【作者】 张志谦；

【导师】 赵宝明；

【作者基本信息】 北京中医药大学 ， 中医外科学， 2012， 博士

【摘要】 1目的近年来慢性肛裂的研究有了新的进展。首先对传统的药物和术式深入的研究得到更多更可靠更翔实的数据,为临床决策提供了有利的证据支持；其次一些新的药物如膝钩藻毒素、磷酸二酯酶抑制剂、左旋精氨酸、毒蕈碱激动剂和血管紧张素转化酶抑制剂等正在研究中；与此同时对传统术式的改进和创新也在不断进行中。虽然传统的药物治疗费用较低,但疗程较长、治愈率不高、副作用频发以及远期复发率较高等导致患者对这些药物治疗依从性较差,手术疗法虽治愈率高,却有一定的大便失禁风险,治疗费用也较高。我们的前期研究表明广痛消泡沫气雾剂对各种肛肠疾病有较好的止痛解痉作用,此外还有一定的抗炎止血和促愈合作用。本研究的目的在于观察广痛消泡沫气雾剂治疗慢性肛裂的疗效,并从缓解肛门内括约肌痉挛和抑制炎性痛痛觉敏化两个角度研究该药的作用机制。2方法本研究分为三部分。第一部分为文献研究,通过回顾广痛消泡沫气雾剂的前期研究基础和国内外慢性肛裂以及痛觉敏化分子生物学的研究进展,我们希望从中找到研究广痛消泡沫气雾剂治疗肛裂机制的一些切入点。第二部分为广痛消泡沫气雾剂临床疗效观察。我们采用随机对照方法从治愈率、缓解疼痛、降低肛管静息压和改善生活质量等角度比较了广痛消泡沫气雾剂和硝酸甘油软膏的疗效,并在治疗和随访过程中密切关注治疗可能带来的副作用和远期复发率。第三部分为广痛消泡沫气雾剂的动物实验研究。实验一通过观察大鼠疼痛行为学、局部组织病理和排便改变三个角度论证大鼠肛裂模型的可行性；实验二从疼痛行为学角度比较了各药物对大鼠肛裂疼痛的疗效；实验三采用硝酸还原酶法检测肛裂裂口局部组织NO浓度,研究广痛消泡沫气雾剂与内括约肌重要的舒张递质的关系；实验四采用酶联免疫分析法检测大鼠血清中PGE2的浓度,研究广痛消泡沫气雾剂与炎症因子PGE2的关系；实验五采用免疫组织化学方法检测大鼠脊髓NR2B的表达,研究广痛消泡沫气雾剂对炎性痛痛觉敏化中的重要受体表达的影响。3结果3.1临床研究(1)总疗效：广痛消泡沫气雾剂治疗慢性肛裂的治愈率为56.25%,硝酸甘油软膏(GTN)治愈率为51.61%,两者无显著差异(p=0.5838)(2)肛管静息压：两组治疗前后比较都有显著下降(p=0.0138,p=0.0154)；但治疗后两组间无显著差异(p=0.6843)(3)疼痛积分：治疗结束后两组间无显著差异(p=0.5654),但两组治疗前后比较都有显著下降(p=0.0011,p=0.0038)；治疗第7天两组疼痛较治疗前均有显著缓解(p=0.0231,p=0.0386),治疗组优于对照组(p=0.0176)；治疗第14天与第7天比较两组均有显著缓解(p=0.0178,p=0.0255),治疗组疼痛积分亦低于对照组(p=0.0148)；治疗第21天与第14天比较两组均有显著缓解(p=0.0258,p=0.0169),治疗组疼痛积分亦低于对照组(p=0.0315)；从治疗第28天开始(第28天、35天和42天)治疗组疼痛积分未有明显下降(p=0.3265,p=0.5284,p=0.5324),但对照组仍缓慢下降(p=0.0232,p=0.0154,p=0.0373)；虽然如此治疗第28天和35天,治疗组疼痛积分仍明显低于对照组(p=0.0139,p=0.0468),第42天也就是治疗结束时两组疼痛积分无显著差异(p=0.5654)(4)生活质量：①躯体疼痛：两组治疗前后比较都有显著下降(p=0.0159,p=0.0278),治疗后两组间比较无显著差异(p=0.8621)；②生理职能：两组治疗前后比较都有显著下降(p=0.0306,p=0.0351),治疗后两组间比较无显著差异(p=0.9781)；③精力：两组治疗前后比较都有显著下降(p=0.0387,p=0.0405),治疗后两组间比较无显著差异(p=0.2572)；④两组患者生理机能、一般健康状况、社会功能、情感职能以及精神健康方面治疗前后均无显著改变(p均大于0.05)。(5)治疗组疗效与相关因素关系：治疗组疗效与患者病程长短和肛裂分期有关(p=0.0079,p=0.0168),与患者性别和年龄无明显关系(p=0.9730,p=0.3295)(6)副作用：对照组有7名患者(20%)出现轻度头痛,其中3名患者因头痛频发退出本研究。治疗组治疗过程中未见明显副作用,两者差异显著(p=0.0112)(7)复发率：虽然对照组(29.41%)复发率高于治疗组(11.11%),但无统计学意义(p=0.2285)。3.2实验研究(1)疼痛行为学检查机械性收缩反射阈值：小剂量广痛消组治疗后阈值无明显改变(p=0.4059)；中剂量广痛消组、大剂量广痛消组、GTN组和吲哚美辛组治疗后阈值均明显升高(p=0.0346,0.0105,p=0.0226,p=0.0188)；末次给药后1h,中剂量广痛消组、硝酸甘油软膏组和吲哚美辛组之间无显著差异(p均大于0.05)；大剂量广痛消组机械性收缩反射阈值明显高于吲哚美辛组(p=0.0454)。热退缩潜伏期：治疗后小剂量广痛消组热退缩潜伏期无明显改变(p=0.1558),中剂量广痛消组、大剂量广痛消组、GTN组和吲哚美辛组治疗后热退缩潜伏期均明显延长(p=0.0231,p=0.0117,p=0.0265,p=0.0185)；末次给药后1h,中剂量广痛消组、硝酸甘油软膏组和吲哚美辛组之间无显著差异(p均大于0.05)；大剂量广痛消组末次给药后1h热退缩潜伏期明显长于吲哚美辛组(p=0.0433)。(2)裂口局部组织NO浓度小剂量广痛消组、中剂量广痛消组和吲哚美辛组与模型组相比则无显著差异(p=0.3073,p=0.1734,p=0.3317)；GTN组和大剂量广痛消组浓度明显高于模型组(p=0.0121,0.0287),GTN组亦明显高于大剂量广痛消组(p=0.0108)。(3)血清PGE2的浓度值小剂量广痛消组、中剂量广痛消组和GTN组与模型组相比则无显著差异(p=0.7760,p=0.0869,p=0.7053)；吲哚美辛组和大剂量广痛消泡沫气雾剂组PGE2浓度明显低于模型组(p=0.0023,p=0.0415),吲哚美辛组亦明显低于大剂量广痛消组(p=0.0410)。(4)脊髓NR2B阳性神经元细胞数小剂量广痛消组与模型组相比无显著差异(p=0.6563)；中剂量广痛消组、大剂量广痛消组、GTN组和吲哚美辛组阳性神经元细胞数明显少于模型组(p=0.0496,p=0.0125,p=0.0465,p=0.0242)；大剂量广痛消组阳性神经元细胞数明显少于吲哚美辛组(p=0.0128),中剂量广痛消组阳性神经元细胞数与吲哚美辛组无显著差异(p=0.0997),GTN组阳性神经元数目明显多于吲哚美辛组(p=0.0454)。4结论广痛消泡沫气雾剂和硝酸甘油软膏用于治疗慢性肛裂时都能显著缓解慢性肛裂患者的疼痛,降低肛管静息压,改善患者生活质量(躯体疼痛、生理职能和精力),两者治愈率无显著差异。但是广痛消泡沫气雾剂具有止痛速度更快和疗程更短的优势。此外广痛消泡沫气雾剂治疗过程中未见明显副作用。疗效与相关因素分析显示,广痛消对于病程较短者疗效较佳,治疗Ⅱ期肛裂疗效优于Ⅲ期肛裂。广痛消泡沫气雾剂治疗肛裂的机制可能有：通过提高肛门内括约肌局部NO浓度缓解括约肌痉挛；通过抑制炎性因子PGE2生成和脊髓背角NR2B的表达抑制炎性痛痛觉敏化,而且上述作用有一定的量效关系,剂量越大,作用越明显。更多还原

【Abstract】 1 ObjectivesStudies of chronic anal fissure have made new progress in recent years. Firstly, the studies of the traditional drugs and classic operations have obtained more reliable datas, which will provide favorable evidence to support clinical decision-making; secondly, Some new drugs such as Gonyautoxin, phosphodiesterase inhibitor, L-arginine and muscarinic agonists and angiotensin-converting enzyme inhibitors are being researched; and the improvements to the traditional operations and bold innovations of the new operations are ongoing at the same time. Although the traditional medication treatments have lower cost, the cure rate of them are not high, meanwhile the side effects and long-term recurrence rate are high, so the compliance of patients to these treatments are not very good. Al though the cure rate of surgical therapies are relatively high, there are a certain risks of fecal incontinence, and the treatment cost is also higher.Our previous studies have showed that the Guangtongxiao foam aerosol (GTX) has significant effects on pain relieving and spasmolysis in addition to certain effects of anti-inflammatory hemostatic and wound healing on a variety of anorectal diseases. The objectives of this subject are to observe the efficacy of GTX in the treatment of chronic anal fissure, and to study its mechanism of action from relieving the internal anal sphincter spasm and inhibition to the hyperalgesia of inflammatory pain.2 MethodsThis study consists of three parts. The first part is the literature research by reviewing the previous studies of GTX and the progress of treatment of chronic anal fissure and hyperalgesia research in molecular biology. We hope to find research targets in the study of mechanisms of GTX in the treatment of chronic anal fissure. The second part is the clinical efficacy research of GTX. We adopted randomized controlled approach to compare the efficacy of GTX and GTN from cure rate, pain relieving, reducing of anal resting pressure and improving to the quality of life, meanwhile we paid close attention to the side effects and and long-term recurrence rate of both drugs during the treatment and the follow-up. The third part is about the animal studies of GTX. We demonstrated the feasibility of the model of chronic anal fissure in rats by the observation of pain behaviors, pathology and bowel movement of the rats before and after the molding in experiment one; we compared the efficacy of various drugs in rats with chronic anal fissure from the perspective of pain behaviors in the second experiment; we adopted the nitrate reductase method to measure the concentration of NO in experiment three, to study the relation between GTX and the important neurotransmitter of internal anal sphincter; we adopted enzyme linked immunosorbent assay to measure concentration of PGE2 in serum in experiment four to study the relation between GTX and PGE2which is an important inflammatory factor; We adopted immunohistochemistry to detect NR2B expression in the spinal cord of rats to study the impact of GTX on the important receptor of hyperalgesia in experiment five.3 Results3.1 clinical research(1)the cure rate:The cure rate of GTX was 56.25%, while the cure rate of glyceryl trinitrate ointment (GTN) was 51.61%, and there was no significant difference between them(p=0.5838);(2)anal resting pressure:The anal resting pressures of both groups decreased significantly after the treatment (both p were less than 0.0001); and there was no significant difference between the two groups after the treatment (p=0.6843);(3) pain scores:Pain of both groups alleviated significantly after the treatment(p=0.0011, p=0.0038), but there was no significant difference (p=0.5654) between the two groups after the treatment; pain of both groups alleviated significantly (p=0.0231, p=0.0386) at the 7th day of the treatment, and the treatment group alleviated more significantly than the control group (p=0.0176); pain of both groups alleviated significantly (p=0.0178, p=0.0255) at the 14th day than those of the 7th day, and the treatment group alleviated more significantly than the control group (p=0.0148); pain of both groups alleviated significantly (p=0.0258, p=0.0169) at the 21th day than those of the 14th day, and the treatment group alleviated more significantly than the control group (p=0.0315); pain scores of the treatment group did not decreased significantly ever since the 28th day of the treatment(p=0.3265, p=0.5284, p=0.5324), but the control group decreased all the time until the end of the treatment (p=0.0232, p=0.0154, p=0.0373); but the pain scores of the treatment group were still significantly lower than those of the control group (p=0.0139, p=0.0468), no significant difference existed between the two groups at the 42th day of the treatment (p=0.5654).(4) quality of life:①bodily pain:both groups decreased significantly (p=0.0159, p=0.0278) after the treatment, but no significant difference(p=0.8621)existed between the two groups after the treatment;②role physical:both groups decreased significantly (p=0.0306, p=0.0351)after the treatment, but no significant difference (p=0.9781)existed between the two groups after the treatment;③vitality:both groups decreased significantly (p=0.0387, p=0.0405) after the treatment, but no significant difference (p=0.2572) existed between the two groups after the treatment; (4) there was no significant change about the physical functioning, general health, social functioning, role emotional and mental health (all p were greater than 0.05).(5)Analysis to the relationship between efficacy of the treatment group and relevant factors:efficacy of the treatment group had relationship with duration of disease and anal fissure stage (p=0.0079, p=0.0168); no significant relationship was observed between efficacy and gender/age (p=0.9730, p=0.3295).(6)side effects:seven patients in the control group (20%) had mild headache in the course of treatment, and three of them withdrew from the study because of headache-prone. There was no significant side effects in the treatment group in the course of treatment, significant difference existed between them(p=0.0112).(7)relapse rate:the relapse rate of the control group (29.41%) was higher than that of the treatment group (11.11%)in the follow-up,but no statistical significance existed between them(p=0.2285).3.2 zoopery research(1)pain behavior testsMWT:MWT of the low-dose group of GTX did not change significantly (p=0.4059) after the treatment; MWT of the middle-dose group of GTX, large-dose group of GTX, GTN group and the indomethacin group rised significantly (p=0.0346, 0.0105, p=0.0226, p=0.0188)at the end of the treatment; there was no significant difference among the middle-dose group of GTX, GTN group and the indomethacin group (all p were greater than 0.05); MWT of the large-dose group of GTX was significantly higher than that of the indomethacin group (p=0.0454).TWL:TWL of the low-dose group of GTX didn’t change significantly (p=0.1558) after the treatment; TWL of the middle-dose group of GTX, large-dose group of GTX, GTN group and the indomethacin group rised significantly (p=0.0231, p=0.0117, p=0.0265, p=0.0185) at the end of the treatment; there was no significant difference among the middle-dose group of GTX, GTN group and the indomethacin group (all p were greater than 0.05); TWL of the large-dose group of GTX was significantly higher than that of the indomethacin group (p=0.0433).(2)concentration of NO in the local organization The concentration of NO of the low-dose group of GTX, middle-dose group of GTX and the indomethacin group were not significantly different with model group (p=0.3073, p=0.1734, p=0.3317); but that of GTN group was significantly higher than those of the model group (p=0.0121) and large-dose group of GTX (p=0.0108).(3)serum concentration of PGE2 The serum concentration of PGE2 of the low-dose group of GTX, middle-dose group of GTX and the GTN group were not significantly different from model group (p=0.7760, p=0.0869, p=0.7053); but that of indomethacin group was significantly higher than those of the model group (p=0.0023) and large-dose group of GTX (p=0.0410).(4)numbers of NR2B positive neurons in the spinal cord There was no significant difference between the low-dose group of GTX and the model group (p=0.6563); and the numbers of NR2B positive neurons of the middle-dose group of GTX, the large-dose group of GTX, the GTN group and the indomethacin group were all less than the model group remarkably (p=0.0496, p=0.0125, p=0.0465, p=0.0242); the number of NR2B positive neurons of the large-dose group of GTX was less than the indomethacin group remarkably(p=0.0128); there was no significant difference between the middle-dose group of GTX and the indomethacin group (p=0.0997); and the number of NR2B positive neurons of the GTN group was more than the indomethacin group (p=0.0454).4 ConclusionsGTX and GTN could both relieve the pain of patients, reduce anal resting pressure, and improve patients’quality of life (bodily pain, role physical and vitality) significantly in treating patients with chronic anal fissure, no significant differences were observed in the cure rate. But GTX could relieve the pain more quickly and cured the chronic anal fissure in shorter course of treatment. Besides, no significant side effects were observed in the research. The analysis between efficacy and correlative factors showed that the shorter course of disease the better efficacy, and GTX was more effective in treating stageⅡanal fissure than stage III anal fissure.The mechanism of GTX in treating chronic anal fissure were:to alleviate sphincter spasm by increasing the local NO concentration in the internal anal sphincter; to inhibit inflammatory hyperalgesia by inhibiting the expression of inflammatory factors--PGE2 in the serum and the expression of NR2B in the spinal cord dorsal horn, and the greater the dose, the more obvious efficacy.更多还原