【作者】 张海燕；

【导师】 黄穗平；

【作者基本信息】 广州中医药大学 ， 中医内科学， 2009， 博士

【摘要】 研究目的、意义近年来溃疡性结肠炎(ulcerative colitis,UC)在我国的发病率呈逐渐升高趋势,且被认为是结肠癌的癌前病变,已被世界卫生组织列为现代难治病之一。因其病因和发病机制尚未完全阐明,目前尚无根治办法。西药治疗本病,存在着疗效不理想及副作用较大等缺点,影响了病人的依从性,因此努力寻找临床疗效显著且副作用小的治疗方法是当务之急。在全面总结前期大量临床研究和实验研究的基础上,我们提出UC的病机特点,活动期以大肠湿热为主,治疗当以清热祛湿为主;缓解期病机特点以脾胃气虚为主,治疗当以健脾益气为主,而气滞血瘀贯穿病程始终。为了凸现中医药治疗本病的特色及优势,我们以UC轻中度病例为突破口,对活动期UC予清热祛湿中药口服+保留灌肠,形成肠炎清1号方和肠涤清灌肠液,并将其作为院内制剂在广东省中医院使用十余年,临床疗效显著。近年来研究发现,氧自由基参与了UC疾病的发生发展过程,本研究通过动物实验观察清热祛湿法(肠涤清灌肠+肠炎清1号灌胃)对实验性UC大鼠结肠黏膜损伤指数、血清和结肠组织匀浆SOD活力和MDA含量的影响,探讨其作用机制;同时采取随机对照前瞻性的临床研究,对清热祛湿法治疗活动期轻中度大肠湿热型UC的临床疗效及其安全性作出科学评价,探索治疗本病的最佳方案,以进一步推广其在临床应用。研究方法本课题分为实验研究和临床研究两部分。实验研究方法:选择SPF级健康成年雌性SD大鼠51只,先随机抽取8只大鼠作为正常组,不予造模,剩余的43只大鼠利用三硝基苯磺酸(TNBS)+乙醇溶液诱导出急性期UC大鼠模型,造模后第3天随机抽取2只解剖以观察造模是否成功。剩余的41只大鼠随机分为4组:模型组(空白组)11只;肠涤清组、肠涤清+肠炎清组、SASP组,每组10只。造模后第4天开始用药,正常组和模型组大鼠每日给予生理盐水灌胃+灌肠,其余3组分别给予肠涤清灌肠、肠涤清灌肠+肠炎清灌胃、SASP灌胃+灌肠治疗,疗程结束后观察大鼠一般情况、体重、结肠黏膜损伤指数、光镜下结肠黏膜病理形态、血清和结肠组织匀浆SOD活力及MDA含量的变化。疗程为2周。临床研究方法:将符合纳入标准的活动期轻、中度大肠湿热型UC患者70例,随机分为治疗组35例,对照组35例。治疗组予肠炎清1号方口服+肠涤清灌肠,对照组予SASP口服+灌肠,观察两组患者治疗前后的临床症状及体征(包括腹泻、粘液血便、里急后重等)、舌象、脉象、ESR、CRP、大便潜血及结肠镜黏膜病变特点。疗程为4周。研究结果1实验研究结果1.1大鼠一般情况改善:所有大鼠在造模后的第2天即出现稀烂便,随后相继出现粘液便、脓血便。模型组大鼠伴有反应迟钝,不喜活动,倦怠懒动、毛发凌乱、拱背、饮食饮水减少、体重减轻,甚至死亡现象。其他3个治疗组用药1周后大鼠粘液血便逐渐减少,活动逐渐增多,饮食饮水量逐渐增加,其中以肠涤清+肠炎清组大鼠症状改善最为显著。1.2大鼠体重变化:肠涤清组与肠涤清+肠炎清组大鼠体重增长均较快,两组比较差异无统计学意义(P＞0.05);肠涤清组与肠涤清+肠炎清组大鼠体重增长同SASP组比较,差异均有统计学意义(P＜0.01);SASP组大鼠体重增长和模型组比较,差异无统计学意义(P＞0.05),SASP组大鼠体重增长较慢。1.3大鼠结肠黏膜损伤指数(CMDI)变化:CMDI以模型组为最高,与正常组比较,差异有统计学意义(P＜0.01);经过治疗后3个用药组CMDI均有所下降,与模型组比较,差异均有统计学意义(P＜0.01);肠涤清+肠炎清组CMDI与肠涤清组、SASP组比较,差异均有统计学意义(P＜0.01);肠涤清组和SASP组CMDI比较,差异无统计学意义(P＞0.05)。1.4大鼠血清和结肠组织匀浆SOD活力变化:各组大鼠血清和结肠组织匀浆SOD活力从高到低,依次为:正常组＞肠涤清+肠炎清组＞肠涤清组＞SASP组＞模型组,其中以肠涤清+肠炎清组大鼠SOD活力升高最为显著(与其他3组比较,均P＜0.01)。1.5大鼠血清和结肠组织匀浆MDA含量变化:各组大鼠血清和结肠组织匀浆MDA含量从高到低,依次为:模型组＞SASP组＞肠涤清组＞肠涤清+肠炎清组＞正常组,其中以肠涤清+肠炎清组MDA含量下降最为显著(与其他3组比较,P＜0.05或P＜0.01)。2临床研究结果2.1治疗后两组患者ESR、CRP比较:治疗组有21例患者、对照组有22例患者复查ESR、CRP。治疗后两组患者ESR和CRP都有所下降,与治疗前比较,差异均有统计学意义(P＜0.05或P＜0.01)。治疗后,两组ESR比较,差异有统计学意义(P＜0.05),治疗组ESR降低优于对照组;两组CRP比较,差异无统计学意义(P＞0.05),两组疗效相当。2.2治疗后两组患者大便潜血改善比较:对大便潜血的改善情况,治疗组优于对照组(P＜0.05)。2.3治疗后两组患者主要症状积分比较:治疗组所有症状均有改善,与治疗前比较,差异均有统计学意义(P＜0.05或P＜0.01);对照组除肛门灼热和溲赤2个症状改善不明显外,其余6个症状均有改善,与治疗前比较,差异有统计学意义(P＜0.05或P＜0.01)。治疗后两组患者症状积分改善比较,治疗组对里急后重和溲赤症状的改善优于对照组(P＜0.01);而其它6个症状(腹泻、粘液血便、腹痛、腹胀、发热、肛门灼热)的改善,两组比较无显著性差异(P＞0.05)。2.4两组患者中医证候疗效比较:治疗组临床痊愈7例,显效10例,有效12例,无效2例,总有效率为92.5%;对照组临床痊愈2例,显效5例,有效14例,无效9例,总有效率为70.0%,治疗组中医证候疗效优于对照组(P＜0.01)。2.5治疗后两组患者结肠黏膜病变情况比较:治疗组有15例患者,对照组有18例患者复查肠镜,治疗组对结肠黏膜病变的改善优于对照组(P＜0.05)。2.6两组患者临床综合疗效比较:治疗组完全缓解6例,显效9例,好转12例,无效4例,总有效率为87.1%;对照组完全缓解3例,显效4例,好转15例,无效8例,总有效率为73.3%,治疗组临床综合疗效优于对照组(P＜0.05)。2.7临床综合疗效与病变范围、病情严重程度的相关性分析:临床综合疗效与病变范围无相关性(P＞0.05),与病情严重程度呈正相关(P＜0.01),病情越轻,临床疗效越显著。2.8不良反应观察:用药期间治疗组未见明显毒副作用,对照组有1例患者出现白细胞减少,疗程结束后停用西药,未做特殊处理。研究结论1肠涤清+肠炎清可以显著改善UC大鼠的腹泻和便血情况,减轻结肠黏膜损伤指数,改善结肠黏膜的病理形态学情况,提高血清和结肠组织SOD活力,降低血清和结肠组织MDA含量。2清热祛湿法治疗活动期轻中度大肠湿热型UC疗效确切,可以显著降低UC患者ESR,改善大便潜血、主要症状和结肠黏膜病变程度,中医证候疗效和临床综合疗效优于西药对照组。结合动物实验结果,考虑清热祛湿法治疗活动期UC的机制之一,在于减轻机体的脂质过氧化强度,提高血清和结肠组织中SOD活力,降低血清和结肠组织中MDA含量,从而增强对细胞的保护作用,促进炎症和溃疡的愈合。更多还原

【Abstract】 Objective and Significance:The incidence of ulcerative colitis(UC) has been steadily increased in China since last decades.UC has been considered as precancerous lesions of colon cancers and classified as one of refractory diseases in modern society by World Health Organization.The etiology and pathogenesis of UC have not been fully elucidated,so there is no radical treatment for UC.Treatment of UC by western medicine has some shortcomings,such as unsatisfied efficacy and considerable side effects,which reduce patients’ compliance.Therefore, it urgently needs to find alternative treatments with significant clinical improvement and little adverse effects.Based on the results from large amounts of previous clinical and experimental studies,we propose the pathogenesis of UC from the Chinese traditional medicine point of view.The characteristic of active UC is mainly wetness-heat of large intestine while that of remission stage is largely deficiency of spleen-Qi and stomach-Qi.Treatment for the former is dependent on removing heat and dispersing dampness but treatment for the latter should strengthen the spleen and replenish Qi.Both acute and remission stages of UC have Qi-stagnancy and blood stasis.Chinese traditional medicines were applied to treat patients with mind and moderate UC which can reflect on their characteristics and advantages.Patients with UC at acute stage were treated with a combination of oral Changyanging 1 and enema Changdiging fluid.Both Changyanging 1 and Changdiging fluid have been used in TCM hospital of Guangdong province for more than 10 years.Recent studies have demonstrated that oxygen-free radicals play a role in the pathogenesis of UC.To explore the therapeutic effects and mechanisms, we measured the effect of removing heat and dispersing dampness(treatment by combination of oral Changyanging 1 and enema Changdiging fluid) on colon mucosa damage index(CMDI),the dynamic changes of superoxide dismutase(SOD) activity and MDA level in serum and colon tissues of rats with experimental ulcerative colitis.By means of randomized controlled prospective clinical study,we also evaluated the clinical efficacy and safety of the combination of Changyanqing 1 and Changdiqing fluid in the treatment of UC.Results from these studies,we could demonstrate their effectiveness on the treatment of UC and facilitate their clinical application.Methods:This thesis included two parts:experiment study and clinical study.Methods of experimental study:8 rats were randomly selected as the normal group from 51 healthy female Sprague-Dawley(SD) rats.Active UC was induced by trinitro-benzene-sulfonic acid(WNBS) and ethanol solution in 43 rats.Three days after establishing the model of UC,2 rats randomly selected were dissected in order to observe the success of model.The remainders(41 rats) were randomly divided into three model groups,i.e.,Changdiqing group, Changdiqing + Changyanqing group and salicylazosulfapyridine(SASP) group.Four days after establishing the model of UC,the rats in both normal and model groups were treated with normal Saline enema(NSE).Rats in the other 3 groups were treated with Changdiqing enema,Changdiqing enema plus Changyanqing garage,and SASP by gavage and enema,respectively.The protection mechanism of the method of removing heat and dispersing dampness was observed in terms of general condition,weight,CMDI,dynamic changes of SOD activity and MDA level in serum and tissues of colon.The course of treatment was 2 weeks.Methods of clinical study:Seventy patients fulfilling the inclusion criteria were randomly divided into two groups.Thirty-five cases in experimental group were treated with the combination of oral Changyanqing 1 and enema Changdiqing fluid,while 35 cases in control group were treated with SASP by oral administration and enema.The clinical efficacies were evaluated by observing patients with clinical symptoms and signs(including diarrhea, mucous bloody stool,rectal tenesmus,etc.),the characteristics of tongue and pulse,by measuring ESR and CRP,and by detecting fecal occult blood and colon mucous.The course of treatment was 4 weeks.Results:1 The results of experimental study: 1.1 The improvement of general conditions in rats:Two days after establishing the model of UC,all rats had loose stools,followed by mucous stool and bloody purulent stool.Rats in model group were companied with slow response,lack of movement,tiredness,messy hair,hollow back,poor appetite and little drinking-water,lose weight,and even death.One week after medication,mucous bloody stool gradually reduced while physical activities gradually improved. Both diet-uptake and drinking-water were gradually increased in the rats of other three treatment groups.The improvement of symptoms was most significant in Changdiqing + Changyanqing group.1.2 Weight changes in rats:The weight of rats had rapid growth in Changdiqing group and Changdiqing + Changyanqing group,but there was no significant difference in weight change between these groups(P＞0.05).Comparing Changdiqing group with SASP group,a significant difference in weight change was noted(P＜0.01).Comparing Changdiqing + Changyanqing group with SASP group, the difference in weight change was also statistically significant (P＜0.01).Comparing SASP group with model group,no significant difference in weight change was found(P＞0.05).Rats grew slower in SASP group.1.3 CMDI changes in rats:CMDI was highest in model group,compared with normal group,the difference was statistically significant(P＜0.01).After treatment,CMDI declined in 3 treatment groups.Comparing the 3 treatment groups with model group,the differences were statistically significant (P＜0.01).Comparing Changdiqing + Changyanqing group with Changdiqing group and SASP group,the differences were statistically significant (P＜0.01).Comparing Changdiqing group with SASP group,no significant difference in CMDI was noted(P＞0.05).1.4 Dynamic changes of SOD activity in rats serum and tissues of colon:Normal group had highest SOD activity,followed by Changdiqing + Changyanqing group, Changdiqing group,SASP group,and untreated model group.The increase of SOD activity was the most remarkable in Changdiqing + Changyanqing group,compared with the other 3 groups,the difference was statistically significant(P＜0.01).1.5 Dynamic changes of MDA level in rats serum and tissues of colon:Dynamic changes of MDA level was as follows:model group＞SASP group＞Changdiqing group＞Changdiqing + Changyanqing group＞normal group.The decline of MDA level was the most notable in Changdiqing + Changyanqing group,compared with the other 3 groups,the differences were statistically significant(P＜0.05 or P＜0.01).2 The results of clinical study:2.1 The result of ESR,CRP:Twenty-one patients in treat group completed the measurements of ESR and CRP after treatment,while 22 patients in control group did.After treatment,both ESR and CRP were decreased when compared to those before treatment(P＜0.05 and P＜0.01 for ESR and CRP,respectively).ESR was significantly low in treated groups if compared to that in control group (P＜0.05).However,CRP had no significant change between treated and control groups.2.2 The detection of fecal occult blood showed that the treat group was superior to the control group(P＜0.05).2.3 Scoring for major symptoms:In treated group all symptoms have improved, compared to those before treatment,the differences were statistically significant(P＜0.05 or P＜0.01) In control group,in addition to rectum searing heat and short red urine,the improvement of other 6 symptoms were compared with before treatment,the difference was statistically significant (P＜0.05 or P＜0.01).After treatment,the improvement of rectal tenesmus and short red urine,the treat group was superior to the control group(P＜0.01).The improvement of other 6 symptoms,comparing the two groups,the difference was not statistically significant(P＞0.05).2.4 Syndromes judged by Chinese traditional medicine standards:In treated group,among the 31 cases,7 cases were cured,lO cases were markedly effective, 12 cases were effective and 2 cases were ineffective,the total effective rate was 92.5%.As for control group,among the 30 cases,2 cases were cured, 5 cases were markedly effective,14 cases were effective and 9 cases were ineffective,the total effective rate was 70.0%.The treat group was superior to the control group in term of Chinese medicine syndromes efficacy(P＜0.05).2.5 The result of examining colon mucosal lesions:Fifteen patients in treat group received colonoscopy after treatment,while18 patients in control group did.Pathologic examination showed that colon mucosal lesions in the treated group improved better than that in the control group(P＜0.05).2.6 The result of clinical comprehensive efficacy:In treated group,among the 31 cases,6 cases were cured,9 cases were markedly effective,12 cases were effective and 4 cases were ineffective,the total effective rate was 87.1%.As for control group,among the 30 cases,3 cases were cured,4 cases were markedly effective,15 cases were effective and 8 cases were ineffective, the total effective rate was 73.3%.The treated group was superior to control group in term of effectiveness on clinical outcome(P＜0.05).2.7 The correlation analysis of clinical comprehensive efficacy and the extent of disease,the severity of disease:There was no correlation between clinical comprehensive efficacy and the extent of disease(P＞0.05).Clinical comprehensive efficacy was negatively correlated with the severity of disease(P＜0.01),the more simple the disease is,the more effective the treatment is.2.8 The result of adverse reactions:During treatment the treated group had no obvious side effects,while one cases in control group occurred leukopenia, and western medicine was suspended after one course of treatment,no special treatment was given.Conclusions:Animal experiments have shown that:the combination of Changdiqing and Changyanqing can significantly relief symptoms such as diarrhea and hematochezia,reduce the ulcer index of colonic mucosa,improve the pathomorphology,increase SOD activity in serum and tissues of colon,and decrease the level of MDA in rats with experimental UC.Clinical study results have shown that:the method of removing heat and dispersing dampness in treating active mild and moderate UC belonging to wetness-heat of large intestine had significant clinical modifications with decrease of ESR,disappearance of fecal occult blood and improvements of cardinal symptom and colon mucosal lesions.The treated group was superior to the control group in term of measurements by Chinese medicine syndromes efficacy and clinical comprehensive efficacy.Results from this study have demonstrated that Changyanqing and Changdiqing combination therapy in treating UC can modify inflammatory inflammation,enhance the protective effect on mucosa cells and promote ulcer healing,through the mechanisms of increasing SOD activity and decreasing MDA level in serum and tissues of the colon.更多还原