难治性特发性血小板减少性紫癜中医证候分析

【作者】 施怡；

【导师】 陈信义；

【作者基本信息】 北京中医药大学 ， 中西医结合内科， 2009， 硕士

【摘要】 概述:特发性血小板减少性紫癜(ITP)为自身免疫性出血性疾病,有15%～35%的患者经激素或者脾切除等治疗无效,称之为难治性特发性血小板减少性紫癜(RITP)。由于西药治疗RITP具有停药后易反复、毒副作用大、费用昂贵等缺点,越来越多的患者寻求中医药治疗。然而纵观文献,目前,对RITP的中医治疗尚处于探索阶段,缺乏对RITP系统规范的中医证候研究。我们在多年临床观察中总结出RITP是以“气虚血瘀”为主要病机变化的难治性血液病,并以“益气活血”为法、以黄芪、穿山龙等药物组方治疗难治性血小板减少性紫癜,临床获得了良好效果。本研究作为首都医学发展基金批准的中医临床研究自主创新课题“芪龙颗粒治疗RITP临床应用研究”的一部分,希望通过回顾性调查75例RITP患者的四诊信息,能够对RITP证候进行初步的总结,验证我们既往的临床经验,为本病中医辨证论治的规范起到良好的作用,这对后续的研究工作有一定指导意义。方法:对北京中医药大学东直门医院及东方医院血液科2003年至2008年的住院患者中符合RITP诊断标准之病例75例,进行回顾性分析。观察纳入RITP患者的性别、年龄、病程、外周血象、骨髓巨核细胞等情况,统计常见症状的出现频率,描述舌苔、脉象、证候等分布的情况,分析相关临床因素对证候的影响,并对患者的症状进行因子分析,推导潜在的规律,以认识本病的中医证候规律。结果:①基线数据:发病率女性明显高于男性(P＜0.05)。患者平均年龄47.56±18.96,病程中位数为27个月,最长可达10年以上。②实验室检查:患者外周血象变化以血小板减少为特点,血小板计数平均值为28.84±13.64(×10~9/1)。红细胞、血红蛋白、白细胞都可以在正常范围内。骨髓象变化以巨核细胞数量增多或正常、发育成熟障碍、产板巨核细胞减少为特点。③四诊信息:症状频率以神疲乏力最高,其次为皮下紫斑。通过对出现频率＞10%的症状进行因子分析,筛选出了对证候贡献度较大的12个症状:神疲乏力、气短、少气懒言、皮下紫斑、面唇紫暗、经血色黑有块、五心烦热、潮热盗汗、口干、便秘、小便黄、食少纳呆。这12个症状分别隶属于气虚血瘀、阴虚、热证、脾系症状四个公因子。舌象以舌质淡黯、苔白为主,其次为舌红少津、苔少,其中黯舌在舌象中最为多见。出现频率前三位的脉象分别是细弱脉、细涩脉、细数脉。④证型分布:证型分布以含气虚血瘀要素的证型为最多;在复杂证型中,基础证型为气虚血瘀,主要兼挟证型为阴虚证。结论:本病基本病因是气虚血瘀,主要的证候类型也是气虚血瘀。这与我们临床经验相符。更多还原

【Abstract】 Background:Idiopathic thrombocytopenic purpura(ITP) is an autoimmune disease characterized by low platelets and bleeding.About one thrid of adults with ITP do not respond to standard doses of corticosteroids and aplenectomy and require anther therapy to raise their platelet count,which belong to Refractory Idiopathic thrombocytopenia purpura(RITP).To treat RITP by Western medicine associated with easier to relapse,more side effects,and more expensive,compare with by TCM. However,from wide view of literature,the study of Traditional Chinese Medicine(TCM) treatment of RITP still on initial stage and lack of system research in aspect of standardized TCM syndrome.Through clinic observing for several years,we concluded that blood stasis due to qi deficiency is the essential mechanism of RITP. According to this theory,we use supplementing qi and promoting blood circulation for removing blood stasis as therapeutic principle,and use traditional Chinese compound which is mainly composed of Hangqi,Chuanshanlong to treat patients.This study is the component part of clinical application of Qi Long granule reseach,which is authorized self-determination innovated study in traditional chinese medicine in 2005 by the fund of medicine development in Beijing(number:SF-2005-031).We hope we could get the primary summery of RITP syndrome features by retrospective investigate 75 cases of RITP,in order to verify our previous experiences,contribute to standardize syndrome differentiation and treatment of RITP,and direct the coming research.Methods:75 cases of RITP patients,who were admitted to the Donghzhimen hospital and Dongfang hospital after 1st January,2003 from 10 to 80 years old,were studied retrospectively.We analyzed the patients’ data,including gender,age,course of disease,peripheral hemogram,bone marrow morphology,symptom,tongue condition, pulse condition,etc.Sum up the distribution of syndrome,and use factor analysis to discover the significance of the symptoms’ different occurrence frequencies in aspect of syndrome.Results:①Baseline data:Female patient is significant more than male(P＜0.05). The average age was 47.56±18.96.The median of course of disease was 27 month, while the maxima may over 10 years.②Lab examination data:The main character of peripheral hemogram was the decrease of platelet,and the average platelet count was 28.84±13.64(×109/1),however the RBC,HGB,WBC could be normal.Megakaryocyte was overabundance or normal with maturation arrest.③Four diagnostic methods information:the most common symptom was lassitude,and the secondary was purpura. We had selected 12 symptoms to dedicate to 4 factors by factor analysis.The 12 symptoms were fatigue and lassitude,insufficiency of Qi,disinclination of talk,purpura, dark purple face,dark purplemenstrual blood,burning sensation of five centres,tidal fever and night sweating,dry mouth and dry pharynx,constipation,reddish yellow urine,anorexia.And the 4 factors represented qi deficiency and blood stasis,yin deficiency,heat syndrome,and the symptoms related to spleen respectively.Pale and dark tongue body and white tongue coating was the most common tongue condition, and the secondary was red and dry tongue body and little tongue coating.The most common pulse conditions were weak thready pulse,unsmooth thready pulse,rapid thready pulse.④distribution of syndrome:the most common syndrome fundamental elements were qi deficiency and blood stasis.And among the complex syndrome,the fundamental syndrome was qi deficiency and blood stasis,mainly accompanying with yin deficiency.Conclusion:Qi deficiency and blood stasis is not only the main etiology and pathogenesis,but also the main type of RITP syndrome in terms of TCM.And this accords with our clinic experiences.更多还原