“分消泄?jié)帷狈ㄔ谕达L治療中的理論探討與臨床研究
發(fā)布時間：2018-05-08 19:38
本文選題：痛風 + 分消泄?jié)?/strong>��； 參考：《中國中醫(yī)科學院》2017年碩士論文
【摘要】：痛風(Gout)是一類以嘌呤代謝紊亂、尿酸排泄減少引起血尿酸水平升高所導致的疾病。根據(jù)疾病發(fā)展的過程將痛風分為三期:急性期、慢性期和間歇期。痛風在中醫(yī)中屬于“痹病”范疇。大多數(shù)醫(yī)家將其病機概括為:痰瘀互阻、脾虛濕盛、濕熱蘊結、肝腎陰虛。由于近年來人民生活水平提高,痛風、高尿酸血癥及其他代謝性疾病的發(fā)病率也呈逐年上升的趨勢。在隨診過程中發(fā)現(xiàn)痛風患者常伴有其它代謝性疾病,如肥胖、代謝綜合征、血脂代謝異常、糖尿病。導師在治療痛風時常采用辨病與辯證相結合的方法,治療效果明顯;研究導師處方發(fā)現(xiàn)利水滲濕類藥物的出現(xiàn)頻率較高;通過閱讀發(fā)現(xiàn),近幾年來討論痛風病因病機及診療的文獻十分豐富;痛風與其他代謝類疾病的聯(lián)系也逐漸被發(fā)現(xiàn)并被重視,中藥治療痛風及高尿酸血癥的實驗和臨床研究也取得了一定的進展,有一部分文獻提及濁邪、濕濁是引發(fā)痛風的主要致病邪氣。目的:探討痛風患者的飲食規(guī)律、痛風發(fā)作的誘因、痛風與其他代謝性疾病的關系以及血尿酸(UA)、血糖(GLU)、甘油三酯(TG)、總膽固醇(CHO)、低密度脂蛋白(LDL)、高密度脂蛋白(HDL)的變化是否相關。并對納入的病例進行療效觀察,分析殷海波教授治療痛風的經驗。探討分消泄?jié)岱ㄔ谕达L治療中的理論基礎。方法:通過收集符合條件的痛風患者的門診病歷,填寫病歷采集表;運用Epidate3.1軟件建立數(shù)據(jù)庫,錄入數(shù)據(jù),通過SPSS24軟件進行數(shù)據(jù)的統(tǒng)計分析。結果:1.納入病例的一般情況:(1)基本資料及發(fā)病情況:本研究共收集44例病例資料,患者性別均為男性,其中有痛風家族史者14例,無痛風家族史者30例。有20人處于急性發(fā)作期。本例研究納入病例年齡:平均年齡為(43.14±11.33)歲,其中最小年齡為19歲,最大為67歲,發(fā)病年齡以20-29歲為多。本研究所取病例的平均病程為(6.18±6.41)年,其中程最短的為3天,最長的達28年。多數(shù)病例的病程小于5年,占全部病例的59.09%。44例患者近一年來痛風的平均發(fā)作次數(shù)為(4.7±2.88)次/年,以每年發(fā)作兩次的患者居多。(2)飲食情況:在收取病例納入研究的44例患者中有25例患者平時有飲酒的習慣,約占總人數(shù)的56.82%,患者的日常飲食大多種類豐富,以谷類、蔬菜和水果、肉類為多,也有部分患者日常食用肉類、加工肉類、油炸類、燒烤、膨化食品。將肉類、加工肉類、動物內臟、油炸類、膨化類、燒烤類等高熱量的食物統(tǒng)一為膏粱厚味;本研究所納入的44例病例中有41例嗜食膏粱厚味,占總人數(shù)的93.18%。通過調查發(fā)現(xiàn),部分患者并未戒酒、控制飲食。2.合并代謝性疾病及生化結果:本研究所選取的44例病例,或多或少均伴有代謝性疾病,其中有37例伴有血脂代謝異常,占患者總數(shù)的84.09%;TG的平均值(2.57±1.37)mmol/l,高于正常值者共29人,占患者總數(shù)的65.91%;CHO的平均值為(5.01±1.03)mmmol/l,高于正常值的共18人,占患者總數(shù)的40.91%;HDL的平均值為(1.07±0.22)mmol/l,低于正常值的共25人,占患者總數(shù)的56.82%;LDL的平均值為(3.24±8.3)mmmol/l,高于正常值的共13人,占患者總數(shù)的29.55%;TG的均值沒有落在其正常范圍內。44名患者的BMI平均為(29.4±4.04)kg/m2,最低為 22.9kg/m2,最高達 41kg/m2,根據(jù) 1997 年《WHO 成年人BMI分類標準》,本研究的患者分為體重過低、正常范圍、肥胖前期、Ⅰ度肥胖、Ⅱ度肥胖、Ⅲ度肥胖,其中體重指數(shù)正常的患者僅占13.64%。在參與研究的44名病例之中僅有5人的腰圍處于正常范圍內,有36人的腰圍90cm,即81.82%的患者存在腹型肥胖;腰圍的平均值為(96.05±8.1)cm。在44例患者中,有23人伴有高血壓,11人伴有空腹血糖升高,血糖的平均值為(5.9±0.97)mmol/l。根據(jù)2009年《代謝綜合征臨床診斷標準》,44名患者中有26名可診斷為代謝綜合征,占總人數(shù)的59%。在所有病例中,血尿酸的平均值為(545.48±106.57)umol/l,最高值為793umol/l,最低值為359umol/l,其中有4例患者的血尿酸處于正常水平,40例患者的血尿酸水平升高,占總人數(shù)的90.90%。通過SPSS軟件對血UA、TG、CHO、LDL、HDL進行相關性分析得出結論為:UA與GLU線性弱相關,但沒有統(tǒng)計學意義;UA與TG、CHO、LDL、HDL線性極弱相關或不相關。TG與CHO、GLU線性弱相關,且有統(tǒng)計學意義(P0.05);TG與HDL呈負向線性弱相關,且有統(tǒng)計學意義(P0.05);TG與LDL極弱相關或不相關。CHO與HDL、GLU線性弱相關,且有統(tǒng)計學意義(P0.05);CHO與LDL呈線性強相關,且有統(tǒng)計學意義(P0.01)。LDL與GLU線性弱相關,且有統(tǒng)計學意義(P0.05);LDL與HDL線性極弱相關或不相關。HDL與GLU線性極弱相關或不相關。3.臨床癥狀:本研究統(tǒng)計了自病人發(fā)病以來,所有的痛風性關節(jié)炎的發(fā)病部位,疼痛多發(fā)于第一跖趾關節(jié)(41.13%)、踝關節(jié)(18.55%)。在本研究中,多數(shù)患者是因為進食高嘌呤食物(30.49%)、飲酒(24.39%)、疲勞(21.95%)、寒冷(13.14%)引起痛風的急性發(fā)作。患者的主要伴隨癥狀為:肢體/關節(jié)麻木、肢體/關節(jié)困重(56.82%),自汗(54.55%),乏力(52.27%),口干(45.45%),盜汗(36.36%),胸悶(34.09),心煩、頭暈(31.82%),兩目干澀、痰多、氣短、失眠、腰膝酸軟(27.27%)。本研究44例痛風病人的舌色主要為淡紅或淡/白,占所有舌色的77%;舌形以蒼老、舌嫩、舌胖大/齒痕為主,苔質以苔潤、苔膩為主。44例病人的脈象以沉、滑為主。4.通過對疾病證候的分布研究表明,符合痰瘀互阻的病例占52.27%,脾虛濕盛占50.00%,肝腎陰虛者占38.34%,濕熱蘊結者占27.27%。其中3種證候相兼者3人,占6.82%:兩種證候相兼者25人,占56.82%;僅有一種證候者16人,占36.36%。通過對導師44名患者155處方劑使用的藥物共計2491味·次進行分析,平均每張方劑使用藥物16味,其中出現(xiàn)頻率大于50次的藥物有薏苡仁(149)、車前子(147)、蒼術(138)、丹參(130)、浙貝母(127)、萆參(126)、半夏(123)、茯苓(117)、甘草(110)、苦參(109)、黃柏(102)、金錢草(99)、青蒿(94)、益母草(84)、大黃(76)、雞血藤(53)。單獨分析每張方劑,得出每類藥在155張方劑中的出現(xiàn)頻率,可知在每張方劑中均含有健脾/運脾藥,98.06%的方劑中含有活血藥,93.55%的方劑中含有化痰藥�；颊咴谥委�2-3個月以后,血尿酸均有明顯降低,初診時患者的血尿酸平均值為(545.48±106.58)umol/l,就診2-3個月后的血尿酸前后平均值為(424.75±76.87)umol/l,治療后的血尿酸水平較治療前明顯降低,且有統(tǒng)計學意義(p0.01)。結論:1.大多數(shù)痛風患者飲食不節(jié),其日常飲食中含有高嘌呤食物,部分痛風患者的飲食結構不科學。飲食不節(jié)是本病的主要病因及急性發(fā)作的主要誘因。2.痛風患者常伴發(fā)其他代謝類疾病,如高脂血癥、肥胖、代謝綜合征等,痛風病人的證型分類以痰瘀互阻、脾虛濕盛為主。其常見癥狀除發(fā)作時關節(jié)紅、腫、熱、痛外還有肢體/關節(jié)困重/麻木、汗出異常、口干、胸悶,舌紅、苔膩水滑,脈沉滑。3.痛風的發(fā)生與體重指數(shù)、腰圍、血脂、血壓、血糖的異常關系密切,且TG與CHO,TG與GLU,CHO與HDL,CHO與GLU,LDL與GLU的關系為正相關且有統(tǒng)計學意義;TG與HDL的關系為負相關且有統(tǒng)計學意義。4.濁邪與濕邪均產生于脾胃運化的水谷之氣,濁邪產生于谷氣,濕邪產生于水;濁邪通過經脈運行于周身,濕邪通過三焦水道運行于周身。5.濁邪的性質及致病特點:(1)致病隱匿,發(fā)展緩慢。(2)濁邪易滯而成痰。(3)濁邪粘滯穢濁,易阻滯氣機,影響血行。(4)濁邪病勢纏綿。(5)濁邪致病廣泛。6.濁邪致病的治療方法:(1)一般治療:①合理飲食,以杜絕濁邪的來源;②體育鍛煉。(2)中醫(yī)藥治療:①芳香化濁;②健脾化濁;③;補腎祛濁;④暢肺泄?jié)?⑤利水泄?jié)?⑥通腑瀉濁;⑦活血化瘀。7.導師在痛風的治療上多使用辨病辨證相結合的方法,臨床上常使用分消泄?jié)岬姆椒?運脾胃、利小便、通大便、暢血脈、化痰濁,常使用的方劑為四妙散合萆參滲濕湯,并強調調攝飲食、適當鍛煉在治療中的重要作用。
[Abstract]:Gout (Gout) is a kind of disease caused by the disorder of purine metabolism and the decrease of uric acid excretion caused by the decrease of uric acid excretion. According to the process of disease development, gout is divided into three stages: acute, chronic and intermittent. Gout is a category of "arthralgia" in traditional Chinese medicine. Most doctors summarize the pathogenesis of phlegm stasis, spleen deficiency and damp. The incidence of gout, hyperuricemia and other metabolic diseases is also increasing year by year because of the improvement of people's living standard in recent years. In the course of follow-up, the patients with gout often have other metabolic diseases, such as obesity, metabolic syndrome, dyslipidemia, diabetes. Tutors often treat gout The treatment effect is obvious with the method of combining disease differentiation with dialectics, and the therapeutic effect of the treatment is obvious. The study of the prescription of the tutor found that the frequency of the water and humid drugs has a high frequency. Through reading, the literature on the pathogenesis and diagnosis of gout is very rich in recent years; the relationship between gout and other metabolic diseases has been gradually found and paid attention to. The experimental and clinical studies of wind and hyperuricemia have also made some progress. Some documents refer to turbid evil, and wet turbid is the main pathogenic factor causing gout. Objective: To explore the diet law of gout, the causes of gout attack, the relationship between gout and other metabolic diseases, and the blood uric acid (UA), blood glucose (GLU), triglyceride (TG), Whether the total cholesterol (CHO), low density lipoprotein (LDL) and high density lipoprotein (HDL) are related, and observe the curative effect of the included cases, analyze the experience of Professor Yin Haibo's treatment of gout, and discuss the theoretical basis of the treatment of gout with the method of eliminating turbidity. Methods: through the outpatient records of patients with gout conforming to the conditions and filling out the medical records Collect the table; use the Epidate3.1 software to establish the database, enter the data and analyze the data through the SPSS24 software. Results: 1. the general cases are included: (1) the basic data and the incidence of the disease: This study collects 44 case data, the sex of the patient is male, among which there are 14 cases of gout family history, and 30 cases without the history of gout family history. 20 people were in an acute attack. The age of this case study was included in the age of (43.14 + 11.33) years, of which the minimum age was 19 years and the largest was 67 years. The age of onset was 20-29 years old. The average course of the case was (6.18 + 6.41) years, the shortest course was 3 days and the longest was 28 years. The course of the majority of cases was less than 5 years. The average episodes of gout in 59.09%.44 patients in all cases were (4.7 + 2.88) times per year. The majority of patients were two times a year. (2) diet: 25 of the 44 patients enrolled in the study included the habit of drinking at ordinary times, accounting for 56.82% of the total number of patients, and most of the patients' daily diet was rich. Cereals, vegetables and fruits, meat are more, and some patients eat meat, processed meat, fry, barbecue, puffed food. High calorie foods such as meat, processed meat, animal viscera, fried, puffing, barbecue and other high calorie foods are unified into thick flavor; 41 of the 44 cases included in this study account for the total number of ploophore, accounting for the total number of people. 93.18%. found that some patients did not abstain from alcohol, control the diet.2. with metabolic diseases and biochemical results: 44 cases selected in this study were more or less accompanied by metabolic diseases, of which 37 cases were accompanied by abnormal lipid metabolism, accounting for 84.09% of the total number of patients, and the average value of TG (2.57 + 1.37) mmol/l, higher than the normal value of 29 people. 65.91% of the total number of patients; the average value of CHO was (5.01 + 1.03) mmmol/l, higher than the normal value of 18 people, accounting for 40.91% of the total number of patients; the average value of HDL was (1.07 + 0.22) mmol/l, less than the normal value of the total number of patients, accounting for 56.82%; the average value of LDL was (3.24 + 8.3) mmmol/l, higher than the normal value of 13 people, accounting for 29.55% of the total number of patients; TG The average BMI of the.44 patients in the normal range was (29.4 + 4.04) kg/m2, the lowest was 22.9kg/m2, and the highest was 41kg/m2. According to the
【學位授予單位】：中國中醫(yī)科學院
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R259
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