慢性萎(wei)縮(suo)性胃(wei)炎(yan)(以下簡(jian)稱(cheng)CAG)是消化系統疾(ji)病(bing)中常見病(bing)和難治病(bing)之一。臨床上以胃(wei)脘脹滿、疼痛、嘈雜納少，大便或干或稀(xi)為主要表(biao)現。病(bing)理特(te)點為胃(wei)腺體萎(wei)縮(suo)，粘膜(mo)變薄，粘膜(mo)肌層增厚及(ji)伴有腸上皮化生(sheng)、不(bu)典型增生(sheng)。目前國內外對(dui)本病(bing)尚無好的(de)治療辦法，而中醫藥治療本病(bing)有著明顯的(de)優勢，并且取(qu)得(de)很好的(de)療效(xiao)。
從痞滿辨治
胃(wei)脘(wan)痞(pi)(pi)(pi)滿是本(ben)病的主癥(zheng)之(zhi)一，其病因不同，有虛(xu)實之(zhi)分。《景岳全書》曰：“有邪有滯(zhi)(zhi)而痞(pi)(pi)(pi)者(zhe)，實痞(pi)(pi)(pi)也(ye)；無邪無滯(zhi)(zhi)而痞(pi)(pi)(pi)者(zhe)，虛(xu)痞(pi)(pi)(pi)也(ye)。”此雖曰虛(xu)痞(pi)(pi)(pi)，實乃本(ben)虛(xu)標實，而非無邪無滯(zhi)(zhi)。其發病過程可概括為(wei)“因滯(zhi)(zhi)致虛(xu)，因虛(xu)夾邪”。因此導(dao)滯(zhi)(zhi)法需貫穿于治(zhi)療(liao)始(shi)終。如脘(wan)痞(pi)(pi)(pi)飽脹，食后噯腐，氣滯(zhi)(zhi)、食滯(zhi)(zhi)明顯者(zhe)，予大(da)腹子(zi)皮(pi)(pi)、枳(zhi)實(或(huo)(huo)枳(zhi)殼)、萊菔(fu)子(zi)、焦三(san)仙(xian)行氣消食，忌(ji)(ji)用(yong)苦(ku)寒攻(gong)下之(zhi)品(pin)。時常胃(wei)脘(wan)痞(pi)(pi)(pi)滿，食后加劇，選用(yong)百合、烏藥(yao)、香(xiang)椽(chuan)皮(pi)(pi)、綠(lv)薯(shu)梅等性(xing)味平和之(zhi)理氣藥(yao)，忌(ji)(ji)用(yong)香(xiang)燥(zao)疏散破氣之(zhi)品(pin)，以免(mian)傷(shang)及正氣。癥(zheng)見(jian)脘(wan)痞(pi)(pi)(pi)、胸(xiong)悶(men)、納(na)呆、身重、苔白膩等，證(zheng)屬(shu)挾(xie)濕，治(zhi)當健脾(pi)化濕，少佐芳化，常用(yong)蒼術(shu)、白術(shu)、扁豆、薏苡仁、茯(fu)苓(ling)、藿香(xiang)、佩蘭(lan)、厚樸花(hua)等，忌(ji)(ji)用(yong)辛開苦(ku)降(jiang)治(zhi)實痞(pi)(pi)(pi)之(zhi)法。癥(zheng)見(jian)胃(wei)脘(wan)痞(pi)(pi)(pi)滿，灼熱，口苦(ku)吞酸，大(da)便干結，舌質紅(hong)，苔黃，證(zheng)屬(shu)挾(xie)熱，治(zhi)以甘(gan)涼養胃(wei)，少佐辛苦(ku)泄(xie)熱，藥(yao)用(yong)少許黃連、吳萸(yu)、蒲(pu)公(gong)英，忌(ji)(ji)用(yong)苦(ku)寒直折胃(wei)熱之(zhi)法。癥(zheng)見(jian)久病脘(wan)痞(pi)(pi)(pi)，或(huo)(huo)有隱(yin)隱(yin)刺痛，舌暗或(huo)(huo)有瘀(yu)(yu)點瘀(yu)(yu)斑，證(zheng)屬(shu)挾(xie)瘀(yu)(yu)，治(zhi)當活血通絡，選用(yong)當歸(gui)、丹參、三(san)七粉、地龍，忌(ji)(ji)用(yong)活血逐(zhu)瘀(yu)(yu)攻(gong)逐(zhu)，以免(mian)克伐中氣。
從疼痛論治
“通(tong)者(zhe)，不痛(tong)(tong)也；痛(tong)(tong)者(zhe)，不通(tong)也”。治(zhi)療應止痛(tong)(tong)為(wei)先(xian)，宜選生(sheng)浦(pu)黃、炒(chao)五靈脂、醋元(yuan)胡理氣活(huo)血，化瘀止痛(tong)(tong)。癥(zheng)見胃(wei)(wei)脘隱痛(tong)(tong)，口干欲(yu)飲，大(da)便干結(jie)，舌紅少苔者(zhe)，為(wei)胃(wei)(wei)陰不足，治(zhi)當(dang)益胃(wei)(wei)養陰，藥(yao)用(yong)(yong)北沙參(can)、麥冬、烏(wu)梅、石斛等。癥(zheng)見脘痛(tong)(tong)連脅，攻竄不定，疼痛(tong)(tong)與(yu)情志(zhi)關系密切者(zhe)為(wei)肝(gan)逆犯胃(wei)(wei)，治(zhi)當(dang)疏肝(gan)和胃(wei)(wei)，藥(yao)用(yong)(yong)蘇梗、香附(fu)、陳皮、清(qing)半夏等。癥(zheng)見胃(wei)(wei)痛(tong)(tong)纏綿，喜食(shi)喜按，噯氣呃逆者(zhe)為(wei)脾(pi)胃(wei)(wei)虛弱(ruo)，治(zhi)當(dang)健(jian)脾(pi)益氣，和胃(wei)(wei)降逆，藥(yao)用(yong)(yong)黨參(can)、茯(fu)苓、白術、清(qing)半夏等，如進一步發(fa)展出(chu)現胃(wei)(wei)痛(tong)(tong)纏綿，喜溫(wen)喜按，泛吐清(qing)水(shui)，手足欠溫(wen)，大(da)便稀溏者(zhe)為(wei)脾(pi)胃(wei)(wei)虛寒，治(zhi)當(dang)溫(wen)中健(jian)脾(pi)，藥(yao)用(yong)(yong)良(liang)姜、香附(fu)、桂枝、白芍。癥(zheng)見胃(wei)(wei)脘刺(ci)痛(tong)(tong)，痛(tong)(tong)有定處，夜晚加(jia)甚，得食(shi)加(jia)重者(zhe)為(wei)瘀血阻滯(zhi)，治(zhi)當(dang)活(huo)血止痛(tong)(tong)，藥(yao)用(yong)(yong)乳香、沒藥(yao)、丹(dan)參(can)、田(tian)三(san)七等。
從嘈雜辨治
嘈(cao)雜是脘(wan)中(zhong)饑(ji)嘈(cao)，或作或止。其證有(you)寒(han)熱之(zhi)分，上海黃(huang)文東(dong)教授曾指出(chu)：“胃中(zhong)虛寒(han)，嘈(cao)而(er)(er)喜(xi)熱，惡(e)寒(han)，苔白者，宜(yi)(yi)(yi)用(yong)(yong)(yong)溫中(zhong)和(he)胃；胃中(zhong)有(you)熱，嘈(cao)而(er)(er)口干，舌(she)紅苔黃(huang)，宜(yi)(yi)(yi)用(yong)(yong)(yong)清熱和(he)胃，肝火(huo)犯胃者，嘈(cao)而(er)(er)煩(fan)躁泛酸，宜(yi)(yi)(yi)用(yong)(yong)(yong)清肝瀉火(huo)”。筆者根據上述(shu)觀點，溫中(zhong)和(he)胃劑選用(yong)(yong)(yong)黃(huang)芪(qi)建(jian)中(zhong)湯之(zhi)類；清熱養胃劑選用(yong)(yong)(yong)溫膽湯之(zhi)類，清肝瀉火(huo)劑選用(yong)(yong)(yong)左金丸之(zhi)類，用(yong)(yong)(yong)之(zhi)臨床，常能應(ying)效。
從食欲辨治
食(shi)欲不(bu)振(zhen)是本病的最常見(jian)癥狀之一，宜選用(yong)焦三仙、炒(chao)雞內金、萊菔子(zi)等消(xiao)食(shi)和胃。脾胃氣虛者，食(shi)欲不(bu)振(zhen)，疼痛每于空腹時(shi)加重，而食(shi)后又(you)易(yi)發(fa)脹。胃陰不(bu)足(zu)者，知饑不(bu)思食(shi)，喜進流汁軟食(shi)，食(shi)粗糙食(shi)物則痛作。而腹滿畏食(shi)者，多(duo)屬肝(gan)氣犯胃或瘀血阻滯。應(ying)根(gen)據上(shang)述辨證，處方(fang)用(yong)藥(yao)。
從胃酸辨治
CAG患者胃(wei)(wei)(wei)(wei)(wei)(wei)液分析(xi)常提(ti)示(shi)胃(wei)(wei)(wei)(wei)(wei)(wei)酸(suan)(suan)(suan)(suan)(suan)(suan)減少(shao)，但(dan)治療仍需(xu)根據病(bing)人(ren)不同情(qing)況，進(jin)(jin)行辨證用(yong)(yong)(yong)藥，方能奏效。如低(di)酸(suan)(suan)(suan)(suan)(suan)(suan)而(er)見胃(wei)(wei)(wei)(wei)(wei)(wei)陰不足者，除用(yong)(yong)(yong)烏梅酸(suan)(suan)(suan)(suan)(suan)(suan)甘化陰養酸(suan)(suan)(suan)(suan)(suan)(suan)外，宜選用(yong)(yong)(yong)生地、沙參、麥(mai)(mai)冬、石(shi)(shi)斛甘寒生津引致胃(wei)(wei)(wei)(wei)(wei)(wei)酸(suan)(suan)(suan)(suan)(suan)(suan)產生。食積酸(suan)(suan)(suan)(suan)(suan)(suan)少(shao)或(huo)脾胃(wei)(wei)(wei)(wei)(wei)(wei)氣虛食滯(zhi)酸(suan)(suan)(suan)(suan)(suan)(suan)少(shao)者，首選山楂補酸(suan)(suan)(suan)(suan)(suan)(suan)兼(jian)(jian)消(xiao)食，另(ling)(ling)加用(yong)(yong)(yong)雞內(nei)金、麥(mai)(mai)芽(ya)等藥，促進(jin)(jin)胃(wei)(wei)(wei)(wei)(wei)(wei)腸(chang)運動增強，提(ti)高胃(wei)(wei)(wei)(wei)(wei)(wei)液及胃(wei)(wei)(wei)(wei)(wei)(wei)酸(suan)(suan)(suan)(suan)(suan)(suan)分泌。低(di)酸(suan)(suan)(suan)(suan)(suan)(suan)而(er)見痰濕之病(bing)人(ren)，可用(yong)(yong)(yong)木瓜(gua)補酸(suan)(suan)(suan)(suan)(suan)(suan)，兼(jian)(jian)和(he)胃(wei)(wei)(wei)(wei)(wei)(wei)化濕，另(ling)(ling)加藿香、佩蘭、厚(hou)樸(pu)花(hua)、菖(chang)蒲等芳香化濕之品(pin)，促進(jin)(jin)消(xiao)化和(he)胃(wei)(wei)(wei)(wei)(wei)(wei)酸(suan)(suan)(suan)(suan)(suan)(suan)分泌。寒證病(bing)人(ren)而(er)見酸(suan)(suan)(suan)(suan)(suan)(suan)少(shao)者，則可用(yong)(yong)(yong)良姜、肉桂(gui)等辛溫之品(pin)，刺激胃(wei)(wei)(wei)(wei)(wei)(wei)粘(zhan)膜分泌胃(wei)(wei)(wei)(wei)(wei)(wei)酸(suan)(suan)(suan)(suan)(suan)(suan)。CAG合并有淺表性(xing)胃(wei)(wei)(wei)(wei)(wei)(wei)炎(yan)，疣(you)狀胃(wei)(wei)(wei)(wei)(wei)(wei)炎(yan)，糜(mi)爛出血性(xing)胃(wei)(wei)(wei)(wei)(wei)(wei)炎(yan)，或(huo)胃(wei)(wei)(wei)(wei)(wei)(wei)、十二指腸(chang)球部(bu)潰瘍時，胃(wei)(wei)(wei)(wei)(wei)(wei)液檢(jian)查常提(ti)示(shi)胃(wei)(wei)(wei)(wei)(wei)(wei)酸(suan)(suan)(suan)(suan)(suan)(suan)增加，臨床表現泛酸(suan)(suan)(suan)(suan)(suan)(suan)、吞(tun)(tun)酸(suan)(suan)(suan)(suan)(suan)(suan)、嘈雜(za)、胃(wei)(wei)(wei)(wei)(wei)(wei)灼熱等癥狀，應選用(yong)(yong)(yong)烏賊骨(gu)、煅(duan)瓦楞子、煅(duan)牡(mu)蠣等制酸(suan)(suan)(suan)(suan)(suan)(suan)藥。如泛酸(suan)(suan)(suan)(suan)(suan)(suan)、吞(tun)(tun)酸(suan)(suan)(suan)(suan)(suan)(suan)明顯，配合旋覆花(hua)、代(dai)赭石(shi)(shi)、清(qing)半(ban)夏降逆和(he)胃(wei)(wei)(wei)(wei)(wei)(wei)之品(pin)，嘈雜(za)明顯，配合消(xiao)導或(huo)柔(rou)潤藥如枳(zhi)殼、砂仁，胃(wei)(wei)(wei)(wei)(wei)(wei)灼熱明顯加用(yong)(yong)(yong)白芨、山藥等保護胃(wei)(wei)(wei)(wei)(wei)(wei)粘(zhan)膜。
從胃粘膜相辨治
隨著(zhu)纖維(wei)胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)鏡(jing)的廣泛應用，中醫臨床(chuang)工作者常將(jiang)胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)鏡(jing)作為望診(zhen)的延伸，通過觀察胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)粘(zhan)膜(mo)(mo)(mo)(mo)(mo)相(xiang)，進行辨證(zheng)(zheng)(zheng)和(he)辨病(bing)，宏觀辨證(zheng)(zheng)(zheng)和(he)微觀辨證(zheng)(zheng)(zheng)相(xiang)結合，以(yi)求(qiu)提(ti)(ti)高臨床(chuang)療(liao)效。胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)粘(zhan)膜(mo)(mo)(mo)(mo)(mo)相(xiang)見(jian)(jian)粘(zhan)膜(mo)(mo)(mo)(mo)(mo)紅(hong)白(bai)相(xiang)間，以(yi)白(bai)為主，絲狀血(xue)(xue)管可(ke)見(jian)(jian)，但相(xiang)當(dang)部分(fen)胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)粘(zhan)膜(mo)(mo)(mo)(mo)(mo)紅(hong)紅(hong)為主，或有(you)發赤斑，胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)鏡(jing)提(ti)(ti)示(shi)慢性(xing)胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)炎(yan)(淺表+萎(wei)縮(suo))，證(zheng)(zheng)(zheng)屬脾(pi)胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)虛寒，予(yu)黃芪建中湯加(jia)味。胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)粘(zhan)膜(mo)(mo)(mo)(mo)(mo)相(xiang)見(jian)(jian)粘(zhan)膜(mo)(mo)(mo)(mo)(mo)萎(wei)縮(suo)呈彌漫性(xing)或局限(xian)性(xing)，粘(zhan)膜(mo)(mo)(mo)(mo)(mo)變(bian)薄，粘(zhan)膜(mo)(mo)(mo)(mo)(mo)下血(xue)(xue)管網清(qing)晰可(ke)見(jian)(jian)，分(fen)泌物減(jian)少，蠕動減(jian)慢，胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)鏡(jing)提(ti)(ti)示(shi)慢性(xing)萎(wei)縮(suo)性(xing)胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)炎(yan)，證(zheng)(zheng)(zheng)屬胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)陰不(bu)足(zu)，予(yu)一貫煎加(jia)烏梅(mei)、木瓜、山楂等。胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)粘(zhan)膜(mo)(mo)(mo)(mo)(mo)相(xiang)見(jian)(jian)粘(zhan)膜(mo)(mo)(mo)(mo)(mo)紅(hong)白(bai)相(xiang)間，以(yi)白(bai)為主，小(xiao)彎側多見(jian)(jian)，其余部分(fen)粘(zhan)膜(mo)(mo)(mo)(mo)(mo)充血(xue)(xue)水腫，分(fen)泌物量多，散(san)在均勻糜爛(lan)(lan)出血(xue)(xue)點，胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)鏡(jing)提(ti)(ti)示(shi)慢性(xing)胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)炎(yan)(淺表+糜爛(lan)(lan)+萎(wei)縮(suo))，證(zheng)(zheng)(zheng)屬脾(pi)胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)濕熱(re)，予(yu)半夏(xia)瀉心湯加(jia)減(jian)。胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)粘(zhan)膜(mo)(mo)(mo)(mo)(mo)相(xiang)見(jian)(jian)粘(zhan)膜(mo)(mo)(mo)(mo)(mo)紅(hong)白(bai)相(xiang)間，以(yi)白(bai)為主，小(xiao)彎側多見(jian)(jian)，其余部分(fen)胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)粘(zhan)膜(mo)(mo)(mo)(mo)(mo)紅(hong)白(bai)相(xiang)間，以(yi)紅(hong)為主，粘(zhan)膜(mo)(mo)(mo)(mo)(mo)水腫或見(jian)(jian)粘(zhan)膜(mo)(mo)(mo)(mo)(mo)散(san)在糜爛(lan)(lan)、出血(xue)(xue)點，并見(jian)(jian)膽汁反流，膽汁瘀積，胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)鏡(jing)提(ti)(ti)示(shi)慢性(xing)胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)炎(yan)(淺表+萎(wei)縮(suo))，膽汁反流，證(zheng)(zheng)(zheng)屬膽熱(re)犯胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)，予(yu)柴芩溫膽湯加(jia)減(jian)。胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)粘(zhan)膜(mo)(mo)(mo)(mo)(mo)相(xiang)見(jian)(jian)粘(zhan)膜(mo)(mo)(mo)(mo)(mo)紅(hong)白(bai)相(xiang)間，樹枝樣血(xue)(xue)管透見(jian)(jian)，色暗紅(hong)，粘(zhan)膜(mo)(mo)(mo)(mo)(mo)呈顆粒(li)樣或結節樣增(zeng)生(sheng)，胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)鏡(jing)提(ti)(ti)示(shi)慢性(xing)萎(wei)縮(suo)性(xing)胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)炎(yan)，病(bing)理活檢常示(shi)腸(chang)化生(sheng)和(he)不(bu)典(dian)型增(zeng)生(sheng)，證(zheng)(zheng)(zheng)屬胃(wei)(wei)(wei)(wei)(wei)(wei)(wei)絡瘀阻，予(yu)失笑散(san)合丹參飲加(jia)三棱、莪術、路(lu)路(lu)通、穿山甲等。
從病理及幽(you)門螺旋桿菌辨治(zhi)
本病病理活(huo)檢報告伴見腸上皮化生及不典型增(zeng)生，屬胃癌(ai)前期病變(bian)，治療時(shi)針對病理，結合舌(she)苔(tai)是(shi)否黃(huang)(huang)膩，進行選(xuan)(xuan)擇用藥。如舌(she)苔(tai)黃(huang)(huang)膩則(ze)選(xuan)(xuan)用黃(huang)(huang)連、黃(huang)(huang)芩、大(da)黃(huang)(huang)一類具有燥濕作(zuo)用的清(qing)熱(re)解毒藥，否則(ze)可(ke)選(xuan)(xuan)用白花蛇舌(she)草、半支蓮、半邊蓮、蒲公英等(deng)清(qing)熱(re)解毒藥。西醫學認為幽門螺旋(xuan)桿菌(HP)與慢性胃炎(yan)關系(xi)密切，臨床(chuang)上，HP陽(yang)性患者可(ke)選(xuan)(xuan)用大(da)黃(huang)(huang)、黃(huang)(huang)連、丹參、田三七(qi)、桂枝等(deng)對HP高度敏感(gan)的藥物，以便提高臨床(chuang)療效。
【相關鏈接】
李軍祥，男，42歲，主任醫師(shi)，博士生導師(shi)。北京(jing)中醫藥大學東方醫院(yuan)消(xiao)化內(nei)科主任，北京(jing)市首屆群(qun)眾喜愛的中青年名中醫。擅長治療慢性(xing)肝(gan)病如酒精性(xing)肝(gan)硬化、肝(gan)炎(yan)肝(gan)硬化、脂肪(fang)肝(gan)、肝(gan)癌、肝(gan)囊(nang)腫、自身免疫性(xing)肝(gan)病等(deng)疾病和慢性(xing)胃(wei)腸病如萎(wei)縮性(xing)胃(wei)炎(yan)、癌前(qian)病變、反流性(xing)食管(guan)炎(yan)、潰瘍性(xing)結(jie)腸炎(yan)等(deng)。
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