“分消泄浊”法在痛风治疗中的理论探讨与临床研究

发布时间：2018-05-08 19:38

本文选题：痛风 + 分消泄浊　；参考：《中国中医科学院》2017年硕士论文

【摘要】：痛风(Gout)是一类以嘌呤代谢紊乱、尿酸排泄减少引起血尿酸水平升高所导致的疾病。根据疾病发展的过程将痛风分为三期:急性期、慢性期和间歇期。痛风在中医中属于“痹病”范畴。大多数医家将其病机概括为:痰瘀互阻、脾虚湿盛、湿热蕴结、肝肾阴虚。由于近年来人民生活水平提高,痛风、高尿酸血症及其他代谢性疾病的发病率也呈逐年上升的趋势。在随诊过程中发现痛风患者常伴有其它代谢性疾病,如肥胖、代谢综合征、血脂代谢异常、糖尿病。导师在治疗痛风时常采用辨病与辩证相结合的方法,治疗效果明显;研究导师处方发现利水渗湿类药物的出现频率较高;通过阅读发现,近几年来讨论痛风病因病机及诊疗的文献十分丰富;痛风与其他代谢类疾病的联系也逐渐被发现并被重视,中药治疗痛风及高尿酸血症的实验和临床研究也取得了一定的进展,有一部分文献提及浊邪、湿浊是引发痛风的主要致病邪气。目的:探讨痛风患者的饮食规律、痛风发作的诱因、痛风与其他代谢性疾病的关系以及血尿酸(UA)、血糖(GLU)、甘油三酯(TG)、总胆固醇(CHO)、低密度脂蛋白(LDL)、高密度脂蛋白(HDL)的变化是否相关。并对纳入的病例进行疗效观察,分析殷海波教授治疗痛风的经验。探讨分消泄浊法在痛风治疗中的理论基础。方法:通过收集符合条件的痛风患者的门诊病历,填写病历采集表;运用Epidate3.1软件建立数据库,录入数据,通过SPSS24软件进行数据的统计分析。结果:1.纳入病例的一般情况:(1)基本资料及发病情况:本研究共收集44例病例资料,患者性别均为男性,其中有痛风家族史者14例,无痛风家族史者30例。有20人处于急性发作期。本例研究纳入病例年龄:平均年龄为(43.14±11.33)岁,其中最小年龄为19岁,最大为67岁,发病年龄以20-29岁为多。本研究所取病例的平均病程为(6.18±6.41)年,其中程最短的为3天,最长的达28年。多数病例的病程小于5年,占全部病例的59.09%。44例患者近一年来痛风的平均发作次数为(4.7±2.88)次/年,以每年发作两次的患者居多。(2)饮食情况:在收取病例纳入研究的44例患者中有25例患者平时有饮酒的习惯,约占总人数的56.82%,患者的日常饮食大多种类丰富,以谷类、蔬菜和水果、肉类为多,也有部分患者日常食用肉类、加工肉类、油炸类、烧烤、膨化食品。将肉类、加工肉类、动物内脏、油炸类、膨化类、烧烤类等高热量的食物统一为膏粱厚味;本研究所纳入的44例病例中有41例嗜食膏粱厚味,占总人数的93.18%。通过调查发现,部分患者并未戒酒、控制饮食。2.合并代谢性疾病及生化结果:本研究所选取的44例病例,或多或少均伴有代谢性疾病,其中有37例伴有血脂代谢异常,占患者总数的84.09%;TG的平均值(2.57±1.37)mmol/l,高于正常值者共29人,占患者总数的65.91%;CHO的平均值为(5.01±1.03)mmmol/l,高于正常值的共18人,占患者总数的40.91%;HDL的平均值为(1.07±0.22)mmol/l,低于正常值的共25人,占患者总数的56.82%;LDL的平均值为(3.24±8.3)mmmol/l,高于正常值的共13人,占患者总数的29.55%;TG的均值没有落在其正常范围内。44名患者的BMI平均为(29.4±4.04)kg/m2,最低为 22.9kg/m2,最高达 41kg/m2,根据 1997 年《WHO 成年人BMI分类标准》,本研究的患者分为体重过低、正常范围、肥胖前期、Ⅰ度肥胖、Ⅱ度肥胖、Ⅲ度肥胖,其中体重指数正常的患者仅占13.64%。在参与研究的44名病例之中仅有5人的腰围处于正常范围内,有36人的腰围90cm,即81.82%的患者存在腹型肥胖;腰围的平均值为(96.05±8.1)cm。在44例患者中,有23人伴有高血压,11人伴有空腹血糖升高,血糖的平均值为(5.9±0.97)mmol/l。根据2009年《代谢综合征临床诊断标准》,44名患者中有26名可诊断为代谢综合征,占总人数的59%。在所有病例中,血尿酸的平均值为(545.48±106.57)umol/l,最高值为793umol/l,最低值为359umol/l,其中有4例患者的血尿酸处于正常水平,40例患者的血尿酸水平升高,占总人数的90.90%。通过SPSS软件对血UA、TG、CHO、LDL、HDL进行相关性分析得出结论为:UA与GLU线性弱相关,但没有统计学意义;UA与TG、CHO、LDL、HDL线性极弱相关或不相关。TG与CHO、GLU线性弱相关,且有统计学意义(P0.05);TG与HDL呈负向线性弱相关,且有统计学意义(P0.05);TG与LDL极弱相关或不相关。CHO与HDL、GLU线性弱相关,且有统计学意义(P0.05);CHO与LDL呈线性强相关,且有统计学意义(P0.01)。LDL与GLU线性弱相关,且有统计学意义(P0.05);LDL与HDL线性极弱相关或不相关。HDL与GLU线性极弱相关或不相关。3.临床症状:本研究统计了自病人发病以来,所有的痛风性关节炎的发病部位,疼痛多发于第一跖趾关节(41.13%)、踝关节(18.55%)。在本研究中,多数患者是因为进食高嘌呤食物(30.49%)、饮酒(24.39%)、疲劳(21.95%)、寒冷(13.14%)引起痛风的急性发作。患者的主要伴随症状为:肢体/关节麻木、肢体/关节困重(56.82%),自汗(54.55%),乏力(52.27%),口干(45.45%),盗汗(36.36%),胸闷(34.09),心烦、头晕(31.82%),两目干涩、痰多、气短、失眠、腰膝酸软(27.27%)。本研究44例痛风病人的舌色主要为淡红或淡/白,占所有舌色的77%;舌形以苍老、舌嫩、舌胖大/齿痕为主,苔质以苔润、苔腻为主。44例病人的脉象以沉、滑为主。4.通过对疾病证候的分布研究表明,符合痰瘀互阻的病例占52.27%,脾虚湿盛占50.00%,肝肾阴虚者占38.34%,湿热蕴结者占27.27%。其中3种证候相兼者3人,占6.82%:两种证候相兼者25人,占56.82%;仅有一种证候者16人,占36.36%。通过对导师44名患者155处方剂使用的药物共计2491味·次进行分析,平均每张方剂使用药物16味,其中出现频率大于50次的药物有薏苡仁(149)、车前子(147)、苍术(138)、丹参(130)、浙贝母(127)、萆參(126)、半夏(123)、茯苓(117)、甘草(110)、苦参(109)、黄柏(102)、金钱草(99)、青蒿(94)、益母草(84)、大黄(76)、鸡血藤(53)。单独分析每张方剂,得出每类药在155张方剂中的出现频率,可知在每张方剂中均含有健脾/运脾药,98.06%的方剂中含有活血药,93.55%的方剂中含有化痰药。患者在治疗2-3个月以后,血尿酸均有明显降低,初诊时患者的血尿酸平均值为(545.48±106.58)umol/l,就诊2-3个月后的血尿酸前后平均值为(424.75±76.87)umol/l,治疗后的血尿酸水平较治疗前明显降低,且有统计学意义(p0.01)。结论:1.大多数痛风患者饮食不节,其日常饮食中含有高嘌呤食物,部分痛风患者的饮食结构不科学。饮食不节是本病的主要病因及急性发作的主要诱因。2.痛风患者常伴发其他代谢类疾病,如高脂血症、肥胖、代谢综合征等,痛风病人的证型分类以痰瘀互阻、脾虚湿盛为主。其常见症状除发作时关节红、肿、热、痛外还有肢体/关节困重/麻木、汗出异常、口干、胸闷,舌红、苔腻水滑,脉沉滑。3.痛风的发生与体重指数、腰围、血脂、血压、血糖的异常关系密切,且TG与CHO,TG与GLU,CHO与HDL,CHO与GLU,LDL与GLU的关系为正相关且有统计学意义;TG与HDL的关系为负相关且有统计学意义。4.浊邪与湿邪均产生于脾胃运化的水谷之气,浊邪产生于谷气,湿邪产生于水;浊邪通过经脉运行于周身,湿邪通过三焦水道运行于周身。5.浊邪的性质及致病特点:(1)致病隐匿,发展缓慢。(2)浊邪易滞而成痰。(3)浊邪粘滞秽浊,易阻滞气机,影响血行。(4)浊邪病势缠绵。(5)浊邪致病广泛。6.浊邪致病的治疗方法:(1)一般治疗:①合理饮食,以杜绝浊邪的来源;②体育锻炼。(2)中医药治疗:①芳香化浊;②健脾化浊;③;补肾祛浊;④畅肺泄浊;⑤利水泄浊;⑥通腑泻浊;⑦活血化瘀。7.导师在痛风的治疗上多使用辨病辨证相结合的方法,临床上常使用分消泄浊的方法:运脾胃、利小便、通大便、畅血脉、化痰浊,常使用的方剂为四妙散合萆參渗湿汤,并强调调摄饮食、适当锻炼在治疗中的重要作用。
[Abstract]:Gout (Gout) is a kind of disease caused by the disorder of purine metabolism and the decrease of uric acid excretion caused by the decrease of uric acid excretion. According to the process of disease development, gout is divided into three stages: acute, chronic and intermittent. Gout is a category of "arthralgia" in traditional Chinese medicine. Most doctors summarize the pathogenesis of phlegm stasis, spleen deficiency and damp. The incidence of gout, hyperuricemia and other metabolic diseases is also increasing year by year because of the improvement of people's living standard in recent years. In the course of follow-up, the patients with gout often have other metabolic diseases, such as obesity, metabolic syndrome, dyslipidemia, diabetes. Tutors often treat gout The treatment effect is obvious with the method of combining disease differentiation with dialectics, and the therapeutic effect of the treatment is obvious. The study of the prescription of the tutor found that the frequency of the water and humid drugs has a high frequency. Through reading, the literature on the pathogenesis and diagnosis of gout is very rich in recent years; the relationship between gout and other metabolic diseases has been gradually found and paid attention to. The experimental and clinical studies of wind and hyperuricemia have also made some progress. Some documents refer to turbid evil, and wet turbid is the main pathogenic factor causing gout. Objective: To explore the diet law of gout, the causes of gout attack, the relationship between gout and other metabolic diseases, and the blood uric acid (UA), blood glucose (GLU), triglyceride (TG), Whether the total cholesterol (CHO), low density lipoprotein (LDL) and high density lipoprotein (HDL) are related, and observe the curative effect of the included cases, analyze the experience of Professor Yin Haibo's treatment of gout, and discuss the theoretical basis of the treatment of gout with the method of eliminating turbidity. Methods: through the outpatient records of patients with gout conforming to the conditions and filling out the medical records Collect the table; use the Epidate3.1 software to establish the database, enter the data and analyze the data through the SPSS24 software. Results: 1. the general cases are included: (1) the basic data and the incidence of the disease: This study collects 44 case data, the sex of the patient is male, among which there are 14 cases of gout family history, and 30 cases without the history of gout family history. 20 people were in an acute attack. The age of this case study was included in the age of (43.14 + 11.33) years, of which the minimum age was 19 years and the largest was 67 years. The age of onset was 20-29 years old. The average course of the case was (6.18 + 6.41) years, the shortest course was 3 days and the longest was 28 years. The course of the majority of cases was less than 5 years. The average episodes of gout in 59.09%.44 patients in all cases were (4.7 + 2.88) times per year. The majority of patients were two times a year. (2) diet: 25 of the 44 patients enrolled in the study included the habit of drinking at ordinary times, accounting for 56.82% of the total number of patients, and most of the patients' daily diet was rich. Cereals, vegetables and fruits, meat are more, and some patients eat meat, processed meat, fry, barbecue, puffed food. High calorie foods such as meat, processed meat, animal viscera, fried, puffing, barbecue and other high calorie foods are unified into thick flavor; 41 of the 44 cases included in this study account for the total number of ploophore, accounting for the total number of people. 93.18%. found that some patients did not abstain from alcohol, control the diet.2. with metabolic diseases and biochemical results: 44 cases selected in this study were more or less accompanied by metabolic diseases, of which 37 cases were accompanied by abnormal lipid metabolism, accounting for 84.09% of the total number of patients, and the average value of TG (2.57 + 1.37) mmol/l, higher than the normal value of 29 people. 65.91% of the total number of patients; the average value of CHO was (5.01 + 1.03) mmmol/l, higher than the normal value of 18 people, accounting for 40.91% of the total number of patients; the average value of HDL was (1.07 + 0.22) mmol/l, less than the normal value of the total number of patients, accounting for 56.82%; the average value of LDL was (3.24 + 8.3) mmmol/l, higher than the normal value of 13 people, accounting for 29.55% of the total number of patients; TG The average BMI of the.44 patients in the normal range was (29.4 + 4.04) kg/m2, the lowest was 22.9kg/m2, and the highest was 41kg/m2. According to the
【学位授予单位】：中国中医科学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R259

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