【作者】 叶柏川；

【导师】 陈群；

【作者基本信息】 广州中医药大学 ， 中医诊断学， 2009， 博士

【摘要】 消化性溃疡（peptic ulcer）泛指胃肠道黏膜被胃消化液消化而形成深达黏膜下层的黏膜破损,可发生于食管、胃、十二指肠及胃空肠吻合口、含胃黏膜的憩室内。临床以胃溃疡（gastric ulcer,GU）和十二指肠溃疡（duodenal ulcer,DU）常见,故一般所谓的消化性溃疡是指GU和DU。消化性溃疡在中医属于“胃脘痛"的范畴,对于本病的病因病机,虽然观点不一,但大多数医家认为主要是由于七情刺激、饮食不节、劳倦内伤以及外感六淫,导致脾胃虚弱,肝胃不和,从而升降失常、损伤肠胃,久而成病。《内经》指出:“饮食自倍,肠胃乃伤”,“思伤脾”,“寒气客于肠胃,厥逆上出,故痛而呕也”。《景岳全书》认为“脾胃之伤于情志者,较之饮食寒暑为更多也”。脾胃虚寒,则肝木乘之,肝气犯胃,则脾胃更为虚弱,日久则阳气更虚,变为虚寒之证。而且中气虚弱则气血不通,瘀阻经络,不通则痛。从临床观察来看,不论何种类型的消化性溃疡,均以胀痛为主。从消化道病理角度来看,主要机理是胃肠道动力功能障碍。从中医辨证来看,就是脾虚、气滞的一系列症状。其病机病理主要是脾胃升降失常,脾虚、气滞、血瘀。生理上,脾主运化,胃主受纳;脾以升为健,胃以降为和,升降有序,则气机调和,胃气通降是脾胃升降有序的重要环节。在治疗上,不论中、西医治疗消化性溃疡的目标有三方面:（1）止痛;（2）促使溃疡早日愈合;（3）防止复发。在西医则重活动期溃疡的溃疡修复。而针对病人的个体体质,予中医辨证治疗尤为重要。临床中辨证施治有侧重,以脾虚为主者,治疗则健脾益气为主,兼活血化瘀;以气滞为主者,则应行气导滞和胃止痛。而肝与脾胃,相侮相克,相互制约,脾胃一气虚,则易肝木乘脾土。叶天士曰:“木横乘土,中宫受病。”肝郁气滞或胃气壅滞。从气、血辨证方面治疗,就可止痛,促进溃疡愈合和防止复发三方而兼而得之。有利于脾胃功能恢复正常。目的:在前人使用肾气丸的基础上,透过现代科学理论,科技手段与实验研究来扩大其运用范围。通过实验研究,从组织学观察、病理学观察、胃液分析、溃疡愈合质量（QOUH）四方面研究肾气丸治疗消化性溃疡的作用机制及靶点,揭示肾气丸治疗消化性溃疡损伤及黏膜再生的具体作用机理,为临床应用提供科学依据。多角度评价肾气丸对各种常见消化性溃疡模型的疗效,研究其作用靶点和作用理,为补肾法治疗消化性溃疡提供合理的科学依据,丰富治”胃”病的治法,拓展中医诊断思路。方法:造模方法1.建立脾肾阳虚动物模型2.脾肾阳虚大鼠乙酸烧灼性胃溃疡实验3.动物分组及给药:随机分为5组,每组10只:A模型组;B.生理盐水对照组;C.雷尼替丁组;D.肾气丸组;E.肾气丸+手参组;。4.标本采集和处理（1）取一批脾肾阳虚动物造成乙酸烧灼胃溃疡模型后,不行胃内细菌数测定,测其它指标。分组及造模同前。待全部动物实验完毕后一起用放射免疫法测PGE2、EGF、SS与GAS、NO与ET-1表达。（2）胃酸及胃蛋白酶的测定:（A）中和法测定胃液总酸度（B）改良Mett法测定胃蛋白酶活性（3）胃壁结合黏液含量的测定5.观察指标胃液pH值;溃疡面积计算;血清PGE₂、EGF、GAS、NO与ET-1含量;病理观察,并进行光学显微镜下分析。6.统计学处理数据统计采用SPSS 13.0进行统计,计量资料多组间比较采用方差分析,组间两两比较方差齐时用LSD检验,方差不齐时用Dunnett’s T3检验,计数资料采用X²检验。结果:1.观察各组对胃壁结合黏液含量的影响结果显示:运用计算机图像分析测量再生黏膜总面积中PAS阳性面积的百分数。结果胃黏膜表面上皮细胞分泌中性黏液而被染成红色,故呈PAS阳性,雷尼替丁组、肾气丸组、肾气丸+手参组PAS阳性面积明显多于模型组（P＜0.05）,结果见表3,图1。2.各组对血清EGF、GAS的影响结果显示:①模型组与肾气丸+手参组之间EGF值水平差异有显着意义,（P＜0.01）;②GAS各组均数符合方差齐性,但组间差异并无统计学意义。结果见表4。各组对血清PGE2、NO、ET-1的影响结果显示:①模型组与雷尼替丁组、肾气丸组、肾气丸+手参组之间PGE₂值水平差异有显着意义,（P＜0.05）。治疗后雷尼替丁组、肾气丸组、肾气丸+手参组明显下降;②模型组与雷尼替丁组、肾气丸组、肾气丸+手参组之间NO值水平差异有显着意义,（P＜0.05）。治疗后雷尼替丁组、肾气丸组、肾气丸+手参组明显上升。③各用药组、模型组、生理盐水对照组之间对血清ET-1做比较,模型组与各用药组间的比较都有统计学意义,治疗后雷尼替丁组、肾气丸组、肾气丸+手参组明显下降,其中肾气丸+手参组有非常显着意义（P＜0.01）。结果见表5。结论:有关肾气丸的药理研究报道多从对某一系统或某一病变指标的影响入手,观察该方的治疗效果并探讨作用机制。在实验中,多根据现代医学发病原理进行动物模型的复制或在原有动物模型基础之上稍加改进而制作病理模型,观察内容从症状表现、生命体征、形态学和组织学、各项免疫和生化指标逐渐深入到基因表达。这种研究方法固然可以在一定层面上揭示肾气丸的某些作用靶点和影响机制,但由于中医学特色是辨证论治指导下的整体调节,以“病”为着眼点的中药药理学实验研究方法显然与中医“辨证用药”的治疗准则相差甚远。尽管广大学者在中医证候动物模型的研究领域进行了积极的探索,然而成熟定论的动物模型并不多见。今后若能从改进动物模型入手,发掘现代医学病症和中医辨证分型之间的内在联系,建立中医证候的客观综合指标体系,进而复制出符合该指标体系的中医证候动物模型,从方证对应的角度着手用药,立足整体,将多层次、多靶点的指标检测纳入药物疗效评价标准,采用基因芯片等现代科学技术,从多学科、多系统、多病种的角度探讨药物治疗机制,对于准确把握中药复方的体内作用原理以及客观评价中药复方的治验结果,将会更具说力,有助于推动中医药发展的现代化。创新点1.首创国内外结合运用中医名方肾气丸加上藏医珍贵药手参来作实验研究。评价与证明了肾气丸及手参治疗脾肾阳虚型消化性溃疡大鼠模型的疗效,发现了其可能的作用机制和靶点,揭示肾气丸治疗消化性溃疡的机理,为进一步的基因和蛋白表达研究奠定基础,为临床应用提供了科学依据。2.对于消化性溃疡医家多从脾胃、从肝论治,鲜有从肾论治者。我们以大鼠采用中医证候动物模型造模方法,建立脾肾阳虚型消化性溃疡模型,从组织学观察、病理学观察、胃液分析及细胞因子检测等方面,评价肾气丸治疗脾肾阳虚型消化性溃疡的作用机理,是国内首次进行补肾法治疗消化性溃疡的动物实验研究。更多还原

【Abstract】 Peptic ulcer(peptic ulcer) refers to the gastrointestinal tract by gastric mucosa and the formation of digestive juice digestive submucosa as deep as the mucosa is damaged,can occur in the esophagus,stomach,duodenum and gastrojejunostomy mouth of the diverticulum with gastric mucosa inside. Clinical to gastric ulcer(gastric ulcer,GU) and duodenal ulcer(duodenal ulcer,DU) common,it generally refers to the so-called peptic ulcer GU and DU.Peptic ulcer in Chinese medicine as "Epigastralgia" areas for the disease pathogenesis,although views vary,but most doctors believe was mainly due to the impassioned stimulation,diet,internal injuries,as well as exogenous tired Six,lead to weak spleen and stomach,hepatogastric not and,thus lifting disorders,gastrointestinal injury,a long time from disease."Neijing" pointed out:"Since the times of eating,gastrointestinal injury is," "think of spleen injury," "cold off at the stomach,the Jue-Inverse out,it is also pain and vomit." "Jing Yue Quan Shu" that "the spleen and stomach injuries in the emotions of those who,for more years than eating it." Cold spleen and stomach,then violations by the liver,Violations by the liver-qi to the stomach,spleen and stomach are more weak and more a long time while yang is true,the evidence becomes cold.And weakness in the blood gas barrier, Blood Meridian,the pain is not General.Judging from the clinical observation,regardless of what type of peptic ulcer,are mainly pain,gastrointestinal pathology from the point of view, is the main mechanism of gastrointestinal motility dysfunction.From the TCM perspective,is the deficiency,a series of symptoms of Qi stagnation.Its pathogenesis pathological movements mainly the spleen and stomach disorders, deficiency,Qi stagnation,blood stasis.Physiological,spleen governs transport and satisfied by the main stomach and spleen health to be promoted. Down to the stomach and,landing and taking off in an orderly manner,then reconcile Qi,Wei Qi is the spleen and stomach Tongjiang an important part of movements in an orderly manner.In treatment,whether in the goal of TCM treatment of peptic ulcer is three-fold:(1) pain;(2) to promote ulcer healing as soon as possible;(3) to prevent recurrence.In Western medicine is re-active ulcer ulcer repair.Against the patient’s individual physique,to the TCM treatment is particularly important.Differential Treatment of clinical focused to the main deficiency,treatment is mainly Jianpi Yiqi,and promoting blood circulation,mainly to stagnation of qi,the hardship of the liver and spleen.Grams of phase insult each other constraints,the spleen and stomach qi deficiency,liver by soil.Ye Tianshi’s said:" Violations of the liver to the spleen and stomach are sick stomach." Wei Qi stagnation of liver Qi stagnation or Pause.From the qi and blood differentiation aspects of treatment,can relieve pain,promote healing and prevent ulcer recurrence and derived from the tripartite and.In favor of the spleen and stomach function returned to normal.Objective:Shenqi Pill use in the past,based on the use of modern scientific theories, and experimental study of scientific and technological means to expand its scope of application.Through experimental research,from the histological observation,pathological observation,gastric analysis,thequality of ulcer healing(QOUH) Shenqi PillⅣstudy the mechanism of the treatment of peptic ulcer and target,revealed Shenqi Pill mucosal injury and the treatment of peptic ulcer the specific mechanism of regeneration,in order to provide scientific basis for clinical application.Shenqi Pill evaluation of multi-angle on a variety of common peptic ulcer effects model to examine the role of targets and the rationale for the treatment of peptic ulcer Busben law to provide a reasonable scientific basis to enrich the government, "stomach" Disease Treatment and expand ideas of TCM diagnosis Methods:The model approach1.The establishment of animal models of kidney-yang deficiency of spleen2.Spleen and kidney yang deficiency rats with gastric ulcer3.Animal grouping and drug delivery:were randomly divided into 5 groups of 10:A model group;B.saline control group;C.ranitidine group;D.Shenqi pill group;E.Shenqi Pill +RIRr group;. 4.Specimen collection and processing(1) the animals from a group of kidney-yang deficiency of spleen acid burn caused by gastric ulcer,the bacteria can not stomach the determination of other indicators measured.Division and with the former model.All animal experiments to be together after the test by radioimmunoassay PGE2,EGF,SS and GAS,NO and ET-1 expression.(2) gastric acid and pepsin determination of:(A) Determination of gastric juice and total acidity(B) Determination of improved Mett pepsin activity(3) combined gastric wall mucus determination5.Observed gastric pH;ulcer area;serum PGE2,EGF,GAS,NO and ET-1 content;pathological observation,and analysis of optical microscope.6.Statistical data using SPSS 13.0 statistical measurement data to compare the use of multiple analysis of variance,22 inter-group homogeneity when compared with LSD test at variance with missing Dunnett’s T3 test,the use of count data X2 test.The results:1.To observe the group of gastric wall mucus content of combined results showed that:the use of computer image analysis measuring the total area of mucosal regeneration in the percentage of PAS-positive area.The results of gastric mucosa surface epithelial cells and mucus secretion by neutral red dye,it was PAS positive,ranitidine group,Shenqi Pill group Shenqi pill + RIRr Group PAS-positive area significantly more than the model group(P＜0.05), the results shown in Table 3,Figure 1.2.In each group of serum EGF,GAS showed the impact:①the model group with Shenqi pill + RIRr value between the level of EGF significant difference, (P＜0.01);②GAS few in each group were in line with the side poor homogeneity, but there is no difference between groups statistically significant.The results in table 4.Each group on serum PGE2,NO,Er-1 results showed the impact:①the model group and the ranitidine group,Shenqi Pill group Shenqi pill + RIRr group difference between the PGE2 levels significantly,(P＜0.05).Ranitidine group after treatment,Shenqi Pill group Shenqi pill + RIRr group decreased significantly;②model group and the ranitidine group,Shenqi Pill group Shenqi pill + RIRr value between the level of NO There was significant difference,(P＜0.05).Ranitidine group after treatment,Shenqi Pill group Shenqi pill + RIRr group was significantly increased.③the medication group, model group,normal saline control group between the serum ET-1 compared with model group,treatment group comparisons are statistically significant, ranitidine group after treatment,Shenqi Pill Group Shenqi pill + RIRr group decreased significantly,which Shenqi pill + RIRr group was significant(P＜0.01).The results in table 5.Conclusion:The Shenqi Pill pharmacological research reports from the system or of a lesion index of a start,observe the side effects of treatment and to explore the mechanism of action.In the experiment,more than modern medicine in accordance with animal models of pathogenesis for a copy of the original animal model or in some improvements based on the production of pathological model, the content from the observation of symptoms,vital signs,morphology and histology,the immune and gradually into the biochemical indicators of gene expression.While this approach can reveal a certain level,some of the role of Shenqi Pill target and impact of the mechanism,but because of characteristics of syndrome differentiation in Chinese medicine,under the guidance of the overall regulation of the "disease" as the focus of experimental study on pharmacology of Chinese medicine obviously with the Chinese "differentiation agents" a far cry from the treatment guidelines. Although the majority of scholars in the TCM Syndrome animal model of an active area of research for the exploration,but the maturity of the animal model findings rare.From the future to improve the animal model can start to explore the disease and modern medicine of TCM Syndrome Types of the intrinsic link between the establishment of the objective of TCM Syndrome comprehensive index system,and then replicate with the index system of TCM Syndrome animal model, from the side perspective permits the corresponding drug,based on a whole will be multi-layered,multi-target detection of indicators included in the evaluation criteria of drug efficacy,the use of gene chips and other modern science and technology,from multi-disciplinary,multi-system perspective of the health of drug treatment mechanism for an accurate grasp of the role of Chinese herbal compound in vivo,as well as objective evaluation of the principle of Chinese medicine composed of government inspection results,will be more said,and help to promote the development of Chinese medicine modernization.Innovation1.’s First at home and abroad of a combination of Chinese medicine pill side Shenqi precious Tibetan medicine in RIRr to experimental research. Evaluation and proof of participation Shenqi Pill and hand treatment of peptic ulcer spleen rat model of yang-deficiency type of effect and found that the possible role of its mechanism and target in the treatment of peptic Shenqi Pill reveal the mechanism for further gene and protein expression studies to lay the foundation for the clinical application provides a scientific basis.2.For peptic ulcer treatment at home from the spleen and stomach,from the Liver,fresh from the kidney of the ruler.We used rat animal model of TCM Syndrome model for ways to build on the spleen yang-deficiency type of peptic ulcer model,from the histological observation,pathological observation,gastric analysis and cytokine detection,the evaluation of treatment of spleen and kidney Shenqi Pill Yang-type mechanism of peptic ulcer, is the first method for the treatment of peptic ulcer Bushen experimental study of animals.更多还原