【作者】 蒋红梅；

【导师】 朱京慈；

【作者基本信息】 第三军医大学 ， 护理学， 2007， 硕士

【摘要】 目的:胃肠动力障碍(gastrointestinal motility disturbance,GMD)是重型颅脑损伤(severe head injury,SHI)患者最常见的早期并发症之一,主要表现为胃潴留增加、返流、腹胀、腹泻、呕吐等症状,可导致肠源性感染、吸入性肺炎和多器官功能障碍,增加病死率。本研究旨在探讨肠内营养和中药藿香正气液对SHI大鼠胃肠动力的影响及其相关胃肠肽的变化,为临床肠内营养顺利实施提供实验依据。方法:采用气动冲击致伤装置建立重型颅脑损伤大鼠模型,将108只大鼠随机分为5组:假手术组(sham operation,SO组):仅行左侧顶部骨窗而无脑损伤,灌喂营养液与复方氯化钠液的时间和量同早期肠内营养组;单纯脑损伤组(severe head injury,SHI组):致脑损伤后灌喂同早期肠内营养组等量等次复方氯化钠液;早期肠内营养组(early enteral nutrition,EEN组):脑损伤后每天分6次按时灌喂肠内营养液,同时灌胃复方氯化钠液10ml/kg×2/日;肠内营养联合藿香正气液组(enteral nutrition and HXZQ,ENH组):脑损伤后在肠内营养的基础上灌喂藿香正气液10ml/kg×2/日;肠内营养联合莫沙比利组(enteral nutrition and mosapride,ENM组):脑损伤后在肠内营养的基础上每灌喂5×10-2mg/ml莫沙必利溶液10ml/kg×2/日。SO组、SHI组、EEN组各24只大鼠,分别选择伤后6h、24h、48h、72h4个时相点;ENH组、ENM组各组18只大鼠,分别选择伤后24h、48h、72h 3个时相点。以葡聚糖蓝-2000为胃肠内标志物的染料法检测大鼠胃排空和小肠传输比率,采用放射免疫分析法(radioimmunoassay,RIA)测定血浆和胃窦、空肠组织胃动素(motilin,MTL)和降钙素基因相关肽(calcitonin gene-related peptide,CGRP)含量。数据均以均数加标准差( x±s)表示,统计学处理采用SPSS10.0统计软件包进行单因素方差分析,以P<0.05为相差显著,P<0.01为相差非常显著。结果:1.成功建立大鼠重型颅脑损伤模型本实验采用气动冲击致重型颅脑损伤大鼠模型。模型死亡率达43%左右。观察致伤大鼠大脑解剖和病理变化,显示大脑不同的部位存在脑挫裂伤、出血或硬膜下血肿等;伤后24小时HE染色可见海马区明显出血。因此,可以判定本研究的动物模型符合重型颅脑损伤的标准。2.大鼠胃排空改变SHI组大鼠各时相点胃内色素相对残留率显著高于SO组(P<0.01)。EEN组48h以前与SHI组无显著差异,72h显著低于SHI组(P<0.01),已接近SO组水平。ENH组与ENM组在24h与SHI组无显著差异,高于SO组,但低于EEN组(P<0.01);48h以后显著低于SHI组(P<0.01),恢复至SO组水平;在48h均低于EEN组(P<0.05),72h与EEN组无显著差异。说明创伤后胃排空明显延迟,6h就已出现,72h仍未恢复。EEN后胃排空仍明显延迟,至72h才恢复至SO组水平。EEN联合藿香正气液或莫沙比利在伤后24h开始促进创伤后胃排空,但高于SO组,48h以后改善胃排空,使之恢复至SO组水平。3.大鼠小肠传输改变SHI组大鼠各时相点小肠传输显著低于SO组(P<0.01)。EEN组24h以前小肠传输与SHI组无差异,显著低于SO组(P<0.01);但48h开始高于SHI组(P<0.01),至72h恢复至SO组水平。ENH组与ENM组在伤后24h开始均高于SHI组(P<0.01或P<0.05),与SO组无差异;24h、48h均高于EEN组(P<0.01或P<0.05),72h与之无显著差异。说明脑创伤后6h小肠传输降低,持续至72h仍未恢复。EEN后小肠传输仍明显延迟,48h开始恢复,到72h才恢复至SO组水平。EEN联合藿香正气液或莫沙比利在伤后24h开始就促进肠传输,恢复至SO组水平。4.大鼠血浆和胃肠组织MTL含量变化伤后大鼠各个时相血浆、胃窦、空肠MTL含量显著高于SO组(P<0.01或P<0.05)。EEN组6h～48h血浆、胃窦、空肠MTL含量与SHI组无差异,显著高于SO组(P<0.01或P<0.05);72h低于SHI组(P<0.01或P<0.05),恢复至SO组水平。ENH组与ENM组胃窦和空肠MTL含量在24h以后、血浆在48h以后均低于SHI组(P<0.01或P<0.05),恢复至SO组水平;ENH组与ENM组在伤后24h血浆MTL含量与SHI组无差异,高于SO组,但低于EEN组(P<0.05);血浆、胃肠组织MTL含量24h、48h低于EEN组(P<0.01或P<0.05),在伤后72h与EEN组比较无明显差异。说明脑创伤后6h血浆、胃肠MTL含量升高,持续至72h仍未恢复。EEN后血浆、胃肠MTL含量仍升高,到72h才恢复至SO组水平。EEN联合藿香正气液或莫沙比利在伤后24h以后胃肠组织MTL含量就下降至SO组水平,两组血浆MTL含量在24h虽仍升高,但低于EEN组水平,至48h恢复至SO组水平。5.大鼠血浆和胃肠组织CGRP含量变化SHI伤后大鼠各个时相点血浆、胃窦、空肠CGRP含量显著高于SO组(P<0.01)。EEN组6h～48h胃窦CGRP含量与SHI组无差异,显著高于SO组(P<0.01或P<0.05),72h恢复至SO组水平;但血浆和空肠CGRP含量在48h显著低于SHI组(P<0.01),开始恢复至SO组水平。ENH组与ENM组在伤后24h开始血浆和胃肠CGRP含量就低于SHI组(P<0.01),恢复至SO组水平;血浆和胃窦CGRP在24h、48h,空肠CGRP在24h低于EEN组(P<0.01),以后与EEN组无显著差异。说明脑创伤后6h血浆、胃肠CGRP含量升高,持续至72h仍未恢复。EEN后血浆、胃肠CGRP含量仍升高,但血浆、空肠CGRP含量在48h开始降低(空肠CGRP已恢复至SO水平),三者均到72h恢复至SO组水平。EEN联合藿香正气液或莫沙比利在伤后24h以后胃肠组织CGRP含量就下降至SO组水平。结论:1.重型颅脑损伤后6h即可出现胃排空延迟,小肠传输减慢,血浆和胃肠组织MTL、CGRP含量升高,可持续至72h以上,给早期肠内营养的顺利实施带来困难。2.早期肠内营养可一定程度上促进重型颅脑损伤胃肠动力恢复,胃排空和小肠传输在伤后48和72h即开始恢复,可能与影响血浆和胃肠组织MTL、CGRP水平有关。3.早期肠内营养联合藿香正气液可促进重型颅脑损伤后早期胃肠动力的改善,效果与莫沙比利相当,可能与调节血浆和胃肠组织MTL、CGRP水平有关。更多还原

【Abstract】 Objective: Gastrointestinal motility disturbance is one of the most common complications of severe head injury (SHI) characterized by increased gastric retention, reflux, abdominal distension, diarrhea and vomiting etc. It may lead to enterogenic infection, aspiration pneumonitis and multi-organ functional disturbance and increased mortality. This study aimed at discussing the effect of Hexiangzhengqi Liquid, a Chinese herbal medicine in combination with the enteral nutrition on gastrointestinal motility disturbance and the related change in gastrointestinal peptide in SHI rats so as to provide experimental evidences for the practice of enteral nutrition therapy in the clinic.Methods: The SHI model was established in rats by local impact injury. A total of 108 rats were randomly divided into 5 groups: sham operation group (SO group, n=24), severe head injury group (SHI group, n=24), early enteral nutrition group (EEN group, n=24), enteral nutrition plus Hexiangzhengqi liquid group (ENH group, n=18) and enteral nutrition and mosapride group (ENM group, n=18). SO group was treated with fenestration in left copular part yet without head injury and fed with enteral nutrition and Sodium Chloride with dosage and feeding frequency similar to those in the EEN group; SHI group was fed with Sodium Chloride liquid after head injury with dosage and feeding frequency also similar to those in the EEN group and intragastrically administered with Sodium Chloride liquid 10ml/kg bid; EEN group was fed with early enteral nutrition 6 times/day and intragastrically administered with Sodium Chloride liquid 10ml/kg bid; ENH group was intragastrically administered with Hexiangzhengqi liquid 10ml/kg bid in combination with enteral nutrition; ENM group was intragastrically administered with mosapride liquid (at a daily dose of 5×10-2mg/ml) 10ml/kg bid in combination with enteral nutrition. The main outcomes measures for SO group, SHI group and EEN group were observed at 6h, 24h, 48h and 72h after injury, and which were observed at 24h, 48h and 72h for ENH group and ENM group. The gastric emptying and bowel transit rates were determined by staining method with dextran blue-2000 using as gastrointestinal internal marker, and levels of motilin (MTL) and calcitonin gene-related peptide (CGRP) in plasma, sinus ventriculi, and jejunum were determined by radioimmunoassay (RIA). All of the data are presented as mean value±SD ( x±s). The one-factor analysis of variance was performed with the aid of SPSS10.0 statistical package, with P<0.05 considered as significant and P<0.01 as highly significant.Results:1. SHI model was established successfullyIn our study, the SHI model was established in rats by local impact injury. The mortality of model reached about 43%. Anatomically and pathologically, the injured rats were characterized by the contusion and laceration of brain, hemorrhage and subdural hematoma etc. HE staining at 24h after injury showed marked hemorrhage in hippocampus area, indicating that the model under study was in conformity with the criteria of SHI.2. Change in rats’gastric emptyingThe relative residual rates of gastric stain in SHI group at different time point were significantly higher than in SO group (P<0.01). In EEN group, the level before 48h was of no significance as compared with SHI group, at 72h, which was significantly lower than in SHI (P<0.01) and close to SO group’s level. Levels in ENH group and ENM group at 24h were of no significance but higher than in SO group and lower than in EEN group (P<0.01), after 48h, which were significantly lower than in SHI group (P<0.01) and returned to SO group’s level, and which were all lower than in EEN group at 48h (P<0.05) but were of no significance at 72h as compared with EEN group, which indicated a marked delayed gastric emptying occurred at 6h and remained un-returned at 72h. After application of EEN, there was still marked delayed gastric emptying, it didn’t return to SO group’s level until after 72h. EEN combined Hexiangzhengqi liquid or mosapride could promote the gastric emptying at 24h but with a higher level than in SO group, improve the gastric emptying after 48h and bring it back to SO group’s level.3. Change in rats’bowel transitIn SHI group, the bowel transits at different time point were significantly lower than in SO group (P<0.01). In EEN group, the bowel transit before 24h was of no significance as compared with SHI group but was significantly lower than in SO group (P<0.01), which was higher than in SHI group at 48h (P<0.01), and at 72h, which returned to SO group’s level. In ENH group and ENM group, at 24h the bowel transits levels were all higher than in SHI group (P<0.01or P<0.05) but were of no significance as compared with SO group, were all higher than in EEN group at 24h and 48h (P<0.01or P<0.05) but were of no significance at 72 as compared with EEN group, which indicated that the bowel transit at 6h after injury was lowered and remained un-returned at 72h. After application of EEN, there was still marked bowel transit delay, but it began to recover at 48h and returned to the level in SO group at 72h. EEN combined Hexiangzhengqi liquid or mosapride could promote the bowel transit at 24h and help it recovery to SO group’s level.4.Change in MTL level in rats’plasma and gastrointestinal tissuesMTL levels in plasma, sinus ventriculi and jejunum in rats at different time points after injury were all significantly higher than in SO group (P<0.01or P<0.05). In EEN group, MTL level in plasma, sinus ventriculi and jejunum from 6h to 48h were of no significance as compared with SHI group (P<0.01or P<0.05)., but significantly higher than in SO group (P<0.01or P<0.05)., lower than in SHI group at 72h (P<0.05) and returned to SO group’s level. In ENH group and ENM group, MTL levels in sinus ventriculi and jejunum after 24h and plasma MTL levels after 48h were all lower than in SHI group (P<0.01or P<0.05) but recovered to SO group’s level, at 24h, plasma MTL levels in both groups were of no significance as compared with SHI group but higher than in SO group and lower than in EEN group (P<0.05), at 24h and 48h, plasma and gastrointestinal MTL levels were lower than in EEN group (P<0.01 or P<0.05), but were of no significance at 72h as compared with EEN group, which was suggestive that plasma and gastrointestinal MTL levels increased from 6h and remained un-recovered at 72h. After application of EEN, plasma and gastrointestinal MTL levels remained high, which didn’t return to SO group’s level until after 72h. EEN combined Hexiangzhengqi liquid or mosapride could help bring down MTL level in gastrointestinal tissues to SO group’s level at 24h, but plasma MTL levels in the two groups at 24h were still high yet lower than in EEN group, and which returned to SO group’s level at 48h.5. Change in CGRP level in plasma and gastrointestinal tissues of ratsCGRP level in plasma, sinus ventriculi and jejunum in SHI rats at different time points were all significantly higher than in SO group (P<0.01). In EEN group, from 6h to 48h, CGRP levels in jejunum were of no significance as compared with SHI group but were significantly higher than in SO group (P<0.01or P<0.05), which returned to SO group’s level at 72h, and CGRP level in plasma and jejunum at 48h were significantly lower than in SHI group (P<0.01) and began to return to SO group’s level. In ENH group and ENM group, plasma and gastrointestinal CGRP levels at 24h were lower than in SHI group (P<0.01) and recovered to SO group’s level, and CGRP levels in plasma and sinus ventriculi at 24h and 48h and those in jejunum at 24h were lower than in EEN group (P<0.01) but were of no significance as compared with EEN group thereafter, which indicated that plasma and gastrointestinal CGRP levels increased at 6h and remained un-returned at 72h. After application of EEN, plasma and gastrointestinal CGRP levels were still high, but lowered at 48h (CGRP level in jejunum had returned to SO group’s level), at 72, levels in all all the three had recovered to SO group’s level. EEN combined Hexiangzhengqi liquid or mosapride could help bring down CGRP level to SO group’s level at 24h.Conclusion:1. At 6h after SHI, conditions like delayed gastric emptying, slow bowel transit, increased levels of MTL and CGRP in plasma and gastrointestinal tissues may appear, which may lasts more than 72h, thus bringing problems for the practice of enteral nutrition therapy.2. Early enteral nutrition therapy can promote the recovery of gastrointestinal motility to some degree following SHI, gastric emptying and bowel transit showed recovery at 48h and 72 after SHI, this may be related to the effect on levels of MTL and CGRP in plasma and gastrointestinal tissues.3. Enteral nutrition in combination with Hexiangzhengqi liquid can facilitate the improvement of early gastrointestinal motility after SHI, with efficacy equivalent to mosapride, this may be attributed to the regulation on levels of MTL and CGRP in plasma and gastrointestinal tissues.更多还原