沈舒文辨治萎缩性胃炎经验诠释及萎缩性胃炎癌前病变医案挖掘研究

发布时间：2018-01-20 13:10

  本文关键词： 学术经验 萎缩性胃炎 沈舒文 胃癌前病变 医案挖掘　出处：《中国中医科学院》2016年博士论文　论文类型：学位论文

【摘要】：研究背景：名老中医临床经验继承是中医药领域当前带有使命性的工作,国家“十五”科技支撑计划将“名老中医学术思想、经验传承研究”纳入研究之列。沈舒文教授是陕西中医药大学二级教授、陕西省首批名中医、全国第四、第五批名老中医药专家学术经验继承指导老师,他中医理论造诣颇深,临床经验丰富。我作为学术经验继承人对他辨治慢性萎缩性胃炎的经验进行研究整理,并将他治疗过的发生在慢性萎缩性胃炎(chronic atrophie gastritis, CAG)基础上的胃癌前病变(Precancerous lesion of gastric cacer, PLGC)医案采用数据挖掘方法进行了深入研究。研究目的：系统总结沈舒文教授辨治萎缩性胃炎的临床经验和学术思想,旨在继承他辨治CAG的临床经验,并从学术层面探讨学术思想；通过对发生在CAG基础上的120例萎缩性胃炎癌前病变(PLGC)医案进行数据化挖掘研究,揭示沈舒文教授辨治PLGC取得良好疗效的科学内涵,并为学术经验继承工作作出有益的探索。研究方法：临床经验与学术思想研究部分采用“领悟法”：通过研读导师论文、跟师侍诊学习、导师答疑解惑、整理导师医案等学习方式,领悟导师辨治CAG的思想渊源、学术思想及临床经验,并加以整理、凝练、梳理,达到挖掘、掌握、继承的学习目的。PLGC临床医案挖掘研究的方法：首先构建了《名中医辨证论治的临床医案证候单元化管理系统》数据库,并将其作为沈舒文教授临床医案采集记录与统计管理的载体,对导师近3年来诊治过的发生在CAG基础上的120例萎缩性胃炎癌前病变医案先进行病位、病性、病势等证候要素的辨识提取,再进行证候术语规范化,形成证候单元诊断,然后对其病名、病位、病性、证候类型、治法及使用药物等的频次、用药归类、处方组成及各项疗效指标等进行数字化挖掘分析,以揭示其经验性疗效的科学内涵及临床思维特征。研究结果：学术经验研究结果：1.沈舒文教授辨治CAG的学术思想首先源于《内经》,彰显了土生万物的观点；并汲取各家之长,融会贯通,辨治CAG以寒热错杂痞满为主者效法张仲景,常以半夏泻心汤等消痞散结,脾胃虚寒胃痛者以黄芪建中汤等甘补温运；以痞满纳差为主者常师李东垣以枳实消痞丸助纳运,胃胀腹泻则以补中益气汤补脾升阳；以嘈杂为主者则宗叶桂养阴滋胃,常用自拟养阴益胃汤,血瘀胃痛常用失笑散或丹参饮化瘀通络；制方得何伦教授真传,组方注重脾胃纳运、升降、燥湿(润)结合,方药精道。2.沈舒文教授辨治CAG的临床思维方法为：采病史四诊合参,舌为胃之镜,尤重舌诊,详于问诊；采用辨析标本的临床思维方法,CAG证候结构多呈虚实关联证。3.沈舒文教授辨治CAG的学术观点与临床经验有：对CAG病机提出“滞损交加”论,其“滞”有气滞、食滞、湿滞、络滞之分,其“损”则有气虚及阴虚之别,治疗“补虚治本,通滞治标”,补虚与通滞相兼；根据胃以润为降的特性,辨治CAG擅长养胃阴以和胃气；对PLGC提出“毒瘀交阻”核心病机论,长于用“益气养阴,解毒化瘀”治法；制方用药经验特点为组方药执简驭繁,走精方之道,根据脾胃功能特性及病机特点反向用药有特色,纳运失常注重化纳相助,升降失常则升降合用,脾湿胃燥善燥湿(润)相济,善用组药,灵活多变,师古不泥,创制验方。萎缩性胃炎癌前病变临床医案挖掘研究结果：医案挖掘统计结果显示PLGC病名以痞满(占38.33%)和嘈杂居多(占20.83%),其首诊临床症状中出现频率较高的症状依次为：胃脘痞满饱胀嘈杂胃脘疼痛口千胃灼热感,与其基础病变CAG无差异性。病位可涉及胃(占90.00%)、脾(占76.67%)、肝、胆、腹、肾等,以胃、脾为主,也常涉及肝。病性有邪实与正虚之辨,统计显示邪实依次为气滞(气逆)毒瘀湿热寒凝血瘀痰湿,而以毒瘀交阻、气滞、湿热最为多见；其虚证依次为胃阴虚脾气虚中阳虚肝血虚肾阳虚,而以胃阴虚及脾气虚为主；医案病性统计显示毒瘀、气或阴虚、气滞在首诊及复诊中均占有很大比例,其中气或／并阴虚占63.14%,毒或／并瘀共占58.62%。病程中常有因虚致实,因实致虚的动态特征,且虚中常兼有实邪,从而呈现虚实兼夹之势,导师称其为虚实关联证。120例PLGC医案临床证候分型共有14种,其中单证侯有6种,单证侯类型者频次总计在证候结构类型中仅占23.73%,而虚实关联证达76.27%,揭示了PLGC具有本虚标实,虚实相兼,虚实相关联的证候特点,其中尤以气阴两虚并／兼毒瘀交阻证最常见(35.30%)。PLGC治法共有11种,其中以解毒化瘀(54.68%)、.益气养阴(42.61%)最常用,其次为和降胃气(35.14%)。120例医案共收集处方1218张,用药累计15398频次,平均每张处方用药12.6味,用药频次大于10次者共96种。治疗用药中抗肿瘤(解毒)药、活血化瘀药、补阴药、补气药单药使用频次较高,其次理气药使用频次相对也高。治疗用药频次在280次以上的核心药物依次有：麦冬、半枝莲、石斛、莪术、太子参、半夏、枳实、黄连、藤梨根、刺猬皮、白术、佛手、旋复花、黄药子、吴茱萸、丹参；治疗PLGC的解毒抗癌核心用药主要有莪术、枸橘、半枝莲、藤梨根、山慈菇、黄药子。本研究对PLGC常见证侯处方组成(主要药物频次)也进行了统计,以揭示其处方用药规律。医案统计结果显示患者辨证治疗前后其临床症状嗳气改善P0.05,其余主要症状及症状总积分比较均PO.01,表明治疗前后差异具有统计学意义；中医证候疗效有效率达94.17%；治疗后患者胃镜下改变、病理检查胃黏膜炎症活动度、萎缩、肠化、异型增生均疗效显著；胃镜及活检病理积分治疗前后比较均P0.01,提示统计学差异显著；PLGC伴有Hp感染者高达60.83%,而中医药辨证论治具有较高的根除率84.93%；120例医案共有2例发生癌变；辨证论治PLGC的综合疗效达86.67%。治疗前后患者尿、血、粪常规及肾功、肝功、心电图等安全性指标均无明显异常变化。结论：1.沈舒文教授辨治CAG的学术思想源于《黄帝内经》,兼收并蓄了张仲景、李东垣、叶天士等古代中医名家的辨治思想及用药特色,并得到老一辈中医药专家何伦教授的悉心指导,形成了自己独特的临床辨治思维及用药特色。2.沈教授辨治CAG提出“滞损交加”病机论及“虚实关联证”,治疗补虚与通滞相兼,注重养胃阴以和降胃气；对PLGC提出“毒瘀交阻”核心病机论；临床制方用药注重脾胃化纳相助,升降合用,燥湿(润)相济,灵活多变。3.萎缩性胃炎癌前病变临床医案数据挖掘研究结论：PLGC证候结构以虚实关联证居多；萎缩性胃炎癌前病变的核心病机为“毒瘀交阻,气阴两虚”；PLGC的核心治法为“解毒化瘀,益气养阴”；PLGC治疗的处方用药以益气养阴药及解毒化瘀药最为常用；沈教授辨治PLGC疗效显著；120例萎缩性胃炎癌前病变临床医案数据化挖掘研究能真实反映沈教授辨治PLGC的临床思维特征及遣方用药规律,其具有科学性,构建的《名中医辨证论治的临床医案证候单元化管理系统》成功用于临床是对名老中医学术经验继承工作做出的有益探索。本论文的创新点：1.系统整理了沈舒文教授辨治CAG的临床经验与学术思想。2.对沈舒文教授辨治萎缩性胃炎癌前病变临床医案运用数据挖掘的方法进行研究,在《名中医辨证论治的临床医案证候单元化管理系统》(2015年3月19日已获得中华人民共和国国家版权局计算机软件著作权登记证书：软著登字第0935887号)数据库构建中将辨识证候的四诊资料按照病位、病性、病势等证候要素提取,使证候辨识单元化隐藏在数据库中,并经测试使用能反映其辨治PLGC的临床辨治思维、用药频次、疗效判定等科学内涵,其具有创新性。
[Abstract]:Background: the old Chinese medicine clinical experience inheritance is the field of traditional Chinese medicine with the mission of the current work, "fifteen" National Science and technology support program "the name of the old Chinese academic thought, research experience into study. Professor Shen Shuwen is Shaanxi University of Chinese Medicine professor level two, the first batch of Shaanxi Province Traditional Chinese medicine, fourth of the country number fifth, an old Chinese medicine expert guidance teacher of academic experience inheritance, he has deep knowledge of traditional Chinese medicine theory, clinical experience. I as his heir to the academic experience of treating chronic atrophic gastritis experience of finishing, and he was treated in the chronic atrophic gastritis (chronic atrophie, gastritis, CAG) lesions on the basis of gastric cancer (Precancerous lesion of gastric cacer, PLGC) by using the data mining methods were studied. Objective: To summarize professor Shen Shuwen Wei Shrink gastritis clinical experience and academic thought, to inherit his clinical experience on treatment of CAG, and to explore the academic thought from the academic level; based on CAG on the basis of the 120 cases of precancerous lesions of chronic atrophic gastritis (PLGC) medical data mining research, reveal the scientific connotation of Professor Shen Shuwen on treating PLGC good effect and, as the academic experience inheritance made beneficial exploration. Research methods: clinical experience and academic research of the part of the "comprehend": by studying the learning with the teacher mentor, waitresses, teacher unriddling, the tutor records such as learning, understanding the thought origin of tutor on treatment of CAG, the academic thought and clinical experience, and finishing, concise, combing, to mining, master, clinical medical learning objective.PLGC inherited mining research methods: firstly build the clinical medical treatment of TCM "syndrome differentiation The syndrome element management system > database, and as professor Shen Shuwen carrier of clinical medical records and statistics collection management, tutor for nearly 3 years and had occurred in the CAG on the basis of 120 cases of atrophic gastritis and precancerous lesions of medical disease, illness, disease and syndrome factors identification then the extraction, the syndrome standardization, forming syndrome unit diagnosis, and then the name of disease, disease location, disease, syndrome type, treatment and drug use frequency, drug classification, prescription and the efficacy index of digital mining analysis to reveal the scientific connotation and its empirical effect the clinical thinking characteristics. Results: 1. academic experience of Professor Shen Shuwen in treating CAG's academic thought first in the < >, highlighting the native view and learn all things; the length of each CAG to mastery, and chills and fever ruffian With the main follow Zhang Zhongjing, often with Banxiaxiexin Decoction and Xiaopi Sanjie decoction, spleen deficiency with stomach Huangqijianzhong Gan temperature compensation; in the fullness of anorexia mainly by Li Dongyuan often Zhishuxiaopiwan help Na transport, bloating diarrhea with BUZHONGYIQITANG spleen sun; as to the noisy the main person in Guangxi leaves nourish yin and stomach, commonly used Nourishing Yin Yiwei decoction, blood stasis or common stomachache Shixiaosan danshenyin Huayu Tongluo prescription; why Professor Chuan Lun, lifting transport, pay attention to spleen and stomach, prescription, dampness (run) combined with clinical thinking method of prescription genital tract treated by Professor Shen Shuwen CAG for.2. history: collected four diagnostic methods, the tongue as a stomach mirror, especially in tongue diagnosis, detailed interrogation; clinical thinking methods of specimens, CAG syndrome is associated with card.3. structure and Professor Shen Shuwen CAG of the academic ideas and clinical experience are put forward: "the pathogenesis of CAG and hysteresis loss" 璁，

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