张武主任治疗慢性肝炎学术经验总结及临床研究

发布时间：2018-04-16 13:17

本文选题：慢性肝炎 + 学术经验　；参考：《中国中医科学院》2016年博士论文

【摘要】：目的：张武主任在肝病防治方面积累了丰富的临床经验,此次通过系统收集、整理老师辨治慢性肝炎的学术经验,并对其临床经验方疏肝实脾汤治疗慢性肝炎肝郁脾虚型进行临床研究,希冀可以升华传承老师的学术思想,并为慢性肝炎的临床辨治及进一步研究提供参考。方法：本研究以跟师学习过程中老师的临证指导为基础,结合老师多年来发表的论文、书写的读书心得、教学讲稿及临证经验体会等第一手资料,以慢性肝炎的中西医文献综述,老师的学术渊源、对慢性肝炎病因病机的认识、辨治慢性肝炎的学术思想及经验总结以及老师临床经验方疏肝实脾汤治疗慢性肝炎肝郁脾虚型的临床研究三部分为研究内容。在第一部分慢性肝炎的中西医文献综述中,中医文献部分分别从古代医家的认识、现代中医名家的认识以及当代中医的认识等方面进行系统的梳理及总结。现代医学研究部分则分别从慢性乙型肝炎的发病机制、诊断及治疗等方面进行论述；在第二部分老师的学术渊源及学术经验研究中,将老师的肝病学术渊源进行了全面的梳理,并系统总结了老师治疗慢性肝炎的学术思想特色及临床经验；在第三部分疏肝实脾汤治疗慢性肝炎肝郁脾虚型的临床研究中,采用随机对照的临床研究方法,选择符合纳入标准的病例72例,按照随机数字表随机分为治疗组和对照组,治疗组入选病例37例,对照组入选病例35例,对两组病例分别从年龄、性别、婚姻、病情轻重、病程、化验指标、中医证候分级等方面进行资料分析,确定其具有可比性。其中,对照组予以西医基础治疗,转氨酶升高者予以口服葡醛内酯片降酶保肝治疗,病毒复制者口服恩替卡韦抗病毒治疗,治疗组在对照组基础上加服老师临床经验方疏肝实脾汤。对两组病例治疗前后的中医临床证候积分、肝功能指标、彩超情况以及HBV-DNA定量等方面进行临床疗效评价。结果：1.通过对老师的肝病学术渊源及学术经验的研究,探知其至今已行医四十余年,八十年代初开始专攻中医肝胆病。老师习医并非家传,其能取得一定成就,完全靠兴趣爱好及自身勤奋。老师精研理论,勇于实践,医术精湛,医德高尚。其学术思想,远宗《内经》、《金匮要略》、《脾胃论》等经典之作,近承现代、当代中医各家之学,择精而选,继承创新,从而自成一家。2.经过多年临床实践总结,老师认为,慢性肝炎的病因有正虚不足、感受邪毒、情志不畅、饮食不节、失治误治等种种,其病机可用虚、郁、湿、热、瘀、毒六字加以概括。正气不足,邪气易侵,疾病可迁延及肝脾肾三脏；肝气郁结失疏,则病症由生；湿热内阻,既是获病之因,又是患病之果;瘀血内生,更是伴随疾病全程;疫毒之邪壅滞,导致诸症丛生,这也是疾病后期病势缠绵,变症丛生的重要原因。3.老师治疗慢性肝炎的学术思想,可以简述为以下四点：①治病求本、强调病因。因为患者的临床表现错综复杂,所以要积极探求疾病的根本原因,针对根本原因施以正确的治本方法,老师常常从追因溯源、务求其本,标本缓急、灵活取舍以及正治反治、随症而施三点着手。②扶正祛邪、攻补兼施。在临床治疗慢性肝炎的过程中,老师发现,单纯虚证或实证者很少见,多是虚实兼夹者,尤其到了慢性肝炎后期合并肝硬化腹水阶段,患者的临床表现更是虚实真假互见,所以老师常常扶正祛邪兼顾,必要时攻补兼施。③四诊合参、中西合璧。老师认为,在诊治疾病的过程中,只有做到四诊俱备,才能全面了解把握证候资料,准确判断出正邪虚实,从而正确辨证施治。其次,因为中西医各自的优势所在,还需要中西合璧,辨证与辨病相结合,才能在微观及宏观上对疾病有一个全面准确的认识,从而也才能更好的指导临床用药。④临证治肝、尤重实脾。肝脾两脏,在生理上相互依存,在病理上互相影响,“肝病实脾”之说由来己久,导师临床中强调治疗肝病不可“见肝只知治肝”,要重视他脏之变疾,尤其以调养脾胃为要,要重视“实脾”之法,才能取得良效。老师对“实脾”法有自己独特的认识和见解,总结了“实脾三法”,论文中有详细论述。4.老师治疗慢性肝炎的临床经验,简述为以下五个方面：①辨证分期论治。老师认为,对于慢性肝炎而言,随着病情的发展,不同病程阶段的病机变化不同,治则也当区别对待。疾病早期,病邪多以湿热为主,或者肝郁,兼有脾虚,故当以清热利湿、疏肝健脾治疗为主；疾病中期,病位多由肝脾两脏延及到肾,导致诸脏虚损,出现肝肾阴虚,或阴损及阳,致脾肾阳虚不足之症,故治疗又当以滋补肝肾或温补脾肾为主；疾病后期,病机更为复杂,脏腑亏虚、气血瘀毒内阻,故治疗应以扶正祛邪、攻补兼施为务。②治肝以通为用。老师认为,无论慢性肝炎初期、中期还是后期,都存在着病邪内侵、脏腑受损的或虚或实,或虚实互见等错综复杂局面,故治疗肝病当以“通”为法。这里所讲的“通”,不单纯指攻下之法,老师认为,凡是辨证求因,给邪以出路者,皆谓之“通”。解表、发汗、通利小便谓之通,补益正气、理气消滞、活血通络、滋补阴血、温补阳气、清热利湿、化湿利水、驱寒破阻、涤痰开壅、破血逐瘀等均为通法之活用。③随症用药。老师临证用药,还善于抓住疾病之主症而选方用药。文中主要从临床常见的黄疸、胁痛、食欲不振、鼓胀等症状论述老师治疗肝病的用药特点。④治肝化瘀八法。老师认为慢性肝炎病程中,瘀血或轻或重都会贯穿疾病始终,经过多年临床实践,他总结了化瘀八法,分别为清热解毒化瘀法、益气扶正化瘀法、滋补阴血化瘀法、疏肝理气化瘀法、健脾利湿化瘀法、温补脾肾化瘀法、攻逐水饮化瘀法及软坚散结化瘀法。⑤用药精准、注重调摄。老师临床用药力倡精准,喜用药对、善用虫类药物以加强疗效。其熟知药性,临床用药生熟有别,故常能充分发挥药效而取得良效。此外,因肝病的特殊性,用药不当,或调摄失宜,均易致疾病难愈或变证丛生,故老师临床中亦十分重视用药禁忌及饮食、情志、劳逸等方面的调摄,认为这些方面也是影响疾病治疗不可或缺的一部分。5.老师认为慢性肝炎病程中肝郁脾虚是为常见证型,经过多年的临床实践,提出了疏肝实脾大法,并且创制了临床验方“疏肝实脾汤”。临床研究过程中,因多种原因,治疗组共完成35例,对照组共完成32例。在疏肝实脾汤治疗慢性乙型肝炎肝郁脾虚型的临床研究中,治疗组各种中医证候均有不同程度改善(P0.01或P0.05),对照组部分临床证候有一定程度改善(P0.01或P0.05)。两组相比较,治疗组在改善临床证候方面优于对照组。治疗组总有效率为88.6%,对照组总有效率为59.4%,两组总有效率比较,差异有显著性意义。治疗后两组肝功能、HBV-DNA定量较治疗前均有明显改善,差异有显著性意义,而腹部彩超结果提示治疗组P0.01,改善明显,差异有显著统计学意义,对照组P0.05,治疗前后无明显改善,差异无统计学意义。两组相比较,治疗组各项指标改善更为明显。结论：老师的学术渊源,远宗经典,近承各家,进而发扬创新；老师将慢性肝炎的病因总结为正虚不足、感受邪毒、情志不畅、饮食不节、失治误治等,将其病机概括为虚、郁、湿、热、瘀、毒；老师临证治疗中,倡导治病求本、强调病因,扶正祛邪、攻补兼施,四诊合参、中西合璧,临证治肝、尤重实脾,形成了其独特的学术思想特色；诊治疾病过程中,老师善于分期论治、辨证用药,治疗肝病时巧用通法,依据临床症状选方用药,活用活血化瘀之法,且用药精准,关注调摄；老师根据慢性肝炎的病因病机特点,提出了疏肝实脾大法,并创制了临床验方疏肝实脾汤,临床研究证实该方在缓解患者临床症状、改善肝功能、降低病毒复制以及改善腹部彩超方面明显优于西药对照组,是安全有效的。疏肝实脾汤是治疗慢性乙型肝炎肝郁脾虚型的有效方药。
[Abstract]:Objective : Zhang Wu ' s clinical experience in the prevention and treatment of chronic hepatitis , which is based on the clinical study of the traditional Chinese and western medicine literature of chronic hepatitis , and the clinical research on the clinical study of chronic hepatitis due to liver depression and spleen deficiency .
In the second part of the teachers ' academic origin and academic experience research , the teacher ' s academic origin of liver disease has been thoroughly combed , and the academic thought characteristics and clinical experience of the teacher in the treatment of chronic hepatitis are summarized systematically .
In the third part , the clinical curative effect of Shugan Shipi Tang in the treatment of chronic hepatitis due to liver depression and spleen deficiency was studied . Its pathogenesis can be summarized by deficiency , depression , dampness , heat , blood stasis , and toxic six characters . It is deficient in qi , easy to invade , disease can be prolonged , and liver and spleen kidney are three viscera ;
If the stagnation of liver qi is sparse , the condition is caused by birth ;
In the course of clinical treatment of chronic hepatitis , the teacher found that only four times of diagnosis and treatment should be made in order to fully understand the root cause of disease . In order to get good results , we should pay more attention to the changes of spleen and stomach , especially the method of nourishing spleen and stomach , to pay more attention to " real spleen " .
In the middle of the disease , the disease position is caused by the two organs of the liver and spleen to extend and to the kidney , leading to the deficiency of the viscera , the deficiency of the liver and kidney yin deficiency , or the yin loss and yang , the deficiency of the spleen and kidney yang deficiency , so the treatment is also mainly used for nourishing the liver and kidney or warming the spleen and kidney ;
In the later stage of the disease , the pathogenesis is more complicated , the zang - fu organs deficiency , qi and blood stasis toxin internal resistance , so the treatment should be used for strengthening body resistance , eliminating pathogenic factors and attacking and nourishing . The invention relates to a method for treating liver diseases , which comprises the following steps of : clearing heat and toxic materials removing blood stasis , invigorating qi , removing blood stasis , nourishing yin and blood , dispersing stagnated liver qi , dispelling blood stasis , invigorating spleen , promoting blood circulation , dispelling blood stasis , invigorating spleen , promoting blood circulation , dispelling blood stasis , invigorating spleen , promoting blood circulation , removing blood stasis , invigorating spleen , promoting blood circulation , removing blood stasis , invigorating spleen , promoting blood circulation , removing blood stasis , invigorating spleen , promoting blood circulation , removing blood stasis , invigorating spleen , promoting blood circulation , removing blood stasis , invigorating spleen , promoting blood circulation , removing blood stasis , invigorating spleen , promoting blood circulation , removing blood stasis , invigorating spleen , promoting blood circulation , removing blood stasis , invigorating spleen , promoting blood circulation , removing blood stasis , invigorating spleen , promoting blood circulation , removing blood stasis , invigorating spleen , promoting blood circulation , removing blood stasis , promoting blood circulation , removing blood stasis , etc . In the treatment group , the total effective rate was 88.6 % , the total effective rate was 59.4 % in the treatment group and the control group was significantly improved ( P0.01 or P0.05 ) .
The teacher summarized the cause of chronic hepatitis to be deficiency of deficiency , feeling of evil spirit , unsmooth feeling , improper diet , missed treatment , etc . , summarized its pathogenesis as virtual , depressed , wet , heat , blood stasis , toxin ;
In the treatment of the teacher ' s syndrome , the author advocates the disease seeking , the emphasis on the cause , the strengthening of the body , the strengthening of the body , the treatment of the liver , especially the consolidation of the spleen , and the formation of its unique academic and ideological characteristics .
In the course of diagnosing and treating diseases , the teacher is good at the treatment of stage theory , treatment of syndrome differentiation , the treatment of liver disease by the coincidence method , according to the clinical symptom choice prescription drugs , living with the method of promoting blood circulation and removing blood stasis , and the medication is accurate and the focus is concerned ;
According to the characteristics of the etiology and pathogenesis of chronic hepatitis , the authors put forward the method of dispersing stagnated liver qi and strengthening spleen , and created a clinical laboratory for dispersing stagnated liver and spleen soup . The clinical study confirmed that the prescription is safe and effective in relieving the clinical symptoms of patients , improving liver function , reducing viral replication and improving abdominal color Doppler ultrasound , which is an effective prescription for treating chronic hepatitis B liver depression and spleen deficiency .

【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】：2016
【分类号】：R259;R249

【参考文献】