胆道闭锁Kasai术后中医证候暨中药干预治疗的临床研究
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摘要
【研究目的】
观察、分析胆道闭锁Kasai术后的中医证候分布规律,探讨胆道闭锁Kasai术后的中医病因病机及治疗法则；观察中医药干预治疗胆道闭锁Kasai术后的临床疗效。
【研究方法】
1.胆道闭锁中医证候研究：以面对面的调查方法收集胆道闭锁Kasai术后的临床资料,统计分析胆道闭锁Kasai术后的中医证候分布规律,分析可能的发病因素及其与证候的关系,进一步探讨道闭锁Kasai术后的中医病因病机及治疗法则。
2.观察以健脾化湿、温阳活血法的中药治疗胆道闭锁Kasai术后患儿的中医证候积分、肝功能指标及身高体重、生活质量情况,以评价其临床疗效。
【研究结果】
1.胆道闭锁中医证候研究
1.1胆道闭锁术后主要症状为：肝功能异常、黄疸、便溏、疲倦乏力、纳差、胁下肿块、腹胀膨隆等；舌质主要表现为舌质淡,或舌体胖有齿印；舌苔多见厚腻白苔,或有灰黑苔；指纹表现多为淡红、达气关,或淡滞兼见。
1.2胆道闭锁术后与气血阴阳虚证的关系：胆道闭锁术后多有气虚表现,出现频率为90.2%,阳虚者次之,为46.3%,血虚及阴虚者较少。气虚证及阳虚证可以单独存在,亦可以与其它虚证相兼存在。相兼证中以气虚+阳虚最多,占31.8%。Logistic回归分析显示：手术次数为血虚证的影响因素,手术次数为2次的患儿多有血虚表现；胆管炎为血虚证、阴虚证的影响因素,有胆管炎发生者,阴虚证、血虚证的比例越大；性别、手术日龄为阳虚的影响因素,阳虚证中男孩占73.6%,比例明显高于女孩,手术日龄越小,阳虚证患儿比例越大。
1.3胆道闭锁术后与五脏的关系：胆道闭锁术后有脾虚表现者最多,占92.7%,其中脾气虚证为主要证候,占58.5%,脾阳虚证占36.6%；肾虚表现者次之,肾气虚证占29.3%,肾阳虚证占21.9%；肺虚者第三,为17.1%。脾虚、肾虚可以单独存在,亦可以与其它虚证相兼存在。Logistic回归分析显示：过敏史是肺虚的影响因素,有过敏史患儿出现肺虚证的比例越大。就诊年龄为肺虚、肾虚的影响因素,就诊年龄越大,肾虚、肺虚证越多。
1.4胆道闭锁术后与实证的关系：胆道闭锁术后实证41例均有湿邪,湿邪分寒湿、湿热,以寒湿为主,占85.4%,且多见有气滞、血瘀表现,分布占90.2%、90.2%。气滞证均与其他实证相兼出现,且以气滞+血瘀+寒湿证为主,占75.7%。各种实证广泛分布于气血阴阳虚证的各种组合中,并与脾、肾、肺虚证相兼并存。以脾虚(寒)湿困、气滞血瘀最多见,20例,占48.8%。Logistic回归分析显示：胆管炎为血瘀证的影响因素,有胆管炎发生者,血瘀证比例越大。
1.5证候相关性：结果显示气血阴阳虚证、五脏虚证与实证相互相关、相互影响,使胆道闭锁术后的证候表现虚实兼夹、错综复杂。
2.健脾化湿、温阳活血法治疗胆道闭锁Kasai术后的临床观察
2.1中医证候积分观察：结果显示经健脾化湿、温阳活血法中药干预治疗后,胆道闭锁Kasai术后患儿的各主要症状均有较好的改善,且随着疗程的增加,各症状改善的有效率逐渐增加。其中黄疸改善最快,经第1个疗程后有效率已达56.25%,经3个疗程治疗后,黄疸消退有效率达100%；食欲、精神、大便情况经第2个疗程治疗后明显改善；腹胀、胁下肿块、青筋暴露等症状改善较慢,经第3疗程之后有效率明显提高。
2.2胆道闭锁Kasai术后患儿中药治疗前后肝功能情况：结果显示经中药治疗1个疗程后,总胆红素TB、直接胆红素DB、胆汁酸TBA、谷丙转氨酶ALT、谷草转氨酶AST、谷氨酰转肽酶GGT即明显逐渐下降,随着疗程的增加,其中总胆红素TB、直接胆红素DB在第3个疗程后均已降至正常范围,胆汁酸TBA、谷丙转氨酶ALT、谷草转氨酶AST经3个疗程后接近正常范围。碱性磷酸酶ALP下降较慢,经中药治疗2个疗程后才显示较治疗前有统计学差异(p<0.05)。
2.3胆道闭锁Kasai术后中药干预治疗后生长发育情况：16例胆道闭锁术后患儿经中药干预治疗后,除有2例身高较正常偏低、1例体重较正常偏低外,其余均生长发育良好,15例IBM指标均正常。
2.4胆道闭锁Kasai术后中药干预治疗后生活质量评价情况：16例胆道闭锁术后经中药干预治疗后,除有2例因反复发生胆管炎,对生活评价质量为稍差外,其余评价生活质量为“很好”者4例,评价为“一般”者10例。绝大部分患儿能如正常儿童一样生活和学习,其中有7例3岁以上患儿已上幼儿园,1例11岁患儿在读小学,学习成绩优良。
【研究结论】
1.胆道闭锁Kasai术后中医证候特点为：虚证以脾气虚、脾肾阳虚多见,实证以气滞、寒湿、血瘀为主；各种证候相互相关、相互影响,常相兼出现,病性属虚实夹杂；其病位主要在肝胆、脾、肾、肺；主要病性要素为：湿、气虚、阳虚、气滞、血瘀；常见证型为：脾虚湿困、气滞血瘀；胆道闭锁Kasai术后的中医病因病机可概括为“湿、滞、瘀、虚”。
2.健脾化湿、温阳活血法中药干预治疗可改善患儿的各主要症状及肝功能指标,从而进一步改善患儿的生长发育情况及生活质量。
Objective
1.The objective of this research is to investigate the regularities of distribution on TCM syndrome of biliary atresia after Kasai operation, and further to discuss Chinese medicine cause and pathogenesis and therapy method about biliary atresia after Kasai operation.
2. The objective of the research is also to observe the clinical effect of the treatment with traditional Chinese medicine to biliary atresia after Kasai operation.
Method
1. Study on TCM syndrome of biliary atresia after Kasai operation:Firstly, We collect the clinical data on TCM syndrome of biliary atresia after Kasai operation through the investigation method by face to face. Secondly, we analyse the regularities of distribution on TCM syndrome of biliary atresia after Kasai operation, and then according to the result we try to discuss the Chinese medicine cause and pathogenesis about the disease. Lastly, we advance some Chinese therapy method about biliary atresia after Kasai operation.
2. We treat the children of biliary atresia after Kasai operation with Chinese medicine by tonifying spleen and resolving dampness, warming yang and invigorate the circulation of blood. And then we record the integral of TCM syndrome, the index of liver function, height and weight before and after the therapy with Chinese medicine. Lastly, we can estimate the clinical effect of the Chinese medicine used to treat the children of biliary atresia after Kasai operation.
Result
1. Study on TCM syndrome of biliary atresia after Kasai operation:The main syndrome of biliary atresia after Kasai operation is that:abnormal liver function、jaundice、loose stool、fatigue、poor diet、phyma below the costal region、enlarged abdomen, etc. The tongue manifestation is pale tongue, or corpulent tongue with casts of the teeth; and with white or grey tongue fur. The characteristic of TCM syndrome about biliary atresia after Kasai operation: asthenia syndrome is mamily from qi deficiency type, yang deficiency type and spleen deficiency type; sthenia-syndrome is mamily from Stagnation of Qi, Stagnation of Blood, Cold and Dampness type.These types of syndrome are interrelated and influenced each other, and will appear simultaneously. The nature of this disease is deficiency and excess interlaced each other. The location of disease can be in liver,gall, spleen, kidney or lung.The key element of the nature about this disease is dampness, blood stasis, stagnation of qi.The most common type of syndrome is spleen dysfunction due to dampness, qi and blood stasis. The Chinese medicine cause and pathogenesis about biliary atresia after Kasai operation can be summarized by "dampness、stagnate、stagnate、asthenia".
2. Chinese medicine through tonifying spleen and resolving dampness,warming yang and invigorate the circulation of blood can alleviate the symptom and the index of liver function. And the the symptoms like jaundice, anorexia, weary and stool will be better faster, but the the symptoms like abdominal distension, phyma below the costal region, blue veins stand out on belly will be alleviated slowly. The index of liver function like total bilirubin, direct bilirubin have delined after the third course of treatment. The index of liver function like alkaline phosphatase(ALP) decreased moe slowly. Most of the children of biliary atresia after Kasai operation can grow and live like normal children.
Conclusion
1. The characteristic of TCM syndrome about biliary atresia after Kasai operation:asthenia syndrome is mamily from qi deficiency type, yang deficiency type and spleen deficiency type. Sthenia-syndrome is mamily from stagnation of qi, stagnation of blood, cold and dampness type.These types of syndrome are interrelated and influenced each other, and appear simultaneously. The nature of this disease is deficiency and excess interlaced each other. The location of this disease can be liver, gall, spleen, kidney or lung. The key element of the nature about this disease is dampness, blood stasis, stagnation of qi. The most common type of syndrome is spleen sysfunction due to sampness, qi and blood stasis. The Chinese medicine cause and pathogenesis about biliary atresia after Kasai operation can be summarized by "dampness、stagnate、stagnate、asthenia".
2. Chinese medicine through tonifying spleen and resolving dampness, warming yang and invigorate the circulation of blood can alleviate the symptom and the index of liver function, and then improve thelevel of grouth and life quality.
观察、分析胆道闭锁Kasai术后的中医证候分布规律,探讨胆道闭锁Kasai术后的中医病因病机及治疗法则；观察中医药干预治疗胆道闭锁Kasai术后的临床疗效。
【研究方法】
1.胆道闭锁中医证候研究：以面对面的调查方法收集胆道闭锁Kasai术后的临床资料,统计分析胆道闭锁Kasai术后的中医证候分布规律,分析可能的发病因素及其与证候的关系,进一步探讨道闭锁Kasai术后的中医病因病机及治疗法则。
2.观察以健脾化湿、温阳活血法的中药治疗胆道闭锁Kasai术后患儿的中医证候积分、肝功能指标及身高体重、生活质量情况,以评价其临床疗效。
【研究结果】
1.胆道闭锁中医证候研究
1.1胆道闭锁术后主要症状为：肝功能异常、黄疸、便溏、疲倦乏力、纳差、胁下肿块、腹胀膨隆等；舌质主要表现为舌质淡,或舌体胖有齿印；舌苔多见厚腻白苔,或有灰黑苔；指纹表现多为淡红、达气关,或淡滞兼见。
1.2胆道闭锁术后与气血阴阳虚证的关系：胆道闭锁术后多有气虚表现,出现频率为90.2%,阳虚者次之,为46.3%,血虚及阴虚者较少。气虚证及阳虚证可以单独存在,亦可以与其它虚证相兼存在。相兼证中以气虚+阳虚最多,占31.8%。Logistic回归分析显示：手术次数为血虚证的影响因素,手术次数为2次的患儿多有血虚表现；胆管炎为血虚证、阴虚证的影响因素,有胆管炎发生者,阴虚证、血虚证的比例越大；性别、手术日龄为阳虚的影响因素,阳虚证中男孩占73.6%,比例明显高于女孩,手术日龄越小,阳虚证患儿比例越大。
1.3胆道闭锁术后与五脏的关系：胆道闭锁术后有脾虚表现者最多,占92.7%,其中脾气虚证为主要证候,占58.5%,脾阳虚证占36.6%；肾虚表现者次之,肾气虚证占29.3%,肾阳虚证占21.9%；肺虚者第三,为17.1%。脾虚、肾虚可以单独存在,亦可以与其它虚证相兼存在。Logistic回归分析显示：过敏史是肺虚的影响因素,有过敏史患儿出现肺虚证的比例越大。就诊年龄为肺虚、肾虚的影响因素,就诊年龄越大,肾虚、肺虚证越多。
1.4胆道闭锁术后与实证的关系：胆道闭锁术后实证41例均有湿邪,湿邪分寒湿、湿热,以寒湿为主,占85.4%,且多见有气滞、血瘀表现,分布占90.2%、90.2%。气滞证均与其他实证相兼出现,且以气滞+血瘀+寒湿证为主,占75.7%。各种实证广泛分布于气血阴阳虚证的各种组合中,并与脾、肾、肺虚证相兼并存。以脾虚(寒)湿困、气滞血瘀最多见,20例,占48.8%。Logistic回归分析显示：胆管炎为血瘀证的影响因素,有胆管炎发生者,血瘀证比例越大。
1.5证候相关性：结果显示气血阴阳虚证、五脏虚证与实证相互相关、相互影响,使胆道闭锁术后的证候表现虚实兼夹、错综复杂。
2.健脾化湿、温阳活血法治疗胆道闭锁Kasai术后的临床观察
2.1中医证候积分观察：结果显示经健脾化湿、温阳活血法中药干预治疗后,胆道闭锁Kasai术后患儿的各主要症状均有较好的改善,且随着疗程的增加,各症状改善的有效率逐渐增加。其中黄疸改善最快,经第1个疗程后有效率已达56.25%,经3个疗程治疗后,黄疸消退有效率达100%；食欲、精神、大便情况经第2个疗程治疗后明显改善；腹胀、胁下肿块、青筋暴露等症状改善较慢,经第3疗程之后有效率明显提高。
2.2胆道闭锁Kasai术后患儿中药治疗前后肝功能情况：结果显示经中药治疗1个疗程后,总胆红素TB、直接胆红素DB、胆汁酸TBA、谷丙转氨酶ALT、谷草转氨酶AST、谷氨酰转肽酶GGT即明显逐渐下降,随着疗程的增加,其中总胆红素TB、直接胆红素DB在第3个疗程后均已降至正常范围,胆汁酸TBA、谷丙转氨酶ALT、谷草转氨酶AST经3个疗程后接近正常范围。碱性磷酸酶ALP下降较慢,经中药治疗2个疗程后才显示较治疗前有统计学差异(p<0.05)。
2.3胆道闭锁Kasai术后中药干预治疗后生长发育情况：16例胆道闭锁术后患儿经中药干预治疗后,除有2例身高较正常偏低、1例体重较正常偏低外,其余均生长发育良好,15例IBM指标均正常。
2.4胆道闭锁Kasai术后中药干预治疗后生活质量评价情况：16例胆道闭锁术后经中药干预治疗后,除有2例因反复发生胆管炎,对生活评价质量为稍差外,其余评价生活质量为“很好”者4例,评价为“一般”者10例。绝大部分患儿能如正常儿童一样生活和学习,其中有7例3岁以上患儿已上幼儿园,1例11岁患儿在读小学,学习成绩优良。
【研究结论】
1.胆道闭锁Kasai术后中医证候特点为：虚证以脾气虚、脾肾阳虚多见,实证以气滞、寒湿、血瘀为主；各种证候相互相关、相互影响,常相兼出现,病性属虚实夹杂；其病位主要在肝胆、脾、肾、肺；主要病性要素为：湿、气虚、阳虚、气滞、血瘀；常见证型为：脾虚湿困、气滞血瘀；胆道闭锁Kasai术后的中医病因病机可概括为“湿、滞、瘀、虚”。
2.健脾化湿、温阳活血法中药干预治疗可改善患儿的各主要症状及肝功能指标,从而进一步改善患儿的生长发育情况及生活质量。
Objective
1.The objective of this research is to investigate the regularities of distribution on TCM syndrome of biliary atresia after Kasai operation, and further to discuss Chinese medicine cause and pathogenesis and therapy method about biliary atresia after Kasai operation.
2. The objective of the research is also to observe the clinical effect of the treatment with traditional Chinese medicine to biliary atresia after Kasai operation.
Method
1. Study on TCM syndrome of biliary atresia after Kasai operation:Firstly, We collect the clinical data on TCM syndrome of biliary atresia after Kasai operation through the investigation method by face to face. Secondly, we analyse the regularities of distribution on TCM syndrome of biliary atresia after Kasai operation, and then according to the result we try to discuss the Chinese medicine cause and pathogenesis about the disease. Lastly, we advance some Chinese therapy method about biliary atresia after Kasai operation.
2. We treat the children of biliary atresia after Kasai operation with Chinese medicine by tonifying spleen and resolving dampness, warming yang and invigorate the circulation of blood. And then we record the integral of TCM syndrome, the index of liver function, height and weight before and after the therapy with Chinese medicine. Lastly, we can estimate the clinical effect of the Chinese medicine used to treat the children of biliary atresia after Kasai operation.
Result
1. Study on TCM syndrome of biliary atresia after Kasai operation:The main syndrome of biliary atresia after Kasai operation is that:abnormal liver function、jaundice、loose stool、fatigue、poor diet、phyma below the costal region、enlarged abdomen, etc. The tongue manifestation is pale tongue, or corpulent tongue with casts of the teeth; and with white or grey tongue fur. The characteristic of TCM syndrome about biliary atresia after Kasai operation: asthenia syndrome is mamily from qi deficiency type, yang deficiency type and spleen deficiency type; sthenia-syndrome is mamily from Stagnation of Qi, Stagnation of Blood, Cold and Dampness type.These types of syndrome are interrelated and influenced each other, and will appear simultaneously. The nature of this disease is deficiency and excess interlaced each other. The location of disease can be in liver,gall, spleen, kidney or lung.The key element of the nature about this disease is dampness, blood stasis, stagnation of qi.The most common type of syndrome is spleen dysfunction due to dampness, qi and blood stasis. The Chinese medicine cause and pathogenesis about biliary atresia after Kasai operation can be summarized by "dampness、stagnate、stagnate、asthenia".
2. Chinese medicine through tonifying spleen and resolving dampness,warming yang and invigorate the circulation of blood can alleviate the symptom and the index of liver function. And the the symptoms like jaundice, anorexia, weary and stool will be better faster, but the the symptoms like abdominal distension, phyma below the costal region, blue veins stand out on belly will be alleviated slowly. The index of liver function like total bilirubin, direct bilirubin have delined after the third course of treatment. The index of liver function like alkaline phosphatase(ALP) decreased moe slowly. Most of the children of biliary atresia after Kasai operation can grow and live like normal children.
Conclusion
1. The characteristic of TCM syndrome about biliary atresia after Kasai operation:asthenia syndrome is mamily from qi deficiency type, yang deficiency type and spleen deficiency type. Sthenia-syndrome is mamily from stagnation of qi, stagnation of blood, cold and dampness type.These types of syndrome are interrelated and influenced each other, and appear simultaneously. The nature of this disease is deficiency and excess interlaced each other. The location of this disease can be liver, gall, spleen, kidney or lung. The key element of the nature about this disease is dampness, blood stasis, stagnation of qi. The most common type of syndrome is spleen sysfunction due to sampness, qi and blood stasis. The Chinese medicine cause and pathogenesis about biliary atresia after Kasai operation can be summarized by "dampness、stagnate、stagnate、asthenia".
2. Chinese medicine through tonifying spleen and resolving dampness, warming yang and invigorate the circulation of blood can alleviate the symptom and the index of liver function, and then improve thelevel of grouth and life quality.
引文
[1]Sokol RI, Mack C, Narkew cz MR, etal. Pathogenesis and outcome of biliary atresia:Current concepts. J Pediatr Gastroenterol Nutr,2003,37:4-21.
[2]Perlmutter DH, Shephercl R. Extrahepatic biliary atresia:A disease or a phenoltype Hepatology,2002,35:1297-1304.
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