摘要
粘连性肠梗阻(Adhesive Intestinal Obstruction,AIO)是由于腹腔内粘连导致肠道内容物通过障碍的一种疾病,是临床常见的急腹症之一,也是各类肠梗阻中最常见的一种。它是普外科常见且棘手的问题,给许多患者造成极大痛苦和经济负担。目前临床无一种公认的、有效的方法来预防腹腔粘连的发生。因此,积极探讨对AIO的有效预防是当今医学领域研究的重要课题之一。本文从中医针灸学的角度对此病进行系统探讨,拟从以下两个方面进行研究。
1.文献研究
从现代医学对AIO的认识,指出AIO与肠上皮细胞有密切的关系,肠上皮细胞在AIO的发病中占有重要地位。
小肠是维持人体正常生理活动的重要器官,担负着消化、吸收、分泌、排泄和免疫防疫等功能。各种损伤、感染、梗阻、缺血等因素均可以引起不同程度的小肠屏障功能障碍。肠梗阻的初期肠道平滑肌出现相应肌动力学的变化,增强蠕动,克服梗阻,随梗阻时间延长,梗阻对肠道的血液循环、酶学、离子平衡及代谢的不良反应会逐渐加重。肠腔内压力增高,小肠能量代谢功能衰竭,肠管逐渐膨胀,肠壁张力增加,压迫粘膜下血管导致小肠粘膜微循环障碍,小肠组织供氧进一步减少,组织氧合不良,肠上皮细胞破坏受损,肠屏障功能丧失,终致肠功能衰竭。
现代医学对本病主要是采取手术治疗和特殊药物腹腔内灌注为主,如透明质酸钠、尿激酶、脂肪乳剂等。
从中医对粘连性肠梗阻的病因病机、辨证论治认识的阐述以及对针灸治疗本病的回顾,指出中医对腹部疾病的生理、病理认识历史久远。但有关粘连性肠梗阻的病名、病因病机、辨证论治,古医籍中则无系统的专门论述,而散见于“腹痛”、“积聚”、“关格”等范畴。中医针灸疗法方法多样,如针刺、艾灸、中药灌肠、推拿按摩等,其治疗AIO显示出良好的疗效,导师张家维在针灸治疗内科疑难疾病的研究中积累了丰富的经验,这些为探讨针灸治疗粘连性肠梗阻提供了坚实的理论基础。
在回顾中西医有关粘连性肠梗阻的认识后,指出探讨针刺对粘连性肠梗阻的预防机制,具有坚实的理论基础及重要的临床意义。
2.实验研究
目的:从动物实验角度探讨针刺对粘连性肠梗阻的预防机制。
方法:将75只SD大鼠,随机分为5组:正常组、假手术组、模型组、中药灌肠组、针刺组。针刺组取穴:足三里(双)、天枢(双)、上巨虚(双),每天针刺一次,每次30min;灌肠组用大承气汤,按照5ml/kg剂量保留灌肠,模型组、假手术组用生理盐水保留灌肠,用量为5ml/kg,每天一次,以上各组实验动物分别在造模术后14天处死,观察以下指标:
(1)各组大鼠小肠肠粘连Phyllips分级、上皮细胞损伤chiu分级;
(2)各组大鼠小肠光镜下病理形态学的改变;
(3)各组大鼠小肠超微结构变化(细菌包涵体细胞和粗面内质网囊液腔计数):
(4)各组大鼠小肠上皮细胞内Ca~(2+)含量的变化;
(5)各组大鼠小肠上皮细胞线粒体功能的变化
(6)各组大鼠小肠上皮细胞组胺酶的活性;
(7)各组大鼠小肠上皮细胞氧自由基的变化;
结果:
(1)模型组大鼠腹腔内粘连处数多,粘连紧密,扭曲成团,部分肠段出现近端肠管扩张,远端肠管缩窄变细的粘连性肠梗阻的改变。术后各组与假手术组比较,粘连分级均有增加;针刺组和灌肠组肠粘连分级显著低于模型组(P＜0.01):造模后各组Chiu分级均较对照组明显升高,模型组损伤最为严重,与正常组、假手术组相比,具有明显差异(P＜0.01),灌肠和针刺防治后,肠粘膜损伤减轻,较模型组差异具有统计学意义(P＜0.05)。
(2)模型组可见光镜下模型组肠上皮细胞严重损伤,可见肠腔内可见多量变性红细胞和脱落变性肠上皮细胞,绒毛排列紊乱、萎缩变短、间距增宽、间质充血水肿,大部分上皮细胞脱落,绒毛破损伴有固有层毛细血管大量暴露,固有层水肿,中等量炎细胞浸润,小肠绒毛水肿,固有层血管充血,肠腔炎性渗出,灌肠和针刺后粘膜损伤改善明显。
(3)造模14天后,细菌包涵体细胞和粗面内质网囊液腔计数数量增多,针刺或灌肠治疗后梗阻均有显著减少。术后小肠粘膜上皮细胞微绒毛减少,线粒体和粗面内质网明显减少,炎性细胞浸润增多。针刺能明显改善肠梗阻时小肠上皮细胞的损伤,促进线粒体和粗面内质网功能和形态恢复。
(4)在造模术后,与假手术组相比,正常组上皮细胞内Ca~(2+)与其无统计学差异(p＜0.05)。模型组上皮细胞内Ca~(2+)明显高于假手术组,差异显著(p＜0.01)。灌肠组、针刺组均使上皮细胞内Ca~(2+)明显降低(P＜0.01或P＜0.05)。
(5)与假手术组相比,模型组肠上皮细胞线粒体三态呼吸(ST_3)降低,四态呼吸(ST_4)升高,线粒体呼吸控制率(RCR)均下降(P＜0.011);灌肠组以上指标均有所改善,但仍不如正常对照组好;针刺治疗后,ST_3升高,ST_4降低,RCR均升高,与模型组比相差非常显著(P＜0.01),与正常对照组相比差别不显著。
(6)模型组小肠DAO水平明显低于假手术组,血浆DAO水平明显高于假手术组,差异显著(P＜0.01);针刺组经针刺干预后,小肠DAO提高,较模型组有统计学差异(P＜0.05),血浆DAO降低,较模型组均有显著差异(P＜0.05)。正常组和假手术组DAO较稳定,两者差异无显著性(P＞0.05)。
(7)大鼠造模术后肠粘膜和血浆中MDA含量明显升高,SOD显著下降。粘连性肠梗阻大鼠针刺后,血浆和肠粘膜中的NO、MDA含量低于模型组,SOD高于模型组,并随治疗时间的延长,其水平逐渐趋于正常。
结论:
(1)针刺能够改善大鼠小肠炎症,降低肠粘连Phyllips分级、肠上皮细胞损伤chiu分级,改善肠粘膜粘连情况。
(2)针刺能明显改善肠梗阻时小肠组织超微结构的损伤,促进线粒体和粗面内质网功能和形态恢复,减少细菌包涵体细胞和粗面内质网囊液腔的数量,保持肠上皮细胞的完整性。
(3)针刺能降低上皮细胞内钙离子超载,改善线粒体呼吸功能,减轻肠上皮细胞损伤。
(4)针刺能抗氧自由基损伤,降低肠二胺氧化酶,保护肠道屏障功能。
Adhesive intestinal obstruction(AIO) is a kind of clinical disease caused by adhesive intesinal which leads to transmission disorder of intestinal content.It is one of most clinical frequent acute abdomen disease.It may cause many kinds of severe complication for threating to life such as multiple system organ failure(MSOF).It is a common and intractable problem.It means a lot of pain and cost that patient should suffer from. Although many medicines can play some roles,there is still one recognized method is available for prevention of adhesion in abdominal cavity.It is one of the most important tasks in the medical field to actively search for how to prevent and cure AIO.
The following two aspects are concerned in this dissertation to discuss AIO systematically in the field of acupuncture and moxibustion of traditional Chinese medicine.
1.Literature research
On reviewing the knowledge of AIO,animal model of AIO in western medicine.The authors pointed out that there was closely related between AIO and intestinal epithelial cell.
Small intestine is the critical organ which maintain nonnal function of human body,and take on digestion,digestion,externalization,excretion and immunifaction.Disruption of gastroin-testinal epithelial barrier integrity may induce increasing of permeability of gastrointestinal wall, bacterial and endotoxin translocation,releasing inflammatory mediators,and lead to lethal sepsis and distant organ injury,finally result in multiple system organ failure.The original sign of impairment of mucosal is increasing of permeability.Before the marked change of morphology of mucosal,increasing of permeability of intestinal tract has happened.So increasing of permeability of mucosal can reflect injury of intestinal barrier earlier. Increasing of permeability of mucosal may provide a chance for absorption of toxin in enteric cavity,which is the pathological foundation of bacterial translocation.
As far as its treatment was concerned,at present,it still stayed at operation and infusing into abdominal cavity with some special medicine such as sodium hyaluronate,urokinase and intralipid et al.
On reviewing the etiology and pathogenesis,treatment selection on syndrome differentiation of AIO in TCM,the author pointed out that the history of the cognition of physiology and pathology for the coeliac disease in TCM is very long.Not a few literatures are relative to AIO,while none of them is specialized in AIO.The symptoms are included in the following chapters,such as "bellyache","accumulation "," intense carotid and radial pulsation ",etc.Acu-bustion has many kinds of therapeutic methods including acupunture, moxibustion,tuina,decoction edema,etc.It has desirable effect on AIO.In addition,my director has got a great experience on research of AIO.
On reviewing the cognition of AIO in both Traditional Chinese Medicine and modern medical science,the author pointed out that there is stable and forceful theoretic foundation and significant clinical meaning to probing into the protective effect of acupuncture in points for the treatment of AIO.
2.Experimental research
Purpose:To probe the protective effect of acupuncture for the treatment of AIO from the angle of animal experiment.
Methods:75 SD rats were randomly divided into groups:normal group, sham-operation group,model group,Dachengqi decoction enema group,acupuncture group. Acupuncture group was treated by electro-Acupuncture 30 min every day.Acupoints chosen in acupuncture group were as follows:Zusanli(ST36),Tianshu(ST25),Shangiuxu (ST37).Enema group was given enema with Dachengqi decoction 5ml/kg once everyday while sham-operation group and model group with physiological saline at same dose.All of the experimental animals were averagely put to death on the 14~(th) day after operation,and collected serum and samples,measured and observed the following indexes:
(1) The chiu score and W/D ratio of intestinal epithelial cell,The Phyllips score of adhesive intestinum.
(2) The pathomorphological change of intestinal epithelial cell in adhesive intestinal obstruction injury rat models with light-microscope.
(3) The ultrastructure change of intestinal epithelial cell in adhesive intestinal obstruction injury rat models with electon-microscope,including the amounts of bacterium cytoryctes cell and rough endoplasmic reticulum rough endoplasmic reticulum cav.
(4) The content of Ca~(2+) in intestinal epithelial cell
(5) The changes of chondriosome's function in intestinal epithelial cell
(6) The activity of diamine oxidase(DAO) of intestinal epithelial cell.
(7) The content of oxygen free radical in intestinal epithelial cell.
Results:
(1) Edema of intestine in model group was serious.The W/D ratio in three operation group was significantly higher(p＜0.05) than that in the sham-operation group at all time points,but it was obviously reduced by the acupuncture treament at 14,28 days after operation.
Adhesive intestinum in model group was compacted and twisted lumping,proximate intestinal of some stage became distention,other distal end intestinal was coarctation and thin than normal group.The Phyllips score and chiu score of adhesive intestinum was significantly higher(P＜0.01) than that in the sham-operation group and normal group at all time points,but it was obviously reduced by acupuncture or enema treament at 14,28 days after operation(P＜0.05).
(2) The intestinal mucosa injury of model group in light-microscope was worse than other groups.There was great amount of degen-akaryocyte and amotio epithelium mucosae endothelial cell,villi was getting confused,atrophy and shorter.Intestinal villi edema, capillary congestion,polymophonuclear infiltration in enteric cavity was noted in the model group after intestinal operation,pathomorphological change of the enema group and acupuncture group in light-microscope was better than model group.
(3) The amounts of bacterium cytoryctes cell and rough endoplasmic reticulum rough endoplasmic reticulum cav in model group after 14 days were highest.And then it was obviously reduced by acupuncture than that in enema group.The amounts of microvilli, mitochondria and rough surface endoplasmic reticulum(RSER) were all decreased, infiltration of inflammatory cells were increased under the electromicroscope.Acupuncture can improve the ultrastructure injury of the obstructive intestinal tissues,promote the recovery of both the function and morphology of the mitochondria and RSER.
(4)The content of Ca~(2+) in model group was significantly higher than that in the sham-operation group at all time points(P＜0.05),especially after 14days.The content of Ca~(2+) was obviously reduced by the acupuncture treament at 14 days after operation (p＜0.01),and the same between normal group and sham-operation group(P＞0.05).
(5)The ST_4 and PCR of chondriosome on IEC in model group was significantly reduced than that in the sham-operation group,and The ST_3 of chondriosome on IEC was higher inversely(P＜0.01).But the ST_4 and PCR of chondriosome in acupunture group was obviously increased by the acupuncture treament after operation,The ST_3 of chondriosome was decreased.There was significantly higher between model group.(P＜0.01),but no as to normal group.
(6) The DAO of intestinal mucosa in model group was significantly reduced than that in the sham-operation group,and the DAO in plasma was higher inversely(P＜0.01).But the DAO of intestinal mucosal in acupunture group was obviously increased by the acupuncture treament after operation,DAO in plasma was decreased at all time points. There was no significantly higher between normal group and sham- operation group. (P＞0.05)
(7) The level of SOD was higher obviously in acupuncture group than that in model group,and the content of NO,MDA in acupuncture group were lower significantly than that of model group.
Conclusions:
(1) Acupuncture can relieve the edema of the obstructive intestinal tissues,The chiu score and W/D ratio of intestinal mucosa injury,the Phyllips score of adhesive intestinum were all decreased.Acupuncture can relieve intestinal adhensive.
(2) Acupuncture can improve the ultrastructure injury of the obstructive intestinal tissues,promote the recovery of both the function and morphology of the mitochondria and rough surface endoplasmic reticulum(RSER).The amounts of bacterium cytoryctes cell and rough endoplasmic reticulum rough endoplasmic reticulum cav were all decreased.
(3)Acupuncture can decrease Ca~(2+) of intestinal epithelial cell and improve the function of chondriosome,lessen injury to IEC.
(4) Acupuncture can anti-free radicals,decrease DAO and protect the the intestinal mucosa from adhesive intestinal obstruction injury.
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