肝硬化的病证结合诊疗若干热点问题述评

Review of some hot issues in the disease⁃syndrome combined differentiation,diagnosis and treatment of liver cirrhosis

肝硬化属于中医“肝积”范畴,由本病病变发展所致的病死率较高,病证结合是我国当今中医临床诊疗的主要策略。抗病毒药物及微创技术的快速发展与中医药抗肝纤维化中成药的广泛应用在降低我国肝硬化的发病率和病死率方面彰显出明显特色与优势。主要阐述病证结合策略在肝硬化及其并发症诊治中应用的若干临床议题,包括扶正化瘀法抗肝纤维化/肝硬化,胃镜结合补虚化瘀清热法治疗肝硬化所致上消化道出血,中医辨证诊疗肝硬化所致难治性腹水,滋肾养肝法促进肝细胞恢复代偿等。已有临床疗效的论据揭示了肝硬化的核心病机“气虚血瘀”以及“阴虚瘀热”病机的演变规律,但还需要更多临床研究数据的支撑。认为推进建立病证结合治疗肝硬化及其并发症的临床方案,需要积累更规范的循证依据。

Liver cirrhosis belongs to the category of“liver accumulation”in traditional Chinese medicine(TCM),which has a high mortality rate with its progression.Disease-syndrome combined differentiation is the main TCM clinical treatment strategy in China today.The rapid development of antiviral drugs and minimally invasive technology,as well as the wide application of novel traditional Chinese patent medicines and TCM simple preparations against liver fibrosis,have demonstrated distinctive medical advantages in reducing the morbidity and mortality of cirrhosis in China.This paper mainly expounds several clinical issues in the application of disease-syndrome combined differentiation strategy in the diagnosis and treatment of liver cirrhosis and its complications,including:anti-liver fibrosis/cirrhosis by the method of strengthening vital qi and removing stasis;treatment of upper gastrointestinal bleeding due to cirrhosis by gastroscopy combined with the method of invigorating deficiency,removing stasis and clearing heat;TCM syndrome differentiation,diagnosis and treatment of refractory ascites due to liver cirrhosis;and the method of nourishing the kidney and liver to promote hepatocyte recovery and compensation.The evidence of clinical efficacy has revealed the evolution of the core pathogenesis of liver cirrhosis,namely“qi deficiency and blood stasis”and“yin deficiency and stasis-heat”,but more clinical research data are needed to support the finding.It requires more standardized evidence-based support to advance the establishment of clinical protocols for the disease-syndrome combined differentiation and treatment of cirrhosis and its complications.