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CT定量诊断与脂肪肝中医证型的相关性
作者:佚名  文章来源:中国新闻网  点击数  更新时间:2007-12-16 20:09:08  文章录入:huangyf81  责任编辑:huangyf81

  在脂肪肝中医证候研究和疗效评价方面,多采用超声检测技术[1],而较少见应用CT定量测定方 法研究脂肪肝的中医证型[2]。本研究利用CT定量分析的优势,参照国家中医药管理局发布的《中医病症诊断疗效标准》[3],初步探讨了CT定量诊断与脂肪肝中医辨证分型的相关性。

  1 资料与方法

  1.1 研究对象 选取本院2005年1月~2006年 1月 就诊的脂肪肝病例113例,其中门诊病例 83例, 年龄27~77岁,平均45岁。其中男性66例(年龄27~73岁),平均43岁;女性17例(年龄29~ 77岁), 平均54岁。住院病例30例,年龄26~ 86岁, 平均55岁。其中男性16例(年龄26~ 72岁), 平均50岁;女性14例(年龄29~86岁),平均60岁。所有病例均参照中华医学会肝脏病学会脂肪肝和酒精性肝病学组制定的脂肪肝诊断标准[4],均经常规肝脾CT平扫定量诊断,其中35例行增强CT检查,由两名高年资影像科医师阅片;入选病例排除合并病毒性肝炎、药物性肝炎和自身免疫性肝病等肝脏疾病或消化道恶性肿瘤患者,并另由两位高年资中医医师参照国家中医药管理局发布的《中医病症诊断疗效标准》[3],结合魏华凤等[5]《脂肪肝辨证分型规律的初步研究》,辨证分为肝郁脾虚(syndrome of stagnation of liver qi and spleen defi-ciency)、痰瘀互结(syndrome of intermingled phlegm and blood stasis)、痰湿内阻(syndrome of phlegm-dampness blocking internally)、肝肾不足(syndrome of deficiency of liver and kidney)和湿热内蕴(syndrome of interior dampness-heat)五型。入选病例中,住院病例中合并胆道结石、炎症13例,胆囊息肉2例,胰腺炎5例,冠心病、高血压3例,肾结石、肾积水1例。

  1.2 CT检查 采用美国GE公司Lightspeed Plus四层螺旋CT扫描机,常规肝脾CT平扫检查,必要 时增强扫描(如肝岛、局灶型脂肪肝的鉴别诊断)。 兴趣区测量选取病灶的中心层面,应用GE公司AW 4.0工作站的测量软件,分别测量病灶和脾脏的CT值,以不同的兴趣区各测值3次,获取肝脂肪浸润区及脾脏CT值的平均值,计算肝脾CT值比值。CT诊断标准参照中华医学会肝脏病学会脂肪肝和酒精性肝病学组关于CT诊断脂肪肝的标准[4]。

  1.3 统计学方法 采用SPSS 12.0统计软件。计量资料采用方差分析( q 检验),计数资料采用χ2检验。

  2 结果

  2.1 脂肪肝中医证型与CT分型、分度的相关性

  2.1.1 脂肪肝中医证型与CT分型的相关性 脂肪肝中医证型与肝脂肪浸润关系密切。脂肪肝五个证型,均以弥漫型脂肪浸润为主,弥漫型和局灶型脂肪浸润构成比的差异有统计学意义( P <0.05)。见表1,图1和图2.

  2.1.2 脂肪肝中医证型与CT分度的关系 轻度脂肪肝以肝郁脾虚型为主,其次为湿热内蕴型、痰湿内阻型、肝肾不足型、痰瘀互结型。见表1.

  2.2 脂肪肝中医证型与肝脾CT值比值的相关性 肝郁脾虚、痰瘀互结、痰湿内阻、肝肾不足和湿热内蕴型的肝脾CT值比值分别为(0.882 4±0.112 0)、(0.734 8±0.157 2)、(0.762 8±0.281 7)、(0.922 1±0.052 8)和(0.851 8±0.137 1) .痰湿内阻型、痰瘀互结型与肝郁脾虚型、肝肾不足型、湿热内蕴型之间的肝脾CT值比值的差异有统计学意义( P <0.05 ),痰湿内阻型与痰瘀互结型之间的肝脾CT值比值差异无统计学意义( P >0.05)。见图1和图2.

  表1 脂肪肝中医证型与CT分型、分度的关系(略)

  Table 1 Relation of syndrome differentiation and the typing and graduation of CT scanning results

  图1 局灶性脂肪肝(略)

  Figure 1 Focal type fatty liver

  A: The fatty infiltration of the liver was local; there was low lamellar density shadow in posterior segment of the right lobe of the liver, which was non-globular and showed transitional change without positioning effect; the ratio of liver and spleen CT values was 0.365 0. B: Enhance-ment scanning of the same case of A. It could be distinguished from occupying lesion in the liver.

  图2 弥漫性脂肪肝(略)

  Figure 2 Diffusion type fatty liver

  A: This case was diagnosed as mild fatty liver with syndrome of stagnation of liver qi and spleen deficiency. The liver density was reduced wide-ly; the CT value of the liver was lower than that of the spleen; the ratio of the liver and spleen CT values was 0.935 7, between 1.0 and 0.7. B: This case was diagnosed as severe fatty liver with syndrome of phlegm-dampness blocking internally. CT scanning showed diffused, severe fatty liver, there was limpid blood vessel shadow; the ratio of the liver and spleen CT values was 0.449 3. C: This case was diagnosed as mild fatty liver with syndrome of interior dampness-heat. CT scanning showed diffused, mild fatty liver; the ratio of the liver and spleen CT values was 0.969 6. D: This case was diagnosed as moderate fatty liver with syndrome of interior dampness-heat. There was undefined blood vessel shadow; the ratio of the liver and spleen CT values was 0.685 2, between 0.7 and 0.5.

  3 讨论

  随着生活水平的提高,脂肪肝的发病率逐年上升,并大有向年轻化发展的趋势[6,7]。在中医学中无此病名,根据其临床表现,可归属于“积证”、“痞满”、“胁痛”、“痰癖”、“眩晕”、“瘀血”、“痰湿”和“积聚”等范畴[8]。本病的发病原因主要是饮食不节、情志失调。其病理机制主要是肝失疏泄、脾失健运、湿热内蕴、痰浊郁结和瘀血阻滞,其中气滞、气虚者病轻,湿阻、血瘀者病重[9]。病位主要在肝,与脾、胃、肾密切相关。医学影像学作为中医四诊的补充,以及中医证的研究手段和指标,已逐步被引入到中医辨证分型规范化的研究中。目前,国内在脂肪肝中医辨证分型的规范化研究中,多采用超声检测技术、血清生化指标等[10~12],应用CT定量测定方法的研究相对较少。根据文献资料的统计分析[13~16],以及Jacobs等[17]、Johnston等[18]分别对CT定量诊断与定性诊断、常规平扫与增强定量诊断的比较,CT定量诊断脂肪肝较B超量化诊断更为可靠,而在不典型脂肪 肝、脂肪肝合并肿瘤的诊断以及脂肪肝与肝脏肿瘤的鉴别诊断上,可以结合MRI检查。本研究采用CT定量诊断,初步研究其与脂肪肝中医证型的相关性,结果显示,在一定程度上,CT对中医各证型脂肪肝的定量诊断与脂肪肝中医病理机制、证型演变相吻合。本结论与缪锡民[9]的研究结果一致,即对脂肪肝的中医辨证认为,脾失健运,湿热内蕴,痰浊阻滞,瘀血内停,而形成湿、痰、瘀互结,痹阻于肝脏脉络,故而肝郁脾虚型较痰瘀互结型、痰湿内阻型、湿热内蕴型轻,表明CT定量诊断与脂肪肝中医证型有一定的相关性。肝脾CT值比值的统计学分析表明,肝郁脾虚型、肝肾不足型相对于湿热内蕴型、痰湿内阻型、痰瘀互结型病情为轻。说明各证型之间轻、中、重度脂肪肝的肝脾CT值比值可能存在一定的差别,提示肝脾CT值比值可以作为区分各证型的一种客观指标之一,对判断各证型脂肪浸润程度,具有参考价值。本研究的主要局限在于样本量仍较小,在本组资料五个证型中,轻、中度脂肪肝较多,共108例,重度脂肪肝仅5例,所示各证型肝脾CT值比值相互有重叠;此外,疾病发展的各个阶段并非截然分开,证型之间可能相互兼夹,而临床辨证分型时往往是以某一个证型为主;因而需更大的样本量,做进一步的研究,以期通过CT定量测定来规范中医证型。

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