發(fā)布時間：2018-01-20 13:10

  本文關(guān)鍵詞： 學(xué)術(shù)經(jīng)驗 萎縮性胃炎 沈舒文 胃癌前病變 醫(yī)案挖掘　出處：《中國中醫(yī)科學(xué)院》2016年博士論文　論文類型：學(xué)位論文

【摘要】：研究背景：名老中醫(yī)臨床經(jīng)驗繼承是中醫(yī)藥領(lǐng)域當(dāng)前帶有使命性的工作,國家“十五”科技支撐計劃將“名老中醫(yī)學(xué)術(shù)思想、經(jīng)驗傳承研究”納入研究之列。沈舒文教授是陜西中醫(yī)藥大學(xué)二級教授、陜西省首批名中醫(yī)、全國第四、第五批名老中醫(yī)藥專家學(xué)術(shù)經(jīng)驗繼承指導(dǎo)老師,他中醫(yī)理論造詣頗深,臨床經(jīng)驗豐富。我作為學(xué)術(shù)經(jīng)驗繼承人對他辨治慢性萎縮性胃炎的經(jīng)驗進(jìn)行研究整理,并將他治療過的發(fā)生在慢性萎縮性胃炎(chronic atrophie gastritis, CAG)基礎(chǔ)上的胃癌前病變(Precancerous lesion of gastric cacer, PLGC)醫(yī)案采用數(shù)據(jù)挖掘方法進(jìn)行了深入研究。研究目的：系統(tǒng)總結(jié)沈舒文教授辨治萎縮性胃炎的臨床經(jīng)驗和學(xué)術(shù)思想,旨在繼承他辨治CAG的臨床經(jīng)驗,并從學(xué)術(shù)層面探討學(xué)術(shù)思想；通過對發(fā)生在CAG基礎(chǔ)上的120例萎縮性胃炎癌前病變(PLGC)醫(yī)案進(jìn)行數(shù)據(jù)化挖掘研究,揭示沈舒文教授辨治PLGC取得良好療效的科學(xué)內(nèi)涵,并為學(xué)術(shù)經(jīng)驗繼承工作作出有益的探索。研究方法：臨床經(jīng)驗與學(xué)術(shù)思想研究部分采用“領(lǐng)悟法”：通過研讀導(dǎo)師論文、跟師侍診學(xué)習(xí)、導(dǎo)師答疑解惑、整理導(dǎo)師醫(yī)案等學(xué)習(xí)方式,領(lǐng)悟?qū)煴嬷蜟AG的思想淵源、學(xué)術(shù)思想及臨床經(jīng)驗,并加以整理、凝練、梳理,達(dá)到挖掘、掌握、繼承的學(xué)習(xí)目的。PLGC臨床醫(yī)案挖掘研究的方法：首先構(gòu)建了《名中醫(yī)辨證論治的臨床醫(yī)案證候單元化管理系統(tǒng)》數(shù)據(jù)庫,并將其作為沈舒文教授臨床醫(yī)案采集記錄與統(tǒng)計管理的載體,對導(dǎo)師近3年來診治過的發(fā)生在CAG基礎(chǔ)上的120例萎縮性胃炎癌前病變醫(yī)案先進(jìn)行病位、病性、病勢等證候要素的辨識提取,再進(jìn)行證候術(shù)語規(guī)范化,形成證候單元診斷,然后對其病名、病位、病性、證候類型、治法及使用藥物等的頻次、用藥歸類、處方組成及各項療效指標(biāo)等進(jìn)行數(shù)字化挖掘分析,以揭示其經(jīng)驗性療效的科學(xué)內(nèi)涵及臨床思維特征。研究結(jié)果：學(xué)術(shù)經(jīng)驗研究結(jié)果：1.沈舒文教授辨治CAG的學(xué)術(shù)思想首先源于《內(nèi)經(jīng)》,彰顯了土生萬物的觀點；并汲取各家之長,融會貫通,辨治CAG以寒熱錯雜痞滿為主者效法張仲景,常以半夏瀉心湯等消痞散結(jié),脾胃虛寒胃痛者以黃芪建中湯等甘補(bǔ)溫運(yùn)；以痞滿納差為主者常師李東垣以枳實消痞丸助納運(yùn),胃脹腹瀉則以補(bǔ)中益氣湯補(bǔ)脾升陽；以嘈雜為主者則宗葉桂養(yǎng)陰滋胃,常用自擬養(yǎng)陰益胃湯,血瘀胃痛常用失笑散或丹參飲化瘀通絡(luò)；制方得何倫教授真?zhèn)?組方注重脾胃納運(yùn)、升降、燥濕(潤)結(jié)合,方藥精道。2.沈舒文教授辨治CAG的臨床思維方法為：采病史四診合參,舌為胃之鏡,尤重舌診,詳于問診；采用辨析標(biāo)本的臨床思維方法,CAG證候結(jié)構(gòu)多呈虛實關(guān)聯(lián)證。3.沈舒文教授辨治CAG的學(xué)術(shù)觀點與臨床經(jīng)驗有：對CAG病機(jī)提出“滯損交加”論,其“滯”有氣滯、食滯、濕滯、絡(luò)滯之分,其“損”則有氣虛及陰虛之別,治療“補(bǔ)虛治本,通滯治標(biāo)”,補(bǔ)虛與通滯相兼；根據(jù)胃以潤為降的特性,辨治CAG擅長養(yǎng)胃陰以和胃氣；對PLGC提出“毒瘀交阻”核心病機(jī)論,長于用“益氣養(yǎng)陰,解毒化瘀”治法；制方用藥經(jīng)驗特點為組方藥執(zhí)簡馭繁,走精方之道,根據(jù)脾胃功能特性及病機(jī)特點反向用藥有特色,納運(yùn)失常注重化納相助,升降失常則升降合用,脾濕胃燥善燥濕(潤)相濟(jì),善用組藥,靈活多變,師古不泥,創(chuàng)制驗方。萎縮性胃炎癌前病變臨床醫(yī)案挖掘研究結(jié)果：醫(yī)案挖掘統(tǒng)計結(jié)果顯示PLGC病名以痞滿(占38.33%)和嘈雜居多(占20.83%),其首診臨床癥狀中出現(xiàn)頻率較高的癥狀依次為：胃脘痞滿飽脹嘈雜胃脘疼痛口千胃灼熱感,與其基礎(chǔ)病變CAG無差異性。病位可涉及胃(占90.00%)、脾(占76.67%)、肝、膽、腹、腎等,以胃、脾為主,也常涉及肝。病性有邪實與正虛之辨,統(tǒng)計顯示邪實依次為氣滯(氣逆)毒瘀濕熱寒凝血瘀痰濕,而以毒瘀交阻、氣滯、濕熱最為多見；其虛證依次為胃陰虛脾氣虛中陽虛肝血虛腎陽虛,而以胃陰虛及脾氣虛為主；醫(yī)案病性統(tǒng)計顯示毒瘀、氣或陰虛、氣滯在首診及復(fù)診中均占有很大比例,其中氣或／并陰虛占63.14%,毒或／并瘀共占58.62%。病程中常有因虛致實,因?qū)嵵绿摰膭討B(tài)特征,且虛中常兼有實邪,從而呈現(xiàn)虛實兼夾之勢,導(dǎo)師稱其為虛實關(guān)聯(lián)證。120例PLGC醫(yī)案臨床證候分型共有14種,其中單證侯有6種,單證侯類型者頻次總計在證候結(jié)構(gòu)類型中僅占23.73%,而虛實關(guān)聯(lián)證達(dá)76.27%,揭示了PLGC具有本虛標(biāo)實,虛實相兼,虛實相關(guān)聯(lián)的證候特點,其中尤以氣陰兩虛并／兼毒瘀交阻證最常見(35.30%)。PLGC治法共有11種,其中以解毒化瘀(54.68%)、.益氣養(yǎng)陰(42.61%)最常用,其次為和降胃氣(35.14%)。120例醫(yī)案共收集處方1218張,用藥累計15398頻次,平均每張?zhí)幏接盟?2.6味,用藥頻次大于10次者共96種。治療用藥中抗腫瘤(解毒)藥、活血化瘀藥、補(bǔ)陰藥、補(bǔ)氣藥單藥使用頻次較高,其次理氣藥使用頻次相對也高。治療用藥頻次在280次以上的核心藥物依次有：麥冬、半枝蓮、石斛、莪術(shù)、太子參、半夏、枳實、黃連、藤梨根、刺猬皮、白術(shù)、佛手、旋復(fù)花、黃藥子、吳茱萸、丹參；治療PLGC的解毒抗癌核心用藥主要有莪術(shù)、枸橘、半枝蓮、藤梨根、山慈菇、黃藥子。本研究對PLGC常見證侯處方組成(主要藥物頻次)也進(jìn)行了統(tǒng)計,以揭示其處方用藥規(guī)律。醫(yī)案統(tǒng)計結(jié)果顯示患者辨證治療前后其臨床癥狀噯氣改善P0.05,其余主要癥狀及癥狀總積分比較均PO.01,表明治療前后差異具有統(tǒng)計學(xué)意義；中醫(yī)證候療效有效率達(dá)94.17%；治療后患者胃鏡下改變、病理檢查胃黏膜炎癥活動度、萎縮、腸化、異型增生均療效顯著；胃鏡及活檢病理積分治療前后比較均P0.01,提示統(tǒng)計學(xué)差異顯著；PLGC伴有Hp感染者高達(dá)60.83%,而中醫(yī)藥辨證論治具有較高的根除率84.93%；120例醫(yī)案共有2例發(fā)生癌變；辨證論治PLGC的綜合療效達(dá)86.67%。治療前后患者尿、血、糞常規(guī)及腎功、肝功、心電圖等安全性指標(biāo)均無明顯異常變化。結(jié)論：1.沈舒文教授辨治CAG的學(xué)術(shù)思想源于《黃帝內(nèi)經(jīng)》,兼收并蓄了張仲景、李東垣、葉天士等古代中醫(yī)名家的辨治思想及用藥特色,并得到老一輩中醫(yī)藥專家何倫教授的悉心指導(dǎo),形成了自己獨(dú)特的臨床辨治思維及用藥特色。2.沈教授辨治CAG提出“滯損交加”病機(jī)論及“虛實關(guān)聯(lián)證”,治療補(bǔ)虛與通滯相兼,注重養(yǎng)胃陰以和降胃氣；對PLGC提出“毒瘀交阻”核心病機(jī)論；臨床制方用藥注重脾胃化納相助,升降合用,燥濕(潤)相濟(jì),靈活多變。3.萎縮性胃炎癌前病變臨床醫(yī)案數(shù)據(jù)挖掘研究結(jié)論：PLGC證候結(jié)構(gòu)以虛實關(guān)聯(lián)證居多；萎縮性胃炎癌前病變的核心病機(jī)為“毒瘀交阻,氣陰兩虛”；PLGC的核心治法為“解毒化瘀,益氣養(yǎng)陰”；PLGC治療的處方用藥以益氣養(yǎng)陰藥及解毒化瘀藥最為常用；沈教授辨治PLGC療效顯著；120例萎縮性胃炎癌前病變臨床醫(yī)案數(shù)據(jù)化挖掘研究能真實反映沈教授辨治PLGC的臨床思維特征及遣方用藥規(guī)律,其具有科學(xué)性,構(gòu)建的《名中醫(yī)辨證論治的臨床醫(yī)案證候單元化管理系統(tǒng)》成功用于臨床是對名老中醫(yī)學(xué)術(shù)經(jīng)驗繼承工作做出的有益探索。本論文的創(chuàng)新點：1.系統(tǒng)整理了沈舒文教授辨治CAG的臨床經(jīng)驗與學(xué)術(shù)思想。2.對沈舒文教授辨治萎縮性胃炎癌前病變臨床醫(yī)案運(yùn)用數(shù)據(jù)挖掘的方法進(jìn)行研究,在《名中醫(yī)辨證論治的臨床醫(yī)案證候單元化管理系統(tǒng)》(2015年3月19日已獲得中華人民共和國國家版權(quán)局計算機(jī)軟件著作權(quán)登記證書：軟著登字第0935887號)數(shù)據(jù)庫構(gòu)建中將辨識證候的四診資料按照病位、病性、病勢等證候要素提取,使證候辨識單元化隱藏在數(shù)據(jù)庫中,并經(jīng)測試使用能反映其辨治PLGC的臨床辨治思維、用藥頻次、療效判定等科學(xué)內(nèi)涵,其具有創(chuàng)新性。
[Abstract]:Background: the old Chinese medicine clinical experience inheritance is the field of traditional Chinese medicine with the mission of the current work, "fifteen" National Science and technology support program "the name of the old Chinese academic thought, research experience into study. Professor Shen Shuwen is Shaanxi University of Chinese Medicine professor level two, the first batch of Shaanxi Province Traditional Chinese medicine, fourth of the country number fifth, an old Chinese medicine expert guidance teacher of academic experience inheritance, he has deep knowledge of traditional Chinese medicine theory, clinical experience. I as his heir to the academic experience of treating chronic atrophic gastritis experience of finishing, and he was treated in the chronic atrophic gastritis (chronic atrophie, gastritis, CAG) lesions on the basis of gastric cancer (Precancerous lesion of gastric cacer, PLGC) by using the data mining methods were studied. Objective: To summarize professor Shen Shuwen Wei Shrink gastritis clinical experience and academic thought, to inherit his clinical experience on treatment of CAG, and to explore the academic thought from the academic level; based on CAG on the basis of the 120 cases of precancerous lesions of chronic atrophic gastritis (PLGC) medical data mining research, reveal the scientific connotation of Professor Shen Shuwen on treating PLGC good effect and, as the academic experience inheritance made beneficial exploration. Research methods: clinical experience and academic research of the part of the "comprehend": by studying the learning with the teacher mentor, waitresses, teacher unriddling, the tutor records such as learning, understanding the thought origin of tutor on treatment of CAG, the academic thought and clinical experience, and finishing, concise, combing, to mining, master, clinical medical learning objective.PLGC inherited mining research methods: firstly build the clinical medical treatment of TCM "syndrome differentiation The syndrome element management system > database, and as professor Shen Shuwen carrier of clinical medical records and statistics collection management, tutor for nearly 3 years and had occurred in the CAG on the basis of 120 cases of atrophic gastritis and precancerous lesions of medical disease, illness, disease and syndrome factors identification then the extraction, the syndrome standardization, forming syndrome unit diagnosis, and then the name of disease, disease location, disease, syndrome type, treatment and drug use frequency, drug classification, prescription and the efficacy index of digital mining analysis to reveal the scientific connotation and its empirical effect the clinical thinking characteristics. Results: 1. academic experience of Professor Shen Shuwen in treating CAG's academic thought first in the < >, highlighting the native view and learn all things; the length of each CAG to mastery, and chills and fever ruffian With the main follow Zhang Zhongjing, often with Banxiaxiexin Decoction and Xiaopi Sanjie decoction, spleen deficiency with stomach Huangqijianzhong Gan temperature compensation; in the fullness of anorexia mainly by Li Dongyuan often Zhishuxiaopiwan help Na transport, bloating diarrhea with BUZHONGYIQITANG spleen sun; as to the noisy the main person in Guangxi leaves nourish yin and stomach, commonly used Nourishing Yin Yiwei decoction, blood stasis or common stomachache Shixiaosan danshenyin Huayu Tongluo prescription; why Professor Chuan Lun, lifting transport, pay attention to spleen and stomach, prescription, dampness (run) combined with clinical thinking method of prescription genital tract treated by Professor Shen Shuwen CAG for.2. history: collected four diagnostic methods, the tongue as a stomach mirror, especially in tongue diagnosis, detailed interrogation; clinical thinking methods of specimens, CAG syndrome is associated with card.3. structure and Professor Shen Shuwen CAG of the academic ideas and clinical experience are put forward: "the pathogenesis of CAG and hysteresis loss" 璁，

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