溃疡性结肠炎的中医证候学研究

【作者】 王鹏；

【导师】 王耀献；

【作者基本信息】 北京中医药大学 ， 中医内科学， 2014， 博士

【摘要】 目的探讨溃疡性结肠炎的中医证候规律,分析中医症状、证素及证候类型的分布以及不同证候与疾病病情分期、严重程度、临床类型等临床因素的相关性。方法研究分为文献研究及临床流调两部分。1.文献研究检索中国学术期刊全文数据库(CNKI)(2009年-2013年),纳入溃疡性结肠炎中医证候分布研究和中医辨证论治临床研究的相关期刊文献,提取中医证候信息,采用SPSS18.0进行频数、频率统计,归纳总结溃疡性结肠炎中医证候类型及证候要素。2.临床流调对收治于5家课题协作医院病房及门诊的363例溃疡性结肠炎患者进行流行病学调查,收集患者的一般情况、西医诊断、中医辨证、四诊信息、内镜病理等相关资料,采用现代统计学方法分析溃疡性结肠炎中医证候分布规律及与临床因素的相关性。采用因子分析和聚类分析相结合的方法对中医证候进行分析和归纳。结果1.文献研究纳入文献共124篇,涉及溃疡性结肠炎患者10749例。病例数占总比例5%以上的证型有7个,依次是湿热、肠道湿热、脾肾阳虚、脾胃虚弱、气滞血瘀、肝郁脾虚和脾虚湿热。病位类证素以脾、肠、胃、肾、肝为主；病性类证素中,虚性证素以气虚、阳虚为主,实性证素以内湿、内热(实热、虚热)、血瘀、气滞、气郁为王。2.临床研究363例溃疡性结肠炎患者,临床类型以慢性复发型最为常见,严重程度以轻度为主,病情分期以活动期为主,病变范围以直肠及远段结肠受累最常见。大肠湿热证及肝郁脾虚证在活动期的出现频率显著高于缓解期,脾气虚弱证及脾肾阳虚证在缓解期的出现频率显著高于活动期。大肠湿热证在中度组及重度组的出现频率显著高于轻度组；脾气虚弱证及肝郁脾虚证在中度组及重度组出现频率显著低于轻度组,在重度组的出现频率显著低于中度组；脾肾阳虚证在重度组的出现频率显著低于中度组及轻度组；血瘀肠络证在重度组的出现频率显著高于中度组及轻度组。大肠湿热证在初发型的出现频率显著高于慢性复发型及慢性持续型,而脾肾阳虚证在慢性持续型中的出现频率显著高于初发型及慢性复发型。脾肾阳虚证及血瘀肠络证在全结肠型的出现频率显著高于直肠远段结肠型。大肠湿热证在青年组及中年组的出现频率显著高于老年组,脾肾阳虚证在老年组的出现频率显著高于青年组及中年组,脾气虚弱证及肝郁脾虚证在中年组的出现频率显著高于青年组及老年组。大肠湿热证在1年以内组的出现频率明显高于1-10年组及10年以上组,且在1-10年组显著高于10年以上组；脾肾阳虚证在10年以上组的出现频率显著高于1-10年组及1年以内组；肝郁脾虚证在1年以内组的出现频率显著低于1-10年组。大肠湿热证及血瘀肠络证的内镜指数显著高于其他证型。内镜下分级为正常黏膜及Ⅰ级均以脾气亏虚证及肝郁脾虚证为主,Ⅱ、Ⅲ级以大肠湿热证为主,Ⅳ级以大肠湿热证及血瘀肠络证为主。黏膜组织严重程度分级为Ⅰ、Ⅱ级以脾气虚弱证及肝郁脾虚证为主,Ⅲ级以大肠湿热证及血瘀肠络证为主。腹泻、脓血便、里急后重、肛门灼热、泻下急迫、腹痛、腹胀、纳呆、肢体倦怠、面色萎黄的症状积分在活动期显著高于缓解期；余症状积分无显著性差异。腹泻、脓血便、里急后重、肛门灼热、泻下急迫、腹痛、腹胀、肠鸣、纳呆、肢体倦怠、神疲懒言、面色萎黄的症状积分在中度组及重度组的积分明显高于轻度组；气短、畏寒在重度组的积分显著高于轻度组；排便不爽在中度组的积分显著高于轻度组,但重度组与轻度组比较无显著性差异；腹泻、脓血便、里急后重、泻下急迫、腹痛、腹胀、气短、肢体倦怠、神疲乏力、畏寒在重度组的积分显著高于中度组。因子分析提取公因子10个,初步对其证素进行专业判断显示,溃疡性结肠炎的主要病位证素为大肠、脾、胃、肝、肾,病性证素,实证证素有湿热、气滞、气郁、血瘀、痰湿,虚证证素有气虚、阳虚。进一步对这10个公因子进行系统聚类显示,聚为3类,分别为大肠湿热兼肝郁脾虚证、脾阳虚兼湿热证和气虚血瘀兼大肠湿热证。结论1.溃疡性结肠炎病位证素以脾、肠、胃、肾、肝为主；病性类证素中,虚证证素以气虚、阳虚为主,实证证素以内湿、内热(实热、虚热)、血瘀、气滞、气郁为主。2.活动期、初发型、直肠及远段结肠受累、青年人、病程短、黏膜损伤严重等因素与大肠湿热证、血瘀肠络证呈正相关；缓解期、慢性复发型及慢性持续型、全结肠、中、老年人、病程长、黏膜损伤较轻等因素与脾气虚弱证及脾肾阳虚证呈正相关。3.溃疡性结肠炎多为虚实夹杂,缓解期以本虚为主,活动期以标实为主,且活动期个别正虚表现较缓解期更加明显,需结合舌脉、内镜表现等资料辨证分析。4.采用因子分析和聚类分析进行中医证候学研究具有一定的意义。更多还原

【Abstract】 ObjectiveTo explore the rule of TCM syndrome of ulcerative colitis, analysis the distribution of TCM symptoms, syndrome factor and the correlation of clinical factors such as disease stages, severity and clinical type with different TCM syndrome.MethodsThe research consists of two parts, literature research and clinical epidemiological investigation.1.Literature researchThe literatures about distribution of syndromes and syndrome differentiation of traditional Chinese medicine clinical research of ulcerative colitis were retrieved in CNKI databases (2009-2013), to sort out and analyze distribution of ulcerative colitis TCM syndromes.2. Clinical epidemiological investigationA total of363cases were investigated from wards and outpatients of five hospitals, to collect the patient’s general condition, clinical diagnosis, TCM Syndromes, symptom distribution, clinical indicators, endoscopic and pathology data. Using modern statistical methods to analyze TCM syndrome distribution regularity of ulcerative colitis and the correlation of TCM syndrome and clinical factors. TCM syndrome of ulcerative colitis was summarized and analyzed by adopting factor analysis and cluster analysis.Results1. Literature researchA total of124literature were included, involving10,749cases of patients with ulcerative colitis. The seven syndrome types, justification of the number of cases accounted for over5%of the total proportion, is hot and humid, intestinal damp heat, spleen kidney Yang deficiency, weak spleen and stomach, qi and blood stasis, stagnation of liver qi and spleen deficiency and Hot and humid pixu. The main syndrome elements of disease location is spleen, intestine, stomach, kidney, liver. The main deficient syndrome elements of the nature of disease is Qi deficiency, Yang deficiency,while the main excessive syndrome elements of the nature of disease is endogenous dampness, internal heat(hot real and imaginary heat), blood stasis, stagnation of qi. 2. Clinical epidemiological investigationThe majority of363cases were patients with chronic relapsing, mild activity, lesions involving the rectum and sigmoid.Patients in remission mainly suffered from spleen and stomach qi deficiency syndrome and spleen and kidney yang deficiency syndrome,ptients with active mainly suffered from the large intestine damp heat syndrome, liver depression and spleen deficiency syndrome and intestinal blood stasis syndrome. Patients with mild activity mainly suffered from liver depression and spleen def iciency syndrome and spleen and stomach qi def iciency syndrome, patients with moderate activity mainly suffered from the large intestine damp heat syndrome, while patients with severe activity mainly suffered from large intestine damp heat syndrome and intestinal blood stasis syndrome. Patients with early onset mainly suffer from the large intestine damp heat syndrome, patients with chronic relapsing mainly suffer from the large intestine damp heat syndrome, liver depression and spleen deficiency syndrome and spleen and stomach qi deficiency syndrome, and patients with chronic persistent mainly suffer from the spleen and kidney yang deficiency syndrome. Patients with lesions involving the rectum and far section of the colon mainly suffered from liver depression and spleen deficiency syndrome and spleen and stomach qi deficiency syndrome, while patients with lesions involving the entire colon mainly suffered from spleen and kidney yang deficiency syndrome and intestinal blood stasis syndrome.Young people mainly suffer from the large intestine damp heat syndrome, while middle-aged people mainly suffer from the large intestine damp heat syndrome, liver depression and spleen deficiency syndrome and spleen and stomach qi deficiency syndrome, and old people mainly suffer from the spleen and kidney yang deficiency syndrome. Patients with duration of less than1year mainly suffer from the large intestine damp heat syndrome, patients with duration of more than10years mainly suffer from spleen and kidney yang deficiency syndrome, while patients with duration of1to10years mainly suffer from large intestine damp heat syndrome, liver depression and spleen deficiency syndrome and spleen and stomach qi deficiency syndrome.Endoscopic index of patients with the large intestine damp heat syndrome is the highest value, that of spleen and stomach qi deficiency syndrome was the lowest. Cases of normal mucosa and class I under colonoscopy graded mainly suffered from liver depression and spleen deficiency syndrome and spleen and stomach qi deficiency syndrome, class II and III mainly suffered from the large intestine damp heat syndrome, class IV mainly suffered from the large intestine damp heat syndrome and intestinal blood stasis syndrome. Cases with mucosa severity rating of Ⅰ, Ⅱ level mainly suffered from liver depression and spleen deficiency syndrome and spleen and stomach qi deficiency syndrome, III level mainly suffered from the large intestine damp heat syndrome and intestinal blood stasis syndrome.The symptom score of diarrhea, purulent blood, diarrhea, tenesmus, anal burning under urgent, abdominal pain, abdominal distension, stay, and physical symptoms of burnout, sallow complexion, integral in activity was significantly higher than in remission. The symptom score of diarrhea, purulent blood, diarrhea, tenesmus, anal burning under urgent, abdominal pain, abdominal distension, the bowel, stay, the body is tired, exhausted god lazy speech, sallow complexion in the moderate group and severe group was obviously higher than that of mild group, while the symptom score of shortness of breath, chills in severe points is significantly higher than mild group. The symptom score of diarrhea, urgent under the purulent blood, tenesmus, have diarrhoea, abdominal pain, abdominal distension, shortness of breath, the body is tired, fatigue, chills, god in the group of severe points is significantly higher than moderate.There are10common factor extracted by factor analysis. The main syndrome elements of disease location is intestine, spleen, stomach, liver, kidney. The main excessive syndrome elements of the nature of disease is hot and humid, and qi stagnation, qi depression, blood stasis and phlegm wet, while the main deficient syndrome elements of the nature of disease is Qi deficiency, Yang deficiency. We get three syndrome types by clustering analysis, and they are hot and humid with liver depression and spleen deficiency, spleen Yang deficiency damp heat syndrome and qi deficiency and blood stasis with hot and humid.Conclusion1.The main syndrome elements of disease location is spleen, intestine, stomach, kidney, liver. The main deficient syndrome elements of the nature of disease is Qi deficiency, Yang deficiency,while the main excessive syndrome elements of the nature of disease is endogenous dampness, internal heat (hot real and imaginary heat), blood stasis, stagnation of qi.2. Some clinical factors are positively correlated with e. humid bowel syndrome and blood stasis collaterals card, such as activity, early hairstyle, rectum and far section of the colon, young man, short duration, mucosa damage severely affected. While some clinical factors are positively correlated with spleen weakness syndrome and spleen kidney Yang deficiency syndrome, such as remission, chronic recurrent and chronic, all in the colon, and the elderly, long duration, mild mucosal damage.3.Deficiency complicated with excessiveness is the common syndromes of ulcerative colitis, and remission is given priority to root deficiency, while activity is given priority to with the branch excess. Carefully identify is needed for clinical physicians, such as the data of Tongue, pulse condition and endoscopic check.4. It has a certain significance to study the TCM syndrome using factor analysis and cluster analysis.更多还原