【作者】 吴佩莼；

【导师】 李坤寅；

【作者基本信息】 广州中医药大学 ， 中医妇科学， 2008， 硕士

【摘要】 【研究目的】妇科腹部术后患者由于麻醉、腹膜刺激、术中操作对胃肠的牵拉、术后腹腔内少量渗血渗液及手术本身的创伤、水电解质失衡、胃肠激素调节紊乱等都不同程度抑制了胃肠功能,导致胃肠蠕动减弱或消失;而且由于女性的生理和心理特点,痛阈低,对疾病的反应往往更为强烈,术后常害怕疼痛而不敢翻身及下床活动,因此常常出现腹胀腹痛、纳呆、恶心呕吐,甚或盆腹腔粘连、肠梗阻等一系列临床症状。目前中西医对妇科腹部术后出现胃肠功能紊乱的治疗各有优劣。西医多主张自然恢复,往往是在患者出现腹胀、腹痛、恶心呕吐等症状后才对症用药,如出现肠梗阻,则作胃肠减压,甚至需再次手术行剖腹探查术。相对于西医,中医对腹部术后出现胃肠功能紊乱的内外治手段较多,疗效较好,而且中医药可主动干预,预防腹部术后胃肠功能紊乱的发生,在围手术期有明显优势。随着妇科手术日益增多,在围手术期发挥中医药优势有着广阔的研究前景。腹部手术创伤为一现代致病因素,具有自身的病理特点。中医认为其病机多与气滞血瘀、腑气不通、气机升降失调有关;治则以通里泻下、行气散结、活血祛瘀、健脾和胃等为主。治法有内服中药(中成药),外用如保留灌肠、敷脐,针灸治疗等。而我们认为,对择期手术的病人来说,脾失健运是其关键的病机,治疗应以运脾化湿为法。据此,我们选用运脾饮以健运脾胃,理气祛湿。运脾饮是张玉珍教授主持研制、由广州中医药大学第一附属医院妇科医生集体研究的经验方,其组成有苍术、枳实、厚朴、藿香各12g,丹参、黄芪各15g,陈皮6g,具有健运脾胃、理气消胀的作用,目前已完成了前期研究表明,运脾饮能明显缩短肛门排气时间,较好较快地促进妇科腹部手术后胃肠功能的恢复,减少相关并发症;并能使血浆MTL、GLU短时间内恢复术前水平。西医学认为腹部术后出现消化道功能紊乱的原因主要有术中麻醉、腹膜刺激、术中操作对胃肠的牵拉、术后腹腔内少量渗血渗液及手术本身的创伤、术后解剖位置改变、水电解质失衡、胃肠激素调节紊乱等。其中胃肠神经激素调节紊乱是造成较持续性功能紊乱的主要因素。近年的研究多集中于腹部术后胃肠运动与胃肠激素水平的关系。胃泌素(GAS)是由G细胞分泌的一种17肽消化道激素,亦属脑肠肽之一,具有循环激素和神经递质的双重作用,它不仅能刺激胃酸、胃蛋白酶和胰酶等消化酶分泌,而且能直接刺激胃肠平滑肌细胞,从而使胃肠蠕动增强、加速胃肠排空,并促进胃肠黏膜的生长发育和功能成熟。相关的研究表明,手术后GAS水平的下降是导致胃肠道抑制的重要原因。血管活性肠肽(VIP)为28个氨基酸组成的直链肽,是一种非肾上腺素非胆碱能(NANC)抑制系统的神经递质,对胃肠活动具有明显的抑制作用,不仅可松弛胃体部,而且VIP受体能阻断电刺激和迷走神经反射所引起的胃肌条收缩,对胃肠蠕动有明显的抑制作用。在前期研究的基础上,本课题通过研究运脾饮对妇科腹部术后患者血清胃泌素(GAS)及血管活性肠肽(VIP)的影响,进一步观察运脾饮治疗妇科腹部术后诸症的临床疗效,探讨其作用机理,为研究中医药防治围手术期疾病及围手术期新药的研制提供新的思路。【研究方法】本研究所有的病例选自2007年11月—2008年4月在广州中医药大学第一附属医院妇科住院患者,按照纳入标准和排除标准进行筛选。选择拟行腹部手术者,麻醉方式为硬外麻、或硬腰联合麻、或全麻,术后出现不同程度的腹胀腹痛或恶心呕吐、纳呆、舌苔厚腻等胃肠功能紊乱症状,中医辨证为脾虚湿困者51例。随机分为治疗组(30例)和对照组(21例)。治疗组患者年龄为31—49岁,平均41.03±5.92岁,麻醉时间2.00—6.91小时,平均3.58±0.97小时,手术时间1.60—5.75小时,平均2.98±0.79小时;对照组患者年龄为25—62岁,平均38.00±8.54岁,麻醉时间2.33—5.50小时,平均3.76±0.90小时,手术时间2.00—4.91小时,平均3.08±0.79小时。两组的年龄、病种、麻醉时间、手术方式及时间等资料比较,均无统计学差异(P＞0.05),具有可比性。两组患者均采用术后常规处理方法,治疗组于术后第1天服运脾饮,每次100ml,每天2次,连服2天;对照组术后2天内服等量的温开水。观察患者术后肛门排便时间、体温、舌象、恶心呕吐、腹胀、腹痛等临床症状改善程度,且于术前、术后第1天早晨(治疗组未服中药干预)及术后第3天早晨抽取空腹静脉血,采用放射免疫法检测GAS和VIP水平。所有数据均用SPSS13.0软件处理,计数资料采用x~2检验,计量资料用t检验。【结果】(1)治疗前后积分比较,治疗组明显优于对照组(P＜0.05)。治疗组有效率达95.0%,对照组有效率为69.7%;两组疗效的比较差异有显著性(P＜0.05)。(2)治疗组患者术后的肛门排便、起床和进食的恢复时间,均比对照组明显提早(P＜0.05)。(3)所有患者于术后第1天均出现GAS明显下降(P＜0.05),VIP明显升高(P＜0.05)。术后第3天,治疗组患者GAS含量较术后第1天明显升高(P＜0.05),VIP含量较术后第1天明显降低(P＜0.05),与对照组比较差异有显著性(P＜0.05)。对照组患者术后第1天和术后第3天的GAS和VIP含量比较差异无显著性(P＞0.05)。【结论】(1)本研究证实了腹部术后患者的胃肠激素水平出现GAS含量降低,VIP含量升高的变化,运脾饮能增加术后患者的GAS,降低VIP水平,从而促进胃肠功能的恢复。(2)本研究表明,增加术后患者GAS的浓度,刺激胃酸、胃蛋白酶和胰酶等消化酶分泌,直接刺激胃肠平滑肌细胞,增强胃肠蠕动、加速胃肠排空,并促进胃肠黏膜的生长发育和功能成熟;同时降低VIP的水平,解除该激素对胃肠道蠕动的抑制作用及其抗体对电刺激和迷走神经反射所引起的胃肌条收缩阻断,促进胃肠平滑肌细胞收缩,可能是运脾饮治疗妇科腹部术后胃肠功能紊乱的作用机理之一。运脾饮是否还通过其他机制防治腹部术后胃肠功能紊乱有待于进一步研究。(3)本研究再次证明了以运脾除湿、行气消胀立法的运脾饮对妇科腹部术后患者胃肠功能紊乱有良好的疗效,能明显缩短术后患者的肛门排便时间,减少腹痛腹胀、恶心、呕吐等症状。更多还原

【Abstract】 Objective:The gastroenteric function of the patients after abdominal operations of gynecology is more or less inhibited,that make the gastrointestinal peristalsis weaken or disappear,because of the anesthesia,peritoneal irritation,gastrointestinal tensions by operating,a little bleeding and oozing liquid in the cavity of the abdomen after operation,operative trauma, water and electrolytes imbalance,and regulating disturbances of gastrointestinal hormones.In addition,with Women’s physical and psychological traits,having low painful threshold,being more sensitive to diseases,they are afraid of pain and dare not move after operations, therefore the clinical symptoms such as abdominal distention,abdominal pain, anepithymia,nausea and vomiting,thick and greasy fur on tongue,or even abdominal adhesion and intestinal obstruction etc usually appear after abdominal operations of gynecology.Either Traditional Chinese Medicine(TCM)or Western medicine has advantage in curing the patients who have impaired digestion after abdominal operations of gynecology at present.However,Western medicine congsider it naturally recover and the medical treatments of Western medicine are usually after the patients suffer from abdominal distention,abdominal pain,anepithymia,nausea and vomiting etc.For example,gastrointestinal decompression or even re-operation of laparotomy would be performed if ileus appeared.Compare with Western medicine,TCM has more complex treatments and better effective to the patients after abdominal operations.Moreover,TCM can intervene actively,prevent gastrointestinal dysfunction after abdominal operations and exert obvious advantages in perioperative period.With more and more gynecological operations,there are greater prospects of making full use of the advantages of TCM in perioperative period.The trauma of abdominal surgery is a modern factor of causing diseases,which has its own pathological characteristic.TCM believes that the pathogenesis is mostly concerned with stagnation of Qi and stasis of blood,obstruction of Fu Qi,disturbance in ascending and descending of the functional activities of qi etc.The main principles of treatment are clearing the hollow viscera and purging away the heat,promoting circulation of Qi and dissolving lumps,promoting blood circulation by removing blood stasis,strengthening the spleen and stomach etc.The methods of treatment are taking herbal drugs or Chinese patent medicine orally,external applications such as clystering by herbal drugs,navel administration,acupuncture and moxibustion etc.However,to the patients undergoing selective operations,we think the key pathogenesis is dysfunction of the spleen in transport,the principles of treatment is resolving Dampness by tonifying Spleen and relieving flatulence by promoting circulation of Qi.Accordingly,we choose Yunpiyin in order to reinforce spleen and stomach,regulate qi and relieve distension. The development was presided over by Professor Zhang Yuzhen and worked over by other gynecologists from the No.1 Affiliated Hosptial of Guangzhou University of Traditional Chinese Medicine.This prescription is composed of Cangzhu(12g)Zhishi(12g)Houpu(12g)Huoxiang(12g)Danshen(15g)Huangqi(15g) Chenpi(6g).It can resolve Dampness by tonifying Spleen and relieve flatulence by promoting circulation of Qi.Previous research have proved that Yunpiyin can shorten the time of anal aerofluxus obviously,promote the disgestive ability of the stomach and intestines after operation of abdominal gynecology,reduce the occurrence of related complications.Besides,make MTL and GLU in plasma restore to the level before operation in a short period of time.Western medicine considers that the reasons for gastrointestinal dysfunction after abdominal operations,are the anesthesia,peritoneal irritation,gastrointestinal tensions by operating,a little bleeding and oozing liquid in the cavity of the abdomen after operation,operative trauma,anatomic change,water and electrolytes imbalance,and regulating disturbances of gastrointestinal hormones etc..The key factor is the regulating dysfunction of gastrointestinal hormones and nerves.The recent studies have focused on the relationship between gastroenteric movement and gastrointestinal hormones.GAS is a 17 mer peptide.digestive tract hormone and one of the brain-gut peptide secreted from G cell,which has a dual role as circulation hormone and neurotransmitter.It can not only stimulate the secretion of digestive enzymesgastric,such as gastric acid and pepsin,trypsin etc.,but also directly stimulate gastrointestinal smooth muscle cells to enhance gastric peristalsis,accelerate the stomach emptying and promote the growth and development and function of maturity of gastrointestinal mucosa.Relative reseaches have showed that the level of GAS reduced after an operation is the important reason leading to gastrointestinal inhibition. Vasoactive intestinal peptide(VIP),a straight-chain peptide composed of 28 amino acid,is a neurotransmitter of non-adrenergic non-cholinergic(NANC) inhibition systems.It has a significant inhibition on gastrointestinal activities which can loosen gastric body.Furthermore,VIP receptor can block stomach contraction caused by electrical stimulation and vagus nerve reflection,which has a significant inhibition on gastrointestinal peristalsis.On the basis of previous study,through studying on the impact of Yunpiyin on serum GAS and VIP after abdominal operations of gynecology,this research observed further clinical efficancy of Yunpiyin treating various symptoms after abdominal operations of gynecology,explored its mechanism,and provided new ideas for TCM to prevent and cure diseases in perioperative period as well as the development of perioperative new drugs.Methods:We chose patients who were in the Gynecology Department of the No.1 Affiliated Hosptial of Guangzhou University of Traditional Chinese Medicine between November,2007and April,2008.All cases are filtered by enter standard and exclusion standard.51 patients are filtered and their operation ways are abdominal operations.The anaesthesia way is outside the hard membrane anaesthetize or hard waist union anaesthetize or general anesthesia.The patients after abdominal operations have varying degree symptioms of gastrointestinal dysfunction such as abdominal distention,abdominal pain,anepithymia,nausea and vomiting,thick and greasy fur on tongue etc,the dialectical of TCM is that Spleen Dysfunction due to Dampness.By the stochastic comparison method,51 patients were divided into the control group(n=21)and the treated group(n=30).Treated group:age ranged from 31 to 49,average(41.03±5.92),the average time of anaesthesia is(3.58±0.97) hours,the average time of operation is(2.98±0.79)hours.Control group: age ranged from 25 to 62,average(38.00±8.54),the average time of anaesthesia is(3.76±0.90)hours,the average time of operation is(3.08±0.79) hours.Compared with the materials of two groups,such as the patients’ ages,the kinds of disease,the time of anaesthesia,the ways and times of operations etc,has no statistics significance(P＞0.05).Two groups were both nursed by routine nursing method.Patients in treated group drank Yunpiyin in the first day after operations,100ml at a time,twice a day,taking 2 days.But patients in control group drank isometric water.To observe patients’ improvement of the symptoms,such as temperature,tongue picture,nausea and vomiting,abdominal distention, abdominal pain and the time of anal aerofluxus etc.We also respectively examine two-group patients’ GAS and VIP before operation,the first day morning and the Third day morning after operations by radioimmunoassay.All data is processed by SPSS 13.0,both t-test and x~2 test are used repectively.Results:(1)The effective rate of treated group is 100.0%,control group’s is 69.7%, there is obvious statistics significance(P＜0.05).(2)Shorten time of anal aerofluxus and improve the symptoms,such as abdominal distention,nausea and vomiting etc in treated group,were superior to those in control group(P＜0.05).(3)All patients after operations have a low-level of GAS(P＜0.05)and an increase of VIP(P＜0.05).In the third day,compared with the first day,the level of GAS has increased obviously(P＜0.05),the level of VIP has decreased obviously(P＜0.05)in treated group.There is obvious difference to compared with the control group(P＜0.05).Conclusions:(1)It indicates that the patients after abdominal operations have a low-level of GAS and an increase of VIP.But Yunpiyin can raise GAS and reduce VIP,consequently promote gastrointestinal functional recovery.(2)It indicates that Yunpiyin can stimulate the secretion of digestive enzymesgastric,such as gastric acid and pepsin,trypsin etc.,directly stimulate gastrointestinal smooth muscle cells to enhance gastric peristalsis,accelerate the stomach emptying and promote the growth and development and function of maturity of gastrointestinal mucosa by raising GAS.Moreover,it can release from the inhibitory action of VIP to the gastrointestinal peristalsis and the stomach contraction block of VIP receptor to electrical stimulation and vagus nerve reflection by reducing VIP.That’s why Ynpiyin can strengthen gastrointestinal digestant,absorptive and kinetic enginery of the patients after operations.More researches are to be made to understand Yunpiyin’s active mechanism.(3)It indicates again that Yunpiyin has an effct of activating spleen and eliminate dampness,promoting qi circulation and relieving distension,which is good for the patients with gastrointestinal dysfunction after abdominal operations.It can shorten the time of anal aerofluxus,reducing the symptoms of abdominal distention,abdominal pain,anepithymia,nausea and vomiting etc.更多还原