【摘要】：慢傳輸型便秘是一種常見的功能性疾病,作為功能性疾病中多發(fā)的一種一類身心疾病,隨著生活習(xí)慣及飲食習(xí)慣的改變,該病的發(fā)病率呈明顯上升趨勢(shì),嚴(yán)重影響了病患的生活質(zhì)量,且其發(fā)病人群分布廣泛,從兒童到老年,均是高發(fā)人群,功能性疾病是現(xiàn)代疾病的一個(gè)棘手疾病,如何提高該病的臨床療效,是對(duì)消化科醫(yī)生的要求,也是現(xiàn)今研究的熱點(diǎn)之一。目前現(xiàn)代醫(yī)學(xué)對(duì)慢傳輸型便秘的發(fā)病機(jī)制有一定的認(rèn)識(shí),但仍無法全面了解其發(fā)病原因,并且在治療方面的療效仍欠佳。祖國醫(yī)學(xué)對(duì)于便秘有長久深遠(yuǎn)的認(rèn)識(shí),在臨床治療上亦積累了豐富的經(jīng)驗(yàn),無論從病因病機(jī)還是綜合治療上,都有其獨(dú)特性及優(yōu)勢(shì)所在。研究目的便秘是消化系統(tǒng)一類常見的慢性功能性疾病,臨床表現(xiàn)為排便次數(shù)減少、糞便干結(jié)、排便費(fèi)力等癥,一般分為慢傳輸型便秘、出口梗阻型便秘及混合型便秘三種類型。隨著飲食結(jié)構(gòu)及生活習(xí)慣的改變,便秘的發(fā)病率逐年升高,重者可影響患者的生活和工作,便秘也越來越引起人們的重視。慢傳輸型便秘是由醫(yī)學(xué)家Proton和Lennard Jonors于1986年提出,排除了結(jié)腸生理解剖性、器質(zhì)性及結(jié)腸外病因所致的便秘以及出口梗阻性便秘基礎(chǔ)上,由于結(jié)腸傳輸傳導(dǎo)功能減慢引起的頑固性便秘,臨床特點(diǎn)為便秘、結(jié)腸通過的時(shí)間延長和對(duì)纖維素、緩瀉劑等治療反應(yīng)差為特征,同時(shí)伴有腹脹腹痛、煩躁易怒、憂慮、抑郁失眠等軀體及精神心理癥狀。慢傳輸型便秘嚴(yán)重地影響了人們的身心健康,大概占所有便秘患者中的16%-40%,在我國發(fā)生率較高。跟隨導(dǎo)師門診時(shí)筆者發(fā)現(xiàn),便秘患者以中青年女性居多,結(jié)合其發(fā)病特點(diǎn)以慢傳輸型便秘為主,由于便秘原因復(fù)雜,診斷相對(duì)困難,早期治療不及時(shí),治療方法不規(guī)范,出現(xiàn)嚴(yán)重的亂用渴藥問題,常常延誤或者加重病情,也導(dǎo)致臨床治療有效性差、復(fù)發(fā)率高等問題。西醫(yī)治療慢性傳輸型便秘多以改善胃腸動(dòng)力、緩瀉為主,其存在耐藥、依賴、易反復(fù)等缺點(diǎn),而中醫(yī)則能整體調(diào)節(jié)、循序漸進(jìn),能有效減少藥物依賴。通過研究枳術(shù)湯加減治療結(jié)腸慢傳輸型便秘臨床療效的觀察與評(píng)價(jià),以闡明肝郁脾虛影響胃腸傳輸功能而至便秘的病因病機(jī)的發(fā)展過程,從而提高慢傳輸型便秘治療的有效率。研究方法全部患者來源于2014.12-2015.12年脾胃病科廣州中醫(yī)藥大學(xué)附屬第一醫(yī)院門診,符合(排除流出道梗阻型便秘)中西醫(yī)診斷,且愿意配合預(yù)后追蹤及治療的患者90例。西醫(yī)采用符合羅馬標(biāo)準(zhǔn)Ⅲ及2007年在揚(yáng)州全國專家肛腸制訂的《中國慢性便秘的指南診治》,標(biāo)準(zhǔn)。中醫(yī)據(jù)《中醫(yī)病癥診斷療效標(biāo)準(zhǔn)》制定,一般便秘臨床表現(xiàn)為：多數(shù)三五日排一次大便,甚至更久才能排便一次,或者均能每天排便,但是排出費(fèi)力,干如羊糞,部分也有患者大便黏膩偏軟,難出,便意頻作,但很難一次排干凈或不能順利排出。照《中醫(yī)病證診斷療效標(biāo)準(zhǔn)》國家中醫(yī)管理局頒布的,治愈標(biāo)準(zhǔn)為兩天以內(nèi)排便一次解時(shí)通暢,,便質(zhì)轉(zhuǎn)軟,短時(shí)間內(nèi)沒有復(fù)發(fā)便秘；好轉(zhuǎn)為便質(zhì)不硬,三天左右至少排便一次,但有時(shí)大便欠暢；無效是癥狀前后無明顯改善。病例入院標(biāo)準(zhǔn),需符合肝郁脾虛型便秘的中醫(yī)癥候主癥、次癥診斷標(biāo)準(zhǔn),以及納入的四項(xiàng)標(biāo)準(zhǔn)、病歷排除的9項(xiàng)標(biāo)準(zhǔn)。研究主要方法從樣本量估算、隨機(jī)分組、給藥方法、辨證湯藥加減制備,逐一完善進(jìn)行。給藥方案為：①.對(duì)照A組：枸櫞酸莫沙必利分散片5mg pot tid；②.對(duì)照B組：枸櫞酸莫沙必利分散片5mg pot tid,黛力新10.5mg qd；③.觀察組(中藥組)： 中藥日一劑(共200m1),每次100ml,早午飯后1小時(shí)溫服。觀察方法：服藥前詢問患者曾用過何種治療便秘的藥物,填寫便秘中醫(yī)證候觀察表�；颊咧委熯^程中每周復(fù)診一次,觀察并記錄病情變化：如有無縮短排便間隔時(shí)問,排便是否困難,不適感便后有無、服藥前后的大便形狀、軟硬程度有無變化等情況,是否出現(xiàn)不良反應(yīng),伴隨的腹脹、乏力、便不盡感、舌象、脈象等的前后變化,治療二周、四周后按照統(tǒng)計(jì)學(xué)方法加以分析。數(shù)據(jù)結(jié)果統(tǒng)計(jì)按照《中藥新藥臨床研究指導(dǎo)原則》中慢性便秘的癥狀分級(jí)標(biāo)準(zhǔn)進(jìn)行積分評(píng)估,分別從各項(xiàng)癥狀積分、總療效判定積分、焦慮抑郁量表的治療前后評(píng)分進(jìn)行分析,統(tǒng)計(jì)數(shù)據(jù)處理則對(duì)正態(tài)性分布先進(jìn)行計(jì)量資料檢驗(yàn)及齊性方差檢驗(yàn),若呈方差齊,正態(tài)分布,則行t檢驗(yàn),否則行t’檢驗(yàn),用計(jì)數(shù)卡方檢驗(yàn)資料。研究結(jié)果從年齡上看,發(fā)病以中老年患者居多,達(dá)到34%；STC的病程較長,反復(fù)發(fā)作達(dá)1年以上的比例接近69%；總治療療程結(jié)束后,觀察組總有效率為90%,對(duì)照A組總有效率65.5%,對(duì)照B組總有效率86.7%,治療前及治療后4周的癥狀總積分對(duì)比分別是：觀察組18.02±6.34、4.93±1.21,對(duì)照A組18.25±6.21、8.35±6.89,對(duì)照B組17.93±6.53、5.54±5.43；從各單項(xiàng)積分來看,糞便性質(zhì)、排便時(shí)間、排便頻率、腹部癥狀、噯氣、乏力、煩躁等癥狀均有所改善,其中觀察組中腹部癥狀、噯氣、乏力等癥改善較西藥明顯,而在納呆、煩躁抑郁等方面,其癥狀積分與對(duì)照B組則更接近。從焦慮、抑郁量表統(tǒng)計(jì)結(jié)果可見,觀察組的有效率為86.7%,對(duì)照A組是70%,對(duì)照B則是73.3%,觀察組及對(duì)照B組對(duì)焦慮抑郁等情緒的干預(yù)作用明顯,而對(duì)照B組的作用則較差。結(jié)論枳術(shù)湯加味是許鑫梅教授治療STC的理論指導(dǎo)下配伍而成,具有健脾益氣、疏肝解郁、理氣通便的功效,同時(shí)紫苑一味藥有畫龍點(diǎn)睛之妙,即能潤腸又能起到提壺揭蓋、宣暢肺氣的作用,經(jīng)過臨床療效觀察,顯示枳術(shù)湯加味在改善STC癥狀的同時(shí),對(duì)心理情緒具有良好的調(diào)節(jié)作用,臨床療效佳。
[Abstract]:Slow-transit constipation is a common functional disease. As a kind of physical and mental diseases frequently occurring in functional diseases, the incidence of slow-transit constipation is increasing with the changes of living habits and dietary habits, which seriously affects the quality of life of patients. The incidence of slow-transit constipation is widespread among the population, ranging from children to the elderly. Functional disease is a thorny disease of modern disease. How to improve the clinical efficacy of the disease is the requirement of digestive doctors and one of the hotspots of current research. Chinese medicine has a long-term and profound understanding of constipation and accumulated rich experience in clinical treatment. Both etiology and pathogenesis as well as comprehensive treatment have their unique characteristics and advantages. Constipation and other symptoms, generally divided into slow transit constipation, outlet obstruction constipation and mixed constipation three types. With the change of dietary structure and living habits, the incidence of constipation increased year by year, serious patients can affect the life and work, constipation has attracted more and more attention. In 1986, ard Jonors proposed that obstinate constipation due to slow colonic transmission function was characterized by constipation, prolonged colonic passage time, and poor response to cellulose and laxatives on the basis of excluding constipation due to colonic anatomy, organic and extracolonic causes, and outlet obstruction. Slow transit constipation seriously affects people's physical and mental health, accounting for about 16% - 40% of all constipation patients, with a high incidence in China. Following the tutor's clinic, I found that the majority of constipation patients were young and middle-aged women, combined with their onset. It is characterized by slow transit constipation, which is characterized by complicated causes, relatively difficult diagnosis, untimely early treatment, irregular treatment methods, serious abuse of thirst drugs, often delaying or aggravating the disease, but also leading to poor clinical efficacy and high recurrence rate. Western medicine for chronic transit constipation often improves gastrointestinal motility. In order to clarify the pathogenesis of constipation caused by liver depression and spleen deficiency, the clinical effect of Zhizhu Decoction on slow transit constipation of colon was observed and evaluated. Methods All the patients came from the outpatient department of the First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine from December 2014 to December 2015. They were in accordance with the diagnosis of Chinese and Western medicine, and were willing to cooperate with prognosis tracking and treatment of 90 patients. The clinical manifestations of general constipation are as follows: most of them defecate once every three or five days, or even longer, or can defecate once a day, but the excretion is laborious, dry as sheep dung, part of it. According to the "Diagnostic and Therapeutic Criteria of TCM Diseases and Syndromes" issued by the State Administration of TCM, the curing criteria are smooth defecation within two days, soft stool, no recurrence of constipation within a short period of time; improve for the constipation is not hard, about three days to. The admission criteria should be in accordance with the main symptoms of constipation due to liver depression and spleen deficiency, the diagnostic criteria for secondary symptoms, the four criteria included, and the nine criteria excluded from medical records. Control group A: Mosapride Citrate Dispersible Tablets 5mg pot tid; Control group B: Mosapride Citrate Dispersible Tablets 5mg pot tid, Deanxit 10.5mg qd; Observation group (Chinese medicine group): one dose a day (a total of 200 m1), 100 ml each time, one hour after breakfast warm. Before taking medicine, ask the patient what kind of medicine has been used to treat constipation, fill in the observation form of TCM syndromes of constipation. During the course of treatment, the patient will go back to the doctor once a week to observe and record the changes of the condition: if there is any shortening of the interval between defecation, whether it is difficult to defecate, whether there is any discomfort after defecation, the shape of stool before and after taking medicine, whether there is any change in the degree of softness or hardness, etc. Whether there are adverse reactions, abdominal distention, fatigue, fecal exhaustion, tongue and pulse changes before and after treatment for two weeks, four weeks after the analysis according to statistical methods. Validity score, anxiety and depression scale before and after treatment score analysis, statistical data processing on the normal distribution of the first quantitative data test and homogeneous variance test, if the variance is homogeneous, normal distribution, then t test, otherwise t'test, using counting chi-square test data. The total effective rate was 90% in the observation group, 65.5% in the control group, and 86.7% in the control group. The total score of symptoms before and after treatment was 18.02 (+ 6.34), 4.93 (+ 1.21) in the observation group and 18.02 (+ 1.21) in the control group. 25 [6.21], 8.35 [6.89], 17.93 [6.53], 5.54 [5.43] in control group B, the fecal properties, defecation time, frequency of defecation, abdominal symptoms, belching, fatigue, irritability and other symptoms were improved, of which the abdominal symptoms, belching, fatigue and other symptoms in the observation group were improved more significantly than western medicine, while in the aspects of nausea, restlessness and depression, the symptoms integral points. The results showed that the effective rate of observation group was 86.7%, that of control group A was 70%, and that of control group B was 73.3%. The intervention effect of observation group and control group B on anxiety and depression was obvious, but that of control group B was worse. Compatibility, with the spleen tonifying Qi, soothing liver depression, the effect of clearing constipation, Astragalus medicine has a finishing touch, that is, can moisten the intestines can also play the role of lifting pot uncovering, Xuanchang lung Qi. After clinical observation, Zhizhu Decoction modified in improving STC symptoms at the same time, has a good role in regulating psychological mood, clinical efficacy. Good.
【學(xué)位授予單位】：廣州中醫(yī)藥大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類號(hào)】：R256.35

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3 鄒爭春　朱廣平 本報(bào)記者 趙雪;大坪醫(yī)院首創(chuàng)分類診斷法治療便秘[N];科技日?qǐng)?bào);2011年

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