肝硬化伴肠功能障碍中西医结合治疗的临床研究及中医证候分析

【作者】 刘洋；

【导师】 江宇泳；

【作者基本信息】 北京中医药大学 ， 中西医结合临床， 2014， 硕士

【摘要】 目的：1分析肝硬化伴肠功能障碍的临床特征,根据其核心病机,采用前瞻随机对照研究方法对健脾化湿解毒方加减口服联合理气消积除胀贴敷脐外用的中西医结合治法治疗肝硬化伴肠功能障碍患者的近期疗效进行动态观察。2分析肝硬化伴肠功能障碍的证候分布规律及辨证分型,对其进行归纳、总结；并初步探讨不同证型与相关检查指标之间的相关性。方法：1收集2013年5月—2014年2月期间,北京地坛医院中西医结合中心符合肝硬化伴肠功能障碍诊断及入组标准的住院患者共60例进行前瞻性对照研究,采取随机数字表法将60例患者随机分为试验组(中西医结合治疗组)和对照组(西医治疗组)各30例。对照组采用西医综合治疗(针对病因治疗、保肝治疗、营养和支持治疗、维持肠道微生态环境治疗、肝硬化并发症治疗等),试验组采用中西医结合治疗(西医综合治疗及健脾化湿解毒方加减口服联合理气消积除胀贴敷脐外用)。动态观察基线、治疗1w、2w、随访2w时两组患者的肝肾功能、血常规、凝血机制及血氨等实验室检查指标、中医症状评分(症状总评分、主症评分、单项症状评分)、肠功能障碍评分、不良事件发生率等。应用SPSS17.0统计软件对数据进行统计学分析。2采集并记录入组的60例患者的中医临床症状、舌象、脉象,并归纳、总结证候分布规律及辨证分型；并对不同证型与相关检查指标(影像学检查：门静脉宽度、门静脉血流速度、脾脏长度、脾脏厚度；实验室检查：辅助性T细胞亚群)之间的关系进行初步探讨。结果：1基线时,两组患者肝功能ALT、AST、TBIL、DBIL、ALB,血常规WBC、 NE,以及中医症状评分(症状总评分、主症评分、单项症状腹胀、纳呆评分)肠功能障碍评分(总评分、肠鸣音减弱程度评分)比较,差异均无统计学意义(P值>0.05)。在治疗1w时,中医症状总评分、主症评分、单项症状腹胀评分、症状纳呆评分及肠功能障碍评分比较,差异均具有统计学意义(P值<0.05)；在治疗2w时,单项症状腹胀评分比较,差异具有统计学意义(P值<0.05)；在治疗2w时,两组患者血清中TBIL、DBIL, WBC比较,差异均具有统计学意义(P值<0.05)；在随访2w时,两组患者血清ALB比较,差异具有统计学意义(P值<0.05)；在治疗1w、2w、随访2w时,中西医组在症状改善、肠功能障碍评分改善有效率方面均高于西医组；此外,中西医组在减少肝硬化伴肠功能障碍的严重并发症的发生、减少死亡率方面优于西医组。2肝硬化伴肠功能障碍患者出现频数最高的临床表现依次为腹胀、倦怠乏力、食欲不振、面色萎黄、肢体困重、小便色黄。肝硬化伴肠功能障碍的基本证型归纳为气滞血瘀证、湿热内阻证、气阴两虚证、脾肾阳虚证、肝郁脾虚证。按照是否以气虚证为主为鉴别点,基线时以气虚证为主者与非以气虚证为主者血清T细胞亚群中CD3比较,差异具有统计学意义(P值<0.05)结论：1肝硬化伴肠功能障碍的核心病机为“脾虚气滞,湿毒内蕴”。健脾化湿解毒方加减口服联合理气消积除胀贴敷脐治疗肝硬化伴肠功能障碍,具有健脾益气、理气活血、清热解毒、利湿化浊、通腑泄浊之功效,其能够促进黄疸的消退；能够促进血白蛋白的合成,改善肝脏的储备、合成能力。此外,还能够有效改善患者中医症状评分、肠功能障碍程度评分以及腹胀、食欲不振等常见临床症状；减少肝硬化伴肠功能障碍的严重并发症的发生,减少死亡率。2肝硬化伴肠功能障碍的气虚为主者与机体免疫调节能力下降相关。更多还原

【Abstract】 Objectives:1According to the core pathogenesis of the cirrhosis with intestinal dysfunction, to analyze the clinical features, using the method of prospective, randomized controlled study to observe the short-term efficacy in patients suffered from cirrhosis with intestinal dysfunction who were treated with oral decoction that tonifying spleen for eliminating dampness and detoxification prescription and external using regulating qi and dispersing distention prescription sticking umbilicus dynamically.2To analyze and summarize the syndrome type distribution discipline and the syndrome differentiation. Besides, investing the correlation between different syndromes and laboratory examination indictors.Methods:160patients who were diagnosed cirrhosis with intestinal dysfunction and were hospitalized at DiTan Hospital integrative medicine center from May2013-February2014were involved in the study that was using prospective, randomized controlled method. Taking the random number table,60patients were randomly divided into two groups,30cases were experiment group (integrative medicine therapy group), and the other30cases were control group (western medicine group). Control group used western medicine treatment (treatment for the cause, protecting liver treatment, nutrition and supportive treatment, maintaining intestinal microflora environment treatment, complications of cirrhosis treatment), the experimental group used integrative medicine (western medicine treatment and oral decoction that tonifying spleen for eliminating dampness and detoxification prescription and external using regulating qi and dispersing distention prescription). Dynamically observed the liver and kidney function, blood routine examination, blood clotting mechanism, ammonia and other laboratory examination indicators, and traditional Chinese medicine symptoms score (total symptoms score, the main symptoms score, the individual symptom score), intestinal dysfunction score, incidence of adverse events at baseline,1w after treatment,2w after treatment,2w of follow-up. Applying of SPSS17.0statistical software for statistical analysis.2Collected and recorded clinical TCM symptoms, tongue, pulse of the60patients who were enrolled, and summarized the distribution of syndromes and syndrome differentiation. Besides, preliminarily explored the relationship between the different syndrome and laboratory examination indicators (the width of the portal vein, portal vein blood flow velocity, length of spleen, thickness of spleen and T cell subsets). Results:1At baseline, comparing the liver function (ALT, AST, TBIL, DBIL, ALB), blood routine examination (WBC, NE, LY), and TCM symptoms score (total symptoms score, the main symptoms score, individual symptom such as abdominal distension and inappetence score), intestinal dysfunction score (total score, decreased bowel sounds severity score) of two groups, the difference was not statistically significant (P>0.05). At1w after treatment, comparing the TCM symptoms total score, the main symptoms score, abdominal distension score and inappetence score, intestinal dysfunction score of two groups, the differences were statistically significant (P<0.05). AT2w after treatment, comparing the abdominal distension score, the differences were statistically significant (P<0.05). And, comparing the serum TBIL, DBIL, NE, LY of two groups, the differences were also statistically significant (P<0.05). At2w after follow-up, comparing serum ALB of two groups, the difference was statistically significant (P<0.05). Besides, at1w,2w after treatment and2w after follow-up, the treatment group had more efficiency on the aspects of improvement of symptoms and intestinal dysfunction score than control group. Also, the treatment group had lower complications of the cirrhosis with intestinal dysfunction and lower mortality than control group.2The highest frequency clinical manifestations are abdominal distension, fatigue, loss of appetite, sallow complexion, heavy cumbersome limbs, yellow urine. The basic syndromes of cirrhosis with intestinal dysfunction are summarized as the syndrome of qi stagnation and blood stasis, the syndrome of dampness and heat stagnation, the syndrome of deficiency of both qi and yin, the syndrome of yang deficiency of spleen and kidney and the syndrome of stagnation of liver qi and spleen deficiency. According to regard Qi deficiency as the main syndrome whether or not, compare the T cell subsets CD3of Qi deficiency as the main syndrome and the other group, the difference was statistically significant (P<0.05).Conclusions:1The core pathogenesis of cirrhosis with intestinal dysfunction is "spleen deficiency and qi stagnation, dampness and toxic blocking". The treatment of cirrhosis with intestinal dysfunction with oral decoction that tonifying spleen for eliminating dampness and detoxification prescription and external using regulating qi and dispersing distention prescription sticking umbilicus has ability to tonify the spleen, regulate qi and activate blood, clear heat and detoxicate, remove dampness, free the bowels and discharge detoxification. And, it can promote jaundice decrease so as to reduce liver cell damage; Besides, it can promote blood albumin synthesis and improve liver reserves synthesis; Further more, it also can reduce the white blood cell count within the normal range, which helps to reduce and control abdominal infection. Besides, it can reduce symptoms score and intestinal dysfunction severity score, relieve the abdominal distension, inappetence and other common symptoms, and reduce the serious complications and mortality.2Cirrhosis with intestinal dysfunction being deficiency symptom as the main symptom has relation with of the immune regulation ability.更多还原