慢性萎缩性胃炎中医证候特征及辨证治疗的疗效研究
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摘要
慢性萎缩性胃炎(Chronic Arophic Gastritis,CAG)是临床常见难治性胃病,发病率高,病情缠绵反复,且具有一定癌变倾向。迄今尚缺乏公认有效的干预措施,中医治疗本病的优势和特色已逐渐为人们所认识,但在认识证候特征、归纳总结中医证治特点和伴随焦虑抑郁状态的诊断治疗,以及评价辨证治疗的疗效方面还存在一定问题,影响优势与特色的发挥,也阻碍临床和科研工作的开展。
目的:总结CAG中医证候特征及辨证用药规律,为临床辨证论治和科研提供参考;总结CAG流行病学发病特点,探讨CAG的中医证候特点与焦虑抑郁异常心理状态之间的相关性,为临床、科研提供参考依据;对中医辨证治疗CAG临床疗效进行客观分析,并探索活血化瘀治疗CAG的疗效特点。
方法:通过对中医辨证治疗CAG文献的收集整理和计量分析,探讨CAG的中医证候特征及辨证用药规律;通过CAG的流行病学横断面调查研究,选取北京地区的239例CAG患者进行调查,描述CAG的危险因素、临床症状、中医证候、胃镜、病理诊断结果、伴随焦虑抑郁状态的临床表现和医院焦虑抑郁量表(Hospital Anxiety andDepression Scale,HAD)的测量结果并进行统计,对CAG的中医证候特征与伴随焦虑抑郁异常心理状态的相关性进行探讨;通过辨证治疗CAG 120例临床观察,从临床症状、胃镜下病变表现、病理组织学、基于患者报告临床结局量表(Patient ReportedOutcome,PRO)的角度客观评价中医辨证治疗CAG的疗效,并探索活血化瘀治疗CAG的疗效优势和特点。
结果:
1CAG中医药研究文献分析
共纳入相关文献149篇。证候分型描述共计30余种,其中有五种最为常见:脾胃虚弱证＞脾胃湿热证＞肝胃不和证＞胃络瘀血证＞胃阴不足证。本病病机特点为虚实夹杂,本虚标实,本虚以气虚、阴虚为主,多于阳虚;标实以气滞为主,其次为血瘀,多于湿热及郁热。辨证治疗使用药物主要包括益气健脾、疏肝理气、化湿、清热、养阴、活血及消导7类,常用并且使用率在10%以上的药物依次为白芍、白术、半夏、陈皮、茯苓、丹参、黄芪、香附等,体现了CAG的常用治法为健脾、理气、活血、养阴。脾胃虚弱证常用香砂六君子汤(脾胃虚寒型用黄芪建中汤)加减,随病情需要可适当配合理气药(枳壳、香附、佛手)、活血药(莪术、丹参、当归、元胡、三七)、消导药(鸡内金)和温里药(吴茱萸、生姜、高良姜);脾胃湿热证常用二陈汤、藿朴夏苓汤、香砂平胃散为基本方进行加减,配合白术、党参健脾,苏梗、枳壳、香附、柴胡疏肝理气,黄连、蒲公英、山栀清热,丹参活血,麦芽消食导滞;肝胃不和证常用四逆散、柴胡疏肝散合金铃子散为基本方,配伍活血药(川芎、丹参、当归、郁金、莪术)、健脾益气药(白术、茯苓)、清热药(山栀、黄芩、赤芍)及消导药(焦三仙);胃络瘀血证常用丹参饮或失笑散,配合其他活血药(当归、白芍、莪术、桃仁、川芎、三棱、赤芍、红花、三七)、健脾益气药(黄芪、白术、党参)及理气药(香附、枳壳、佛手、陈皮、木香);胃阴不足证常用一贯煎或沙参麦冬汤,配合理气药(佛手、川楝子、香附、陈皮、枳壳、半夏、砂仁),益气健脾药(白术、太子参、党参、山药)及消导药(山楂、麦芽、鸡内金)。
2 CAG中医证候规律的流行病学调查研究
2.1发病特征
共调查CAG患者239人。伴有其他消化道疾病占21.3%(51人),疾病主要包括胃食管反流病、消化性溃疡、肠易激综合征、胃下垂、胆囊炎;有一定家族聚集倾向;本病病程较长,发病以春季发病最多,春季＞冬季＞秋季＞夏季;本病发病与饮食因素、精神及情绪因素和气候因素较为密切;发病与饮食特殊嗜好关系密切,其中,喜食腌制食品、辛辣饮食和甜食者较为密切;心理精神状况异常者占52.7%(126人):紧张＞焦虑＞抑郁＞急躁易怒＞精神压抑。
2.2证候特征
主要症状中胃脘疼痛占74.9%(179例)、胃脘胀满占79.0%(189例)、胃脘堵闷占66.9%(160例)、烧心占44.8%(107例)、反酸占50.2%(120例)、嗳气占70.3%(168例)、食欲减退占40.6%(97例)、食量减少占27.2%(65例);主要症状积分在各证候类型间分布比较无统计学差异(P＞0.05);上消化道症状与下消化道症状在各证候类型中呈现一定的重叠和规律性,重叠症状中,重叠频次最高的症状依次为胃脘胀满＆腹胀＞胃脘疼痛＆腹胀＞胃脘堵闷＆腹胀＞嗳气＆腹胀等;上消化道症状与下消化道症状重叠最多的证候类型依次为肝气犯胃证＞脾虚气滞证＞湿热中阻证＞湿浊中阻证＞肝胃郁热证＞脾胃虚寒证等;中医诊断病名统计:胃脘痛占48.1%(115例),痞满占43.9%(105例),其他占7.9%(19例),包括吐酸、吞酸、胁痛、嘈杂、反胃;常见证候类型从多到少排列为肝气犯胃证＞脾虚气滞证＞湿热中阻证＞肝胃郁热证＞脾胃虚寒证＞湿浊中阻证等,胃络瘀血证常合并于其他证候类型中。
2.3 HAD量表测量CAG伴随焦虑抑郁心理状态结果
随机选取的正常人群的HAD积分属于阴性,与焦虑抑郁可疑及有反应积分有差异;239例患者中,积分属于可疑及有反应者(大于7分)占56.5%(135例),积分属于阳性者(大于10分)占43.9%(105例);其中,这些患者的HAD积分与性别有关,女性更易于发生焦虑或抑郁(P＜0.05);与学历有关,较高学历的患者更易发生焦虑或抑郁(P＜0.05);HAD积分与工作强度有关,工作强度越大更易发生焦虑或抑郁(P＜0.05);HAD积分与心理及精神状况有关,心理与精神状态异常易发生焦虑或抑郁(P＜0.05);肝气犯胃证和脾虚气滞证较其他证候更易于出现焦虑情绪(P＜0.05);HAD焦虑积分与病理检查结果呈相关性,尤其是异型增生,较其他病理改变更易于出现焦虑情绪(P=0.001＜0.05);在相关因素中,病情与焦虑积分关系最为密切,尤其是病理积分相关程度最高。
3辨证治疗CAG 120例临床观察
3.1临床症状
治疗后主要症状积分、临床症状总积分和其余各主症积分改善均有统计学差异(P＜0.05):治疗前后各辨证组主症积分及总积分自身比较均有统计学差异(P＜0.05),治疗前后各组主要症状和症状总体情况均得到改善。
3.2 PRO积分
治疗前后PRO量表总积分差异有统计学差异(P＜0.05);治疗前后消化不良、反流、全身症状、排便异常、社会功能、心理功能六个维度积分差异均有统计学差异(P＜0.05);对于CAG患者PRO量表总积分作用最大的是全身症状维度,排列顺序为全身症状维度＞反流＞心理功能维度＞消化不良＞排便异常和社会功能维度。
3.3胃镜病理结果
治疗后胃镜主要病变和总积分比较均有统计学差异(P=0.003＜0.05),胃镜主要病变和总积分均得到改善;治疗前后病理积分比较有统计学差异,(P=0.000＜0.05),治疗后病理积分得到改善。
3.4血瘀组和非血瘀组
血瘀组和非血瘀组部分病变积分(病理主要病变积分、病理总积分)比较有统计学差异(P=0.009、0.021＜0.05),血瘀组病理组织学病变较重;血瘀组和非血瘀组在萎缩、肠化、活动性的病理积分比较有统计学差异(P=0.023、0.013、0.036＜0.05),血瘀组肠化、萎缩、活动性积分比非血瘀组高;治疗后血瘀组和非血瘀组的主要症状积分及症状总积分自身前后比较均有统计学差异(P=0.003＜0.05),症状均得到改善;治疗后非血瘀组胃镜下主要病变积分、次要病变积分及胃镜总积分改善无统计学差异(P=0.446＞0.05),而血瘀组治疗后胃镜主要病变积分和胃镜总积分自身比较均有统计学差异(P=0.002＜0.05),血瘀组治疗后胃镜下主要病变和总积分得到改善;治疗后血瘀组和非血瘀组比较,病理主要病变积分及病理总积分变化均有统计学差异(P＜0.05),血瘀组优于非血瘀组。
结论:
1 CAG中医证候特征及辨证用药规律
CAG临床表现以胃脘胀满、疼痛、堵闷、嗳气、纳差、大便异常等消化不良症状为主,伴疲乏、消瘦等全身症状以及紧张、焦虑等异常心理状态。中医诊断以“痞满”、“胃痞”、“胃脘痛”为主。病机特点为虚实夹杂,本虚标实,本虚以气虚、阴虚为主,多于阳虚,标实以气滞、血瘀为主,多于湿热及郁热。本病多发于中老年人,脾虚与CAG关系密切,是造成CAG的病理基础,因虚生邪而致气滞、湿阻、热蕴、血瘀、痰凝等病理变化,其中气滞、血瘀最为重要,二者是疾病发生和转归中的重要坏节。“久病入络”,“久病必有瘀”,本病病程长、迁延反复为血瘀的形成和发展奠定了基础。无论是气滞、湿阻、郁热还是气虚、阴虚,均可通过影响胃络血液运行,同久形成胃络瘀阻之证候。CAG五种常见证型为脾胃虚弱证、脾胃湿热证、肝胃不和证、胃络瘀血证及胃阴不足证。
依据CAG病机理论,脾虚是病理基础,气滞、血瘀是疾病发生和转归中的重要环节,确定健脾、理气、活血为治疗CAG的重要方法,应贯穿于整个治疗过程中。各证型用药有一定规律,多在主方、主药的基础上,综合考虑本证型病机特点、药物间相互作用及胃腑喜润恶燥、喜通降恶郁滞的生理特性,适当佐用其他类药物,或使其兼顾病机更加全面,提高主药治疗效果,或防止主药作用太过,佐制其潜在的副作用,充分体现中医治病从整体出发,重视辨证论治的思想。脾胃虚弱证治疗以香砂六君子汤(脾胃虚寒型用黄芪建中汤)为基本方,配伍理气药、活血药及消导药;脾胃湿热证以二陈汤、藿朴夏苓汤、香砂平胃散为基本方,配合健脾、理气及清热类药;肝胃不和证以四逆散、柴胡疏肝散合金铃子散为基本方,配伍活血药、健脾益气药及清热药;胃络瘀血证以丹参饮或失笑散为主方,配合健脾益气药及理气药;胃阴不足证以一贯煎或沙参麦冬汤为基础,配合理气药、益气健脾药及消导药。
2 CAG证候特征与伴随焦虑抑郁心理状态的相关性
CAG症状多样且不典型,而且症状与病变程度并不一致,因此给诊断和治疗带来一定困难。本研究发现,CAG主要症状与次要症状无明显规律性,而且上消化道症状与下消化道症状在各证候类型中均呈现不同程度的交叉与重叠。这些症状的交叉重叠导致本病易于与消化系统其他疾病混淆,如功能性消化不良、消化性溃疡等。部分患者可以无明确症状,而是通过内镜和病理组织学证实CAG的诊断。因此,鉴别和诊断CAG必须做到谨慎明确,防止误诊。对于诊断明确的CAG进行监测与临床随诊,定期胃镜复查,是筛查胃癌、达到早期诊断、早期发现和早期治疗的基础。重叠最多的证候类型是肝气犯胃证、脾虚气滞证、湿热中阻证、湿浊中阻证、肝胃郁热证等。中焦气滞而导致下焦气机雍塞,气机不畅而腑气不通,不通则痛。出现上腹疼痛、腹胀、大便不畅等症状,与肝脾关系密切。肝脏调节气机,肝气郁滞则气机逆乱,横逆犯胃导致胃气上逆,气郁日久导致血络瘀阻,出现嗳气、胃脘胀满、疼痛等症状;脾脏转输水谷精微,调节水液代谢,若脾脏运化水湿无权,则湿邪困于中焦,或郁久化热,导致湿阻气机,邪犯中焦,而出现胃脘胀满、腹胀、胃脘疼痛、胃脘堵闷、嗳气等一系列消化道症状。在做好鉴别诊断的同时,治疗应结合消化道的生理与病理特点。
被调查的人群中,43.9%的CAG患者出现不同程度的焦虑抑郁的异常心理状态,合并出现焦虑抑郁异常心理状态必须得到足够重视,因为CAG患者在症状基础上出现焦虑抑郁的表现和危险因素,是判断患者不良预后的重要依据,而且焦虑抑郁等异常心理状态不仅可以诱发疾病,同时又是疾病发展的重要因素。本研究发现,焦虑抑郁异常心理状态与中医证候和病理检查结果有明显相关性。肝气犯胃证与脾虚气滞证的焦虑积分相对偏高,HAD量表焦虑抑郁积分与病理检查结果的严重程度呈明显的相关性,尤其是焦虑亚量表与异型增生严重程度呈正相关性,HAD焦虑积分有反应的患者比可疑的患者相关度更高,这些都说明疾病对于患者心理状态的影响,中医理论阐释了情志因素发病与肝脾关系最为密切。
本研究应用的HAD量表是医院筛查焦虑抑郁心理疾病的自评量表,具有简单、便捷和可操作性强的特点,相对于其他精神科医师使用的他评量表和问卷条目较多的自评量表,更符合消化科的临床实际需要,为消化科医师快速鉴别诊断CAG患者是否合并焦虑抑郁心理异常状态提供帮助。
3中医辨证治疗CAG临床疗效研究
本研究在应用PRO量表评价中医药辨证CAG疗效过程中发现,针对CAG症状复杂、缺乏特异性的特点,PRO量表设计的36个条目基本涵盖了CAG临床症状的全部内容,从6个功能维度、不同侧重点全面地体现了CAG的证候要素所在。该量表条目语言精炼且通俗易懂,具有可操作性强的特点,可以为临床和科研工作提供客观依据。
中医辨证治疗CAG各辨证组在临床症状积分、PRO量表的各个维度及总积分、胃镜及病理组织学积分均有所改善,PRO量表的全身症状维度改善最为明显。以上疗效的改善均证明中医在治疗CAG及其癌前病变疗效是肯定的,并且具有中医的特色和优势。血瘀组患者病理组织学病变尤其萎缩、肠化、活动性较非血瘀组重,而非血瘀组临床症状相对复杂。中医药辨证治疗后,血瘀组的胃镜下黏膜病变及病理组织学积分的疗效优于非血瘀组,尤其在改善病理组织学主要病变如萎缩、肠化等指标时具有明显改善,这一结果说明活血化瘀药治疗CAG的疗效优势和特点。说明活血化瘀对于改善萎缩,防止病变进展具有重要作用。
导师唐旭东教授师特别强调治疗CAG重视调理气血,以理气通降、活血化瘀通络为根本原则,在运用中医理论辨证治疗的同时,注重对于部分焦虑抑郁患者的心理疏导和生活调摄的指导,给予CAG患者更为全面的治疗,以达到提高疗效的目的。
Chronic atrophic gastritis(CAG) as a commonest gastrointestinal disease,has higher prevalence and a certain tendency to canceration.To date,general-accepted effective therapy remains absent.Characteristics and advantages of Chinese medicine treatment in this disease have gradually been recognized.But there are still some problems in syndrome principle distinguishing,characteristics of TCM treatment summarization,especially diagnosis and treatment of patients associated with anxiety and depression,as well as evaluation in the therapeutic effect of differentiation;these problems not only affect the play of advantages and characteristics,but also impedes the development of clinical research.
Aim Summing up the characteristics of TCM syndrome principle and diagnosis and prescription of CAG;Summing up the epidemiological characteristics of the CAG,to explore the correlation between TCM syndromes characteristics and abnormal psychological state of anxiety and depression,and providing reference for clinical and scientific research;Making objective analysis on clinical efficacy of TCM treatment of CAG,and to explore the feature of promoting blood circulation therapy in CAG treatment.
Method Through collection and quantitative analysis on literature about TCM treatment of CAG,explore the TCM syndromes characteristics and diagnosis and prescription regulations of CAG;Through CAG cross-sectional epidemiological study, select 239 cases with CAG in Beijing for investigation,and describe the risk factors, clinical symptoms,TCM Syndrome,endoscope,pathological diagnosis,with clinical manifestations of psychological disease and Hospital Anxiety and Depression Scale(HAD) measurement results and statistics,of the CAG and the laws of TCM Syndrome Scale HAD anxiety and depression evaluation factors and the relevance of traditional Chinese medicine syndromes of scientific summary;Through clinical observation of CAG 120 including clinical symptoms,performance of endoscopic lesions,histopathology,based on the perspective of Patient reported outcome(PRO),conduct objective evaluation on the efficacy of TCM treatment of CAG and explore the advantages and characteristics of promoting blood circulation therapy in CAG treatment.
Result
1 Chinese medical literature analysis about CAG
A total of 149 relevant literatures were brought into.Syndrome type described is 30 in total of which there are five most common:weakness of the spleen and stomach＞damp-heat obstructing in spleen and stomach＞incoordination between the liver and stomach＞blood stasis in gastric venation＞insufficiency of stomach yin.Deficient and excessive syndromes appearing together is the pathogenesis of CAG,and the deficiency mainly refers to Qi-deficiency and Yin- deficiency,more than yang deficiency,while excess to Qi stagnation,blood stasis,more than damp-heat and heat accumulation.Herbs used under differentiation and treatment mainly include:replenishing qi to invigorate the spleen,soothing the liver,eliminating dampness,clearing heat,nourishing yin,promoting blood,and digesting,Commonly used and more than 10%utilization rate herbs followed by white peony root,Atractylodes macrocephala,Banxia,Tangerine peel,Tuckahoe,Salvia, Astragalus,Cyperus,etc.It reflects the common therapeutic methods in CAG are invigorating the spleen,regulating qi,nourishing yin and promoting blood.Commonly used prescription for weakness of the spleen and stomach syndrome is Xiangsha Liujunzi soup(spleen-stomach deficiency-cold withHuangqi Jian Zhong soup),accompanied by regulating qi herbs(Citrus aurtantium Cyperus,Bergamot),promoting blood circulation herbs(zedoary,Salvia,Angelica,Rhizome corydalis,Panax notoginseng),digestive herbs(Ji Nei Jin);warming the internal(Wu Zhu YU,ginger,Alpinia officinarum Hance); Common used prescriptions for damp-heat obstructing in spleen and stomach syndrome are Er Chen soup,Huo Pu Xia Ling soup,and Xiang Shang Ping Wei San,accompanied by Atractylodes,Lanceolata for regulating qi and invigorating spleen,Su Geng,Zhi Qiao, Bergamot and Bupleurum for soothing the liver,Coptis Chinensis,Dandelion, Capejasmine for killing Helicobacter pylori,Salvia for promoting the blood,Malt for digesting;Commonly used prescriptions for incoordination between the liver and stomach syndrome are Si Ni San,Chai Hu Shu Gan San and Jin Ling Zi San,accompanied by promoting blood circulation herbs(Rhizoma Ligustici Chuanxiong,Salvia,Angelica, Curcuma,Zedoary),,invigorating spleen qi herbs(Atractylodes,Poria),and antipyretics herbs(Capejasmine,Scutellaria,Red Peony Root)and digestive herbs(Jiao San Xian); Commonly used prescriptions for Gastric collateral stasis syndrome are Shi Xiao San or Dan Shen Yin,accompanied by other promoting blood herbs(Angelica,White peony root, Zedoary,Peach kernel,Rhizoma Ligustici Chuanxiong,San Leng,Red Peony Root,Panax notoginseng),invigorating spleen qi herbs(Astragalus,Atractylodes,Lanceolata) and regulating qi herbs(Bergamot,Citrus aurtantium,Bergamot,Tangerine Peel,Aristolochia debilis);Common used prescriptions for insufficiency of stomach yin syndrome are Yi Guan Jian or Sha Shen Mai Dong Soup,accompanied by regulating qi herbs(Bergamot, Chuan lian Zi,Bergamot,Tangerine Peel,Citrus aurtantium,Pinellia ternate,Villous amomum),invigorating spleen qi herbs(Atractylodes,Lanceolata,Radix pseudostell, Chinese yam) and digestive herbs(Hawthorn,Malt,Ji Nei Jin).
2 Chronic atrophic gastritis of epidemiological research of TCM syndrome principle
2.1 Onset Characteristics
A total of 239 patients with CAG was surveyed.51 cases with the history of digestive tract diseases(21.3%),mainly including gastroesophageal reflux disease,peptic ulcer, irritable bowel syndrome,gastroptosis,cholecystitis;and have a certain family history; CAG has a long course,incidence of morbidity in the spring＞winter＞autumn＞summer. The disease is closely related with predisposing factors,especially with dietary factors, mental and emotional factors and Climate Change;CAG.onset has close relation with special dietary habits of patients,especially with more salt food,spicy food,sweet;126 patients with abnormal psychological state(52.7%):tensive＞anxiety＞depression＞irritable＞suppression.
2.2 Syndrome character
Main symptoms:stomachaches accounts for 74.9%(179cases),stomachache distension 79.0%(189cases),stomached stuffy 66.9%(160cases),heartburn 44.8%(107cases),acid regurgitation 50.2%(120cases),belching 70.3%(168cases),anorexia 40.6%(97 cases),decreased appetite 27.2%(65cases);Main symptom score showed no significant difference(p＞0.05)among all syndromes types;The upper and lower symptoms showed a certain overlap regularity in various types of syndromes.In overlap symptoms,the highest frequency symptom in turn is as followings:gastric distention and abdominal distention＞stomachache and abdominal distention＞blocked stomach and abdominal distention＞belching and abdominal distention and so on;The most overlap syndromes in turn is;syndrome of hepatic qi attacking stomach＞syndrome of spleen-deficiency and Qi-stagnation＞syndrome of damp-heat obstructing in zhong jiqo＞syndrome of damp turbidity obstructing in zhong jiqo＞syndrome of stagnated heat of liver and stomach＞syndrome of spleen-stomach deficiency-cold etc;The diagnosis contain:stomach-ache accounts for 48.1%(115 case),stuffiness and fullness43.9%(105 cases),others7.9%(19 cases) including casting up of gastric acid,swallow acid,hypochondriac pain,regurgitation. The common syndromes in turn are as follows:syndrome of hepatic qi attacking stomach＞syndrome of spleen-deficiency and Qi-stagnation＞syndrome of damp-heat obstructing in zhong jiqo＞syndrome of stagnated heat of liver and stomach＞syndrome of spleen-stomach deficiency-cold＞syndrome of damp turbidity obstructing in zhong jiqo etc. The syndrome of stagnated blood of stomach meridian often combined the other syndromes.
2.3 Results of CAG accompanied with anxiety and depression state with HAD Scale
The HAD scores of normal population selected randomly were negative,which were different from the positive and the suspicious people.The negative scores were 104 cases (43.5%) in 239 cases,while the positive and suspicious were 135 cases(56.5%).The score was related to gender and the female are prone to anxiety or depression(P＜0.05).It was related to the educational background and the higher are prone to anxiety or depression (P＜0.05).It was also concerned with the psychological and mental state.Abnormal psychological state were prone to be anxious and depressive(P＜0.05).The anxiety scores of HAD were positive related with pathohistology examination,dysplasia was prone to be anxious especially(P=0.001＜0.05).Among all related factors,the disease state is the most related to the anxiety scores;the level of pathological points is the most close factor.
3 Clinical observations of Syndrome Differentiation and Treatment for120 cases of CAG
3.1 Clinical symptoms
After the treatment,the cardinal symptoms score,the clinical symptoms total score and other each host sickness score improvement has statistics difference(P＜0.05).Cardinal symptoms score and total score of each dialectical group between pre and post treatment all has statistics difference(P＜0.05).Cardinal symptoms in each group all have improvements.
3.2 PRO Score
Total score of PRO Scale between pre and post treatment has statistics difference (P＜0.05).The dyspepsia,the regurgitation,the general symptom,the abnormal defecation, the social function,the psychological function six dimension score difference between pre and post treatment has statistics difference(P＜0.05).In PRO Scale total score,the general symptom dimensions have the greatest effect on CAG patients,the order are:the general symptom＞the regurgitation＞the psychological function＞the dyspepsia＞abnormal defecation and the social function dimensions.
3.3 Gastroscopy and pathological findings
After the treatment,the main gastroscope pathological change and gastroscope total score all have statistics difference(P=0.003＜0.05).The main gastroscope pathological change and gastroscope total score all improved.After the treatment,each dialectical group pathology score difference has statistics difference(P=0.000＜0.05),the pathology score all improved.
3.4 Blood stasis group and the Non-blood stasis group
The blood stasis group and the non-blood stasis group partial pathological change score(Pathology main pathological change score,pathology total score) difference has statistics difference(P=0.009,0.021＜0.05),the blood stasis group histo-pathology pathological change is more serious.In the atrophy,intestines,and the activity score,the blood stasis group and the non-blood stasis group has statistics difference(P=0.023、0.013、0.036＜0.05),the blood stasis group intestines,atrophy,and activity score are higher than the non-blood stasis group.After treatment,the blood stasis group and the non-blood stasis group's cardinal symptoms score and the symptom total score have statistics difference (P=0.003＜0.05),symptoms all have been improved.After treatment,improvement of the non-blood stasis group the gastroscopic main pathological change score,the secondary pathological change score and the gastroscopic total score all have non-statistics difference(P=0.446＞0.05),while the blood stasis group gastroscopic main pathological change score and gastroscopic total score have statistics difference(P=0.002＜0.05).After treatment,change of the pathology main pathological score and pathology total score between blood stasis group and non-blood stasis group has statistics difference(P＜0.05), and the blood stasis group is prior to the non-blood stasis group.
Conclusion
1 Characteristics of TCM Syndrome and Regulations of Differentiation and medicine usage in CAG
Clinical manifestations of CAG mainly are indigestive symptoms,such as gasteremphraxis,stomachache,nausea,belching,inappetence,stool abnormity, accompanied by other symptoms such as fatigue,weight loss,and psychological symptoms including tension,anxiety,depression,etc.The diagnosis mainly is stomach-ache accounts, stuffiness and fullness.Defcient and excessive syndromes appearing together is the pathogenesis of CAG,and the deficiency mainly refers to Qi-deficiency and Yin-deficiency, while excess to Qi stagnation,blood stasis,more than damp-heat and heat accumulation.The disease is prone in the wrinkly,whose kidney essence were thought to be deficient increasingly and organs' function also decreased according TCM theory. Modern medicine also believes that the antiviral ability of gastric mucosal and gastric motility become reduced,emptying of food delayed,and glands become atrophied in the wrinkly,Based on the above understanding,we can conclude that spleen deficiency is closely related with the CAG,it is the pathological basis of CAG.The deficiency leads to stagnation of QI,damp obstruction,heat obstruction,blood stasis and phlegm stasis,among that pathogenesis,stagnation of QI and blood stasis are most important.According the theory of"Prolonged illness enters into venation" and" Prolonged illness surely has blood stasis",the long course of the disease will lead the blood stasis.Five common patterns of syndrome are:weakness of the spleen and stomach,damp-heat obstructing in spleen and stomach,incoordination between the liver and stomach,blood stasis in gastric venation, and insufficiency of stomach yin.
According to the pathogenesis of CAG,spleen deficiency is the pathological basis,Qi stagnation,blood stasis is important parts in the disease development,so determine the important methods of invigorating spleen,regulating qi,promoting blood circulation for the treatment of CAG should be throughout the course of treatment.The evidence-based medicine have a certain regularity,on the basis of main decoction and main drugs,have a comprehensive consideration of the characteristics of pathogenesis,and the interaction between drugs,and the physiological characteristic of stomach,appropriate use of other drugs,in order to increase the effectiveness of treatment while reduce its potential side effects,fully embodies the feature of traditional Chinese medicine.Basic prescription for weakness of the spleen and stomach syndrome is Xiangsha Liujunzi soup(spleen-stomach deficiency-cold with Huangqi Jian Zhong soup),accompanied by regulating qi herbs,promoting blood circulation herbs and digestive herbs;Basic prescriptions for damp-heat obstructing in spleen and stomach syndrome are Er Chen soup,Huo Pu Xia Ling soup,and Xiang Shang Ping Wei San,accompanied by regulating qi herbs, invigorating spleen herbs,and antipyretics herbs;Basic prescriptions for incoordination between the liver and stomach syndrome are Si Ni San,Chai Hu Shu Gan San and Jin Ling Zi San,accompanied by promoting blood circulation herbs,invigorating spleen qi herbs, and antipyretics herbs;Basic prescriptions for incoordination between the liver and stomach syndrome are Shi Xiao San or Dan Shen Yin,accompanied by invigorating spleen qi herbs and regulating qi herbs;Basic prescriptions for insufficiency of stomach yin syndrome are Yi Guan Jian or Sha Shen Mai Dong Soup,accompanied by invigorating spleen qi herbs,regulating qi herbs and digestive herbs.
2.Relativity of CAG syndrome characteristics and the psychological state of anxiety and depression
Symptoms of CAG are various and often not typical,and extent of disease and symptoms are not consistent,so the diagnosis and treatment has a certain difficulties.The study found that there is no obvious regularity in CAG main symptoms and secondary symptoms,and upper gastrointestinal symptoms and lower gastrointestinal symptoms show some Overlapping and regularity in all types of the symptoms.These overlapping symptoms make it confuse with other digestive system diseases easily,such as functional dyspepsia,peptic ulcer,etc.Some patients maybe have no clear symptoms;we can diagnose CAG by endoscopy and histopathology.Therefore,the identification and diagnosis of CAG must be cautious and clear,to prevent misdiagnosis.For a clear diagnosed CAG,conduct clinical follow-up monitoring,periodic endoscopy review,gastric cancer screening is the basis of early diagnosis,early detection and early treatment. Overlapping symptoms often occur in hepatic qi attacking stomach syndrome, spleen-deficiency and Qi-stagnation syndrome,damp-heat obstructing in zhong jiqo syndrome,and syndrome of damp turbidity obstructing in zhong jiqo,syndrome of stagnated heat of liver and stomach etc.Qi-stagnation in zhong jiqo will lead to pain. Symptoms as upper abdominal pain,abdominal distension,and stool abnormity have close relation with spleen and liver.Hepatic qi attacking stomach result into belching, inappetence,stomach distension and stomachache etc.Upper digestive tract and the lower digestive tract together form the main channel of the digestive system which is for the digest transform water food,transporting and transforming nutrients from foodstuff of spleen and stomach in physiology,while interact in the pathology.Stagnation of dampness due to splenic deficiency can result in stomach distension,abdominal distension and stomachache,stomach blocking,nausea,belching and other gastrointestinal symptoms.At the same time doing a good job in the differential diagnosis,treatment should be combined with the physiological and pathological characteristics of the digestive tract.
Among surveyed population,43.9%of chronic atrophic gastritis patients had varying degrees of anxiety,depression in performance,CAG accompanied by mental illness should be given enough attention,because the CAG patients with performance and risk factors of mental illness on the basis of premonitory symptoms is an important basis for the adverse prognosis of patients,and such anxiety and depression state can not only induce disease, but also an important factor in the development of the disease.The study found that poor emotional state,TCM syndromes showed relevance with gastroscopy and pathological examination.Hospital Anxiety and Depression(HAD) scale points have some type of relevance with the syndrome,the anxiety card points of hepatic qi attacking stomach, spleen-deficiency and Qi-stagnation syndrome were more obvious than the other types of syndromes.HAD scale points and the seriousness of pathological examination results showed relevance,in particular the anxiety sub-scale and severity of dysplasia was a positive correlation,and patients who responded to HAD points had higher relevance than the suspicious patients。This shows that the influence of disease to psychological state of patients,and traditional Chinese medicine theory explain the incidence of emotional factors is most closely related with the liver and spleen.
In this study,the HAD Scale is the self-rating scale for Anxiety and Depression mental illness Screening in Hospital.It is simple,convenient and easy to operate, Compared to other questionnaire rating scale and self-rating scale used by psychiatrists, HAD Scale is more in line with the actual needs of digestive department physicians for rapid differential diagnosis whether CAG patients combined with abnormal mental state., such as anxiety and depression.
3.The clinical efficacy research in traditional Chinese medicine treatment of CAG
In evaluation of CAG effect applicated with traditional Chinese medicine differentiation with PRO scale,we found that PRO scale designed 36 entries covering all the details of the clinical symptoms from six functional dimensions,different emphasis for complicated CAG symptoms lack of specificity.For its stong maneuverability,this Scale can provide objective basis for clinical and scientific research.
TCM treatment of CAG in the clinical symptom score,the various dimensions of scale and total score of patients clinical report outcome(PRO),endoscopic mucosal lesion, histopathology all improved in varying degrees.;Those above have proved the efficacy of Chinese medicine in the treatment of CAG and precancerous lesions is positive,and Chinese medicine has characteristics and advantages.Histopathological score of blood stasis group improved better than non-blood stasis group,especially in histopathological lesions,such as atrophy,intestinal metaplasia,while the non-blood stasis group is relatively complicated.The result indicates that promoting blood circulation to remove blood stasis played an important role in improving atrophy and preventing the disease progress.
My tutor -Professor Tang Xudong emphasizes that regulating qi and promoting blood circulation to remove blood stasis are the fundamental principle in the treatment of CAG. In the use of Chinese medicine treatment,we should pay attention to patients with anxiety and depression,and apply psychological guidance and life recuperation at the same time, give a more comprehensive treatment in order to achieve the purpose of enhance the effectiveness of treatment.
目的:总结CAG中医证候特征及辨证用药规律,为临床辨证论治和科研提供参考;总结CAG流行病学发病特点,探讨CAG的中医证候特点与焦虑抑郁异常心理状态之间的相关性,为临床、科研提供参考依据;对中医辨证治疗CAG临床疗效进行客观分析,并探索活血化瘀治疗CAG的疗效特点。
方法:通过对中医辨证治疗CAG文献的收集整理和计量分析,探讨CAG的中医证候特征及辨证用药规律;通过CAG的流行病学横断面调查研究,选取北京地区的239例CAG患者进行调查,描述CAG的危险因素、临床症状、中医证候、胃镜、病理诊断结果、伴随焦虑抑郁状态的临床表现和医院焦虑抑郁量表(Hospital Anxiety andDepression Scale,HAD)的测量结果并进行统计,对CAG的中医证候特征与伴随焦虑抑郁异常心理状态的相关性进行探讨;通过辨证治疗CAG 120例临床观察,从临床症状、胃镜下病变表现、病理组织学、基于患者报告临床结局量表(Patient ReportedOutcome,PRO)的角度客观评价中医辨证治疗CAG的疗效,并探索活血化瘀治疗CAG的疗效优势和特点。
结果:
1CAG中医药研究文献分析
共纳入相关文献149篇。证候分型描述共计30余种,其中有五种最为常见:脾胃虚弱证＞脾胃湿热证＞肝胃不和证＞胃络瘀血证＞胃阴不足证。本病病机特点为虚实夹杂,本虚标实,本虚以气虚、阴虚为主,多于阳虚;标实以气滞为主,其次为血瘀,多于湿热及郁热。辨证治疗使用药物主要包括益气健脾、疏肝理气、化湿、清热、养阴、活血及消导7类,常用并且使用率在10%以上的药物依次为白芍、白术、半夏、陈皮、茯苓、丹参、黄芪、香附等,体现了CAG的常用治法为健脾、理气、活血、养阴。脾胃虚弱证常用香砂六君子汤(脾胃虚寒型用黄芪建中汤)加减,随病情需要可适当配合理气药(枳壳、香附、佛手)、活血药(莪术、丹参、当归、元胡、三七)、消导药(鸡内金)和温里药(吴茱萸、生姜、高良姜);脾胃湿热证常用二陈汤、藿朴夏苓汤、香砂平胃散为基本方进行加减,配合白术、党参健脾,苏梗、枳壳、香附、柴胡疏肝理气,黄连、蒲公英、山栀清热,丹参活血,麦芽消食导滞;肝胃不和证常用四逆散、柴胡疏肝散合金铃子散为基本方,配伍活血药(川芎、丹参、当归、郁金、莪术)、健脾益气药(白术、茯苓)、清热药(山栀、黄芩、赤芍)及消导药(焦三仙);胃络瘀血证常用丹参饮或失笑散,配合其他活血药(当归、白芍、莪术、桃仁、川芎、三棱、赤芍、红花、三七)、健脾益气药(黄芪、白术、党参)及理气药(香附、枳壳、佛手、陈皮、木香);胃阴不足证常用一贯煎或沙参麦冬汤,配合理气药(佛手、川楝子、香附、陈皮、枳壳、半夏、砂仁),益气健脾药(白术、太子参、党参、山药)及消导药(山楂、麦芽、鸡内金)。
2 CAG中医证候规律的流行病学调查研究
2.1发病特征
共调查CAG患者239人。伴有其他消化道疾病占21.3%(51人),疾病主要包括胃食管反流病、消化性溃疡、肠易激综合征、胃下垂、胆囊炎;有一定家族聚集倾向;本病病程较长,发病以春季发病最多,春季＞冬季＞秋季＞夏季;本病发病与饮食因素、精神及情绪因素和气候因素较为密切;发病与饮食特殊嗜好关系密切,其中,喜食腌制食品、辛辣饮食和甜食者较为密切;心理精神状况异常者占52.7%(126人):紧张＞焦虑＞抑郁＞急躁易怒＞精神压抑。
2.2证候特征
主要症状中胃脘疼痛占74.9%(179例)、胃脘胀满占79.0%(189例)、胃脘堵闷占66.9%(160例)、烧心占44.8%(107例)、反酸占50.2%(120例)、嗳气占70.3%(168例)、食欲减退占40.6%(97例)、食量减少占27.2%(65例);主要症状积分在各证候类型间分布比较无统计学差异(P＞0.05);上消化道症状与下消化道症状在各证候类型中呈现一定的重叠和规律性,重叠症状中,重叠频次最高的症状依次为胃脘胀满＆腹胀＞胃脘疼痛＆腹胀＞胃脘堵闷＆腹胀＞嗳气＆腹胀等;上消化道症状与下消化道症状重叠最多的证候类型依次为肝气犯胃证＞脾虚气滞证＞湿热中阻证＞湿浊中阻证＞肝胃郁热证＞脾胃虚寒证等;中医诊断病名统计:胃脘痛占48.1%(115例),痞满占43.9%(105例),其他占7.9%(19例),包括吐酸、吞酸、胁痛、嘈杂、反胃;常见证候类型从多到少排列为肝气犯胃证＞脾虚气滞证＞湿热中阻证＞肝胃郁热证＞脾胃虚寒证＞湿浊中阻证等,胃络瘀血证常合并于其他证候类型中。
2.3 HAD量表测量CAG伴随焦虑抑郁心理状态结果
随机选取的正常人群的HAD积分属于阴性,与焦虑抑郁可疑及有反应积分有差异;239例患者中,积分属于可疑及有反应者(大于7分)占56.5%(135例),积分属于阳性者(大于10分)占43.9%(105例);其中,这些患者的HAD积分与性别有关,女性更易于发生焦虑或抑郁(P＜0.05);与学历有关,较高学历的患者更易发生焦虑或抑郁(P＜0.05);HAD积分与工作强度有关,工作强度越大更易发生焦虑或抑郁(P＜0.05);HAD积分与心理及精神状况有关,心理与精神状态异常易发生焦虑或抑郁(P＜0.05);肝气犯胃证和脾虚气滞证较其他证候更易于出现焦虑情绪(P＜0.05);HAD焦虑积分与病理检查结果呈相关性,尤其是异型增生,较其他病理改变更易于出现焦虑情绪(P=0.001＜0.05);在相关因素中,病情与焦虑积分关系最为密切,尤其是病理积分相关程度最高。
3辨证治疗CAG 120例临床观察
3.1临床症状
治疗后主要症状积分、临床症状总积分和其余各主症积分改善均有统计学差异(P＜0.05):治疗前后各辨证组主症积分及总积分自身比较均有统计学差异(P＜0.05),治疗前后各组主要症状和症状总体情况均得到改善。
3.2 PRO积分
治疗前后PRO量表总积分差异有统计学差异(P＜0.05);治疗前后消化不良、反流、全身症状、排便异常、社会功能、心理功能六个维度积分差异均有统计学差异(P＜0.05);对于CAG患者PRO量表总积分作用最大的是全身症状维度,排列顺序为全身症状维度＞反流＞心理功能维度＞消化不良＞排便异常和社会功能维度。
3.3胃镜病理结果
治疗后胃镜主要病变和总积分比较均有统计学差异(P=0.003＜0.05),胃镜主要病变和总积分均得到改善;治疗前后病理积分比较有统计学差异,(P=0.000＜0.05),治疗后病理积分得到改善。
3.4血瘀组和非血瘀组
血瘀组和非血瘀组部分病变积分(病理主要病变积分、病理总积分)比较有统计学差异(P=0.009、0.021＜0.05),血瘀组病理组织学病变较重;血瘀组和非血瘀组在萎缩、肠化、活动性的病理积分比较有统计学差异(P=0.023、0.013、0.036＜0.05),血瘀组肠化、萎缩、活动性积分比非血瘀组高;治疗后血瘀组和非血瘀组的主要症状积分及症状总积分自身前后比较均有统计学差异(P=0.003＜0.05),症状均得到改善;治疗后非血瘀组胃镜下主要病变积分、次要病变积分及胃镜总积分改善无统计学差异(P=0.446＞0.05),而血瘀组治疗后胃镜主要病变积分和胃镜总积分自身比较均有统计学差异(P=0.002＜0.05),血瘀组治疗后胃镜下主要病变和总积分得到改善;治疗后血瘀组和非血瘀组比较,病理主要病变积分及病理总积分变化均有统计学差异(P＜0.05),血瘀组优于非血瘀组。
结论:
1 CAG中医证候特征及辨证用药规律
CAG临床表现以胃脘胀满、疼痛、堵闷、嗳气、纳差、大便异常等消化不良症状为主,伴疲乏、消瘦等全身症状以及紧张、焦虑等异常心理状态。中医诊断以“痞满”、“胃痞”、“胃脘痛”为主。病机特点为虚实夹杂,本虚标实,本虚以气虚、阴虚为主,多于阳虚,标实以气滞、血瘀为主,多于湿热及郁热。本病多发于中老年人,脾虚与CAG关系密切,是造成CAG的病理基础,因虚生邪而致气滞、湿阻、热蕴、血瘀、痰凝等病理变化,其中气滞、血瘀最为重要,二者是疾病发生和转归中的重要坏节。“久病入络”,“久病必有瘀”,本病病程长、迁延反复为血瘀的形成和发展奠定了基础。无论是气滞、湿阻、郁热还是气虚、阴虚,均可通过影响胃络血液运行,同久形成胃络瘀阻之证候。CAG五种常见证型为脾胃虚弱证、脾胃湿热证、肝胃不和证、胃络瘀血证及胃阴不足证。
依据CAG病机理论,脾虚是病理基础,气滞、血瘀是疾病发生和转归中的重要环节,确定健脾、理气、活血为治疗CAG的重要方法,应贯穿于整个治疗过程中。各证型用药有一定规律,多在主方、主药的基础上,综合考虑本证型病机特点、药物间相互作用及胃腑喜润恶燥、喜通降恶郁滞的生理特性,适当佐用其他类药物,或使其兼顾病机更加全面,提高主药治疗效果,或防止主药作用太过,佐制其潜在的副作用,充分体现中医治病从整体出发,重视辨证论治的思想。脾胃虚弱证治疗以香砂六君子汤(脾胃虚寒型用黄芪建中汤)为基本方,配伍理气药、活血药及消导药;脾胃湿热证以二陈汤、藿朴夏苓汤、香砂平胃散为基本方,配合健脾、理气及清热类药;肝胃不和证以四逆散、柴胡疏肝散合金铃子散为基本方,配伍活血药、健脾益气药及清热药;胃络瘀血证以丹参饮或失笑散为主方,配合健脾益气药及理气药;胃阴不足证以一贯煎或沙参麦冬汤为基础,配合理气药、益气健脾药及消导药。
2 CAG证候特征与伴随焦虑抑郁心理状态的相关性
CAG症状多样且不典型,而且症状与病变程度并不一致,因此给诊断和治疗带来一定困难。本研究发现,CAG主要症状与次要症状无明显规律性,而且上消化道症状与下消化道症状在各证候类型中均呈现不同程度的交叉与重叠。这些症状的交叉重叠导致本病易于与消化系统其他疾病混淆,如功能性消化不良、消化性溃疡等。部分患者可以无明确症状,而是通过内镜和病理组织学证实CAG的诊断。因此,鉴别和诊断CAG必须做到谨慎明确,防止误诊。对于诊断明确的CAG进行监测与临床随诊,定期胃镜复查,是筛查胃癌、达到早期诊断、早期发现和早期治疗的基础。重叠最多的证候类型是肝气犯胃证、脾虚气滞证、湿热中阻证、湿浊中阻证、肝胃郁热证等。中焦气滞而导致下焦气机雍塞,气机不畅而腑气不通,不通则痛。出现上腹疼痛、腹胀、大便不畅等症状,与肝脾关系密切。肝脏调节气机,肝气郁滞则气机逆乱,横逆犯胃导致胃气上逆,气郁日久导致血络瘀阻,出现嗳气、胃脘胀满、疼痛等症状;脾脏转输水谷精微,调节水液代谢,若脾脏运化水湿无权,则湿邪困于中焦,或郁久化热,导致湿阻气机,邪犯中焦,而出现胃脘胀满、腹胀、胃脘疼痛、胃脘堵闷、嗳气等一系列消化道症状。在做好鉴别诊断的同时,治疗应结合消化道的生理与病理特点。
被调查的人群中,43.9%的CAG患者出现不同程度的焦虑抑郁的异常心理状态,合并出现焦虑抑郁异常心理状态必须得到足够重视,因为CAG患者在症状基础上出现焦虑抑郁的表现和危险因素,是判断患者不良预后的重要依据,而且焦虑抑郁等异常心理状态不仅可以诱发疾病,同时又是疾病发展的重要因素。本研究发现,焦虑抑郁异常心理状态与中医证候和病理检查结果有明显相关性。肝气犯胃证与脾虚气滞证的焦虑积分相对偏高,HAD量表焦虑抑郁积分与病理检查结果的严重程度呈明显的相关性,尤其是焦虑亚量表与异型增生严重程度呈正相关性,HAD焦虑积分有反应的患者比可疑的患者相关度更高,这些都说明疾病对于患者心理状态的影响,中医理论阐释了情志因素发病与肝脾关系最为密切。
本研究应用的HAD量表是医院筛查焦虑抑郁心理疾病的自评量表,具有简单、便捷和可操作性强的特点,相对于其他精神科医师使用的他评量表和问卷条目较多的自评量表,更符合消化科的临床实际需要,为消化科医师快速鉴别诊断CAG患者是否合并焦虑抑郁心理异常状态提供帮助。
3中医辨证治疗CAG临床疗效研究
本研究在应用PRO量表评价中医药辨证CAG疗效过程中发现,针对CAG症状复杂、缺乏特异性的特点,PRO量表设计的36个条目基本涵盖了CAG临床症状的全部内容,从6个功能维度、不同侧重点全面地体现了CAG的证候要素所在。该量表条目语言精炼且通俗易懂,具有可操作性强的特点,可以为临床和科研工作提供客观依据。
中医辨证治疗CAG各辨证组在临床症状积分、PRO量表的各个维度及总积分、胃镜及病理组织学积分均有所改善,PRO量表的全身症状维度改善最为明显。以上疗效的改善均证明中医在治疗CAG及其癌前病变疗效是肯定的,并且具有中医的特色和优势。血瘀组患者病理组织学病变尤其萎缩、肠化、活动性较非血瘀组重,而非血瘀组临床症状相对复杂。中医药辨证治疗后,血瘀组的胃镜下黏膜病变及病理组织学积分的疗效优于非血瘀组,尤其在改善病理组织学主要病变如萎缩、肠化等指标时具有明显改善,这一结果说明活血化瘀药治疗CAG的疗效优势和特点。说明活血化瘀对于改善萎缩,防止病变进展具有重要作用。
导师唐旭东教授师特别强调治疗CAG重视调理气血,以理气通降、活血化瘀通络为根本原则,在运用中医理论辨证治疗的同时,注重对于部分焦虑抑郁患者的心理疏导和生活调摄的指导,给予CAG患者更为全面的治疗,以达到提高疗效的目的。
Chronic atrophic gastritis(CAG) as a commonest gastrointestinal disease,has higher prevalence and a certain tendency to canceration.To date,general-accepted effective therapy remains absent.Characteristics and advantages of Chinese medicine treatment in this disease have gradually been recognized.But there are still some problems in syndrome principle distinguishing,characteristics of TCM treatment summarization,especially diagnosis and treatment of patients associated with anxiety and depression,as well as evaluation in the therapeutic effect of differentiation;these problems not only affect the play of advantages and characteristics,but also impedes the development of clinical research.
Aim Summing up the characteristics of TCM syndrome principle and diagnosis and prescription of CAG;Summing up the epidemiological characteristics of the CAG,to explore the correlation between TCM syndromes characteristics and abnormal psychological state of anxiety and depression,and providing reference for clinical and scientific research;Making objective analysis on clinical efficacy of TCM treatment of CAG,and to explore the feature of promoting blood circulation therapy in CAG treatment.
Method Through collection and quantitative analysis on literature about TCM treatment of CAG,explore the TCM syndromes characteristics and diagnosis and prescription regulations of CAG;Through CAG cross-sectional epidemiological study, select 239 cases with CAG in Beijing for investigation,and describe the risk factors, clinical symptoms,TCM Syndrome,endoscope,pathological diagnosis,with clinical manifestations of psychological disease and Hospital Anxiety and Depression Scale(HAD) measurement results and statistics,of the CAG and the laws of TCM Syndrome Scale HAD anxiety and depression evaluation factors and the relevance of traditional Chinese medicine syndromes of scientific summary;Through clinical observation of CAG 120 including clinical symptoms,performance of endoscopic lesions,histopathology,based on the perspective of Patient reported outcome(PRO),conduct objective evaluation on the efficacy of TCM treatment of CAG and explore the advantages and characteristics of promoting blood circulation therapy in CAG treatment.
Result
1 Chinese medical literature analysis about CAG
A total of 149 relevant literatures were brought into.Syndrome type described is 30 in total of which there are five most common:weakness of the spleen and stomach＞damp-heat obstructing in spleen and stomach＞incoordination between the liver and stomach＞blood stasis in gastric venation＞insufficiency of stomach yin.Deficient and excessive syndromes appearing together is the pathogenesis of CAG,and the deficiency mainly refers to Qi-deficiency and Yin- deficiency,more than yang deficiency,while excess to Qi stagnation,blood stasis,more than damp-heat and heat accumulation.Herbs used under differentiation and treatment mainly include:replenishing qi to invigorate the spleen,soothing the liver,eliminating dampness,clearing heat,nourishing yin,promoting blood,and digesting,Commonly used and more than 10%utilization rate herbs followed by white peony root,Atractylodes macrocephala,Banxia,Tangerine peel,Tuckahoe,Salvia, Astragalus,Cyperus,etc.It reflects the common therapeutic methods in CAG are invigorating the spleen,regulating qi,nourishing yin and promoting blood.Commonly used prescription for weakness of the spleen and stomach syndrome is Xiangsha Liujunzi soup(spleen-stomach deficiency-cold withHuangqi Jian Zhong soup),accompanied by regulating qi herbs(Citrus aurtantium Cyperus,Bergamot),promoting blood circulation herbs(zedoary,Salvia,Angelica,Rhizome corydalis,Panax notoginseng),digestive herbs(Ji Nei Jin);warming the internal(Wu Zhu YU,ginger,Alpinia officinarum Hance); Common used prescriptions for damp-heat obstructing in spleen and stomach syndrome are Er Chen soup,Huo Pu Xia Ling soup,and Xiang Shang Ping Wei San,accompanied by Atractylodes,Lanceolata for regulating qi and invigorating spleen,Su Geng,Zhi Qiao, Bergamot and Bupleurum for soothing the liver,Coptis Chinensis,Dandelion, Capejasmine for killing Helicobacter pylori,Salvia for promoting the blood,Malt for digesting;Commonly used prescriptions for incoordination between the liver and stomach syndrome are Si Ni San,Chai Hu Shu Gan San and Jin Ling Zi San,accompanied by promoting blood circulation herbs(Rhizoma Ligustici Chuanxiong,Salvia,Angelica, Curcuma,Zedoary),,invigorating spleen qi herbs(Atractylodes,Poria),and antipyretics herbs(Capejasmine,Scutellaria,Red Peony Root)and digestive herbs(Jiao San Xian); Commonly used prescriptions for Gastric collateral stasis syndrome are Shi Xiao San or Dan Shen Yin,accompanied by other promoting blood herbs(Angelica,White peony root, Zedoary,Peach kernel,Rhizoma Ligustici Chuanxiong,San Leng,Red Peony Root,Panax notoginseng),invigorating spleen qi herbs(Astragalus,Atractylodes,Lanceolata) and regulating qi herbs(Bergamot,Citrus aurtantium,Bergamot,Tangerine Peel,Aristolochia debilis);Common used prescriptions for insufficiency of stomach yin syndrome are Yi Guan Jian or Sha Shen Mai Dong Soup,accompanied by regulating qi herbs(Bergamot, Chuan lian Zi,Bergamot,Tangerine Peel,Citrus aurtantium,Pinellia ternate,Villous amomum),invigorating spleen qi herbs(Atractylodes,Lanceolata,Radix pseudostell, Chinese yam) and digestive herbs(Hawthorn,Malt,Ji Nei Jin).
2 Chronic atrophic gastritis of epidemiological research of TCM syndrome principle
2.1 Onset Characteristics
A total of 239 patients with CAG was surveyed.51 cases with the history of digestive tract diseases(21.3%),mainly including gastroesophageal reflux disease,peptic ulcer, irritable bowel syndrome,gastroptosis,cholecystitis;and have a certain family history; CAG has a long course,incidence of morbidity in the spring＞winter＞autumn＞summer. The disease is closely related with predisposing factors,especially with dietary factors, mental and emotional factors and Climate Change;CAG.onset has close relation with special dietary habits of patients,especially with more salt food,spicy food,sweet;126 patients with abnormal psychological state(52.7%):tensive＞anxiety＞depression＞irritable＞suppression.
2.2 Syndrome character
Main symptoms:stomachaches accounts for 74.9%(179cases),stomachache distension 79.0%(189cases),stomached stuffy 66.9%(160cases),heartburn 44.8%(107cases),acid regurgitation 50.2%(120cases),belching 70.3%(168cases),anorexia 40.6%(97 cases),decreased appetite 27.2%(65cases);Main symptom score showed no significant difference(p＞0.05)among all syndromes types;The upper and lower symptoms showed a certain overlap regularity in various types of syndromes.In overlap symptoms,the highest frequency symptom in turn is as followings:gastric distention and abdominal distention＞stomachache and abdominal distention＞blocked stomach and abdominal distention＞belching and abdominal distention and so on;The most overlap syndromes in turn is;syndrome of hepatic qi attacking stomach＞syndrome of spleen-deficiency and Qi-stagnation＞syndrome of damp-heat obstructing in zhong jiqo＞syndrome of damp turbidity obstructing in zhong jiqo＞syndrome of stagnated heat of liver and stomach＞syndrome of spleen-stomach deficiency-cold etc;The diagnosis contain:stomach-ache accounts for 48.1%(115 case),stuffiness and fullness43.9%(105 cases),others7.9%(19 cases) including casting up of gastric acid,swallow acid,hypochondriac pain,regurgitation. The common syndromes in turn are as follows:syndrome of hepatic qi attacking stomach＞syndrome of spleen-deficiency and Qi-stagnation＞syndrome of damp-heat obstructing in zhong jiqo＞syndrome of stagnated heat of liver and stomach＞syndrome of spleen-stomach deficiency-cold＞syndrome of damp turbidity obstructing in zhong jiqo etc. The syndrome of stagnated blood of stomach meridian often combined the other syndromes.
2.3 Results of CAG accompanied with anxiety and depression state with HAD Scale
The HAD scores of normal population selected randomly were negative,which were different from the positive and the suspicious people.The negative scores were 104 cases (43.5%) in 239 cases,while the positive and suspicious were 135 cases(56.5%).The score was related to gender and the female are prone to anxiety or depression(P＜0.05).It was related to the educational background and the higher are prone to anxiety or depression (P＜0.05).It was also concerned with the psychological and mental state.Abnormal psychological state were prone to be anxious and depressive(P＜0.05).The anxiety scores of HAD were positive related with pathohistology examination,dysplasia was prone to be anxious especially(P=0.001＜0.05).Among all related factors,the disease state is the most related to the anxiety scores;the level of pathological points is the most close factor.
3 Clinical observations of Syndrome Differentiation and Treatment for120 cases of CAG
3.1 Clinical symptoms
After the treatment,the cardinal symptoms score,the clinical symptoms total score and other each host sickness score improvement has statistics difference(P＜0.05).Cardinal symptoms score and total score of each dialectical group between pre and post treatment all has statistics difference(P＜0.05).Cardinal symptoms in each group all have improvements.
3.2 PRO Score
Total score of PRO Scale between pre and post treatment has statistics difference (P＜0.05).The dyspepsia,the regurgitation,the general symptom,the abnormal defecation, the social function,the psychological function six dimension score difference between pre and post treatment has statistics difference(P＜0.05).In PRO Scale total score,the general symptom dimensions have the greatest effect on CAG patients,the order are:the general symptom＞the regurgitation＞the psychological function＞the dyspepsia＞abnormal defecation and the social function dimensions.
3.3 Gastroscopy and pathological findings
After the treatment,the main gastroscope pathological change and gastroscope total score all have statistics difference(P=0.003＜0.05).The main gastroscope pathological change and gastroscope total score all improved.After the treatment,each dialectical group pathology score difference has statistics difference(P=0.000＜0.05),the pathology score all improved.
3.4 Blood stasis group and the Non-blood stasis group
The blood stasis group and the non-blood stasis group partial pathological change score(Pathology main pathological change score,pathology total score) difference has statistics difference(P=0.009,0.021＜0.05),the blood stasis group histo-pathology pathological change is more serious.In the atrophy,intestines,and the activity score,the blood stasis group and the non-blood stasis group has statistics difference(P=0.023、0.013、0.036＜0.05),the blood stasis group intestines,atrophy,and activity score are higher than the non-blood stasis group.After treatment,the blood stasis group and the non-blood stasis group's cardinal symptoms score and the symptom total score have statistics difference (P=0.003＜0.05),symptoms all have been improved.After treatment,improvement of the non-blood stasis group the gastroscopic main pathological change score,the secondary pathological change score and the gastroscopic total score all have non-statistics difference(P=0.446＞0.05),while the blood stasis group gastroscopic main pathological change score and gastroscopic total score have statistics difference(P=0.002＜0.05).After treatment,change of the pathology main pathological score and pathology total score between blood stasis group and non-blood stasis group has statistics difference(P＜0.05), and the blood stasis group is prior to the non-blood stasis group.
Conclusion
1 Characteristics of TCM Syndrome and Regulations of Differentiation and medicine usage in CAG
Clinical manifestations of CAG mainly are indigestive symptoms,such as gasteremphraxis,stomachache,nausea,belching,inappetence,stool abnormity, accompanied by other symptoms such as fatigue,weight loss,and psychological symptoms including tension,anxiety,depression,etc.The diagnosis mainly is stomach-ache accounts, stuffiness and fullness.Defcient and excessive syndromes appearing together is the pathogenesis of CAG,and the deficiency mainly refers to Qi-deficiency and Yin-deficiency, while excess to Qi stagnation,blood stasis,more than damp-heat and heat accumulation.The disease is prone in the wrinkly,whose kidney essence were thought to be deficient increasingly and organs' function also decreased according TCM theory. Modern medicine also believes that the antiviral ability of gastric mucosal and gastric motility become reduced,emptying of food delayed,and glands become atrophied in the wrinkly,Based on the above understanding,we can conclude that spleen deficiency is closely related with the CAG,it is the pathological basis of CAG.The deficiency leads to stagnation of QI,damp obstruction,heat obstruction,blood stasis and phlegm stasis,among that pathogenesis,stagnation of QI and blood stasis are most important.According the theory of"Prolonged illness enters into venation" and" Prolonged illness surely has blood stasis",the long course of the disease will lead the blood stasis.Five common patterns of syndrome are:weakness of the spleen and stomach,damp-heat obstructing in spleen and stomach,incoordination between the liver and stomach,blood stasis in gastric venation, and insufficiency of stomach yin.
According to the pathogenesis of CAG,spleen deficiency is the pathological basis,Qi stagnation,blood stasis is important parts in the disease development,so determine the important methods of invigorating spleen,regulating qi,promoting blood circulation for the treatment of CAG should be throughout the course of treatment.The evidence-based medicine have a certain regularity,on the basis of main decoction and main drugs,have a comprehensive consideration of the characteristics of pathogenesis,and the interaction between drugs,and the physiological characteristic of stomach,appropriate use of other drugs,in order to increase the effectiveness of treatment while reduce its potential side effects,fully embodies the feature of traditional Chinese medicine.Basic prescription for weakness of the spleen and stomach syndrome is Xiangsha Liujunzi soup(spleen-stomach deficiency-cold with Huangqi Jian Zhong soup),accompanied by regulating qi herbs,promoting blood circulation herbs and digestive herbs;Basic prescriptions for damp-heat obstructing in spleen and stomach syndrome are Er Chen soup,Huo Pu Xia Ling soup,and Xiang Shang Ping Wei San,accompanied by regulating qi herbs, invigorating spleen herbs,and antipyretics herbs;Basic prescriptions for incoordination between the liver and stomach syndrome are Si Ni San,Chai Hu Shu Gan San and Jin Ling Zi San,accompanied by promoting blood circulation herbs,invigorating spleen qi herbs, and antipyretics herbs;Basic prescriptions for incoordination between the liver and stomach syndrome are Shi Xiao San or Dan Shen Yin,accompanied by invigorating spleen qi herbs and regulating qi herbs;Basic prescriptions for insufficiency of stomach yin syndrome are Yi Guan Jian or Sha Shen Mai Dong Soup,accompanied by invigorating spleen qi herbs,regulating qi herbs and digestive herbs.
2.Relativity of CAG syndrome characteristics and the psychological state of anxiety and depression
Symptoms of CAG are various and often not typical,and extent of disease and symptoms are not consistent,so the diagnosis and treatment has a certain difficulties.The study found that there is no obvious regularity in CAG main symptoms and secondary symptoms,and upper gastrointestinal symptoms and lower gastrointestinal symptoms show some Overlapping and regularity in all types of the symptoms.These overlapping symptoms make it confuse with other digestive system diseases easily,such as functional dyspepsia,peptic ulcer,etc.Some patients maybe have no clear symptoms;we can diagnose CAG by endoscopy and histopathology.Therefore,the identification and diagnosis of CAG must be cautious and clear,to prevent misdiagnosis.For a clear diagnosed CAG,conduct clinical follow-up monitoring,periodic endoscopy review,gastric cancer screening is the basis of early diagnosis,early detection and early treatment. Overlapping symptoms often occur in hepatic qi attacking stomach syndrome, spleen-deficiency and Qi-stagnation syndrome,damp-heat obstructing in zhong jiqo syndrome,and syndrome of damp turbidity obstructing in zhong jiqo,syndrome of stagnated heat of liver and stomach etc.Qi-stagnation in zhong jiqo will lead to pain. Symptoms as upper abdominal pain,abdominal distension,and stool abnormity have close relation with spleen and liver.Hepatic qi attacking stomach result into belching, inappetence,stomach distension and stomachache etc.Upper digestive tract and the lower digestive tract together form the main channel of the digestive system which is for the digest transform water food,transporting and transforming nutrients from foodstuff of spleen and stomach in physiology,while interact in the pathology.Stagnation of dampness due to splenic deficiency can result in stomach distension,abdominal distension and stomachache,stomach blocking,nausea,belching and other gastrointestinal symptoms.At the same time doing a good job in the differential diagnosis,treatment should be combined with the physiological and pathological characteristics of the digestive tract.
Among surveyed population,43.9%of chronic atrophic gastritis patients had varying degrees of anxiety,depression in performance,CAG accompanied by mental illness should be given enough attention,because the CAG patients with performance and risk factors of mental illness on the basis of premonitory symptoms is an important basis for the adverse prognosis of patients,and such anxiety and depression state can not only induce disease, but also an important factor in the development of the disease.The study found that poor emotional state,TCM syndromes showed relevance with gastroscopy and pathological examination.Hospital Anxiety and Depression(HAD) scale points have some type of relevance with the syndrome,the anxiety card points of hepatic qi attacking stomach, spleen-deficiency and Qi-stagnation syndrome were more obvious than the other types of syndromes.HAD scale points and the seriousness of pathological examination results showed relevance,in particular the anxiety sub-scale and severity of dysplasia was a positive correlation,and patients who responded to HAD points had higher relevance than the suspicious patients。This shows that the influence of disease to psychological state of patients,and traditional Chinese medicine theory explain the incidence of emotional factors is most closely related with the liver and spleen.
In this study,the HAD Scale is the self-rating scale for Anxiety and Depression mental illness Screening in Hospital.It is simple,convenient and easy to operate, Compared to other questionnaire rating scale and self-rating scale used by psychiatrists, HAD Scale is more in line with the actual needs of digestive department physicians for rapid differential diagnosis whether CAG patients combined with abnormal mental state., such as anxiety and depression.
3.The clinical efficacy research in traditional Chinese medicine treatment of CAG
In evaluation of CAG effect applicated with traditional Chinese medicine differentiation with PRO scale,we found that PRO scale designed 36 entries covering all the details of the clinical symptoms from six functional dimensions,different emphasis for complicated CAG symptoms lack of specificity.For its stong maneuverability,this Scale can provide objective basis for clinical and scientific research.
TCM treatment of CAG in the clinical symptom score,the various dimensions of scale and total score of patients clinical report outcome(PRO),endoscopic mucosal lesion, histopathology all improved in varying degrees.;Those above have proved the efficacy of Chinese medicine in the treatment of CAG and precancerous lesions is positive,and Chinese medicine has characteristics and advantages.Histopathological score of blood stasis group improved better than non-blood stasis group,especially in histopathological lesions,such as atrophy,intestinal metaplasia,while the non-blood stasis group is relatively complicated.The result indicates that promoting blood circulation to remove blood stasis played an important role in improving atrophy and preventing the disease progress.
My tutor -Professor Tang Xudong emphasizes that regulating qi and promoting blood circulation to remove blood stasis are the fundamental principle in the treatment of CAG. In the use of Chinese medicine treatment,we should pay attention to patients with anxiety and depression,and apply psychological guidance and life recuperation at the same time, give a more comprehensive treatment in order to achieve the purpose of enhance the effectiveness of treatment.
引文
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5.姚宏昌.重视消化系统心身疾病的研究.中华消化杂志,2001,21(3):133-134.
6.Gamerova GS,Bystrov VN.Psychoautonomic and somatic correlations and clinical significance in patients with chronic gastritis.Ter Arkh,1987,59(2):69-72.
7.Dzhula GS,Chernin VV.Quality of life and attitude to the disease in patients with chronic gastritis.Klin Med(Mosk),2002,80(7):32-36.
8.Atanassova PA,Chalakova NT,Goranov SE,et al.A case of encephalomy elopoly neuropathy in vitamin B 12 deficiency.Folia Med(Plovdiv),2004,46(4):52-54.
9.Grossarth-Maticek R,Vetter H,Frentzel-Beyme R,Heller WD.Precursor lesions of the GI tract and psychosocial risk factors for prediction and prevention of gastric cancer.Cancer Detect Prev,1988,13(1):23-29.
10.Gamerova GS,Bystrov VN.Psychoautonomic and somatic correlations and clinical significance in patients with chronic gastritis.Ter Arkh,1987,59(2):69-72.
11.鲁班-普罗查质.实用心身医学,北京:科学出版社,1998:70.
12.叶天氏.临证指南医案.上海:上海科技出版社,1959:190.
13.陈玉龙.消化系统心身疾病的研究与临床.郑州:郑州大学出版社,2005:21-22.
14.李心天.医学心理学.北京:北京医科大学中国协和医科大学联合出版社,1999:315.
15.陈玉龙.消化系统心身疾病的研究与临床.郑州:郑州大学出版社,2005:23-24.
16.徐斌,王效道,刘士林.心身医学.北京:中国科学技术出版社,2000:100.
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