慢性膽囊炎患者電針針刺陽(yáng)陵泉穴后膽囊收縮素變化與膽囊動(dòng)脈血流動(dòng)力學(xué)觀(guān)察

曹子洋，張延彬，張宏春，鄭 英

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·論著·

·中醫(yī)·中西醫(yī)結(jié)合研究 ·

慢性膽囊炎患者電針針刺陽(yáng)陵泉穴后膽囊收縮素變化與膽囊動(dòng)脈血流動(dòng)力學(xué)觀(guān)察

曹子洋，張延彬，張宏春，鄭 英

目的 探討慢性膽囊炎患者電針針刺陽(yáng)陵泉穴對(duì)膽囊收縮素水平和膽囊動(dòng)脈血流動(dòng)力學(xué)的影響。方法 選取2012年12月—2014年6月于聊城市第二人民醫(yī)院就診的慢性膽囊炎患者40例為研究對(duì)象，采用隨機(jī)數(shù)字表法將患者分為試驗(yàn)組和對(duì)照組各20例。試驗(yàn)組電針針刺陽(yáng)陵泉穴，進(jìn)針得氣后連接電針儀，選用連續(xù)波，頻率60 Hz，刺激強(qiáng)度以患者局部有明顯跳動(dòng)但不過(guò)分強(qiáng)烈為度，留針30 min后關(guān)機(jī)出針。對(duì)照組以同樣方法電針針刺同側(cè)足三里穴和陽(yáng)陵泉穴連線(xiàn)中點(diǎn)下方1.5 cm處假穴。于針刺穴位前10 min及針刺后30 min抽取靜脈血，采用放射免疫法檢測(cè)膽囊收縮素水平；采用彩色多普勒超聲診斷儀檢測(cè)膽囊動(dòng)脈血流動(dòng)力學(xué)指標(biāo)，包括最大血流速度(Vmax)、最小血流速度(Vmin)、阻力指數(shù)(RI)。結(jié)果 兩組電針針刺前膽囊收縮素水平比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。試驗(yàn)組電針針刺后膽囊收縮素水平高于對(duì)照組(P<0.05)。試驗(yàn)組電針針刺后膽囊收縮素水平高于電針針刺前(P<0.05)。兩組電針針刺前Vmax、Vmin、RI比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。試驗(yàn)組電針針刺后Vmax、Vmin低于對(duì)照組，RI高于對(duì)照組(P<0.05)。試驗(yàn)組電針針刺后Vmax、Vmin低于電針針刺前，RI高于電針針刺前(P<0.05)。結(jié)論 電針針刺陽(yáng)陵泉穴可促進(jìn)慢性膽囊炎患者膽囊收縮素分泌，膽囊動(dòng)脈血流速度減慢，RI增加。

膽囊炎；針灸療法；穴,陽(yáng)陵泉；膽囊收縮素；膽囊動(dòng)脈

曹子洋，張延彬，張宏春，等.慢性膽囊炎患者電針針刺陽(yáng)陵泉穴后膽囊收縮素變化與膽囊動(dòng)脈血流動(dòng)力學(xué)觀(guān)察[J].中國(guó)全科醫(yī)學(xué)，2016，19(33)：4092-4095.[www.chinagp.net]

CAO Z Y，ZHANG Y B，ZHANG H C,et al.Effects of electroacupuncturing at Yanglingquan on cholecystokinin change and arterial hemodynamics of gallbladder in patients with chronic cholecystitis[J].Chinese General Practice，2016，19(33)：4092-4095.

膽之下合穴——陽(yáng)陵泉穴具有促進(jìn)膽囊收縮的作用，符合《黃帝內(nèi)經(jīng) 素問(wèn)·咳論》中的經(jīng)典理論“治腑者，治其合”，即下合穴對(duì)治療腑病有其特異性。膽囊穴屬于奇穴，但位于膽經(jīng)，同樣有促進(jìn)膽囊收縮的作用。有研究通過(guò)膽囊的形態(tài)學(xué)變化證實(shí)電針針刺穴位有促進(jìn)膽囊收縮的功能[1]，亦有學(xué)者通過(guò)動(dòng)物實(shí)驗(yàn)中膽囊收縮素水平變化探討針刺穴位與膽囊收縮功能的關(guān)系[2]。因膽囊動(dòng)脈顯示較困難，電針針刺穴位對(duì)膽囊動(dòng)脈血流動(dòng)力學(xué)影響的相關(guān)研究較少。本研究通過(guò)分析膽囊收縮素水平和膽囊動(dòng)脈血流動(dòng)力學(xué)指標(biāo)變化，探討電針針刺陽(yáng)陵泉穴促進(jìn)慢性膽囊炎患者膽囊收縮的可能機(jī)制。

1 對(duì)象與方法

1.2 方法

1.2.1 干預(yù)方法 囑患者素食3 d，停用一切藥物，當(dāng)日禁食、禁飲、禁煙12 h以上，由同一名針灸醫(yī)師采用BT701-1B型電針儀(上海華誼醫(yī)用儀器有限公司)實(shí)施干預(yù)。(1)試驗(yàn)組：患者取仰臥位，選取足少陽(yáng)膽經(jīng)的陽(yáng)陵泉穴GB34常規(guī)消毒。選用30號(hào)2.0寸毫針，直刺1.2～1.6寸。進(jìn)針得氣后連接電針儀，選用連續(xù)波，頻率60 Hz，刺激強(qiáng)度以患者局部有明顯跳動(dòng)但不過(guò)分強(qiáng)烈為度，留針30 min后關(guān)機(jī)出針。(2)對(duì)照組：選取同側(cè)足三里穴和陽(yáng)陵泉穴連線(xiàn)中點(diǎn)下方1.5 cm處假穴進(jìn)行干預(yù)，操作方法同試驗(yàn)組。

1.2.2 觀(guān)察指標(biāo)

1.2.2.1 膽囊收縮素水平 于針刺穴位前10 min及針刺后30 min抽取靜脈血5 ml，采血管內(nèi)加抑肽酶30 μl(含150 U以上)和10% EDTANa230 μl，30 min內(nèi)4 ℃條件下以2 000 r/min離心15 min(離心半徑為8 cm)，取上清液。采用放射免疫法檢測(cè)膽囊收縮素水平，試劑盒購(gòu)自北京華英生物技術(shù)研究所，膽囊收縮素參考范圍1.0～3.1 pmol/L。

1.2.2.2 膽囊動(dòng)脈血流動(dòng)力學(xué)變化 分別于針刺穴位前10 min及針刺后30 min采用MyLab 90彩色多普勒超聲診斷儀(探頭頻率3.5 MHz，意大利)檢測(cè)膽囊動(dòng)脈頻譜指標(biāo)。顯示膽囊長(zhǎng)軸斷面，加用彩色多普勒血流顯像，將彩色多普勒閾值調(diào)至0.06 m/s。沿膽囊長(zhǎng)軸于膽囊頸部到體部尋找膽囊動(dòng)脈血流(見(jiàn)圖1，本文彩圖詳見(jiàn)本刊官網(wǎng)www.chinagp.net電子期刊相應(yīng)文章附件)，顯示清楚后，囑患者屏氣，脈沖多普勒取樣點(diǎn)置于血流最明亮處，并保持在血管中部，取樣容積小于4 mm，角度小于30°，測(cè)量膽囊動(dòng)脈血流動(dòng)力學(xué)指標(biāo)，包括最大血流速度(Vmax)、最小血流速度(Vmin)、阻力指數(shù)(RI)。

2 結(jié)果

2.1 膽囊收縮素水平 兩組電針針刺前膽囊收縮素水平比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。試驗(yàn)組電針針刺后膽囊收縮素水平高于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。試驗(yàn)組電針針刺后膽囊收縮素水平高于電針針刺前，差異有統(tǒng)計(jì)學(xué)意義(P<0.05，見(jiàn)表1)。

2.2 膽囊動(dòng)脈血流動(dòng)力學(xué) 兩組電針針刺前Vmax、Vmin、RI比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。試驗(yàn)組電針針刺后Vmax、Vmin低于對(duì)照組，RI高于對(duì)照組，差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)。試驗(yàn)組電針針刺后Vmax、Vmin低于電針針刺前，RI高于電針針刺前，差異均有統(tǒng)計(jì)學(xué)意義(P<0.05，見(jiàn)表2、圖2)。

表2 兩組電針針刺前后膽囊動(dòng)脈頻譜指標(biāo)比較Table 2 Comparison of arterial hemodynamics of gallbladder between the two groups before and after electroacupuncturing

表1 兩組電針針刺前后膽囊收縮素水平比較Table 1 Comparison of the level of cholecystokinin between the two groups before and after electroacupuncturing

圖1 膽囊動(dòng)脈長(zhǎng)軸切面彩色多普勒超聲圖像

Figure 1 Color Doppler ultrasound image of gallbladder artery in long axis

注：A為電針針刺前，B為電針針刺后

圖2 試驗(yàn)組患者電針針刺前后膽囊彩色多普勒超聲圖像

Figure 2 Color Doppler ultrasound image of gallbladder in experimental group before and after electroacupuncturing

3 討論

慢性膽囊炎是臨床上常見(jiàn)疾病，多數(shù)患者由急性膽囊炎慢性遷延而成。慢性膽囊炎患者膽囊收縮功能減退，提高和恢復(fù)膽囊收縮功能可促進(jìn)膽囊排空，以達(dá)到治療目的[4]。

陽(yáng)陵泉穴具有和解少陽(yáng)、疏泄肝膽、清瀉濕熱、祛除風(fēng)邪、舒筋活絡(luò)、緩急止痛之功。中醫(yī)學(xué)認(rèn)為，慢性膽囊炎屬脅痛范疇，多由情志郁結(jié)、肝氣不暢、膽管淤滯、肝膽濕熱、積滯成痕而致，故多取膽經(jīng)穴位及膽的特定穴位予以針刺，起到疏利肝膽、清熱祛濕、行氣化癖導(dǎo)滯作用。研究發(fā)現(xiàn)，針刺上述穴位可促使膽汁分泌和排泄增加，膽總管下段括約肌及Oddi括約肌先收縮后松弛，發(fā)揮鎮(zhèn)痛和促進(jìn)胃腸蠕動(dòng)的作用，有效緩解臨床癥狀[5]。通過(guò)神經(jīng)調(diào)節(jié)，改善膽囊運(yùn)動(dòng)功能，促進(jìn)膽囊收縮[6]。增強(qiáng)T細(xì)胞功能，影響體液或激素的動(dòng)態(tài)平衡，保證療效長(zhǎng)久[7]。多項(xiàng)臨床試驗(yàn)及動(dòng)物實(shí)驗(yàn)已經(jīng)證實(shí)針刺陽(yáng)陵泉穴具有促進(jìn)膽囊收縮的作用[8-11]。

膽囊收縮素又稱(chēng)縮膽囊素，是由小腸黏膜Ⅰ細(xì)胞釋放的肽類(lèi)激素，其主要作用是促進(jìn)胰腺腺泡分泌各種消化酶，促進(jìn)膽囊收縮和排泄。膽囊收縮素還可作用于迷走神經(jīng)傳入纖維，通過(guò)迷走-迷走反射刺激胰酶分泌。研究顯示，膽囊收縮素受體數(shù)量減少有其分子病理學(xué)基礎(chǔ)，膽囊收縮素受體mRNA表達(dá)下調(diào)，導(dǎo)致膽囊對(duì)膽囊收縮素敏感性降低，繼而引起膽囊收縮功能降低[12-14]。常小榮等[15]研究證實(shí)，電針針刺家兔足三里穴和陽(yáng)陵泉穴能夠增加胃竇部平滑肌、Oddi括約肌組織及血漿中胃動(dòng)素及膽囊收縮素水平。何國(guó)棟等[2]發(fā)現(xiàn)，針刺對(duì)膽囊收縮素的影響具有穴位特異性。NIU等[16]認(rèn)為，針刺膽經(jīng)相關(guān)穴位可能通過(guò)提高胃動(dòng)素、膽囊收縮素的釋放，增強(qiáng)胃腸平滑肌的運(yùn)動(dòng)能力。本研究結(jié)果顯示，試驗(yàn)組電針針刺后膽囊收縮素水平較電針針刺前增加，且高于對(duì)照組，提示針刺陽(yáng)陵泉穴可促進(jìn)膽囊收縮素的釋放。

膽囊動(dòng)脈起始在Calot三角內(nèi)，多由右肝動(dòng)脈發(fā)出，行至膽囊頸部，分為前后兩支分布于膽囊的肝面和腹膜面。由于血管細(xì)小，加之解剖變異較多，需選取靈敏度高的彩色多普勒超聲儀器，同時(shí)操作者需具有嫻熟的操作技巧[17]。在清晰顯示膽囊長(zhǎng)軸切面后，加用彩色多普勒血流顯像，將速度標(biāo)尺調(diào)整到0.06 m/s，在膽囊頸部到體部即可顯示膽囊動(dòng)脈血流。

本研究結(jié)果發(fā)現(xiàn)，試驗(yàn)組電針針刺后Vmax、Vmin較電針針刺前減小，RI較電針針刺前增加，而對(duì)照組電針針刺假穴前后膽囊動(dòng)脈血流動(dòng)力學(xué)無(wú)明顯變化，提示膽囊動(dòng)脈血流動(dòng)力學(xué)的改變與膽囊動(dòng)脈的解剖及走行分布有關(guān)。膽囊動(dòng)脈行至膽囊頸部后，分出前支和后支分布于膽囊體部漿膜層表面，前后兩支發(fā)出多條細(xì)小分支穿過(guò)膽囊平滑肌層，分布于膽囊黏膜層。在電針針刺陽(yáng)陵泉穴后，膽總管下段括約肌及Oddi括約肌松弛，膽囊平滑肌收縮，促使膽囊排空。在膽囊平滑肌收縮的同時(shí)，膽囊動(dòng)脈受到膽囊平滑肌的擠壓，血流速度減小，RI增加。

綜上所述，電針針刺陽(yáng)陵泉穴通過(guò)提高血液中膽囊收縮素水平，降低膽囊動(dòng)脈血流速度，RI指數(shù)，以達(dá)到促進(jìn)膽囊排空的作用。而膽囊收縮素受體在針刺穴位后膽囊排空中的具體作用機(jī)制，有待進(jìn)一步研究。

作者貢獻(xiàn)：曹子洋進(jìn)行課題設(shè)計(jì)與實(shí)施、資料收集整理、成文并對(duì)文章負(fù)責(zé)；張延彬、張宏春、鄭英進(jìn)行課題設(shè)計(jì)與實(shí)施、評(píng)估、資料收集整理；張宏春進(jìn)行質(zhì)量控制及審校。

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(本文編輯：吳立波)

Effects of Electroacupuncturing at Yanglingquan on Cholecystokinin Change and Arterial Hemodynamics of Gallbladder in Patients with Chronic Cholecystitis

CAOZi-yang，ZHANGYan-bin，ZHANGHong-chun,ZHENGYing.DepartmentofUltrasonic,theSecondPeople′sHospitalofLiaocheng，Liaocheng252600，China

Correspondingauthor:CAOZi-yang，DepartmentofUltrasonic,theSecondPeople′sHospitalofLiaocheng，Liaocheng252600，China；E-mail：ziguang115@163.com

Objective To explore the effects of electroacupuncturing at Yanglingquan on the level of cholecystokinin and arterial hemodynamics of gallbladder in patients with chronic cholecystitis.Methods We enrolled 40 chronic cholecystitis patients who were admitted into the Second People′s Hospital of Liaocheng from December 2012 to June 2014.We divided the patients into experimental group and control group，with 20 patients in each group.The experimental group were electroacupunctured at Yanglingquan,and connected with electricacupuncture after insertion of needle and the qi sensation,selected continuous wave with 60 Hz.The stimulation intensity degree was that patients had partial obvious beating but not too strong.The needle was retained for 30 min,then electric acupuncture was turned off and the needle was withdrawn.The control group were electroacupunctured at the points 1.5 cm below the midpoint of the line segment of lateral to the acnpoints of Zusanli and Yanglingquan at the same foot side.The level of cholecystokinin was detected by radioimmunoassay at 10 min before and 30 min after electroacupuncturing.Vmax,Vmin,RI of gallbladder artery hemodynamics were measured with color Doppler ultrasound imaging at the same time.Results The comparison of the level of cholecystokinin between two groups before electroacupuncturing showed the difference was not statistically significant(P>0.05).After acupuncture,the level of cholecystokinin in the experimental group was significantly higher than that in the control group(P<0.05).In the experimental group,the level of cholecystokinin after electroacupuncturing was significantly higher than before(P<0.05).Vmax,Vmin and RI of gallbladder artery of the two groups showed that the difference was not statistically in before electroacupuncturing(P>0.05).After electroacupuncturing,Vmax,Vmin of gallbladder artery of the experimental group were significantly lower while and RI was significantly higher than those of control group (P<0.05).In the experimental group,Vmax,Vmin of gallbladder artery were also significantly lower and RI higher after electroacupuncturing than before(P<0.05).Conclusion Electroacupuncturing Yanglingquan can increase promote the level secretion of cholecystokinin of patients with chronic cholecystitis,promote gallbladder emptying,decrease blood flow velocity of gallbladder artery and increase RI.

Cholecystitis；Acupuncture-moxibustion；Point GB34 (yanglingquan)；Cholecystokinin；Gallbladder artery

山東省中醫(yī)藥管理局科技發(fā)展計(jì)劃項(xiàng)目(2013-351)

252600山東省聊城市第二人民醫(yī)院超聲科(曹子洋，張延彬，張宏春)，針灸理療科(鄭英)

曹子洋，252600山東省聊城市第二人民醫(yī)院超聲科；E-mail：ziguang115@163.com

R 575.61

A

10.3969/j.issn.1007-9572.2016.33.014

2016-02-17；

2016-07-20)