姚乃礼教授治疗脾胃病学术思想及慢性胃炎辨治经验的临床研究

发布时间：2018-05-27 07:38

本文选题：姚乃礼 + 传承　；参考：《中国中医科学院》2016年博士论文

【摘要】：中医学是发祥于中国古代的研究健康、生命、疾病的科学,并在数千年的医疗实践中积累了丰富的经验,形成了独特的理论体系。中医学是中华传统文化的瑰宝,同时也是世界医学体系的重要组成部分。作为一名现代中医师,若想真正的学习、掌握它,必须做好传承工作。作为2012年第五批全国老中医药专家学术经验继承项目的继承人,有幸师从中国中医科学院姚乃礼教授,通过“读经典、跟名师、多临床”,以期学习、传承姚师的临床经验,进一步提高自己对中医学的认识,争取成为一名真正、优秀的中医师。一、文献综述1慢性萎缩性胃炎中医诊疗进展从中医对慢性萎缩性胃炎(Chronic Atrophic Gastritis,CAG)的病因病机的认识、中医对CAG的临床治疗、对CAG的病机证候及其胃镜像关系的研究等三方面总结了近年来中医诊治CAG的研究进展。其中中医临床治疗部分从自拟方治疗、辨证分型治疗、针灸及针药联合治疗等三方面进行了回顾。最后总结了既往研究的不足,并提出了自己的建议。2慢性胃炎胃镜像与中医证候的相关性研究进展从慢性胃炎(Chronic Gastritis,CG)中医辨证分型与胃镜下胃黏膜像的关系、CG中医辨证分型与幽门螺杆菌感染的关系、CG患者舌象与胃镜像的关系等三方面总结了近年来中医学者对CG胃镜像与中医证候相关性研究的进展。最后总结了既往研究的不足,并提出了自己的建议。二、姚乃礼教授治疗脾胃病的学术思想及思辨特点姚乃礼教授治疗脾胃病的学术思想归纳为：“补益脾胃为本,和衡二法为常,通络解毒为要,微观辨治为辅”。分别从以下8个方面加以论述：①补益脾胃以固本：姚师认为脾胃虚弱是脾胃病的发病之本,包括脾气虚或胃阴虚,以脾气虚为主要致病因素,故治疗脾胃病时强调以补益脾胃为本；②病证双辨,尤重舌脉：主张辨病辨证与专病专方相结合,这其中尤其重视舌诊、脉诊,从而提高辨治的精准性；③注重调和肝脾,擅用“和法”：脾胃病多与情绪相关,姚师十分重视肝脏对脾胃功能的影响,擅用“和法”调和肝脾,治疗脾胃病；④治中焦如衡,“衡法”为要：根据脾胃的生理病理特点,以“治中焦如衡”为指导辨治脾胃病的重要治则,通过“衡法”来纠正脾胃阴阳、寒热、湿燥等偏盛的病理状态,恢复其正常生理功能；⑤疑难病重视从络病论治：在临床治疗脾胃病的疑难病时,若符合络病的发病特点则从络病论治,如萎缩性胃炎及癌前病变、病毒性肝炎及肝炎后肝硬化；⑥重视微观辨证：姚师诊治脾胃病时,主张在宏观辨证的基础上,重视胃镜下的微观表现,宏微相参以准确辨治；⑦“治未病”思想贯穿始终：姚师认为“治未病”与脾胃病关系密切,若在脾胃病发作之初把握先机、尽早治疗,则可未病先防、既病防变、瘥后防复； ⑧部分脾胃病诊治经验举隅：总结了姚师诊治顽固性便秘及运用“启陷汤”加减治疗难治性胃食管反流病的经验。三、姚乃礼教授治疗慢性萎缩性胃炎的临床经验研究1慢性萎缩性胃炎的基本病机特点总结了姚师从“络病理论”探讨慢性萎缩性胃炎及其癌前病变的病机特点。CAG的病机演变呈现为由气及血入络的病势规律,“脾虚络阻毒损”为CAG的根本病机。其中,脾胃亏虚是CAG的发病之本、始动因素；胃络瘀阻是致病的关键条件；毒损胃络是CAG演变为癌前病变(Precancerous lesions of gastric cancer, PLGC)的重要因素。病机演变表现为：脾胃亏虚→胃络瘀组→毒损胃络,即因虚致瘀,蕴久化毒。2基于“络病理论”治疗慢性萎缩性胃炎经验根据CAG“脾虚络阻毒损”的基本病机,姚师确立了“健脾通络解毒”的治疗法则,主要从补益脾胃、活血通络、解毒散结三方面治疗,并设立了“健脾通络解毒方”为治疗CAG基本方。临诊时,姚师重视胃镜像表现,宏观与微观辨证相结合以提高中医辨证的准确度,辨析“脾虚”、“络阻”、“毒损”三者的虚实主次,以“健脾通络解毒方”为基本方加减治疗,从而有效治疗本病,延缓甚则逆转癌变趋势。3“健脾通络解毒方”治疗萎缩性胃炎的疗效观察观察慢性萎缩性胃炎患者33例,应用“健脾通络解毒方”为基础方,宏微辨证加减用药治疗。研究结果：①症状积分：经“健脾通络解毒方”宏微辨证加减治疗后,各主要、次要症状积分疗后均低于疗前,其中胃脘胀满、胃部喜按、情志变化、嘈杂、口苦、胸闷、恶心、呕吐、面色晦滞、咽喉异物感等诸症疗后较疗前统计学有显著性差异(P0.05)。并进一步对主症、次症及主次症总积分进行疗前疗后比较,发现治疗后主症、次症及总积分均明显低于疗前,统计学上均有显著性差异(P0.05)。33例患者经治疗,治愈1例(3.0%),显效19例(57.6%),有效11例(33.3%),无效2例(6.1%),临床总有效率93.9%,提示本方案治疗CAG疗效明显、确切。②治疗后萎缩及肠化积分均低于疗前,其中疗后肠化积分明显低于疗前(P0.05)；萎缩加重者为26.3%,肠化程度加重者为10.5%,肠化程度减轻者为57.9%。提示本次治疗对于减轻萎缩及肠化程度有一定意义,其中减轻肠化疗效较为明显,可能对延缓甚至逆转慢性胃炎→CAG→PLGC→胃癌(gastric cancer,GC)的演变趋势具有一定意义。四、慢性胃炎胃镜像的中医证候属性研究1姚乃礼教授结合胃镜像微观辨治慢性胃炎经验分别从胃黏膜像、胃粘液像、胃运动像、胃增生像等四个方面探析慢性胃炎胃镜像的中医证候属性,据此总结了姚师微观辨治慢性胃炎的经验。结论如下。倾向于“热证”的胃镜像：①胃黏膜呈绛红色或樱桃红,伴充血水肿明显；②胃液为黄绿色,质地粘稠浑浊者；③胃蠕动增快,甚至胃蠕动紊乱。倾向于“血瘀证”的胃镜像：①胃黏膜色泽暗红,伴黏膜下血管网隐见；②胃黏膜粗糙不平,伴结节状或颗粒状增生。倾向于“气虚”的胃镜像如下：①胃黏膜色泽苍白；②胃蠕动减缓,伴胃液质稀量大；③幽门口松弛,呈开放状。倾向于“气滞”的胃镜像：幽门闭合不开。倾向于“阴虚”的胃镜像如下：胃液减少,胃黏膜呈龟裂状。胃黏膜苍白、出血糜烂、胃液呈黄绿色等表现的中医证候属性较为复杂,需进一步辨析。①胃黏膜苍白：若同时胃黏膜光滑、黏膜下血管网未显露,伴有胃蠕动减缓,则为脾阳亏虚,阳虚内寒；若胃黏膜粗糙不平,黏膜下可见树枝状血管网显露,则为脾气亏虚,兼夹血瘀。②胃黏膜糜烂、出血：若胃黏膜明显充血红肿,出血灶为鲜红色,则为胃热炽盛、迫血妄行；若胃黏膜呈暗红色或灰白色,黏膜凹凸不平,多为胃络瘀滞,血不循经；若胃黏膜色泽苍白,蠕动减缓,出血灶为暗红色陈旧出血或血痂,则多为脾胃气虚,气不摄血。③胃液呈黄绿色：若胃黏膜以红相为主,伴有黏膜充血糜烂,提示为肝胆湿热,胆汁上逆；若胃黏膜以白相为主,胃蠕动明显减缓,则为脾胃气虚,胆汁上逆。2 1167例慢性胃炎患者胃镜像中医证候属性的临床研究通过调查表收集了1167例慢性胃炎患者的胃镜像表现,以深入研究慢性胃炎胃镜像的中医证候属性。结论如下：①脾胃湿热证与胆汁反流及粘液池在统计学上有显著性差异,脾胃湿热证较其他证型易出现胆汁反流、粘液池呈黄绿色(P0.05)。②脾胃虚弱(含虚寒)证与病变部位在统计学上有显著性差异,提示全胃炎多发生于脾胃虚弱(含虚寒)证中(P0.05)。③脾虚气滞证与贲门状态在统计学上有显著性差异(P0.05),提示脾虚气滞证较其他证型易出现贲门松弛或疝囊形成。④黏膜色泽、黏膜颗粒样改变及胃镜下诊断与胃络瘀阻证在统计学上均有显著性差异,提示胃络瘀阻证在黏膜以白相为主、呈颗粒样改变及镜下诊断为萎缩性胃炎等方面较其他证型多见(P0.05)。⑤胃络瘀阻证与黏膜糜烂在统计学上有显著性差异,提示胃络瘀阻证出现黏膜糜烂者多于其他证型(P0.05)。⑥证型与黏膜血管网改变之间统计学上有显著性差异,其中胃络瘀阻(34.7%)及胃阴不足(28.0%)两型黏膜血管网改变的比例较高(P0.05)。⑦进一步行logistic统计分析,黏膜血管网改变、黏膜糜烂与胃络瘀阻证关系较为密切,回归方程模型的适配度有显著性意义(P0.05)。提示胃络瘀阻证胃镜下黏膜出现血管网改变及糜烂的可能性明显大于其他证型。部分佐证了姚师关于慢性胃炎微观辨证的学术观点。分析病理检查结果与证候的关系,初步得出结论：CAG与胃络瘀阻证关系较为密切(P0.05),其次多出现胃阴不足、脾胃虚弱(含虚寒)等脾虚证。提示CAG多见于胃络瘀阻证、脾胃亏虚证,一定程度上佐证了姚师认为“脾虚络阻毒损”为萎缩性胃炎基本病机的学术观点。上述结论表明胃黏膜像与中医证候有较为密切的关系,据此建立了据胃黏膜像辨证流程图。
[Abstract]:Traditional Chinese medicine is a science that originated in ancient China to study health, life and disease. It has accumulated rich experience in thousands of years of medical practice and formed a unique theoretical system. Traditional Chinese medicine is the gem of Chinese traditional culture and an important component of the medical system of the world. As a modern Chinese medicine teacher, we want to learn true. As the successor of the fifth batch of Chinese traditional Chinese medicine experts' academic experience in 2012, he was fortunate to learn from Professor Yao Naili of the Chinese Academy of traditional Chinese medicine (Chinese Academy of traditional Chinese Medicine) by "reading classics, with famous teachers and more clinical" in order to learn and inherit the clinical experience of Yao teachers and to further improve their understanding of traditional Chinese medicine. In order to become a real and excellent doctor of traditional Chinese medicine. 1, literature review 1 the development of TCM diagnosis and treatment of chronic atrophic gastritis from the etiology and pathogenesis of chronic atrophic gastritis (Chronic Atrophic Gastritis, CAG), the clinical treatment of CAG, the pathogenesis of CAG and the study of the relationship of gastroscope, and so on in recent years. The research progress of Chinese medicine and treatment of CAG, the clinical treatment part of traditional Chinese medicine was reviewed from three aspects, such as self-made prescription, syndrome differentiation, acupuncture and acupuncture combined with acupuncture and medicine. Finally, the deficiency of previous research was summarized, and the relevant research progress of.2 chronic gastritis gastric image and TCM syndrome was proposed from chronic gastritis (Chr Onic Gastritis, CG) the relationship between TCM syndrome differentiation and gastric mucosal image under gastroscope, the relationship between the syndrome differentiation of CG and Helicobacter pylori infection, the relationship between the tongue image of CG and the mirror of the stomach in CG patients, summarized the progress in the study of the correlation between the CG and the TCM syndromes of the Chinese medicine in recent years. Finally, the deficiency of the previous study was summed up, and the shortcomings of the previous research were summarized. Two, Professor Yao Naili's academic thought and speculative characteristics for the treatment of spleen and stomach disease, Professor Yao Naili's academic thoughts on the treatment of spleen and stomach diseases are summed up as: "replenishing the spleen and stomach, and balancing two laws, collaterals, detoxification, and micro differentiation as auxiliary". From the following 8 sides to discuss: (1) tonifying the spleen and stomach to fix: Yao Division: Yao teacher It is believed that spleen and stomach weakness is the basis of spleen and stomach disease, including spleen qi deficiency or stomach yin deficiency, and spleen qi deficiency as the main pathogenic factor, so the spleen and stomach is emphasized in the treatment of spleen and stomach disease. 3. To harmonize liver and spleen, use "and method": the spleen and stomach disease is related to emotion, Yao teacher attaches great importance to the influence of liver to spleen and stomach function, to harmonize liver and spleen with the method of "harmony", to Treat Spleen and stomach disease; (4) to cure spleen and stomach disease, and to treat the spleen and stomach according to the physiologic and pathological characteristics of the spleen and stomach, and to distinguish the spleen and stomach disease with the guidance of "treating central coke as a balance" The important rule is to correct the pathological state of spleen and stomach yin, Yang, yin and Yang, cold and heat, wet dryness and so on, and restore its normal physiological function by "Heng Fa". 5. The difficult and difficult diseases should be treated from the theory of collateral disease. In the clinical treatment of the difficult diseases of the spleen and stomach disease, if the disease is conformed to the characteristics of the collateral disease, it is treated from the collateral disease, such as atrophic gastritis and precancerous lesions, viral hepatitis and Liver cirrhosis after hepatitis; 6. Pay attention to microscopic syndrome differentiation: Yao teacher's diagnosis and treatment of spleen and stomach disease, advocate on the basis of the macroscopic syndrome differentiation, pay attention to the microscopic manifestation under the gastroscope, macro and microscopical reference to accurately identify and treat; and the "cure the disease" thought through all the time: Yao teacher thinks that "the treatment of the disease" is closely related to the spleen and stomach disease, and if the first opportunity is grasped at the beginning of the attack of the spleen and stomach disease, we should do the best. Three, Professor Yao Naili's clinical experience in treating chronic atrophic gastritis (1 chronic atrophic gastritis). The characteristics of basic pathogenesis summarized Yao's pathogenesis of chronic atrophic gastritis and the pathogenesis of precancerous lesions from the theory of collateral disease. The pathogenesis of the pathogenesis of.CAG, which is the basic pathogenesis of CAG, is "spleen deficiency and collateral damage", and the deficiency of the spleen and stomach is the origin of the pathogenesis of CAG and the factors of initial movement; the stasis of the stomach and collaterals is the pathogeny. The key conditions of the toxic damage to the stomach and collaterals are the important factors of the evolution of CAG to the Precancerous lesions of gastric cancer (PLGC). The evolution of the pathogenesis is: deficiency of the spleen and stomach, the group of gastric collateral stasis, and the toxic loss of the stomach and collaterals, that is, the deficiency of the blood stasis, and the chronic atrophic gastritis based on the theory of collateral disease for the treatment of chronic atrophic gastritis based on the theory of collateral disease, based on the spleen deficiency collaterals. The basic pathogenesis of "poison damage", Yao Division established the treatment principle of "invigorating the spleen and collaterals and detoxifying", mainly from three aspects of nourishing the spleen and stomach, activating blood circulation to collaterals, detoxifying and dissolving the knot, and setting up the basic prescription of "invigorating the spleen and collaterals and detoxifying the poison", and setting up the basic prescription for the treatment of CAG. To make sure of the "Spleen Deficiency", "collaterals", "toxic loss", the main and the secondary of the three, with "Jianpi Tongluo Jiedu Fang" as the basic prescription treatment, so as to effectively treat the disease, and delay the tendency to reverse the trend of canceration,.3 "Jianpi Tongluo Jiedu" therapeutic effect of atrophic gastritis in the treatment of chronic atrophic gastritis, 33 cases of chronic atrophic gastritis, the application of "health" "Spleen Tongluo Jiedu recipe" as the basis, macro and micro differentiation and reduction of the treatment of drugs. There was significant difference (P0.05) compared with pre treatment statistics after the treatment of the throat foreign body sensation and other symptoms. Furthermore, the main symptoms, secondary symptoms and the total score of primary and secondary symptoms were compared, and the main symptoms, secondary symptoms and total scores were significantly lower than before treatment. There were significant differences (P0.05) in.33 patients, 1 cases (3%) were cured, and 19 were significantly effective. Cases (57.6%), effective 11 cases (33.3%), invalid 2 cases (6.1%), the total effective rate was 93.9%, suggesting that the therapeutic effect of CAG was obvious, accurate. 2. After treatment, the atrophy and intestinal integration were lower than before treatment, and the intestinal integration was significantly lower than before treatment (P0.05), atrophy plus weight was 26.3%, intestinal metaplasia was 10.5% and intestinal metaplasia was 57.9%. It is of certain significance to reduce the degree of atrophy and intestinal metaplasia. It is more obvious to reduce the effect of intestinal metaplasia. It may be of certain significance to postpone or reverse the evolution trend of chronic gastritis, CAG, PLGC, gastric cancer (gastric cancer, GC). Four, study of TCM syndrome properties of chronic gastritis with gastroscope image 1 professor Yao Naili combined with gastroscope Like micro differentiation and treatment of chronic gastritis experience, the TCM syndrome attributes of chronic gastritis and stomach mirrors were analyzed from four aspects of gastric mucosal image, gastric mucus image, gastric motility image, gastric hypertrophy and so on. According to this, the experience of Microcosmic Differentiation and treatment of chronic gastritis was summarized. Concomitant congestion and edema; (2) gastric juice is yellow green, sticky and cloudy; (3) gastric peristalsis faster, even gastric peristalsis disorder. The stomach mirror image of "blood stasis syndrome": (1) the color and lustre of the gastric mucosa is dark red with submucosal vascular network, and the gastric mucosa is rough, with nodular or granular hyperplasia. The gastroscope of the "Qi Deficiency" is like the gastroscope like "Qi Deficiency". Below: (1) the color and lustre of the gastric mucosa is pale; the gastric peristalsis slows down, and the gastric juice is thin and large; (3) the quiet door is relaxed and open. The stomach mirror of "qi stagnation" is not closed. The stomach mirrors of "Yin Deficiency" are as follows: the gastric juice is reduced, the gastric mucosa is cracked. The gastric mucosa is pale, bleeding and yellow green. The syndromes of traditional Chinese medicine are more complex and need to be further discriminated. (1) gastric mucosa paleness: if the gastric mucosa is smooth, the submucosal vascular network is not exposed and the gastric peristalsis slows down, the spleen yang deficiency and the Yang deficiency are cold; if the gastric mucosa is rough and the mucous membrane is unflat and the dendritic vascular network is revealed under the mucous membrane, it is the deficiency of spleen qi and blood stasis. Secondly, the gastric mucosa erosion, and the gastric mucosa erosion Blood: if the gastric mucosa is obviously congested and swollen, the bleeding focus is bright red, the stomach is hot and the blood is forced to go. If the gastric mucosa is dark red or gray, the mucous membrane is uneven, most of the stomach and blood stasis, blood does not follow the meridian; if the gastric mucosa is pale, the peristalsis slows down, the bleeding focus is dark red old bleeding or blood scab, it is mostly spleen stomach qi deficiency, Qi is not taken blood. (3) the gastric juice is yellow green: if the gastric mucosa is mainly red, accompanied by mucosal hyperemia and erosion, it is suggested that the liver and gallbladder are damp heat and the bile is reverse. If the gastric mucosa is mainly white, the gastric peristalsis is obviously slowed down, then the spleen and stomach qi deficiency, the clinical study of the TCM Syndromes of 1167 cases of chronic gastritis with the reverse.2 of the bile, 1167 cases are collected by the questionnaire. The manifestation of gastric mirror image of the patients with gastritis in order to study the TCM Syndromes of chronic gastritis and gastric mirrors. The conclusions are as follows: (1) there is significant difference between the spleen and stomach damp heat syndrome and the bile reflux and the mucous pool, and the spleen and stomach damp heat syndrome is easier to appear bile reflux than the other syndrome types, and the mucous pool is yellow green (P0.05). The lesion sites were statistically significant differences, suggesting that the total gastritis mostly occurred in the spleen and stomach weakness (P0.05). (3) there was a significant difference between the spleen qi stagnation syndrome and the cardia state (P0.05), suggesting that the spleen qi stagnation syndrome is more likely to appear cardia relaxation or hernia sac than the other syndrome types. There were significant differences between the gastroscope diagnosis and the stomach stasis syndrome, suggesting that the gastric stasis syndrome was mainly white in the mucous membrane, the particle change and the diagnosis of atrophic gastritis were more common than the other syndromes (P0.05). 5. There were significant differences in the statistical study of gastric stasis syndrome and mucous erosion, suggesting the appearance of gastric stasis syndrome. There were more than other syndrome types (P0.05). 6. There were significant differences between the syndrome type and the changes of mucosal vascular network. The proportion of gastric collateral stasis (34.7%) and gastric Yin deficiency (28%) was higher (P0.05). (7) further logistic statistical analysis, mucosal vascular network change, mucous erosion and gastric stasis syndrome clearance The adaptability of the regression equation model was significant (P0.05). It was suggested that the changes of vascular network and erosion in the gastric mucosa with gastric stasis syndrome were obviously greater than that of other syndromes. Conclusion: the relationship between CAG and gastric stasis syndrome is more closely related (P0.05), followed by deficiency of stomach yin, spleen and stomach weakness (containing deficiency cold) and other spleen deficiency syndrome. It suggests that CAG is more common in gastric stasis syndrome and deficiency syndrome of spleen and stomach. To a certain extent, the academic viewpoint of Yao division that "spleen deficiency collateral damage" is the basic pathogenesis of atrophic gastritis. Mucous membrane is closely related to TCM syndromes. Based on this, a flow chart based on differentiation of gastric mucosa is established.
【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】