本文選題：乙肝相關(guān)性原發(fā)性肝癌 + 中醫(yī)病機(jī)�。� 參考：《北京中醫(yī)藥大學(xué)》2016年碩士論文

【摘要】：目的乙肝相關(guān)性原發(fā)性肝癌起病隱匿,病情發(fā)展迅速,多數(shù)患者確診時(shí)已至病程中晚期甚至發(fā)生遠(yuǎn)處轉(zhuǎn)移,而該病治療手段有限,復(fù)發(fā)率及病死率很高,給患者帶來(lái)沉重的醫(yī)療負(fù)擔(dān)及巨大的心理?yè)p害。中醫(yī)藥對(duì)肝癌的治療歷史悠久,在防治腫瘤復(fù)發(fā)、改善臨床癥狀、提高病患生存質(zhì)量等方面具有較大優(yōu)勢(shì),已成為防治肝癌重要的臨床手段之一。本課題通過(guò)對(duì)140例乙肝相關(guān)性原發(fā)性肝癌患者進(jìn)行研究,探索乙肝相關(guān)性原發(fā)性肝癌中醫(yī)證候特征,歸納其病因病機(jī)；并對(duì)患者的焦慮、抑郁情況進(jìn)行調(diào)查分析,初步探討乙肝相關(guān)性原發(fā)性肝癌患者的心理健康狀態(tài),以期對(duì)臨床治療有一定的指導(dǎo)作用。方法通過(guò)參考相關(guān)文獻(xiàn),歸納總結(jié)乙肝相關(guān)性原發(fā)性肝癌的常見(jiàn)中醫(yī)癥狀及癥狀分級(jí)量化,并咨詢相關(guān)專家,經(jīng)討論后制出本課題的調(diào)查問(wèn)卷。收集了在北京中醫(yī)藥大學(xué)東直門醫(yī)院、中國(guó)人民解放軍第三○二醫(yī)院、北京大學(xué)第一醫(yī)院門診及病房診治的病例146例,合格病例共140例。采用辨證分型和因子分析法研究證候規(guī)律,探討病因病機(jī)；采用漢密爾頓焦慮量表(HAMA)及漢密爾頓抑郁量表(HAMD)進(jìn)行評(píng)定,探索患者心理健康情況。結(jié)果本研究中140例乙肝相關(guān)性原發(fā)性肝癌病例男女之比為6.37：1,患者平均年齡為54.16歲,男性發(fā)病年齡為53.67±7.803,女性發(fā)病年齡為57.26±7.978,女性發(fā)病年齡晚于男性(P0.05)。本次調(diào)查發(fā)現(xiàn)以機(jī)關(guān)單位工作人員及學(xué)歷在中專、大學(xué)及以上的人群發(fā)病率較高。140例病例中50.7%的患者體重屬于超重狀態(tài),平均體重指數(shù)為24.02±3.648。有29例(20.7%)患者具有肝癌家族史,32.1%的患者HBV感染方式為母嬰垂直傳播。本次調(diào)查中68.6%患者存在吸煙、飲酒不良生活習(xí)慣,其中吸煙且飲酒者達(dá)到45.7%。140乙肝相關(guān)性原發(fā)性肝癌患者中HBeAg陽(yáng)性患者36例(25.7%),HBV-DNA陽(yáng)性患者61例(43.5%),HBeAg陽(yáng)性并HBV-DNA陽(yáng)性患者23例(16.4%),HBeAg陰性并HBV-DNA陽(yáng)性患者38例(27.1%)。甲胎蛋白大于400ug/L的患者占30%。肝功能各項(xiàng)指異常比例均超過(guò)30%,其中GGT (57.9%)、AST (45.0%)、TBIL (45.0%)異常比例較高。血常規(guī)各項(xiàng)指標(biāo)中PLT (45.00%)、WBC (34.29%)異常比例較高。腫瘤門脈侵犯患者46例(32.9%)。140例乙肝相關(guān)性原發(fā)性肝癌患者BCLC分期,0期共1例(0.71%),A期共19例(13.57%),B期共52例(37.14%),C期共59例(42.14%),D期共9例(6.43%)。不同分期患者肝功能中TBIL、ALT、AST、GGT、ALP,血常規(guī)中RBC、HGB、NE%,血凝中PT、PT%、APTT、FIB,腫瘤標(biāo)志物中AFP、CA199均存在差異(P0.05)。不同分期患者中醫(yī)癥狀量化評(píng)分存在差異(P0.05)。140例乙肝相關(guān)性原發(fā)性肝癌患者主要證型出現(xiàn)頻次由高至低依次為：肝郁脾虛證(35.71%),氣滯血瘀證(30.71%),濕熱毒蘊(yùn)證(25.71%),肝腎陰虛證(5.71%),肝氣郁結(jié)證(2.14%)。對(duì)不同證候的理化指標(biāo)進(jìn)行比較,發(fā)現(xiàn)ALB、TBIL在不同證型中存在差異(P0.05)。ALB在各證型中的水平表現(xiàn)為肝郁氣滯型肝腎陰虛型濕熱毒蘊(yùn)型肝郁脾虛型氣滯血瘀型。TBIL在濕熱毒蘊(yùn)型水平最高,肝郁脾虛型最低。中醫(yī)癥狀量化評(píng)分以氣滯血瘀型最高,肝氣郁結(jié)型最低。通過(guò)因子分析法歸納出140例乙肝相關(guān)性原發(fā)性肝癌患者的證候,最常見(jiàn)的兩種證型為氣滯血瘀兼脾虛(27.14%),血瘀濕阻(23.57%)；其余證型依次為肝郁化火兼脾虛瘀阻(12.86%),脾虛濕熱兼肝郁(9.29%),濕熱瘀阻兼肝郁脾虛(9.29%),肝絡(luò)瘀阻兼脾虛濕盛(7.14%),血瘀濕阻兼脾虛(5.17%),肝郁化火兼濕熱中阻(4.28%),肝火上擾(0.71%)。對(duì)各證型的證素進(jìn)行分類歸納,得出本病的證候要素為血瘀(85.71%)、脾虛(71.43%)、氣滯(62.86%)、濕(59.29%)、熱(36.43%)。140例乙肝相關(guān)性原發(fā)性肝癌患者焦慮指數(shù)為20.06±5.97,86.4%的患者存在焦慮狀態(tài),中度焦慮者占39.9%,重度焦慮者占40.7%,嚴(yán)重焦慮者6.4%。140例乙肝相關(guān)性原發(fā)性肝癌患者抑郁指數(shù)為22.37±8.47,61.4%患者檢出抑郁狀態(tài),重度抑郁者占55.0%,嚴(yán)重抑郁者6.4%。單純焦慮的患者37例(26.4%),單純抑郁的患者2例(1.4%),焦慮伴抑郁的患者84例(60.0%)。血型為A型的患者HAMA評(píng)分、HAMD評(píng)分均高于其他血型。肝癌病程不同患者焦慮評(píng)分存在差異(P0.05),其中病程0.5年以下患者焦慮評(píng)分(21.44±5.45)明顯高于其他各組。肝癌分期不同,HAMD評(píng)分指數(shù)存在差異(P0.05)。不同中醫(yī)證型患者焦慮、抑郁評(píng)分均以氣滯血瘀型最高,其次為肝郁脾虛型,而濕熱毒蘊(yùn)型最低。結(jié)論1乙肝相關(guān)性原發(fā)性肝癌病機(jī)復(fù)雜,“正虛毒瘀”為核心,病理因素多為脾虛、氣滯、血瘀、濕、熱；病位主要在肝、脾；通過(guò)因子分析法歸納中醫(yī)證型,得出本病多為復(fù)合證型,少數(shù)為單一證型,病性多為虛實(shí)夾雜。2乙肝相關(guān)性原發(fā)性肝癌患者ALB水平隨陰虛、脾虛及血瘀的加重呈下降趨勢(shì)；TBIL水平以濕熱毒蘊(yùn)型最高,其他證型水平相似。3乙肝相關(guān)性原發(fā)性肝癌患者表現(xiàn)出不同程度的焦慮和抑郁狀態(tài)。
[Abstract]:Objective the hepatitis B related primary liver cancer is insidious and the disease develops rapidly. Most patients have been diagnosed at the middle and late stage of the disease or even distant metastasis, and the treatment means of the disease is limited, the recurrence rate and the fatality rate are very high, which brings a heavy medical burden and great psychological damage to the patients. It is one of the important clinical means to cure the recurrence of the tumor, improve the clinical symptoms and improve the quality of the patient's survival, and it has become one of the important clinical means to prevent and cure the liver cancer. Through the study of 140 cases of primary liver cancer associated with hepatitis B, the characteristics of TCM syndrome of hepatitis B related primary liver cancer are explored and the pathogenesis of the disease is summarized. The psychological health status of patients with hepatitis B related primary liver cancer was preliminarily investigated and analyzed in order to have a certain guiding role in clinical treatment. Methods the classification and quantification of common medical symptoms and symptoms of hepatitis B related primary liver cancer were summed up by reference to relevant literature, and related experts were consulted. After discussing the questionnaire, we collected 146 cases of Dongzhimen hospital in Dongzhimen, the third two hospital of the PLA, the clinic and ward of the No.1 Hospital of Peking University, and 140 qualified cases. The syndrome differentiation and factor analysis were used to study the regularity of syndrome, and the etiology and pathogenesis were discussed. The Hamilton Anxiety Scale (HAMA) and the Hamilton Depression Scale (HAMD) were evaluated to explore the mental health of the patients. Results in this study, the ratio of male and female to 140 cases of hepatitis B related primary liver cancer was 6.37:1, the average age of the patients was 54.16 years, the age of the male was 53.67 + 7.803, the age of the female was 57.26 + 7.978, and the female hair was found. The age of the disease was later than that of the male (P0.05). This survey found that 50.7% of the patients with higher morbidity in.140 cases with higher incidence of college and above were overweight, with an average body mass index of 24.02 + 3.648., 29 cases (20.7%) had a family history of liver cancer, and 32.1% of the patients with HBV infection were the mother. In this survey, 68.6% patients had smoking and drinking bad habits. Among them, 36 cases (25.7%) were HBeAg positive in the patients with 45.7%.140 hepatitis related primary liver cancer, 61 cases (43.5%), HBeAg positive and 23 HBV-DNA positive patients (16.4%), HBeAg negative and HBV-DNA positive patients. 38 cases (27.1%). Patients with alpha fetoprotein greater than 400ug/L accounted for more than 30% of the abnormal proportion of 30%. liver function, of which GGT (57.9%), AST (45%), TBIL (45%) abnormal ratio was higher. The abnormal proportion of PLT (45%) and WBC (34.29%) in the blood routine indexes was higher. The tumor portal vein invasion patients were 46 (32.9%).140 cases of hepatitis B related primary liver cancer BCLC staging, 0 stage 1 cases (0.71%), 19 cases (37.14%) in phase A, 59 cases (42.14%) in phase B, 9 cases (6.43%) in D stage, TBIL, ALT, AST, GGT, ALP in different stages of liver function. There were differences in quantitative score (P0.05).140 cases of hepatitis B related primary liver cancer, the main syndromes of the main syndrome were: liver depression and spleen deficiency syndrome (35.71%), qi stagnation and blood stasis syndrome (30.71%), damp heat syndrome (25.71%), liver kidney yin deficiency syndrome (5.71%), liver qi stagnation syndrome (2.14%). The physical and chemical indexes of different syndromes were compared, and ALB and TBIL were found. Among the different types of syndrome (P0.05) the level of.ALB in each type of syndrome is the liver qi stagnation type of liver kidney yin deficiency type wet heat toxin, the liver qi stagnation and spleen deficiency type of qi stagnation and blood stasis type.TBIL is the highest, the liver qi stagnation and spleen deficiency type is the lowest. The syndromes of 140 patients with hepatitis B related primary liver cancer were summed up, the most common two types of syndrome were qi stagnation and spleen deficiency (27.14%), blood stasis damp resistance (23.57%), the other syndrome types were liver depression and spleen deficiency stasis (12.86%), spleen deficiency and liver stagnation (9.29%), damp heat stasis and liver depression and spleen deficiency (9.29%), liver blood stasis and spleen deficiency dampness (7.14%). The blood stasis damp resistance and spleen deficiency (5.17%), liver depression and damp heat resistance (4.28%), liver fire disturbance (0.71%). The syndrome factors of each syndrome were classified and summed up. The syndrome factors of this disease were blood stasis (85.71%), spleen deficiency (71.43%), Qi Stagnation (62.86%), wet (59.29%), and heat (36.43%).140 patients with hepatitis B related primary liver cancer (20.06 + 5.97,86.4%). The patients had anxiety state, moderate anxiety accounted for 39.9%, severe anxiety accounted for 40.7%. The depressive index of 6.4%.140 patients with hepatitis B related primary liver cancer was 22.37 + 8.47,61.4% in patients with severe anxiety, 55% in severe depression, 37 in 6.4%. with severe depression (26.4%) and 2 in patients with simple depression (2 cases of simple depression). 1.4%), 84 patients with anxiety and depression (60%). The HAMD score of the patients with type A was higher than that of other blood groups. There was a difference in the anxiety score of the patients with different liver cancer (P0.05), and the anxiety score of the patients under the course of disease (21.44 + 5.45) was significantly higher than that of the other groups. The stage of liver cancer was different and the HAMD score was different (P0.05). The scores of different TCM syndrome type patients were the highest of qi stagnation and blood stasis type, followed by the liver depression and spleen deficiency type, and the wet heat toxin type was the lowest. Conclusion 1 hepatitis B related primary liver cancer pathogenesis is complex, "Zheng Xu Qi stasis" is the core, the pathological factors are spleen deficiency, qi stagnation, blood stasis, damp and heat; the disease location is mainly in the liver and spleen; through factor analysis method return. With the syndrome type of traditional Chinese medicine, it is found that the disease is mostly compound syndrome type, a few is a single syndrome type, and the disease sex is mostly virtual and mixed with.2 hepatitis B related primary liver cancer patients ALB level with Yin deficiency, the aggravation of spleen deficiency and blood stasis is decreasing; the level of TBIL is the highest, and the other syndrome types are similar to the patients with primary liver cancer associated with hepatitis B A state of anxiety and depression to varying degrees.
【學(xué)位授予單位】：北京中醫(yī)藥大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2016
【分類號(hào)】：R273

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10 朱永康（江蘇省中醫(yī)院普外科主任）;原發(fā)性肝癌不一定有臨床癥狀[N];上海中醫(yī)藥報(bào);2005年

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