本文關鍵詞： 玄府學說 慢傳輸型便秘 理論和臨床　出處：《遼寧中醫(yī)藥大學》2016年博士論文　論文類型：學位論文

【摘要】：目的:便秘作為癥狀已經(jīng)被廣大患者熟知,但真正因便秘而走進醫(yī)院門診就醫(yī)的患者卻相對較少,這與人民群眾對便秘疾病本身的認識,和所能誘發(fā)心腦血管病發(fā)病認識較少有關,值得我們予以重視。由于該病發(fā)病率較高,西藥治療有一定的副作用,而中醫(yī)藥療效好,故專注于中醫(yī)中藥或針灸等方法治療此病的專家學者不占少數(shù)。特別是從事中醫(yī)脾胃病研究的學者越來越多的開始關注功能性便秘這一疾病�，F(xiàn)代醫(yī)學對慢傳輸型便秘的病因,發(fā)病機制的研究主要集中在腸道平滑肌調(diào)控中的信息傳遞,胃腸道鈦類激素的改變,胃腸道動力障礙,Cajal間質(zhì)細胞等方面異常。近幾年,對精神心理因素對便秘的影響也得到了高度的關注,但是,現(xiàn)代醫(yī)學認識的關于慢傳輸型便秘發(fā)病的任何一種或一類病因,甚至幾種病因的雜揉,也不能解釋疾病的根本發(fā)病機制,這讓藥物研發(fā)遇到困難。由于其治療的多靶點性,故針對便秘的藥物治療種類繁多,西藥經(jīng)臨床應用,大部分初期患者早期用藥效果較佳,但隨著治療時間的延長和推移,臨床效果越來越不盡人意,藥物的副作用如腸道黑變病等發(fā)生機率也隨之而大大增加,這降低了患者對疾病治療的耐心和信心,長期應用的停藥依賴性更是又一問題的存在。在幾千年的傳承與創(chuàng)新中,對便秘的認識和治療上,祖國醫(yī)學積累了豐富的治療經(jīng)驗。中醫(yī)藥包括針灸學在內(nèi)的傳統(tǒng)醫(yī)學在防治便秘方面更顯示了其獨特的優(yōu)勢。依據(jù)中醫(yī)藥學的基本理論,“玄府學說”理論被導師陳蘇寧教授高度重視。導師陳蘇寧教授學貫中西,博覽古今中醫(yī)藥學文獻,結合自己幾十年的臨床實踐,拓展中醫(yī)“玄府學說”理論,認為“五臟六腑皆有玄府”,創(chuàng)新性的將腠理玄府理論應用在脾胃病治療之中。尤其在功能性胃腸病的中醫(yī)藥治療運用上,更是首次提出以“疏肝暢三焦,補脾益肺腎,開腠通玄府”三法立論的慢性便秘的治療。陳教授通過大量的臨床實踐驗證,認為慢傳輸型便秘病位雖在大腸,但與肝脾肺腎關系密切。臨床上脾氣不足無以健運,肝氣郁結玄府閉塞,肺與大腸相表里,肺氣不通腑氣不降,病程日久可累及肺腎導致慢性便秘。因此,陳蘇寧教授針對其肝郁脾虛,肺腎不足,玄府閉塞的病機,提出以針灸配合中藥補脾疏肝,補益肺腎,開通玄府的治療方法,組方胃痛消痞方加減配合針灸治療慢性便秘,臨床副作用小,療效滿意。本論文在“玄府學說”理論的指導下,主要從理論研究和臨床觀察兩方面入手,觀察針灸配合中藥協(xié)定方胃痛消痞方加減治療慢傳輸型便秘的臨床療效;深入探討五臟玄府學說理論在便秘治療中的理論基礎。論文分為如下兩部分:論文一:理論研究1.脾胃“玄府學說”理論基礎探討:從《黃帝內(nèi)經(jīng)》到劉完素的玄府孔隙理論,中醫(yī)學對玄府的認識越來越深入,認為玄府是遍布全身最微的結構,是氣血津液、臟腑氣機和神機出入的通道。脾胃等臟腑亦有玄府,且可以通行臟腑之氣。2.陳蘇寧教授拓展“玄府學說”理論治療慢傳輸型便秘經(jīng)驗總結。陳蘇寧教授拓展傳統(tǒng)醫(yī)學玄府學說理論,認為:“五臟六腑皆有玄府”。而由此衍生的開玄府法,即通過宣通、暢利腠理之法,通達臟腑肌膚留存邪氣,使氣機升降有序的一種治療方法,因其可宣通內(nèi)外,較之汗法意義更為廣范。開玄府法,皮膚、腠理、五臟六腑皆可應用。根據(jù)脾胃的玄府理論,消化系統(tǒng)疾病亦可應用,并介紹應用該法針藥并舉治療此病經(jīng)驗。論文二:臨床研究目的:在拓展脾胃“玄府學說”理論指導下,以臨床試驗為依據(jù),研究針藥結合治療慢傳輸型便秘的臨床療效評價。通過觀察慢傳輸型便秘患者的整體癥狀改善情況,結腸慢傳輸試驗等主要指標,并應用評量工具包括生活質(zhì)量量表(PAC-QOL)和情緒有關的自評量表(SAS、SDS)等進行指標對比分析,進而探討開通玄府法對結腸慢傳輸型便秘的臨床療效,為開通玄府法治療慢傳輸型便秘提供臨床資料和客觀事實依據(jù),從而為日后玄府理論的拓展應用及開玄府法治療便秘的實驗研究提供思路,回溯開玄府法的理論基礎,對拓展創(chuàng)新中醫(yī)藥學理論,造福患者具有重大意義。材料與方法:按照隨機、對照的科研設計原則,根據(jù)疾病診斷標準和試驗納入標準,將2014年9月-2015年12月期間在遼寧中醫(yī)藥大學附屬第三醫(yī)院(遼寧省肛腸醫(yī)院)盆底疾病治療中心慢傳輸型便秘患者,對符合納入標準和排除標準的90例(男42例,女48例)患者進行研究,隨機分配分為3組,每組各30例。針藥結合治療組(A組,胃痛消痞方+辯證針灸);針藥結合對照組(B組,麻仁軟膠囊+常規(guī)針刺),單純西藥對照組(C組,莫沙必利組)。A組采用中藥胃痛消痞方加減配合針灸治療,B組采用麻仁軟膠囊加常規(guī)針刺治療,C組采用枸櫞酸莫沙必利膠囊治療。療程共28天。在治療前后應用結腸慢傳輸試驗、肛管直腸測壓和各量表作為評量工具進行評分,并做統(tǒng)計學處理,對患者治療前后進行療效觀察。結果:1.基線資料比較:共納入90例研究對象,A組、B組、C組各30例,3組病例在性別比例,年齡,病程及結腸傳輸試驗結果和各量表評分等比較無差異(P0.05)。2.三組病例總體療效經(jīng)統(tǒng)計學分析,有顯著性差異(P0.05)A組(針藥結合治療組),總有效率為96.66%;B組(針藥結合對照組),總有效率為90%;C組(單純西藥對照組),總有效率為77%。A組優(yōu)于B、C兩個對照組。3.三組病例治療后總體積分比較,A組與B組無顯著差異(P0.05),但A組較C組有極顯著差異(P0.01),說明A組(針藥結合治療組)較C組(單純西藥對照組)在改善便秘癥狀積分方面有顯著優(yōu)勢。4.三組病例治療前、后總積分組內(nèi)比較,治療后與治療前相比:A、B、C三組總積分改善情況,有統(tǒng)計學差異(P0.05);說明三組用藥治療后,在總積分改善方面,都有一定的治療作用。5.三組病例治療前、后組內(nèi)結腸慢傳輸試驗比較,三組病例治療后與治療前相比,經(jīng)統(tǒng)計學分析,三組治療后與治療前比較有顯著差異(P0.05),比較時,A組明顯于B組和C組(P0.01),A組具有指標方面的優(yōu)勢。6.三組病例焦慮、抑郁心理狀態(tài)經(jīng)統(tǒng)計學分析,A組與B組治療前與治療后均有統(tǒng)計學意義(P0.05);C組治療前與治療后比較,無統(tǒng)計學差異(P0.05)。其中,A組治療后,SAS、SDS評分較B組顯著下降,說明A組療效優(yōu)于B組。7.三組病例治療前后組內(nèi)生活質(zhì)量量表積分比較,三組病例治療前后經(jīng)統(tǒng)計學分析,均有顯著差異(P0.05);其中A組積分下降B組積分下降C組積分下降,說明在改善便秘患者的生活質(zhì)量上,治療組優(yōu)于中藥對照組優(yōu)于單純西藥對照組。治療組有顯著優(yōu)勢。8.三組病例治療前后肛管直腸測壓結果比較,三組在治療前后數(shù)據(jù)統(tǒng)計分析結果均無明顯的統(tǒng)計學差異(P0.05)。結論:陳蘇寧教授遵古而不泥古地拓展傳統(tǒng)中醫(yī)理論,將“玄府學說”應用于慢傳輸型便秘的中醫(yī)藥治療,這在傳承祖國醫(yī)學,創(chuàng)新中醫(yī)理論方面,具有重要意義。同時,依據(jù)玄府理論創(chuàng)立的胃消痞方加減配合針灸治療結腸慢傳輸型便秘臨床療效滿意,不但能顯著地改善患者大便性狀,促進排便,促進腸道蠕動,而且能改善便秘患者生存質(zhì)量及焦慮抑郁狀態(tài)。該方法療效穩(wěn)定,結果滿意,為今后臨床上治療該病探索出一條新路。按照證候診療片斷組的辯證模式,有利于中醫(yī)辯證規(guī)范化應用,便于臨床推廣。
[Abstract]:Objective: constipation symptoms have been known as the majority of patients, but actually because of constipation patients into the hospital outpatient service is relatively less, and the people of the constipation disease itself, and the incidence of cardiovascular disease induced by less understanding about, worth our attention. Because of the high incidence of disease, have side effects some western medicine, Chinese medicine has good curative effect, so focus on Chinese medicine experts or acupuncture and other methods to treat the disease is not in the minority. Especially engaged in diseases of the spleen and stomach in TCM scholars more and more attention to constipation of the disease. Etiology of modern medicine on slow transit constipation, pathogenesis research mainly in the regulation of intestinal smooth muscle in the transmission of information, gastrointestinal hormones titanium changes, gastrointestinal motility disturbance, interstitial cells of Cajal and so on. In recent years, the mental The influence factors of constipation has also been highly concerned, but modern medical knowledge about the pathogenesis of slow transit constipation of any kind of cause, and even several causes are mixed up, also cannot explain the basic pathogenesis of the disease, which make drug development difficulties. The target in the treatment of therefore, according to the kinds of drug therapy of constipation are western medicine clinical application, most of the early patients with early treatment effect is better, but with the prolongation of treatment time and clinical effect goes on, more and more unsatisfactory, the side effects of drugs such as intestinal melanosis and incidence also increased greatly, which reduces the patients in the treatment of disease patience and confidence, the long-term application of the withdrawal dependency is another problem. In the inheritance and innovation for thousands of years, the understanding and treatment of constipation, traditional Chinese medicine has accumulated rich treatment Experience. Traditional Chinese medicine including acupuncture science of traditional medicine in the prevention and treatment of constipation has shown its unique advantages. Based on the basic theory of traditional Chinese medicine, "Xuanfu theory" by Professor Chen Suning. Professor Chen Suning attaches great importance to the Chinese, learned Chinese medicine literature, combined with his own clinical practice of a few years, expand traditional Chinese medicine "Xuanfu theory", that "the viscera are Xuanfu", will be innovative cou Xuanfu theory application in the treatment of spleen and stomach diseases. Especially in the treatment of functional gastrointestinal diseases in Chinese medicine, is the first time to put forward "Shugan Chang Sanjiao, spleen and lung and kidney, treatment through open cou Xuanfu" three law argument with chronic constipation. Professor Chen through clinical practice to prove a lot of thought, slow transit constipation disease in the large intestine, but the relationship between liver and spleen lung kidney closely. Clinical spleen qi deficiency to health Transport, stagnation of Xuanfu occlusion, lung and large intestine Qi Fu Qi, not falling, long duration can affect the lung and kidney lead to chronic constipation. Therefore, Professor Chen Suning for the liver stagnation and spleen deficiency, lung kidney deficiency, occlusion of Xuanfu pathogenesis, proposed by Acupuncture and traditional Chinese medicine spleen and dredging liver, invigorating lung and kidney the opening, treatment of Xuanfu, prescription of Weitongxiaopi decoction combined with acupuncture in the treatment of chronic constipation, clinical side effect is small, curative effect is satisfactory. In this paper, "Xuan Fu theory" under the guidance of the theory, mainly from two aspects of theoretical research and clinical observation of clinical curative effect observation on acupuncture and traditional Chinese medicine prescription Weitongxiaopi Decoction in the treatment of slow transit constipation; discuss five Xuanfu theory theoretical basis in the treatment of constipation. The thesis is divided into two parts as follows: Part One: Theoretical Study on 1. spleen and stomach "Xuanfu theory" theory: from "Huangdi Neijing" To Xuanfu pore theory of traditional Chinese medicine on Liu Wansu, Xuanfu more in-depth understanding, think of Xuanfu structure throughout the body most, is the blood and body fluids, Qi and spirit passages. Spleen stomach and other organs also have Xuanfu, and can pass viscera Qi.2. professor Chen Suning to expand "Xuanfu theory" the treatment of slow transit constipation. To summarize the experience of Professor Chen Suning to expand the traditional medicine Xuanfu theory, said: "the viscera are Xuanfu". Derived from open Xuanfu method, namely through nobumichi, smooth skin of the law, access to organs retained a skin pathogen, treatment gas lift in order, because it can be declared inside and outside, sweating more extensive significance. Open Xuanfu method, skin, skin, the viscera can be applied. According to the spleen and stomach Xuanfu theory, diseases of the digestive system can also be used, and introduces the application of the method of acupuncture for treatment of this Two. The experience of disease: clinical research purpose: in expanding the spleen and stomach "guidance of Xuanfu theory" theory, clinical trials based on Evaluation of clinical curative effect of acupuncture combined with the treatment of slow transit constipation. To improve the situation by observing the overall symptoms in patients with slow transit constipation, the main indicators of colon slow transit test. Application and assessment tools including quality of life scale (PAC-QOL) and emotional self rating scale of (SAS, SDS) are indicators of comparative analysis, and to explore the clinical efficacy of open Xuanfu method of slow transit constipation, which opened Xuanfu provide clinical data and objective facts on the basis of the treatment of slow transit type constipation, so as to expand the application after the experimental study of Xuanfu theory and method in the treatment of constipation of Xuanfu provide ideas, theoretical basis of open Xuanfu backtracking method, to expand the innovation of TCM theory, is of great significance for the benefit of patients. Materials and methods: according to random, scientific research and design principle of control, according to the diagnostic criteria and test standards, September 2014 -2015 year in December in the Third Affiliated Hospital of Liaoning University of Traditional Chinese Medicine (Liaoning Province Hospital) pelvic floor disease treatment center for patients with slow transit constipation, 90 cases met inclusion criteria and exclusion criteria (42 cases were male. 48 cases of female) were studied, were randomly assigned into 3 groups, 30 cases in each group. The treatment group (acupuncture combined with medicine group A, Weitongxiaopi + dialectical Acupuncture Acupuncture Combined with medicine); control group (B group, mziren capsule + routine acupuncture), western medicine control group (C group. Mosapride group).A group were treated with traditional Chinese medicine of Weitongxiaopi decoction combined with acupuncture treatment, B group with mziren capsule combined with routine acupuncture treatment, C group were treated with mosapride citrate capsules. The treatment lasted for 28 days. Before and after the treatment in the application of colonic slow transit test, anorectal test 鍘嬪拰鍚勯噺琛ㄤ綔涓鴻瘎閲忓伐鍏瘋繘琛岃瘎鍒，

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