拓展“玄府学说”针药结合治疗慢传输型便秘理论与临床研究

发布时间：2018-02-04 00:17

  本文关键词： 玄府学说 慢传输型便秘 理论和临床　出处：《辽宁中医药大学》2016年博士论文　论文类型：学位论文

【摘要】：目的:便秘作为症状已经被广大患者熟知,但真正因便秘而走进医院门诊就医的患者却相对较少,这与人民群众对便秘疾病本身的认识,和所能诱发心脑血管病发病认识较少有关,值得我们予以重视。由于该病发病率较高,西药治疗有一定的副作用,而中医药疗效好,故专注于中医中药或针灸等方法治疗此病的专家学者不占少数。特别是从事中医脾胃病研究的学者越来越多的开始关注功能性便秘这一疾病。现代医学对慢传输型便秘的病因,发病机制的研究主要集中在肠道平滑肌调控中的信息传递,胃肠道钛类激素的改变,胃肠道动力障碍,Cajal间质细胞等方面异常。近几年,对精神心理因素对便秘的影响也得到了高度的关注,但是,现代医学认识的关于慢传输型便秘发病的任何一种或一类病因,甚至几种病因的杂揉,也不能解释疾病的根本发病机制,这让药物研发遇到困难。由于其治疗的多靶点性,故针对便秘的药物治疗种类繁多,西药经临床应用,大部分初期患者早期用药效果较佳,但随着治疗时间的延长和推移,临床效果越来越不尽人意,药物的副作用如肠道黑变病等发生机率也随之而大大增加,这降低了患者对疾病治疗的耐心和信心,长期应用的停药依赖性更是又一问题的存在。在几千年的传承与创新中,对便秘的认识和治疗上,祖国医学积累了丰富的治疗经验。中医药包括针灸学在内的传统医学在防治便秘方面更显示了其独特的优势。依据中医药学的基本理论,“玄府学说”理论被导师陈苏宁教授高度重视。导师陈苏宁教授学贯中西,博览古今中医药学文献,结合自己几十年的临床实践,拓展中医“玄府学说”理论,认为“五脏六腑皆有玄府”,创新性的将腠理玄府理论应用在脾胃病治疗之中。尤其在功能性胃肠病的中医药治疗运用上,更是首次提出以“疏肝畅三焦,补脾益肺肾,开腠通玄府”三法立论的慢性便秘的治疗。陈教授通过大量的临床实践验证,认为慢传输型便秘病位虽在大肠,但与肝脾肺肾关系密切。临床上脾气不足无以健运,肝气郁结玄府闭塞,肺与大肠相表里,肺气不通腑气不降,病程日久可累及肺肾导致慢性便秘。因此,陈苏宁教授针对其肝郁脾虚,肺肾不足,玄府闭塞的病机,提出以针灸配合中药补脾疏肝,补益肺肾,开通玄府的治疗方法,组方胃痛消痞方加减配合针灸治疗慢性便秘,临床副作用小,疗效满意。本论文在“玄府学说”理论的指导下,主要从理论研究和临床观察两方面入手,观察针灸配合中药协定方胃痛消痞方加减治疗慢传输型便秘的临床疗效;深入探讨五脏玄府学说理论在便秘治疗中的理论基础。论文分为如下两部分:论文一:理论研究1.脾胃“玄府学说”理论基础探讨:从《黄帝内经》到刘完素的玄府孔隙理论,中医学对玄府的认识越来越深入,认为玄府是遍布全身最微的结构,是气血津液、脏腑气机和神机出入的通道。脾胃等脏腑亦有玄府,且可以通行脏腑之气。2.陈苏宁教授拓展“玄府学说”理论治疗慢传输型便秘经验总结。陈苏宁教授拓展传统医学玄府学说理论,认为:“五脏六腑皆有玄府”。而由此衍生的开玄府法,即通过宣通、畅利腠理之法,通达脏腑肌肤留存邪气,使气机升降有序的一种治疗方法,因其可宣通内外,较之汗法意义更为广范。开玄府法,皮肤、腠理、五脏六腑皆可应用。根据脾胃的玄府理论,消化系统疾病亦可应用,并介绍应用该法针药并举治疗此病经验。论文二:临床研究目的:在拓展脾胃“玄府学说”理论指导下,以临床试验为依据,研究针药结合治疗慢传输型便秘的临床疗效评价。通过观察慢传输型便秘患者的整体症状改善情况,结肠慢传输试验等主要指标,并应用评量工具包括生活质量量表(PAC-QOL)和情绪有关的自评量表(SAS、SDS)等进行指标对比分析,进而探讨开通玄府法对结肠慢传输型便秘的临床疗效,为开通玄府法治疗慢传输型便秘提供临床资料和客观事实依据,从而为日后玄府理论的拓展应用及开玄府法治疗便秘的实验研究提供思路,回溯开玄府法的理论基础,对拓展创新中医药学理论,造福患者具有重大意义。材料与方法:按照随机、对照的科研设计原则,根据疾病诊断标准和试验纳入标准,将2014年9月-2015年12月期间在辽宁中医药大学附属第三医院(辽宁省肛肠医院)盆底疾病治疗中心慢传输型便秘患者,对符合纳入标准和排除标准的90例(男42例,女48例)患者进行研究,随机分配分为3组,每组各30例。针药结合治疗组(A组,胃痛消痞方+辩证针灸);针药结合对照组(B组,麻仁软胶囊+常规针刺),单纯西药对照组(C组,莫沙必利组)。A组采用中药胃痛消痞方加减配合针灸治疗,B组采用麻仁软胶囊加常规针刺治疗,C组采用枸橼酸莫沙必利胶囊治疗。疗程共28天。在治疗前后应用结肠慢传输试验、肛管直肠测压和各量表作为评量工具进行评分,并做统计学处理,对患者治疗前后进行疗效观察。结果:1.基线资料比较:共纳入90例研究对象,A组、B组、C组各30例,3组病例在性别比例,年龄,病程及结肠传输试验结果和各量表评分等比较无差异(P0.05)。2.三组病例总体疗效经统计学分析,有显著性差异(P0.05)A组(针药结合治疗组),总有效率为96.66%;B组(针药结合对照组),总有效率为90%;C组(单纯西药对照组),总有效率为77%。A组优于B、C两个对照组。3.三组病例治疗后总体积分比较,A组与B组无显著差异(P0.05),但A组较C组有极显著差异(P0.01),说明A组(针药结合治疗组)较C组(单纯西药对照组)在改善便秘症状积分方面有显著优势。4.三组病例治疗前、后总积分组内比较,治疗后与治疗前相比:A、B、C三组总积分改善情况,有统计学差异(P0.05);说明三组用药治疗后,在总积分改善方面,都有一定的治疗作用。5.三组病例治疗前、后组内结肠慢传输试验比较,三组病例治疗后与治疗前相比,经统计学分析,三组治疗后与治疗前比较有显著差异(P0.05),比较时,A组明显于B组和C组(P0.01),A组具有指标方面的优势。6.三组病例焦虑、抑郁心理状态经统计学分析,A组与B组治疗前与治疗后均有统计学意义(P0.05);C组治疗前与治疗后比较,无统计学差异(P0.05)。其中,A组治疗后,SAS、SDS评分较B组显著下降,说明A组疗效优于B组。7.三组病例治疗前后组内生活质量量表积分比较,三组病例治疗前后经统计学分析,均有显著差异(P0.05);其中A组积分下降B组积分下降C组积分下降,说明在改善便秘患者的生活质量上,治疗组优于中药对照组优于单纯西药对照组。治疗组有显著优势。8.三组病例治疗前后肛管直肠测压结果比较,三组在治疗前后数据统计分析结果均无明显的统计学差异(P0.05)。结论:陈苏宁教授遵古而不泥古地拓展传统中医理论,将“玄府学说”应用于慢传输型便秘的中医药治疗,这在传承祖国医学,创新中医理论方面,具有重要意义。同时,依据玄府理论创立的胃消痞方加减配合针灸治疗结肠慢传输型便秘临床疗效满意,不但能显著地改善患者大便性状,促进排便,促进肠道蠕动,而且能改善便秘患者生存质量及焦虑抑郁状态。该方法疗效稳定,结果满意,为今后临床上治疗该病探索出一条新路。按照证候诊疗片断组的辩证模式,有利于中医辩证规范化应用,便于临床推广。
[Abstract]:Objective: constipation symptoms have been known as the majority of patients, but actually because of constipation patients into the hospital outpatient service is relatively less, and the people of the constipation disease itself, and the incidence of cardiovascular disease induced by less understanding about, worth our attention. Because of the high incidence of disease, have side effects some western medicine, Chinese medicine has good curative effect, so focus on Chinese medicine experts or acupuncture and other methods to treat the disease is not in the minority. Especially engaged in diseases of the spleen and stomach in TCM scholars more and more attention to constipation of the disease. Etiology of modern medicine on slow transit constipation, pathogenesis research mainly in the regulation of intestinal smooth muscle in the transmission of information, gastrointestinal hormones titanium changes, gastrointestinal motility disturbance, interstitial cells of Cajal and so on. In recent years, the mental The influence factors of constipation has also been highly concerned, but modern medical knowledge about the pathogenesis of slow transit constipation of any kind of cause, and even several causes are mixed up, also cannot explain the basic pathogenesis of the disease, which make drug development difficulties. The target in the treatment of therefore, according to the kinds of drug therapy of constipation are western medicine clinical application, most of the early patients with early treatment effect is better, but with the prolongation of treatment time and clinical effect goes on, more and more unsatisfactory, the side effects of drugs such as intestinal melanosis and incidence also increased greatly, which reduces the patients in the treatment of disease patience and confidence, the long-term application of the withdrawal dependency is another problem. In the inheritance and innovation for thousands of years, the understanding and treatment of constipation, traditional Chinese medicine has accumulated rich treatment Experience. Traditional Chinese medicine including acupuncture science of traditional medicine in the prevention and treatment of constipation has shown its unique advantages. Based on the basic theory of traditional Chinese medicine, "Xuanfu theory" by Professor Chen Suning. Professor Chen Suning attaches great importance to the Chinese, learned Chinese medicine literature, combined with his own clinical practice of a few years, expand traditional Chinese medicine "Xuanfu theory", that "the viscera are Xuanfu", will be innovative cou Xuanfu theory application in the treatment of spleen and stomach diseases. Especially in the treatment of functional gastrointestinal diseases in Chinese medicine, is the first time to put forward "Shugan Chang Sanjiao, spleen and lung and kidney, treatment through open cou Xuanfu" three law argument with chronic constipation. Professor Chen through clinical practice to prove a lot of thought, slow transit constipation disease in the large intestine, but the relationship between liver and spleen lung kidney closely. Clinical spleen qi deficiency to health Transport, stagnation of Xuanfu occlusion, lung and large intestine Qi Fu Qi, not falling, long duration can affect the lung and kidney lead to chronic constipation. Therefore, Professor Chen Suning for the liver stagnation and spleen deficiency, lung kidney deficiency, occlusion of Xuanfu pathogenesis, proposed by Acupuncture and traditional Chinese medicine spleen and dredging liver, invigorating lung and kidney the opening, treatment of Xuanfu, prescription of Weitongxiaopi decoction combined with acupuncture in the treatment of chronic constipation, clinical side effect is small, curative effect is satisfactory. In this paper, "Xuan Fu theory" under the guidance of the theory, mainly from two aspects of theoretical research and clinical observation of clinical curative effect observation on acupuncture and traditional Chinese medicine prescription Weitongxiaopi Decoction in the treatment of slow transit constipation; discuss five Xuanfu theory theoretical basis in the treatment of constipation. The thesis is divided into two parts as follows: Part One: Theoretical Study on 1. spleen and stomach "Xuanfu theory" theory: from "Huangdi Neijing" To Xuanfu pore theory of traditional Chinese medicine on Liu Wansu, Xuanfu more in-depth understanding, think of Xuanfu structure throughout the body most, is the blood and body fluids, Qi and spirit passages. Spleen stomach and other organs also have Xuanfu, and can pass viscera Qi.2. professor Chen Suning to expand "Xuanfu theory" the treatment of slow transit constipation. To summarize the experience of Professor Chen Suning to expand the traditional medicine Xuanfu theory, said: "the viscera are Xuanfu". Derived from open Xuanfu method, namely through nobumichi, smooth skin of the law, access to organs retained a skin pathogen, treatment gas lift in order, because it can be declared inside and outside, sweating more extensive significance. Open Xuanfu method, skin, skin, the viscera can be applied. According to the spleen and stomach Xuanfu theory, diseases of the digestive system can also be used, and introduces the application of the method of acupuncture for treatment of this Two. The experience of disease: clinical research purpose: in expanding the spleen and stomach "guidance of Xuanfu theory" theory, clinical trials based on Evaluation of clinical curative effect of acupuncture combined with the treatment of slow transit constipation. To improve the situation by observing the overall symptoms in patients with slow transit constipation, the main indicators of colon slow transit test. Application and assessment tools including quality of life scale (PAC-QOL) and emotional self rating scale of (SAS, SDS) are indicators of comparative analysis, and to explore the clinical efficacy of open Xuanfu method of slow transit constipation, which opened Xuanfu provide clinical data and objective facts on the basis of the treatment of slow transit type constipation, so as to expand the application after the experimental study of Xuanfu theory and method in the treatment of constipation of Xuanfu provide ideas, theoretical basis of open Xuanfu backtracking method, to expand the innovation of TCM theory, is of great significance for the benefit of patients. Materials and methods: according to random, scientific research and design principle of control, according to the diagnostic criteria and test standards, September 2014 -2015 year in December in the Third Affiliated Hospital of Liaoning University of Traditional Chinese Medicine (Liaoning Province Hospital) pelvic floor disease treatment center for patients with slow transit constipation, 90 cases met inclusion criteria and exclusion criteria (42 cases were male. 48 cases of female) were studied, were randomly assigned into 3 groups, 30 cases in each group. The treatment group (acupuncture combined with medicine group A, Weitongxiaopi + dialectical Acupuncture Acupuncture Combined with medicine); control group (B group, mziren capsule + routine acupuncture), western medicine control group (C group. Mosapride group).A group were treated with traditional Chinese medicine of Weitongxiaopi decoction combined with acupuncture treatment, B group with mziren capsule combined with routine acupuncture treatment, C group were treated with mosapride citrate capsules. The treatment lasted for 28 days. Before and after the treatment in the application of colonic slow transit test, anorectal test 鍘嬪拰鍚勯噺琛ㄤ綔涓鸿瘎閲忓伐鍏疯繘琛岃瘎鍒，

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