摘要
目的:依据脑肠相关理论,对功能性便秘予以中药灵菇合剂联合生物反馈,脑肠并治,深入探讨肛肠动力学的病理生理改变;通过对生活质量及心理因素等相关因素的分析,进一步证实脑肠相关的科学内涵。
方法:理论研究——脑肠相关研究:通过整理、分析祖国医学脑肠相关的功能及物质基础、经络理论及病理相关方面,结合现代医学的研究进展证实脑肠相关理论的科学性,为脑肠并治提供理论依据。临床研究:一、肛肠动力学研究:100例功能性便秘患者予以排粪造影、结肠传输试验及肛肠动力学检测指导临床分型;经上述分型的便秘患者,结肠慢传输型31例,出口梗阻型36例,混合型33例。采用配伍组随机对照设计,分为治疗组33例,对照1组33例,对照2组34例。治疗组予灵菇合剂联合生物反馈,对照1组予灵菇合剂口服,对照2组予生物反馈训练,对临床症状和肛肠动力学指标进行观察分析,两周为一观察疗程,四周后评价疗效。二、便秘相关因素分析:对符合罗马Ⅲ标准的107例便秘患者采用便秘调查问卷、生命质量调查问卷、精神心理状态评定量表问卷调查。调查内容包括症状谱、一般人口学特征、既往诊疗情况、精神心理状况和生命质量等内容。
结果:1.脑肠的功能正常在于气机升降出入,主要物质基础是津液,通过诸经络相连,脑肠并病,奠定了脑肠相关的理论基础。排便机制中神经内分泌网络调控肠动力,证实脑肠相关,为脑肠并治提供依据。2.传输指数三种病理分型比较有显著差异(P<0.01)。肛管静息压出口梗阻型和混合型显著增高;肛管缩榨压及其持续时间混合型和出口梗阻型低于正常;直肠肛管抑制反射慢传输型和出口梗阻型高于正常。初始感觉和排便感觉阈值慢传输型显著增高,混合型和出口梗阻型高于正常;排便窘迫阈值和直肠最大耐受容量慢传输型高于正常,混合型和出口梗阻型正常。3.治疗组总有效率87.5%,对照1组总有效率78.8%,对照2组总有效率78.1%,三组间疗效差异无统计学意义(P>0.05)。三组治疗前后临床症状积分有统计学意义(P<0.01);改善排便不尽感治疗组和对照1组优于对照2组(P<0.05);排便费力治疗组优于其他两组(P<0.05)。改善排便不尽感、排便梗阻感慢传输型优于其他两型,改善大便性状和排便次数其他两型优于慢传输型;改善排便费力其他两型优于出口梗阻型。治疗前后肛管静息压、肛管缩榨压、肛管缩榨压持续时间比较有统计学意义(P<0.01)。肛管缩榨压及其持续时间和直肠肛管抑制反射治疗组优于其他两组(P<0.05)。治疗后肛管静息压出口梗阻型高于正常;直肠肛管抑制反射慢传输型及混合型高于正常;肛管缩榨压及其持续时间慢传输型高于其他两型,改善慢传输型肛管静息压、肛管缩榨压及其持续时间方面疗效强。初始感觉阈值、排便窘迫阈值、直肠最大耐受量治疗组和对照1组优于对照2组(P<0.05);治疗组和对照1组比较无明显差异(P>0.05)。治疗后初始感觉阈值、排便感觉阈值、排便窘迫阈值、直肠最大耐受量慢传输型高于其他两型。4.便秘患者具有病程长、频繁就诊、治疗时间长、滥用通便药、疗效不佳、症状谱广泛等特点。5.患者组生活质量所有8个维度的评分均低于健康对照组;存在明显的焦虑、抑郁情绪。焦虑、抑郁积分与生活质量负相关;肛肠动力学和精神心理因素相关(P<0.05),肛管缩榨压及其持续时间与SAS、SDS呈负相关;初始感觉阈值、排便感觉阈值和最大耐受容量与SAS、SDS呈正相关。
结论:1.脑肠相关理论具有科学内涵,为临床脑肠并治提供理论依据。2.肛肠动力学、结肠传输试验及排粪造影为便秘分型提供依据,慢传输型存在结肠动力和直肠感觉障碍,出口梗阻型存在盆底动力障碍。灵菇合剂联合生物反馈有助于脑调节大肠的传导动力和恢复肠道感觉功能,灵菇合剂恢复正常的胃肠转运和排空,调节直肠感觉功能,生物反馈有助于建立正常的排便规律和排便行为,增强肌力。二者合用脑肠并治,优化了便秘的治疗方法。3.功能性便秘的症状谱广泛;患者存在滥用通便药的情况;便秘显著损害患者的生存质量,易合并有焦虑、抑郁等精神心理的异常。焦虑、抑郁和生存质量相关,肛肠动力学和精神心理因素相关,证实了脑肠相关,与祖国医学的整体观念相符合,是病机理论的深化。
Objective: Studying anorectal motility and pathophysiology of FC under the guidance of the theory of brain-gut correlation and the concept of organic wholeness, discusses the anorectal dynamics thoroughly in the patients with outlet obstructed, slow transitted and mixed constipation of pathology and physiology changes so as to provide the evidence for the diagnosis and make effective therapeutic plan.Through to the patients quality of life and the psychological factor investigation, further confirmed the brain-gut correlation theory.
Methods:1.Theories investigation:Gathering and analyzing traditional Chinese medicine and published medial journal articles with the attempt to learn the past and present achievement,the brain-gut correlation theory are analysed systematically serve as the reference materials for inquiry into and treatment of functional constipation.2.Clinical research:(1)We choosed 100 FC including 31 slow transit constipation, 36 outlet obstructive constipation and 33 mix constipation which were diagnosed by barium defecography, gastrointestinal transit test and anorectal manometry. We divided three groups:33 cases in the observing group were treated by combination of Linggu Mixture and biofeedback,33 cases in the controlling one were treated by Linggu Mixture,and 34 cases in the controlling two were treated by biofeedback. We mainly observed such respects as symptoms,signs,conditional degree of disease, four weeks curative effect before and after treatment.The research on anorectal dynamics adopted anorectal manometry to examine the changes of rectal sensation functions,anorectal and defecate function of FC before and after treatment.(2)Correlation factor investigation: to investigate psychological status and quality of life affected by constipation symptoms which were performed by the 36-item short form health survey,the Zung self-rating anxiety scale and Zung self-rating depression scale. SPSS16.0 was used to do the statistical analysis.
Results: 1.Theoretical results: showed that brain and gut are related closely in many aspects such as structure and function, brain-gut correlation is the further development which studies in the traditional Chinese and modern medicine about constipation. The theory brain-gut correlation provide scientific basis for the future prevention and treatment. 2.Clinical results: (1)Classified diagnosis of FC:showed that compared to STC and MC, there was significant increase in anorectal resting pressure and decrease in anal squeezing pressure and its time in patients with OOC,P<0.01; compared to OOC, increase in RAIR in patients with STC and MC,P<0.01;compared to OOC and MC, there was significant increase in first sensation volume,defecating sensation volume,defecating tolerable volume and maximum tolerable volume in patients with STC (P<0.01),increase in both first sensation volume and defecating sensation volume in patients with obstructed and mixed constipation,P>0.05. Clinical observation indicated: by the look of overall curative effect, among 32 cases in observing group was 87.5%; among 33 cases in control group one was 78.8%;among 32 cases in control group two was 78.1%.Dealt with statistics between three groups,P>0.05,there were not significance differences that observing group curative effect was similar to control groups.There were significant differences in every observation index in observing group and control groups before and after treatment,P<0.01.The observation index of clinical symptoms of three groups, endless defecate feeling in observing group and control group one were better than control group two,P<0.05; defecate straining in observing group was better than control groups,P<0.05.Compared to OOC and MC, endless defecate feeling and obstructed defecate feeling in patients with STC were better, stool traits and stool frequency in patients with STC were worse; compared to STC and MC, defecate straining in patients with OOC was better.Anorectal dynamics showed that anorectal motility intervenes the result of study: anal squeeze pressure and anal squeeze pressure time of the observing group compared with the control groups had significant differences before and after treatment, P<0.01; compared with the control groups before and after treatment, anal squeeze pressure,anal squeeze pressure time and rectoanal inhibitory reflex of the observing group were better, P<0.05; the control groups had not significant differences, P>0.05. Compared to OOC before and after treatment, rectoanal inhibitory reflex in patients with STC and MC were better; anal resting pressure reflex in patients with OOC was higher than normal;anal squeeze pressure and anal squeeze pressure time in patients with STC were better. Compared to OOC and MC,anal resting pressure,anal squeeze pressure,anal squeeze pressure time and rectoanal inhibitory reflex in patients with STC were worse,P<0.01.Compared with the control group two before and after treatment, first sensation volume, defecating tolerable volume and maximum tolerable volume in observing group and control group one were better, P<0.01～0.05, observing group and control group one had not significant differences, P>0.05.(2)Correlation factor investigation results: chronic constipation is a common disorder in patients,and many patients suffered from severe CC;the FC patients had extensive symptom spectrum and took laxatives without doctor’s guidance. Many patients were inclined to suffer from unhealthy psychological status including anxiety and depression,the scores for quality of life evaluated by SF-36 questionnaire in FC patients were significantly lower than those in healthy control.The quality of life in FC patients was negative correlated with anxiety and depression. The observation index of anoretal motility with the anxiety and depression have the relevance, after statistics processing, P<0.05, anal squeeze pressure and anal squeeze pressure time were negative correlated with anxiety and depression; anal resting pressure, first sensation volume,defecating sensation volume and maximum tolerable volume were positive correlated with anxiety and depression.
Conclusion: 1.The brain-gut correlation theory has the scientific connotation, may instruct clinical diagnosing and treating.2.The establishment of FC is followed by the categorizing diagnosis based on GITT, anorectal manometry and BD,which will determine the option of the treatment method. It is concluded that patients with different type of constipation have different anorectal motility disturbances.Based on the theory of brain-gut correlation, diversified factors are so relevant to the pathogen of the patients of FC that combination of Linggu Mixture and biofeedback were superior to parameters of anorectal motility and perception function ,improves FC patients’symptoms effectively and have a better effect than Linggu Mixture and biofeedback therapy. Linggu Mixture increase intestinal motility and improve the symptoms of constipation mechanism and biofeedback therapy raise harmony of rectal sphincter should be to receive the regular reflection.A co-operation can make a better anorectal dynamics and a satisfying clinical result which construct the theoretical basis of brain-gut to be sicked together and is the theoretical basis of curing them together,too.Functional constipation is a common disorder in anoretal patients.Many patients were inclined to suffer from unhealthy psychological status including anxiety and depression.The quality of life in FC patients was negative correlated with anxiety and depression and the observation index of anoretal dynamics with the anxiety and depression have the relevance which confirmed the brain-gut relevance and comform with the traditional medicine concept of organic wholeness. The brain-gut correlation theory is the pathogenesis theory of traditional medicine deepening.
引文
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