肠易激综合征中医证治的现代文献系统评价研究

发布时间：2018-06-08 16:00

本文选题：肠易激综合征 + 证治　；参考：《广州中医药大学》2016年博士论文

【摘要】：背景古代并无肠易激综合征的病名,根据主要临床表现目前多将其归于"泄泻"、"腹痛"、"便秘"、"痛泻"、"肠郁"、"郁症"。中医在临床的疗效情况普遍理想,方药中较多人选用为痛泻要方,在其基础上加减变化运用。中医治疗腹泻型肠易激综合征的主要方剂中,痛泻要方、四逆散、逍遥散、柴胡疏肝散、附子理中丸、升阳益胃汤等较为有实验基础。一般认为,肠易激综合征的病因病机可概括为外邪犯肺、肝郁气滞、脾胃虚弱、阳气不足等等病机。由于病名众多,以及随着近年医家对肠易激综合征的研究更深入,现代医家对肠易激综合征有了很多不同的认识,如周福生教授提出的心胃相关理论及蔡淦教授提出由气机失调理论等。目前中医辨证分型不统一的情况发生,少则2型,多则7型均有报道,以4或5型最常见。即使标准己逐准建立起来,但各个标准间的辨证分型不统一,如《实用中医消化病学》把肠易激综合征分为7型;《中药新药临床研究指导原则》按泄泻把肠易激综合征分为6型;《肠易激综合征中西医结合诊治方案(草案)》把肠易激综合征分为5型;《中医消化病学诊疗指南》分为6型。导致临床上较难有统一的认识。同时,从文献数据显示,国外对中医治疗肠易激综合征研究较少,亦缺乏相关的荟萃分析;在国内对中医治疗肠易激综合征具有一定的经验,但缺乏大规模的循证医学证据,以致疗效尚不完全肯定。总括而言,中医药对该病有较好的疗效,不良反应少,透过对近代文献中中医对肠易激综合征的中医辨证用药进行系统的研究,分析其组合规律,总结现代医家对治疗肠易激综合征的经验,可以简化现代医家对肠易激综合征的认识,便于推广中医药,应用于临床。而整理中医药治疗肠易激综合征的相关文献进行综合荟萃分析,则可探讨现时在研究中医药治疗肠易激综合征的有效性及安全性,及发掘中医治疗肠易激综合征的有效方案及其特点。目的:对中医治疗肠易激综合征的证候要素组合、证候、用药规律进行总结。透过荟萃分析探讨中医药治疗腹泻型肠易激综合征、便秘型肠易激综合征的临床疗效和安全性。方法:本课题分别针对医家的经验及临床对照研究进行文献研究2部分。1.以'肠易激'、'对照'为关键词,检索"相关期刊论文"、"中国优秀硕士学位论文全文数据库","相关博士学位论文",按照纳入d}准及排除标准进行相关参考文献筛选,把所得资料进行频数分析、类别主成分分析、聚类分析。2.以"肠易激"、"对照"为关键词,检索"相关期刊论文"、"中国优秀硕士学位论文全文数据库","相关博士学位论文",并按"腹泻"、"便秘"分别纳入腹泻型及便秘型肠易激综合征的研究。在纳入排除标准上首次使用纯中药不加减原则筛选文献。按照纳入d}准及排除标准进行相关参考文献筛选,按照其有否对照研究中患者有否辨证,分别纳入辨病及辨证的荟萃研究。对纳入的研究进行数据的采集与评价,用Excel及Revman软件进行荟萃分析。结果:1.针对医家的经验研究的文献研究结果1.1纳入61篇文献,在证素方面,频数分析显示提取的病性要素以气滞、气虚的频次较高;病位要素为脾、肝的频次较高;病性要素组合以二证组合频数最高,气虚气滞为主要要素;病位要素组合以二证组合频数最高,以脾肝的频次最高,脾肾次之。证候要素的组合规律很可能为脾气虚、肝气郁滞、肝郁脾虚、脾虚夹湿。1.2在症状/体征方面,频数分析显示腹泻、脘腹痛、便溏三个症状频次较高,与腹泻型肠易激综合征症状相近,提示腹泻型肠易激综合征可能较为常见。类别主成分分析显示症状/体征可分为属于脾气虚,肝经郁滞,心阴不足,气滞,阳虚的主要证候。聚类分析显示症状/体征可分为属于脾虚夹湿,肝郁脾虚,肝郁气滞为主的证候。1.3在药物成分方面,频数分析显示白g.或白芍使用频次较高,与临床上较多人使用痛泻要方治疗肠易激综合征情况吻合。类别主成分分析显示经验用药主要可分为疏肝健脾、健脾温脾、温运脾阳及健脾埅湿类四类中药,而聚类分析显示经验用药主要可分为疏肝健脾为主、健脾理气、疏肝为主兼以化湿、及疏肝为主的中药。2.针对医家临床对照研究的文献研究结果2.1腹泻型肠易激综合征方面,荟萃分析显示,中医药干预的有效率优于单个西药干预,与匹维溴铵、洛呱丁胺、思密达、马来酸曲美布汀及双歧杆菌活菌胶囊比较均有优势。中药在治疗腹泻症状上有优势,但在腹痛症状上与西药无差异。在复发率上,上药的复发率少于西药干预组。且未发现严重不良反应。在治疗辨证后腹泻型肠易激综合征方面,荟萃分析显示,中医药干预的有效率优于单纯西药干预,与匹维溴铵、思密达、马来酸曲美布汀、及益生菌干预比较有优势。在与西药比较,处理肝郁脾虚、脾胃虚弱、脾肾阳虚型患者有优势。在症状方面,中药在处理腹胀及患者大便次数方面有优势,但在泄泻及大便形状方面与西药无统计学上差异。纳入研究中未发现严重不良反应。2.2关于便秘型肠易激综合征,荟萃分析显示有效率显着优于单纯西药干预,但与西沙必利比较无明显差异。中医药干预未发现严重不良反应。关于便秘型肠易激综合征分型以后,对于气秘型及肝郁气滞型患者,荟萃分析显示,中医药干预的有效率优于单纯西药干预。中医药干预未发现严重不良反应。2.3纳入的73篇文献中,41.0%(30/73)的文献报告治疗过程中治疗组或者对照组的不良反应(ADR)或不良事件(ADE),可以反映研究者关注到使用药物的安全性。这些研究中,中药治疗组出现不良反应的种类少于对照组,如口干,便秘、恶心、腹胀、腹泻等,而大多数副作用报导数目出现少于对照组,可以看出中药是安全使用。结论:1.从经验总结方面,可以看到(1)从证候要素方面,频数分析显示提取的病性要素以气滞、气虚是主要要素;病位要素为脾、肝为主。(2)症状/体征方面,频数分析显示腹泻、脘腹痛、便溏三个症状频次较高,与临床常见的腹泻型肠易激综合征症状相近。类别主成分分析及聚类分析显示症状/体征属于肝郁脾虚为主的证候。(3)从药物来说,频数分析显示白术、白芍频次较高,与痛泻要方相近。类别主成分分析及聚类分析显示疏肝健脾,健脾温脾类中药是主要用药。2.从荟萃分析方面,(1)结果显示中医干预腹泻型肠易激综合征上有优势,主要方剂有疏肝健脾方剂,如痛泻要方。(2)分型后见肝郁脾虚证治疗腹泻型肠易激综合征上有优势,选药以白术、白芍、防风、陈皮为主,与痛泻要方用药相近;(3)治疗脾肾阳虚腹泻型肠易激综合征上有优势,选药以炒白g.、茯苓、附子、炙甘草为主,与附子理中丸用药相近,暂未搜寻到相关的荟萃分析。(4)从便秘型肠易激综合征的荟萃分析显示,辨证前后中药在治疗肠易激综合征上有优势,治疗方法主要有疏肝理气润肠等方剂,如六磨汤。综上所述,肝郁脾虚证是在肠易激综合征是常见的证型,本文首次对运用不含加减的药物的临床对照研究进行荟萃分析,证实中药治疗肝郁脾虚证腹泻型肠易激综合征有效,痛泻要方为主要方药,这在临床上值得重视辨证在治疗肠易激激综合征的阶段性作用。透过病案的统计分析,医家经验中脾肾阳虚型腹泻型肠易激综合征患者较为少见,而首次针对有脾肾阳虚型腹泻型肠易激综合征患者的临床对照实验,透过荟萃分析证实其有效性。白g.、茯苓、附子、甘草为主要药物,与较多实验研究提示附子理中丸在治疗肠易激综合征有作用的结果相符、提示阳气在肠易激综合征中的重要性,可加强对温阳药物的应用。
[Abstract]:In the background, there is no name of irritable bowel syndrome in ancient times. According to the main clinical manifestations, it is often attributed to "diarrhea", "abdominal pain", "constipation", "pain diarrhea", "bowel depression" and "depression". The clinical effect of traditional Chinese medicine is generally ideal, many people in the prescription are used for pain and diarrhoea on the basis of it. The treatment of diarrhea type irritable bowel syndrome in Chinese Medicine Among the main prescriptions, the pain and diarrhea prescription, four inverse scatter, Xiaoyao Powder, bupleurum soothing liver, Fuzi Lizhong pill, Shengyang Yiwei soup, etc., are generally believed to be the etiology and pathogenesis of irritable bowel syndrome as external pathogenic, stagnation of liver qi, weakness of spleen and stomach, deficiency of Yang Qi and so on. The research of irritable syndrome is more in-depth. Modern doctors have many different views on irritable bowel syndrome, such as the theory of heart and stomach related to Professor Zhou Fusheng and Professor Cai Gan's theory of Qi disorder. At present, the syndrome differentiation of Chinese medicine is not unified, the 2 and the 7 are reported, which are the most common type of type 4 or 5. Even the standard is the most common. It must be set up, but the syndrome differentiation and classification of each standard is not unified, such as < practical TCM Digestive Disease > to divide irritable bowel syndrome into 7 types; < the guiding principle of clinical research for Chinese medicine new medicine > to divide irritable bowel syndrome into 6 types according to diarrhea; < middle intestinal irritable syndrome with Chinese and Western medicine treatment scheme (Draft) > to divide irritable bowel syndrome into 5 types; < The guide to diagnosis and treatment of medical and digestive diseases is divided into 6 types. It is difficult to have a unified understanding in clinic. At the same time, from the literature data, there are few studies on the treatment of irritable bowel syndrome in Chinese medicine and lack of related meta analysis. In general, traditional Chinese medicine has better curative effect and less adverse reaction. Through the systematic study of traditional Chinese medicine for irritable bowel syndrome in modern literature, it analyses the combination rule and summarizes the experience of modern doctors in treating irritable bowel syndrome, which can simplify the convenience of modern doctors. The understanding of irritable syndrome is convenient to popularize traditional Chinese medicine and apply to clinical practice. And colligate meta analysis of the relevant literature on the treatment of irritable bowel syndrome in Chinese medicine, we can explore the effectiveness and safety of TCM in the treatment of irritable bowel syndrome, and explore the effective scheme and characteristics of TCM Treatment of irritable bowel syndrome. To summarize the combination of TCM syndrome factors, syndrome, and the rule of drug use. Through meta-analysis, the clinical efficacy and safety of TCM in the treatment of diarrhea type irritable bowel syndrome and constipation irritable syndrome were discussed. Methods: the subjects were studied 2 parts of the medical experience and clinical comparative study respectively. .1. was divided into 'irritable bowel' and 'control' as the key words, retrieving "Chinese journal full text database", "full text database of Chinese excellent master's degree thesis", "full text database of Chinese doctoral dissertations", screening relevant reference documents in accordance with the standard and exclusion criteria of d}, and carrying out frequency analysis, category principal component analysis and cluster analysis of the obtained data. .2., with "irritable bowel" and "control" as the key word, retrieves "full text database of Chinese Periodicals", "full text database of Chinese excellent master's degree thesis", "full text database of Chinese doctoral dissertations" and "diarrhea" and "constipation" in the study of diarrhea and constipation irritable bowel syndrome respectively. The first use of pure Chinese medicine in the exclusion criteria is not. Screening the literature with the principle of addition and subtraction. According to the inclusion of d} quasi and exclusion criteria, the relevant reference literature was screened. According to whether or not the patients in the study were based on the syndrome differentiation, they were included in the meta analysis of disease discrimination and syndrome differentiation. Data collection and evaluation of the included studies were carried out with Excel and Revman soft parts. Results: 1. aimed at doctors' Classics The results of literature study 1.1 included 61 documents. In the aspect of syndrome factors, frequency analysis showed that the frequency of the disease factor was higher in Qi stagnation and Qi deficiency, the factor of the disease was spleen and the frequency of liver was higher; the combination of the disease elements was the highest in the combination of two syndrome, Qi deficiency and qi stagnation was the main factor, and the combination of the disease position elements was the highest in the combination of two syndrome. The frequency of spleen and liver is the highest and the spleen and kidney is the second. The combination of syndrome factors is likely to be spleen qi deficiency, stagnation of liver qi, liver qi stagnation, spleen deficiency, spleen deficiency and spleen deficiency. The frequency analysis shows that the three symptoms of diarrhea, abdominal pain and loose stool are higher, which are similar to diarrhea type irritable syndrome, suggesting the possibility of diarrhea type irritable bowel syndrome. Classification principal component analysis showed that symptoms / signs could be divided into main syndromes belonging to spleen qi deficiency, stagnation of liver meridian, deficiency of heart Yin, qi stagnation and yang deficiency. Cluster analysis showed that symptoms / signs could be divided into spleen deficiency, liver depression and spleen deficiency, liver depression and qi stagnation as the main syndrome.1.3 in the composition of drug substances, frequency analysis showed the frequency of white g. or paeony use frequency The classification principal component analysis showed that four kinds of traditional Chinese medicine were divided into liver and spleen, spleen warming, spleen yang, spleen yang and spleen invigorating dampness, and the cluster analysis showed that the master of drug use could be divided into liver and spleen, spleen and spleen, liver and liver. A meta analysis of the literature of Chinese herbal medicine.2., which is mainly based on chemical and liver dispersing, is more effective than single western medicine, compared with pippium bromide, roguaginamine, smecta, trimebutine maleic and Bifidobacterium living bacteria capsules. Traditional Chinese medicine has advantages in the treatment of diarrhea symptoms, but there is no difference in abdominal pain symptoms with western medicine. In the recurrence rate, the recurrence rate of the medicine is less than that in the western medicine intervention group. And there is no serious adverse reaction. In the treatment of syndrome differentiation after syndrome, the meta-analysis shows that the effective efficiency of Chinese medicine intervention is better than that of the western medicine intervention. Compared with the western medicine, the patients with liver depression and spleen deficiency, spleen and stomach weakness, spleen kidney yang deficiency have advantages. In terms of symptoms, Chinese medicine has advantages in dealing with abdominal distention and stool times, but it is not statistically different from western medicine in diarrhea and stool shape. No serious adverse reaction.2.2 was found in the study of constipation irritable bowel syndrome. The meta-analysis showed that the effective rate was significantly better than that of Western medicine, but there was no significant difference from cisapride. Traditional Chinese medicine intervention did not find serious adverse reactions. After the classification of constipation type irritable bowel syndrome, it was for gas constipation and liver depression. Meta-analysis showed that the effectiveness of traditional Chinese medicine intervention was better than that of pure western medicine. In the 73 literature which had not been found in.2.3, the adverse reactions (ADR) or adverse events (ADE) in the treatment group or the control group in the treatment process of 41% (30/73) could reflect the attention of the researchers. In these studies, the types of adverse reactions in the Chinese medicine treatment group were less than those of the control group, such as dry mouth, constipation, nausea, abdominal distention, diarrhea and so on, and the number of most side effects appeared less than the control group. It can be seen that the traditional Chinese Medicine is safe to use. Conclusion: 1. from the experience summary, we can see (1) frequency of syndrome factors. Analysis showed that the essential factors were qi stagnation and Qi deficiency, and the main factors were spleen and liver. (2) symptoms / signs, the frequency analysis showed that three symptoms of diarrhea, abdominal pain and loose stool were higher, which were close to the common symptoms of diarrhea type irritable bowel syndrome. Category principal component analysis and cluster analysis showed symptoms / signs. Syndrome of liver qi stagnation and spleen deficiency mainly. (3) from the drug, frequency analysis showed that the frequency of Atractylodes macrocephala was higher and similar to the prescription for pain and diarrhea. Category principal component analysis and cluster analysis showed that the liver and spleen, spleen warming and spleen are the main use of.2. from meta-analysis, (1) the results showed that TCM Intervention in diarrhea type irritable bowel syndrome has advantages, The main prescription has the prescription of soothing the liver and invigorating the spleen, such as the prescription of pain and diarrhea. (2) the liver qi stagnation and spleen deficiency syndrome has the advantage in the treatment of diarrhea type irritable bowel syndrome. The main choice is Baizhu, Paeoniae Paeoniae, wind proof and orange peel. (3) the treatment of spleen kidney yang deficiency diarrhea type irritable bowel syndrome has advantages, and the drugs are selected to stir fry white g., Poria cocos, aconite, licorice A meta analysis of the constipated irritable bowel syndrome showed that the traditional Chinese medicine has the advantage in the treatment of irritable bowel syndrome, and the treatment methods mainly include the prescription of moistening the liver and moistening the intestines, such as the six mill soup. In summary, the syndrome of liver depression and spleen deficiency is an irritable synthesis in the intestines. (4) The syndrome is a common syndrome type. In this paper, a meta-analysis of the clinical control study which is used without addition and subtraction is the first time to prove that the Chinese medicine is effective in the treatment of diarrhea type irritable bowel syndrome with liver depression and spleen deficiency, and the main prescription is the prescription of pain and diarrhea. It is worth paying attention to the stage effect of syndrome differentiation in the treatment of irritable irritable bowel syndrome. In the medical experience, the patients with diarrhea of spleen and kidney yang deficiency type irritable bowel syndrome are relatively rare, and the clinical control experiments for the patients with spleen kidney yang deficiency type irritable bowel syndrome for the first time prove its effectiveness through meta-analysis. White g., Poria cocos, Aconitum and Glycyrrhiza are the main drugs. The results of treatment for irritable bowel syndrome are consistent, indicating the importance of Yang Qi in irritable bowel syndrome, and can enhance the application of Warming Yang drugs.
【学位授予单位】：广州中医药大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R259

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