床运用上很有指导意义。张师遵循《伤寒论》中对脾胃病变病因病机的阐述及顾护脾胃是《伤寒论》治疗六经病关键的治疗思想,在治疗各经疾病中均贯穿着养胃气、存津液的学术思想。《伤寒论》对于寒热错杂、阴阳失调所引起的脾胃病用半夏泻心汤、生姜泻心汤、甘草泻心汤、大黄黄连泻心汤等治疗,体现了仲景重视调理脾胃气机升降的学术思想,现在用之临床,仍每每获效。《临证指南医案》书中首提胃阴学说,治疗以甘凉柔润,滋养胃阴为主。张师在临床应用中,对症见胃阴虚证的患者,常用麦门冬汤、增液汤、沙参麦冬汤、玉女煎等方治疗,取得良效。清代医家吴鞠通在《温病条辨》中治疗三焦病证方面,提出了“治中焦如衡,非平不安”的著名论点,张师认为凡是以恢复中焦脾胃功能为最终目的的治则皆可谓吴鞠通所论及的“治中焦如衡,非平不安”。“治中焦如衡”,采用升降同调、寒热并进、燥湿相济、补泻兼施的方法,以使中焦如衡,恢复脾胃的功能。张师临证许多辨治方法、经验都根源于《脾胃论》的思想。1.2张凤武主任治疗脾胃病经验总结导师对脾胃病的病因病机有独到的见解,其认识来源于《内经》、《金匮要略》、《伤寒论》、《临证指南医案》、《温病条辨》、《脾胃论》等中医经典著作及当代各位名家经验。张氏认为脾胃病的病因病机主要有四个方面:脾胃气机升降失常,因滞而病;多种因素损伤,易致脾胃虚弱;久病入络,瘀血阻滞;内外相引,湿邪致病。张师认为准确的把握治疗原则,对治疗脾胃病非常重要,临床总结出张师治疗脾胃病特色有:注重通降论,以“通”祛疾;脾胃合治;脾胃分治;注重气血辨证论治;坚持标本论治:注意治胃病不忘健脾除湿热;注重调和肝脾;从心治脾。张师结合40余年临床经验,将六经辨证、脏腑辨证、三焦辨证融会贯通,根据以上治则治法总结出辨治脾胃病十法,即散寒温胃法、补气健脾法、消积导滞法、清胃安中法、和中醒胃法、疏肝和胃法、升清益胃法、降逆调胃法、化瘀通络法、滋阴润胃法。张凤武主任对胃镜下不同表现的7类胃炎,根据中医学“胃痞、胃痛”等证记载,对其有明显临床表现者,采用辨病与辨证相结合的诊疗方法,取得了良好的疗效。建立在治疗脾胃病的认识基础上,张主任对肠炎的治疗亦具特色。其辨治特点为:分清标本虚实;注重气血两调;把握温清并用;善以燥润相济;通涩结合、两相其美。2临床研究方面两组患者性别、年龄、病程及Hp阳性感染情况差异无统计学意义(P＞0.05)。两组临床综合疗效比较,经统计学检验,两组间差异有统计学意义(X2=11.03669,P＜0.05)。两组中医症状积分比较,治疗前两组患者症状积分无统计学差异(P＞0.05),治疗后治疗组和对照组症状积分均显著下降(P＜0.05),其中治疗组症状积分显著低于对照组,差异有统计意义(P＜0.05)。治疗前后胃镜下黏膜评分比较,两组患者治疗后胃镜下黏膜评分均较治疗前有所改善,差异有统计学意义(P＜0.01),治疗组治疗后胃镜下黏膜评分与对照组比较差异有统计学意义(P0.01)。治疗前后病理疗效比较,治疗组和对照组治疗前胃黏膜萎缩积分、肠上皮化生积分和异型增生积分差异无统计学意义(P＞0.05),治疗后治疗组和对照组上述各项病理积分均显著改善(P＞0.01),其中治疗组治疗后萎缩程度积分显著低于对照组,差异有统计学意义(P＜0.01),但肠上皮化生积分和异型增生积分与对照组比较,差异无统计学意义(P＞0.05)。两组幽门螺杆菌根除率比较,治疗前治疗组Hp感染例数为30例(68.18%),对照组为27例(62.79%),两组间的Hp感染率比较差异无统计学意义(P＞0.05)。治疗后治疗组Hp阳性9例,根除率70.0%;对照组Hp阳性14例,根除率48.15%,两组根除率比较差异有统计学意义(X2=6.422723,＜0.05)。安全性评价,治疗组及对照组患者在服药过程中均未出现发热、皮疹等不良反应,治疗前、后血常规、尿常规、肝肾功能、心电图检查未见异常。[结论]张凤武主任熟读各种中医典籍,吸收各医家学术精华,形成了其治疗脾胃病的学术经验特色。中药健脾化瘀解毒方治疗组与对照组治疗后两组症状及病理均有所改善。健脾化瘀解毒方治疗后一方面可以明显缓解患者胃痛、胃胀以及嗳气、纳呆、疲倦和嘈杂等不适症状,并能改善胃镜下胃黏膜局部循环,另一方面还能促进萎缩腺体恢复,缓解胃黏膜炎症状态,并有效提高Hp清除率。
[Abstract]:[Objective] director Zhang Fengwu, the director of the fifth batch of academic experience of Chinese traditional Chinese medicine, has been the successor to the academic experience of the Chinese traditional Chinese medicine. After 40 years of medical treatment, the experience in the treatment of spleen and stomach disease is quite distinctive. I have been the successor of his academic experience. I have been lucky to be the teacher of Zhang Lao, to collect and summarize the medical cases, interview with the teacher, and search and consult the related papers. And so on, combing the origin of Zhang Fengwu's academic experience, summarizing the academic characteristics of the treatment of spleen and stomach disease, so as to inherit the clinical experience of the famous old Chinese medicine. Zhang Shi especially has the best treatment effect on chronic atrophic gastritis, from "Spleen Deficiency", "blood stasis", "evil poison" on chronic atrophic gastritis, and in this way, "spleen invigorating the spleen" is established. To explore the clinical efficacy of Zhang Shi Jianpi Huayu Jiedu recipe in the treatment of spleen deficiency qi stagnation and stasis syndrome type chronic atrophic gastritis through clinical trial and study. [Methods] from the two aspects of theoretical research and clinical trial research, a systematic summary of the academic experience of the academic experience of the treatment of spleen and stomach disease in the.1 theory was collected and the literature was collected. The teacher is a medical case, a medical case, a medical language, a intensive reading of four classics and academic books related to teachers, tutors' teaching and personal consultation, which forms a summary of experience which is not only consistent with the clinical reality but also reflects the academic viewpoint of the spleen and stomach disease of the tutor. The experience of Zhang Fengwu's clinical trial and Research on the treatment of chronic atrophic gastritis (invigorating spleen and removing stasis) is an empirical prescription for Zhang Fengwu. 92 cases of chronic atrophic gastritis with chronic atrophic gastritis in the outpatient of Zhang Fengwu, state medical hall, the Ningxia Hui Autonomous Region Hospital of traditional Chinese medicine in the Ningxia Hui Autonomous Region, in October June 2014. All patients were diagnosed with chronic atrophic gastritis by gastroscopy and pathological results. The syndrome type of TCM was spleen deficiency qi stagnation and blood stasis poisoning. The internal resistance syndrome was divided into the treatment group and the control group by spss19.0 software. The treatment group was given 46 cases in each group. The treatment group was given Zhang's "Jianpi Huayu Jiedu recipe", and the control group was given Wei Fu Chun tablets. The two groups were treated for 3 months, compared with the clinical comprehensive effect, the TCM symptom score, the gastroscope mucosa score, the histopathological curative effect and Helicobacter pylori. The clinical curative effect of Jianpi Huayu Jiedu Recipe on spleen deficiency qi stagnation and stasis syndrome type chronic atrophic gastritis was observed. [results] the academic experience of 1.1 Zhang Fengwu's academic experience on the academic experience of Zhang Fengwu's spleen and stomach disease originated from the classical theory of ancient Chinese books, the immediate medical and Contemporary famous doctors. The theory of the spleen and stomach in the inner Sutra is more comprehensive and systematic, and it is the origin of the theory of "spleen and stomach in the future" in later generations. In the treatment of various diseases, Zhang Shi is always taking care of the stomach as the root of regulating the spleen and stomach, and reflecting the thought of "the spleen and stomach for the day of the day". The theory of "four seasons splenic flourish does not receive evil", the spleen and the stomach flourish, the natural Qi and blood biochemical source is sufficient, the positive gas is filled, the constitution is strong and strong, it can resist the invasion of the external evil. "The liver and the spleen" theory comes from the first of the golden chamber and the viscera meridian meridian syndrome first >, cloud: "the disease of the liver, the liver spleen, the first real spleen", is discussed in this article. The clinical application is of guiding significance. Zhang Shi follows the elaboration of the etiology and pathogenesis of the spleen and stomach diseases in the theory of typhoid fever and the key treatment idea of protecting spleen and stomach is the key to the treatment of six meridian diseases. In the treatment of various diseases, the academic thought of nourishing stomach Qi and storing body fluid is carried out in the treatment of various diseases. Banxia Xiexin Decoction, ginger Xiexin soup, liquorice diarrhea heart soup, Huanglian Xiexin Decoction and other treatment, embodies the academic thought of Zhongjing to regulate the lifting of the spleen and stomach qi, and is still used in clinical. The patients of yin deficiency syndrome, commonly used in the treatment of mamaendong soup, Zeng liquid soup, Sha Shen maidun soup and Jade Maiden decoction, have achieved good effects. The famous Qing Dynasty physician Wu Jutong put forward the famous argument of "treating the central coke as a balance and unpeace" in the treatment of the disease of the disease. It is called "treating middle Jiao like balance, unpeaceful and unpeaceful". "Treating middle coke like balance", using the method of lifting and regulating, cold and heat and entering, drying and damp, making up and reducing the function of the spleen and stomach, so as to restore the function of spleen and stomach, the experience is rooted in the experience of.1.2 Zhang Fengwu, director of the spleen and stomach theory, in the treatment of spleen and stomach disease experience. The knowledge of the etiology and pathogenesis of spleen and stomach disease was summed up by the tutor. Its knowledge came from the classic works of traditional Chinese medicine such as Neijing, "Golden Chamber", "Treatise on Febrile Disease >", "medical case guide", "Clinical Guide to syndrome", "spleen and stomach theory >" and other contemporary experience. The main causes of spleen and stomach disease are four aspects: the disorder of the spleen and stomach qi and the stagnation of the spleen and stomach qi. And the disease; a variety of factors injury, easy to cause weakness of the spleen and stomach; long illness into the collaterals, blood stasis block; internal and external lead, damp pathogenic pathogenic. Zhang Shi believes that accurate grasp the principle of treatment of the spleen and stomach disease is very important to treat the spleen and stomach disease characteristics: pay attention to the "Tong" theory, "Tong" and dispel disease; spleen and stomach treatment; spleen and stomach differentiation and treatment; pay attention to Qi and blood syndrome differentiation and treatment Adhere to the treatment of the specimens: pay attention to the treatment of stomach disease to improve the spleen and damp heat; pay attention to the harmony of the liver and spleen; treat the spleen from the heart. Zhang Shi combined with 40 years of clinical experience, the six meridian syndrome differentiation, the viscera syndrome differentiation, the three focal syndrome differentiation and integration, according to the above treatment method, summed up the differentiation and treatment of spleen and stomach disease ten methods, that is, the method of dispersing the spleen and stomach, invigorating the spleen and invigorating the spleen, eliminating the accumulation and guiding method, clearing stomach safety method, and the method of clearing the stomach in the stomach. The method of stomach and stomach, liver dredging and stomach, ascending and clearing stomach, lowering stomach and stomach regulating stomach, removing blood stasis and dredging collaterals, nourishing yin and moistening stomach. The 7 kinds of gastritis with different manifestations of gastroscope under the gastroscope of Zhang Fengwu were recorded according to the TCM "stomach ruffian, stomachache" and so on. Based on the understanding of the treatment of spleen and stomach disease, Mr. Zhang's treatment of enteritis is also characteristic. The characteristics of the treatment are as follows: distinguish the false and solid of the specimen; pay attention to the two tone of Qi and blood; grasp the temperature and the use; the good with the dryness and temper; the two groups of patients' sex, age, course of disease and positive infection of the two phases of the.2 clinical study Meaning (P > 0.05). Two groups of clinical comprehensive curative effect comparison, the difference between the two groups was statistically significant (X2=11.03669, P < 0.05). The two groups of TCM symptom scores were compared, the symptom scores of the two groups before the treatment were not statistically significant (P > 0.05), and the symptom scores of the treatment group and the control group were significantly decreased (P < 0.05), among them, the treatment group was symptomatic. The difference was significantly lower than that of the control group (P < 0.05). The mucosa scores of the two groups before and after the treatment were better than those before treatment, and the difference was statistically significant (P < 0.01). The difference of the mucous membrane score under the gastroscope of the treatment group was statistically significant (P0.01). Before and after treatment, the score of atrophy of gastric mucosa in the treatment group and the control group was not statistically significant (P > 0.05). All the pathological scores of the treatment group and the control group were significantly improved (P > 0.01) after treatment (P > 0.01), and the scores of the atrophy degree after treatment were significantly lower than those in the treatment group. The difference was statistically significant (P < 0.01), but there was no significant difference between the intestinal metaplasia score and the dysplasia score in the control group (P > 0.05). The number of Helicobacter pylori eradication in the two groups was 30 (68.18%) and 27 (62.79%) in the control group, and there was no statistical difference in the rate of Hp infection among the two groups. Learning significance (P > 0.05). After treatment, 9 cases were positive in the treatment group, the eradication rate was 70%, 14 cases with Hp positive in the control group and 48.15% of eradication rates. The difference of eradication rates in the two groups was statistically significant (X2=6.422723, < 0.05). The safety evaluation, the treatment group and the control group had no fever, rash and other adverse reactions, before and after the treatment. There was no abnormality in the routine urine, liver and kidney function and electrocardiogram. [Conclusion] director Zhang Fengwu was familiar with various classics of traditional Chinese medicine and absorbed the academic essence of various doctors, and formed its academic experience in the treatment of spleen and stomach disease. The symptoms and pathology of the two groups were improved after the treatment of the Chinese medicine Jianpi Huayu Jiedu Fang treatment group and the control group. On the other hand, it can obviously relieve the discomfort symptoms such as stomach pain, stomach distention, belching, tiredness, fatigue and noise, and can improve the local circulation of gastric mucosa under the gastroscope. On the other hand, it can also promote the recovery of atrophy glands, relieve the inflammatory state of the gastric mucosa and effectively improve the Hp clearance rate.
【学位授予单位】：中国中医科学院
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R259;R249

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