枳术汤加味治疗肝郁脾虚型慢传输型便秘的临床研究

发布时间：2018-08-14 16:44

【摘要】：慢传输型便秘是一种常见的功能性疾病,作为功能性疾病中多发的一种一类身心疾病,随着生活习惯及饮食习惯的改变,该病的发病率呈明显上升趋势,严重影响了病患的生活质量,且其发病人群分布广泛,从儿童到老年,均是高发人群,功能性疾病是现代疾病的一个棘手疾病,如何提高该病的临床疗效,是对消化科医生的要求,也是现今研究的热点之一。目前现代医学对慢传输型便秘的发病机制有一定的认识,但仍无法全面了解其发病原因,并且在治疗方面的疗效仍欠佳。祖国医学对于便秘有长久深远的认识,在临床治疗上亦积累了丰富的经验,无论从病因病机还是综合治疗上,都有其独特性及优势所在。研究目的便秘是消化系统一类常见的慢性功能性疾病,临床表现为排便次数减少、粪便干结、排便费力等症,一般分为慢传输型便秘、出口梗阻型便秘及混合型便秘三种类型。随着饮食结构及生活习惯的改变,便秘的发病率逐年升高,重者可影响患者的生活和工作,便秘也越来越引起人们的重视。慢传输型便秘是由医学家Proton和Lennard Jonors于1986年提出,排除了结肠生理解剖性、器质性及结肠外病因所致的便秘以及出口梗阻性便秘基础上,由于结肠传输传导功能减慢引起的顽固性便秘,临床特点为便秘、结肠通过的时间延长和对纤维素、缓泻剂等治疗反应差为特征,同时伴有腹胀腹痛、烦躁易怒、忧虑、抑郁失眠等躯体及精神心理症状。慢传输型便秘严重地影响了人们的身心健康,大概占所有便秘患者中的16%-40%,在我国发生率较高。跟随导师门诊时笔者发现,便秘患者以中青年女性居多,结合其发病特点以慢传输型便秘为主,由于便秘原因复杂,诊断相对困难,早期治疗不及时,治疗方法不规范,出现严重的乱用渴药问题,常常延误或者加重病情,也导致临床治疗有效性差、复发率高等问题。西医治疗慢性传输型便秘多以改善胃肠动力、缓泻为主,其存在耐药、依赖、易反复等缺点,而中医则能整体调节、循序渐进,能有效减少药物依赖。通过研究枳术汤加减治疗结肠慢传输型便秘临床疗效的观察与评价,以阐明肝郁脾虚影响胃肠传输功能而至便秘的病因病机的发展过程,从而提高慢传输型便秘治疗的有效率。研究方法全部患者来源于2014.12-2015.12年脾胃病科广州中医药大学附属第一医院门诊,符合(排除流出道梗阻型便秘)中西医诊断,且愿意配合预后追踪及治疗的患者90例。西医采用符合罗马标准Ⅲ及2007年在扬州全国专家肛肠制订的《中国慢性便秘的指南诊治》,标准。中医据《中医病症诊断疗效标准》制定,一般便秘临床表现为：多数三五日排一次大便,甚至更久才能排便一次,或者均能每天排便,但是排出费力,干如羊粪,部分也有患者大便黏腻偏软,难出,便意频作,但很难一次排干净或不能顺利排出。照《中医病证诊断疗效标准》国家中医管理局颁布的,治愈标准为两天以内排便一次解时通畅,,便质转软,短时间内没有复发便秘；好转为便质不硬,三天左右至少排便一次,但有时大便欠畅；无效是症状前后无明显改善。病例入院标准,需符合肝郁脾虚型便秘的中医症候主症、次症诊断标准,以及纳入的四项标准、病历排除的9项标准。研究主要方法从样本量估算、随机分组、给药方法、辨证汤药加减制备,逐一完善进行。给药方案为：①.对照A组：枸橼酸莫沙必利分散片5mg pot tid；②.对照B组：枸橼酸莫沙必利分散片5mg pot tid,黛力新10.5mg qd；③.观察组(中药组)：中药日一剂(共200m1),每次100ml,早午饭后1小时温服。观察方法：服药前询问患者曾用过何种治疗便秘的药物,填写便秘中医证候观察表。患者治疗过程中每周复诊一次,观察并记录病情变化：如有无缩短排便间隔时问,排便是否困难,不适感便后有无、服药前后的大便形状、软硬程度有无变化等情况,是否出现不良反应,伴随的腹胀、乏力、便不尽感、舌象、脉象等的前后变化,治疗二周、四周后按照统计学方法加以分析。数据结果统计按照《中药新药临床研究指导原则》中慢性便秘的症状分级标准进行积分评估,分别从各项症状积分、总疗效判定积分、焦虑抑郁量表的治疗前后评分进行分析,统计数据处理则对正态性分布先进行计量资料检验及齐性方差检验,若呈方差齐,正态分布,则行t检验,否则行t’检验,用计数卡方检验资料。研究结果从年龄上看,发病以中老年患者居多,达到34%；STC的病程较长,反复发作达1年以上的比例接近69%；总治疗疗程结束后,观察组总有效率为90%,对照A组总有效率65.5%,对照B组总有效率86.7%,治疗前及治疗后4周的症状总积分对比分别是：观察组18.02±6.34、4.93±1.21,对照A组18.25±6.21、8.35±6.89,对照B组17.93±6.53、5.54±5.43；从各单项积分来看,粪便性质、排便时间、排便频率、腹部症状、嗳气、乏力、烦躁等症状均有所改善,其中观察组中腹部症状、嗳气、乏力等症改善较西药明显,而在纳呆、烦躁抑郁等方面,其症状积分与对照B组则更接近。从焦虑、抑郁量表统计结果可见,观察组的有效率为86.7%,对照A组是70%,对照B则是73.3%,观察组及对照B组对焦虑抑郁等情绪的干预作用明显,而对照B组的作用则较差。结论枳术汤加味是许鑫梅教授治疗STC的理论指导下配伍而成,具有健脾益气、疏肝解郁、理气通便的功效,同时紫苑一味药有画龙点睛之妙,即能润肠又能起到提壶揭盖、宣畅肺气的作用,经过临床疗效观察,显示枳术汤加味在改善STC症状的同时,对心理情绪具有良好的调节作用,临床疗效佳。
[Abstract]:Slow-transit constipation is a common functional disease. As a kind of physical and mental diseases frequently occurring in functional diseases, the incidence of slow-transit constipation is increasing with the changes of living habits and dietary habits, which seriously affects the quality of life of patients. The incidence of slow-transit constipation is widespread among the population, ranging from children to the elderly. Functional disease is a thorny disease of modern disease. How to improve the clinical efficacy of the disease is the requirement of digestive doctors and one of the hotspots of current research. Chinese medicine has a long-term and profound understanding of constipation and accumulated rich experience in clinical treatment. Both etiology and pathogenesis as well as comprehensive treatment have their unique characteristics and advantages. Constipation and other symptoms, generally divided into slow transit constipation, outlet obstruction constipation and mixed constipation three types. With the change of dietary structure and living habits, the incidence of constipation increased year by year, serious patients can affect the life and work, constipation has attracted more and more attention. In 1986, ard Jonors proposed that obstinate constipation due to slow colonic transmission function was characterized by constipation, prolonged colonic passage time, and poor response to cellulose and laxatives on the basis of excluding constipation due to colonic anatomy, organic and extracolonic causes, and outlet obstruction. Slow transit constipation seriously affects people's physical and mental health, accounting for about 16% - 40% of all constipation patients, with a high incidence in China. Following the tutor's clinic, I found that the majority of constipation patients were young and middle-aged women, combined with their onset. It is characterized by slow transit constipation, which is characterized by complicated causes, relatively difficult diagnosis, untimely early treatment, irregular treatment methods, serious abuse of thirst drugs, often delaying or aggravating the disease, but also leading to poor clinical efficacy and high recurrence rate. Western medicine for chronic transit constipation often improves gastrointestinal motility. In order to clarify the pathogenesis of constipation caused by liver depression and spleen deficiency, the clinical effect of Zhizhu Decoction on slow transit constipation of colon was observed and evaluated. Methods All the patients came from the outpatient department of the First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine from December 2014 to December 2015. They were in accordance with the diagnosis of Chinese and Western medicine, and were willing to cooperate with prognosis tracking and treatment of 90 patients. The clinical manifestations of general constipation are as follows: most of them defecate once every three or five days, or even longer, or can defecate once a day, but the excretion is laborious, dry as sheep dung, part of it. According to the "Diagnostic and Therapeutic Criteria of TCM Diseases and Syndromes" issued by the State Administration of TCM, the curing criteria are smooth defecation within two days, soft stool, no recurrence of constipation within a short period of time; improve for the constipation is not hard, about three days to. The admission criteria should be in accordance with the main symptoms of constipation due to liver depression and spleen deficiency, the diagnostic criteria for secondary symptoms, the four criteria included, and the nine criteria excluded from medical records. Control group A: Mosapride Citrate Dispersible Tablets 5mg pot tid; Control group B: Mosapride Citrate Dispersible Tablets 5mg pot tid, Deanxit 10.5mg qd; Observation group (Chinese medicine group): one dose a day (a total of 200 m1), 100 ml each time, one hour after breakfast warm. Before taking medicine, ask the patient what kind of medicine has been used to treat constipation, fill in the observation form of TCM syndromes of constipation. During the course of treatment, the patient will go back to the doctor once a week to observe and record the changes of the condition: if there is any shortening of the interval between defecation, whether it is difficult to defecate, whether there is any discomfort after defecation, the shape of stool before and after taking medicine, whether there is any change in the degree of softness or hardness, etc. Whether there are adverse reactions, abdominal distention, fatigue, fecal exhaustion, tongue and pulse changes before and after treatment for two weeks, four weeks after the analysis according to statistical methods. Validity score, anxiety and depression scale before and after treatment score analysis, statistical data processing on the normal distribution of the first quantitative data test and homogeneous variance test, if the variance is homogeneous, normal distribution, then t test, otherwise t'test, using counting chi-square test data. The total effective rate was 90% in the observation group, 65.5% in the control group, and 86.7% in the control group. The total score of symptoms before and after treatment was 18.02 (+ 6.34), 4.93 (+ 1.21) in the observation group and 18.02 (+ 1.21) in the control group. 25 [6.21], 8.35 [6.89], 17.93 [6.53], 5.54 [5.43] in control group B, the fecal properties, defecation time, frequency of defecation, abdominal symptoms, belching, fatigue, irritability and other symptoms were improved, of which the abdominal symptoms, belching, fatigue and other symptoms in the observation group were improved more significantly than western medicine, while in the aspects of nausea, restlessness and depression, the symptoms integral points. The results showed that the effective rate of observation group was 86.7%, that of control group A was 70%, and that of control group B was 73.3%. The intervention effect of observation group and control group B on anxiety and depression was obvious, but that of control group B was worse. Compatibility, with the spleen tonifying Qi, soothing liver depression, the effect of clearing constipation, Astragalus medicine has a finishing touch, that is, can moisten the intestines can also play the role of lifting pot uncovering, Xuanchang lung Qi. After clinical observation, Zhizhu Decoction modified in improving STC symptoms at the same time, has a good role in regulating psychological mood, clinical efficacy. Good.
【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】：R256.35

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