【作者】 吴健文；

【导师】 张家维；

【作者基本信息】 广州中医药大学 ， 针灸推拿学， 2008， 博士

【摘要】 粘连性肠梗阻(Adhesive Intestinal Obstruction,AIO)是由于腹腔内粘连导致肠道内容物通过障碍的一种疾病,是临床常见的急腹症之一,也是各类肠梗阻中最常见的一种,可导致各种严重并发症,甚至出现多器p官功能不全综合征(MODS),危及生命。它是普外科常见且棘手的问题,腹腔术后肠梗阻发生率高达80%-90%,而其中约30%发生粘连性肠梗阻,给许多患者造成极大痛苦和经济负担。尽管许多药物对腹腔粘连有一定的作用,但目前临床无一种公认的、有效的方法来预防腹腔粘连的发生。因此,积极探讨对AIO的有效预防是当今医学领域研究的重要课题之一。本文从中医针灸学的角度对此病进行系统探讨,拟从以下两个方面进行研究。1.文献研究从现代医学对AIO的认识,以及对AIO动物模型研究的回顾,指出AIO与肠粘膜屏障有密切的关系,肠粘膜屏障在AIO的发病中占有重要地位。肠粘膜屏障分为机械屏障、免疫屏障、化学屏障、生物屏障。在粘连性肠梗阻发病机制中,尤以机械屏障和免疫屏障最为重要。肠道粘膜的损伤会引起肠道通透性增加、肠道细菌和内毒素移位、释放大量炎性介质等,其结果可能导脓毒症、远隔器官损伤,最终导致多脏器衰竭(MSOF)。肠粘膜受损最早的表现就是通透性增加,早在肠粘膜形态学出现明显变化之前,肠通透性增高已经发生,故肠粘膜通透性增高可反映早期肠屏障的损伤。肠粘膜通透性增高,为肠腔内毒素及其它毒素吸收入血提供了机会,也是肠道细菌移位的病理基础。防止细菌移位的屏障由以下几部分构成:①肠道连续的粘膜上皮构成的机械屏障;②由肠道淋巴样组织细胞网提供的细胞及体液免疫系统;③正常的、大量的肠道厌氧菌群,防止致病微生物的过度增生及在肠道粘膜的定植。其中任一部分或几部分遭到破坏,都会造成细菌移位,因此肠道屏障功能备受学者关注。现代医学对本病主要是采取手术治疗和特殊药物腹腔内灌注为主,如透明质酸钠、尿激酶、脂肪乳剂等。从中医对粘连性肠梗阻的病因病机、辨证论治认识的阐述以及对针灸治疗本病的回顾,指出中医对腹部疾病的生理、病理认识历史久远。但有关粘连性肠梗阻的病名、病因病机、辨证论治,古医籍中则无系统的专门论述,而散见于“腹痛”、“积聚”、“关格”等范畴。中医针灸疗法方法多样,如针刺、艾灸、中药灌肠、推拿按摩等,其治疗AIO显示出良好的疗效,导师张家维在针灸治疗内科疑难疾病的研究中积累了丰富的经验,这些为探讨针灸治疗粘连性肠梗阻提供了坚实的理论基础。在回顾中西医有关粘连性肠梗阻的认识后,指出探讨针刺对粘连性肠梗阻的预防机制,具有坚实的理论基础及重要的临床意义。2.实验研究目的:从动物实验角度探讨针刺对粘连性肠梗阻的预防机制。方法:将75只SD大鼠,随机分为5组:正常组、假手术组、模型组、中药灌肠组、针刺组。针刺组取穴:足三里(双)、天枢(双)、上巨虚(双),每天针刺一次,每次30min;灌肠组用大承气汤,按照5ml/kg剂量保留灌肠,模型组、假手术组用生理盐水保留灌肠,用量为5ml/kg,每天一次,以上各组实验动物分别在造模术后第4天、14天、28天三个时间点处死,各组每个时间点处死5只,观察以下指标:(1)各组大鼠小肠湿干比、肠粘连Phyllips评分、肠粘膜损伤chiu评分;(2)各组大鼠肠粘膜光镜下病理形态学的改变;(3)各组大鼠肠粘膜超微结构变化(细菌包涵体细胞和粗面内质网囊液腔计数);(4)各组大鼠肠粘膜二胺氧化酶的活性;(5)各组大鼠血浆D-乳酸的含量;(6)各组大鼠肠粘膜分泌型免疫球蛋白A的含量;(7)各组大鼠肠粘膜CD4~+、CD8~+淋巴细胞的变化;(8)各组大鼠脏器肠道细菌移位率的变化。结果:(1)模型组肠道水肿严重,湿干比逐渐增加,针刺组经治疗,14d、28d湿干比均较模型组明显降低,有统计学意义(P＜0.05);模型组大鼠腹腔内粘连处数多,粘连紧密,扭曲成团,部分肠段出现近端肠管扩张,远端肠管缩窄变细的粘连性肠梗阻的改变。术后各组与假手术组比较,粘连评分均有增加;针刺组和灌肠组肠粘连评分显著低于模型组(P＜0.01);造模后各组Chiu评分均较对照组明显升高,模型组损伤最为严重,与正常组、假手术组相比,具有明显差异(P＜0.01),灌肠和针刺防治后,肠粘膜损伤减轻,较模型组差异具有统计学意义(P＜0.05)。(2)模型组可见光镜下模型组肠粘膜严重损伤,可见肠腔内可见多量变性红细胞和脱落变性粘膜上皮细胞,绒毛排列紊乱、萎缩变短、间距增宽、间质充血水肿,大部分上皮细胞脱落,绒毛破损伴有固有层毛细血管大量暴露,固有层水肿,中等量炎细胞浸润,小肠绒毛水肿,固有层血管充血,肠腔炎性渗出,灌肠和针刺后粘膜损伤改善明显;(3)造模4天后,细菌包涵体细胞和粗面内质网囊液腔计数数量最多,针刺或灌肠治疗后梗阻均有显著减少,术后14、28天针刺组预防效果优于灌肠组(P＜0.05),假手术组和正常组比较无显著性差异(P＞0.05)。术后小肠粘膜上皮细胞微绒毛减少,线粒体和粗面内质网明显减少,炎性细胞浸润增多。针刺能明显改善肠梗阻时小肠组织超微结构的损伤,促进线粒体和粗面内质网功能和形态恢复。(4)模型组各时间点小肠DAO水平明显低于假手术组,血浆DAO水平明显高于假手术组,差异显著(P＜0.01);针刺组经针刺干预后,小肠DAO提高,14d、28d较模型组有统计学差异(P＜0.05),血浆DAO降低,各时间点较模型组均有显著差异(P＜0.05)。正常组和假手术组DAO较稳定,两者差异无显著性(P＞0.05)。(5)在造模术后各个时间点,模型组血浆D-乳酸水平明显高于假手术组,差异显著(p＜0.01),其中14d出现最高值。针刺组及灌肠组变化趋势同模型组,14d、28d血浆D-乳酸较模型组低,有显著的统计学差异(P＜0.01),针刺组较灌肠组略低,但差异无统计学意义(P＞0.05)。正常组和假手术组血浆D-乳酸水平较稳定,两者差异无显著性(P＞0.05)。(6)模型组sIgA含量逐渐减少,4d、14d、28d均较假手术组明显降低,差异有统计学意义(P＜0.01)。针刺组能够提高sIgA含量,14d、28d均较模型组高,有统计学差异(P＜0.05),正常组和假手术组比较均无统计学差异(P＞0.05)。(7)与正常组比较,模型组大鼠肠粘膜免疫系统中CD4~+淋巴细胞明显减少,CD4~+/CD8~+比例降低差异有显著性(P＜0.05),针刺后,CD4~+淋巴细胞数量和CD4~+/CD8~+比例明显升高,与模型组比较差异有显著性(P＜0.05)。正常组和假手术组比较均无统计学差异(P＞0.05)。(8)术后14天模型组大鼠肠道细菌移位至肝、脾、肠系膜淋巴结发生率高。术后28天后,针刺组大鼠脏器细菌移位率明显低于模型组(P＜0.01),但和灌肠组比较无显著性差异(P＞0.05)。结论:(1)针刺能够改善大鼠小肠炎症水肿,降低湿干比、肠粘连Phyllips评分、肠粘膜损伤chiu评分,改善肠粘膜粘连情况。(2)针刺能明显改善肠梗阻时小肠组织超微结构的损伤,促进线粒体和粗面内质网功能和形态恢复,减少细菌包涵体细胞和粗面内质网囊液腔的数量,增强肠粘膜的防御屏障功能。(3)针刺能够减轻肠粘膜的通透性,增强肠粘膜机械屏障功能,提高大鼠肠粘膜二胺氧化酶的活性,降低血浆D-乳酸的含量。(4)针刺能够提高或促进sIgA的合成和分泌,增加CD4~+淋巴细胞以及CD4~+/CD8~+比例,进而增强肠道局部免疫,减少肠道细菌移位的发生,对肠粘膜的免疫屏障功能损伤起一定的保护作用。(5)针刺通过增强肠道的机械屏障和免疫屏障这两方面的功能,从而实现对粘连性肠梗阻的预防作用。更多还原

【Abstract】 Adhesive intestinal obstruction(AIO)is a kind of clinical disease caused by adhesive intesinal which leads to transmission disorder of intestinal content.It is one of most clinical frequent acute abdomen disease.It may cause many kinds of severe complication for threating to life such as multiple system organ failure(MSOF).It is a common and intractable problem.The incidence of postoperative intestinal obstruction in abdominal cavity is up to 80-90%,and abut 30%of them is adhesive.It means a lot of pain and cost that patient should suffer from.Although many medicines can play some roles,there is still one recognized method is available for prevention of adhesion in abdominal cavity.It is one of the most important tasks in the medical field to actively search for how to prevent and cure AIO.The following two aspects are concerned in this dissertation to discuss AIO systematically in the field of acupuncture and moxibusfion of traditional Chinese medicine.1.Literature researchOn reviewing the knowledge of AIO,animal model of AIO in western medicine.The authors pointed out that there was closely related between AIO and mucosal barrier.There were some kinds of mucosal barriers,such as physico-barrier,immunologic barrier, microeconomy barrier and chemical barrier.Physico-barrier,immunologic barrier played more important role in AIO.It was thought that degenerative nervous transmitter, hyperactive polyol metabolism,increased free radical and decreased cerebral blood circulation generated diabetic cognitive dysfunction.Disruption of gastroin-testinal epithelial barrier integrity may induce increasing of permeability of gastrointestinal wall,bacterial and endotoxin translocation,releasing inflammatory mediators,and lead to lethal sepsis and distant organ injury,finally result in multiple system organ failure.The original sign of impairment of mucosal is increasing of permeability.Before the marked change of morphology of mucosal,increasing of permeability of intestinal tract has happened.So increasing of permeability of mucosal can reflect injury of intestinal barrier earlier.Increasing of permeability of mucosal may provide a chance for absorption of toxin in enteric cavity,which is the pathological foundation of bacterial translocation.Barrier of preventing bacterial translocation is comprised of follow:①The mechanical barrier is comprised of continual epithelial of mucosal;②Cellular and humoral immunity provided by lymphoid tissue of intestinal tract;③Normal and massive commensal intestinal bacterial clusters,preventing the over proliferating and permanent planting in mucosal of pathogenic micmorganism.One or several of these were injuried, that will induce bacterial translocation.Many scholars have paid attention to the intestinal barrier function.As far as its treatment was concerned,at present,it still stayed at operation and infusing into abdominal cavity with some special medicine such as sodium hyaluronate, urokinase and intralipid et al.On reviewing the etiology and pathogenesis,treatment selection on syndrome differentiation of AIO in TCM,the author pointed out that the history of the cognition of physiology and pathology for the coeliac disease in TCM is very long.Not a few literatures are relative to AIO,while none of them is specialized in AIO.The symptoms are included in the following chapters,such as "bellyache","accumulation"," intense carotid and radial pulsation",etc.Acu-bustion has many kinds of therapeutic methods including acupunture, moxibustion,tuina,decoction edema,etc.It has desirable effect on AIO.In addition,my director has got a great experience on research of AIO.On reviewing the cognition of AIO in both Traditional Chinese Medicine and modern medical science,the author pointed out that there is stable and forceful theoretic foundation and significant clinical meaning to probing into the protective effect of acupuncture in points for the treatment of AIO.2.Experimental researchPurpose:To probe the protective effect of acupuncture for the treatment of AIO from the angle of animal experiment.Methods:75 SD rats were randomly divided into groups:normal group, sham-operation group,model group,Dachengqi decoction enema group;acupuncture group. Acupuncture group was treated by electro-Acupuncture 30 min every day.Acupoints chosen in acupuncture group were as follows:Zusanli(ST36),Tianshu(ST25),Shangjuxu (ST37).Enema group was given enema with Dachengqi decoction 5ml/kg once everyday while sham-operation group and model group with physiological saline at same dose.All of the experimental animals were averagely put to death on the 4th,14th,28th day after operation,and collected serum and samples,measured and observed the following indexes:(1)The chiu score and W/D ratio of intestinal mucosa injury,The Phyllips score of adhesive intestinum.(2)The pathomorphological change of intestinal mucosa in adhesive intestinal obstruction injury rat models with light-microscope.(3)The ultrastructure change of Intestinal Mucosa in adhesive intestinal obstruction injury rat models with electon-microscope,including the amounts of bacterium cytoryctes cell and rough endoplasmic reticulum rough endoplasmic reticulum cav.(4)The activity of diamine oxidase(DAO)of intestinal mucosa.(5)The content of D-lactate in plasma.(6)The content of secreted immunoglobulin A(sIgA)in intestinal mucosa.(7)The changes of CD4~+ and CD8~+ T-Lymphocytes in intestinal mucosa.(8)The changes of the intestinal bacteria translocation rate.Results:(1)Edema of intestine in model group was serious.The W/D ratio in three operation group was significantly higher(p＜0.05)than that in the sham-operation group at all time points,but it was obviously reduced by the acupuncture treament at 14,28 days after operation.Adhesive intestinum in model group was compacted and twisted lumping,proximate intestinal of some stage became distention,other distal end intestinal was coarctation and thin than normal group.The Phyllips score and chiu score of adhesive intestinum was significantly higher(P＜0.01)than that in the sham-operation group and normal group at all time points,but it was obviously reduced by acupuncture or enema treament at 14,28 days after operation(P＜0.05).(2)The intestinal mucosa injury of model group in light-microscope was worse than other groups.There was great amount of degen-akaryocyte and amotio epithelium mucosae endothelial cell,villi was getting confused,atrophy and shorter.Intestinal villi edema, capillary congestion,polymophonuclear infiltration in enteric cavity was noted in the model group after intestinal operation,pathomorphological change of the enema group and acupuncture group in light-microscope was better than model group.(3)The amounts of bacterium cytoryctes cell and rough endoplasmic reticulum rough endoplasmic reticulum car in model group after 4 days were highest.And then it was obviously reduced by acupuncture than that in enema group after 14,28days (P＜0.05).There was no significantly(P＞0.05)higher between normal groups and sham-operation.The amounts of microvilli,mitochondria and rough surface endoplasmic reticulum(RSER)were all decreased,infiltration of inflammatory cells were increased under the electromicroscope.Acupuncture can improve the ultrastructure injury of the obstructive intestinal tissues,promote the recovery of both the function and morphology of the mitochondria and RSER.(4)The DAO of intestinal mucosa in model group was significantly reduced than that in the sham-operation group at all time points,and the DAO in plasma was higher inversely (P＜0.01).But the DAO of intestinal mucosal in acupunture group was obviously increased by the acupuncture treament at 14,28 days after operation,DAO in plasma was decreased at all time points.There was no significantly higher between normal group and shamoperation group.(P＞0.05)(5)The content of D- lactate in model group was significantly higher than that in the sham-operation group at all time points(P＜0.01),especially after 14days.There was same tendency both in enema group and acupuncture group.But The content of D- lactate was obviously reduced by the acupuncture treament at 14,28 days after operation,there was no significantly higher between enema group and acupuncture group(P＞0.05),and the same between normal group and sham-operation group(P＞0.05).(6)The sIgA contents was obviously decreased at all time points compared with that in the sham operation group(P＜0.01).The level of sIgA in the acupuncture group was higher than that in the enema group at 14,28 days after acupuncture.(P＜0.05).There was no significantly higher between normal group and sham-operation group(P＞0.05).(7)Compared with the sham-operation group,in the model group,numbers of CD4 ~+ and ratio of CD4~+/CD8~+ were reduced signifcantly(P＜0.01).After acupuncture treatment, CD4~+ T-lymphocytes and ratio of CD4~+/CD8~+ were increased significantly showed in comparison between the model group(P＜0.05).There was no significantly higher between normal group and sham-operation group(P＞0.05).(8)The rate of intestinal bacteria translocated to live,spleen and mesenteric nodes in model group was significantly higher than that in the sham-operation group at all time points(P＜0.01),and it reach highest at 14days after operation.The intestinal bacteria rate was obviously reduced by the acupuncture treament than that in model group at 28 days after operation(P＜0.01),there was no significantly higher between enema group and acupuncture group(P＞0.05)Conclusions:(1)Acupuncture can relieve the edema of the obstructive intestinal tissues,The chiu score and W/D ratio of intestinal mucosa injury,the Phyllips score of adhesive intestinum were all decreased.Acupuncture can relieve intestinal adhensive.(2)Acupuncture can improve the ultrastructure injury of the obstructive intestinal tissues,promote the recovery of both the function and morphology of the mitochondria and rough surface endoplasmic reticulum(RSER).The amounts of bacterium cytoryctes cell and rough endoplasmic reticulum rough endoplasmic reticulum cav were all decreased. Acupuncture can enhance the defence-barrier function of intestinal mucosa.(3)Acupuncture can depress its permeability and protect its integrity efficiently, enhance the barrier function of intestinal mucosa,incresase the activity of DAO both in plasma and intestinal mucosa,reduce the content of D-lactate in plasma.(4)Acupuncture may promote or elevate the synthesis and secretion of sIgA,increase CD4~+ T-lymphocytes and ratio of CD4~+/CD8~+,enhance the intestinal local immunity, reduce the intestinal bacteria translocation.It can protect the intestinal mucosa and reinforce its immunologic barrier function.(5)Acupuncture can enhance both the physico-barrier and immunologic barrier function of intestinal mucosa,protest the the intestinal mucosa from adhesive intestinal obstruction injury更多还原