慢性胆囊炎患者电针针刺阳陵泉穴后胆囊收缩素变化与胆囊动脉血流动力学观察

曹子洋，张延彬，张宏春，郑 英



·论著·

·中医·中西医结合研究 ·

慢性胆囊炎患者电针针刺阳陵泉穴后胆囊收缩素变化与胆囊动脉血流动力学观察

曹子洋，张延彬，张宏春，郑 英

目的 探讨慢性胆囊炎患者电针针刺阳陵泉穴对胆囊收缩素水平和胆囊动脉血流动力学的影响。方法 选取2012年12月—2014年6月于聊城市第二人民医院就诊的慢性胆囊炎患者40例为研究对象，采用随机数字表法将患者分为试验组和对照组各20例。试验组电针针刺阳陵泉穴，进针得气后连接电针仪，选用连续波，频率60 Hz，刺激强度以患者局部有明显跳动但不过分强烈为度，留针30 min后关机出针。对照组以同样方法电针针刺同侧足三里穴和阳陵泉穴连线中点下方1.5 cm处假穴。于针刺穴位前10 min及针刺后30 min抽取静脉血，采用放射免疫法检测胆囊收缩素水平；采用彩色多普勒超声诊断仪检测胆囊动脉血流动力学指标，包括最大血流速度(Vmax)、最小血流速度(Vmin)、阻力指数(RI)。结果 两组电针针刺前胆囊收缩素水平比较，差异无统计学意义(P>0.05)。试验组电针针刺后胆囊收缩素水平高于对照组(P<0.05)。试验组电针针刺后胆囊收缩素水平高于电针针刺前(P<0.05)。两组电针针刺前Vmax、Vmin、RI比较，差异无统计学意义(P>0.05)。试验组电针针刺后Vmax、Vmin低于对照组，RI高于对照组(P<0.05)。试验组电针针刺后Vmax、Vmin低于电针针刺前，RI高于电针针刺前(P<0.05)。结论 电针针刺阳陵泉穴可促进慢性胆囊炎患者胆囊收缩素分泌，胆囊动脉血流速度减慢，RI增加。

胆囊炎；针灸疗法；穴,阳陵泉；胆囊收缩素；胆囊动脉

曹子洋，张延彬，张宏春，等.慢性胆囊炎患者电针针刺阳陵泉穴后胆囊收缩素变化与胆囊动脉血流动力学观察[J].中国全科医学，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.

胆之下合穴——阳陵泉穴具有促进胆囊收缩的作用，符合《黄帝内经 素问·咳论》中的经典理论“治腑者，治其合”，即下合穴对治疗腑病有其特异性。胆囊穴属于奇穴，但位于胆经，同样有促进胆囊收缩的作用。有研究通过胆囊的形态学变化证实电针针刺穴位有促进胆囊收缩的功能[1]，亦有学者通过动物实验中胆囊收缩素水平变化探讨针刺穴位与胆囊收缩功能的关系[2]。因胆囊动脉显示较困难，电针针刺穴位对胆囊动脉血流动力学影响的相关研究较少。本研究通过分析胆囊收缩素水平和胆囊动脉血流动力学指标变化，探讨电针针刺阳陵泉穴促进慢性胆囊炎患者胆囊收缩的可能机制。

1 对象与方法

1.2 方法

1.2.1 干预方法 嘱患者素食3 d，停用一切药物，当日禁食、禁饮、禁烟12 h以上，由同一名针灸医师采用BT701-1B型电针仪(上海华谊医用仪器有限公司)实施干预。(1)试验组：患者取仰卧位，选取足少阳胆经的阳陵泉穴GB34常规消毒。选用30号2.0寸毫针，直刺1.2～1.6寸。进针得气后连接电针仪，选用连续波，频率60 Hz，刺激强度以患者局部有明显跳动但不过分强烈为度，留针30 min后关机出针。(2)对照组：选取同侧足三里穴和阳陵泉穴连线中点下方1.5 cm处假穴进行干预，操作方法同试验组。

1.2.2 观察指标

1.2.2.1 胆囊收缩素水平 于针刺穴位前10 min及针刺后30 min抽取静脉血5 ml，采血管内加抑肽酶30 μl(含150 U以上)和10% EDTANa230 μl，30 min内4 ℃条件下以2 000 r/min离心15 min(离心半径为8 cm)，取上清液。采用放射免疫法检测胆囊收缩素水平，试剂盒购自北京华英生物技术研究所，胆囊收缩素参考范围1.0～3.1 pmol/L。

1.2.2.2 胆囊动脉血流动力学变化 分别于针刺穴位前10 min及针刺后30 min采用MyLab 90彩色多普勒超声诊断仪(探头频率3.5 MHz，意大利)检测胆囊动脉频谱指标。显示胆囊长轴断面，加用彩色多普勒血流显像，将彩色多普勒阈值调至0.06 m/s。沿胆囊长轴于胆囊颈部到体部寻找胆囊动脉血流(见图1，本文彩图详见本刊官网www.chinagp.net电子期刊相应文章附件)，显示清楚后，嘱患者屏气，脉冲多普勒取样点置于血流最明亮处，并保持在血管中部，取样容积小于4 mm，角度小于30°，测量胆囊动脉血流动力学指标，包括最大血流速度(Vmax)、最小血流速度(Vmin)、阻力指数(RI)。

2 结果

2.1 胆囊收缩素水平 两组电针针刺前胆囊收缩素水平比较，差异无统计学意义(P>0.05)。试验组电针针刺后胆囊收缩素水平高于对照组，差异有统计学意义(P<0.05)。试验组电针针刺后胆囊收缩素水平高于电针针刺前，差异有统计学意义(P<0.05，见表1)。

2.2 胆囊动脉血流动力学 两组电针针刺前Vmax、Vmin、RI比较，差异无统计学意义(P>0.05)。试验组电针针刺后Vmax、Vmin低于对照组，RI高于对照组，差异均有统计学意义(P<0.05)。试验组电针针刺后Vmax、Vmin低于电针针刺前，RI高于电针针刺前，差异均有统计学意义(P<0.05，见表2、图2)。

表2 两组电针针刺前后胆囊动脉频谱指标比较Table 2 Comparison of arterial hemodynamics of gallbladder between the two groups before and after electroacupuncturing

表1 两组电针针刺前后胆囊收缩素水平比较Table 1 Comparison of the level of cholecystokinin between the two groups before and after electroacupuncturing

图1 胆囊动脉长轴切面彩色多普勒超声图像

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

注：A为电针针刺前，B为电针针刺后

图2 试验组患者电针针刺前后胆囊彩色多普勒超声图像

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

3 讨论

慢性胆囊炎是临床上常见疾病，多数患者由急性胆囊炎慢性迁延而成。慢性胆囊炎患者胆囊收缩功能减退，提高和恢复胆囊收缩功能可促进胆囊排空，以达到治疗目的[4]。

阳陵泉穴具有和解少阳、疏泄肝胆、清泻湿热、祛除风邪、舒筋活络、缓急止痛之功。中医学认为，慢性胆囊炎属胁痛范畴，多由情志郁结、肝气不畅、胆管淤滞、肝胆湿热、积滞成痕而致，故多取胆经穴位及胆的特定穴位予以针刺，起到疏利肝胆、清热祛湿、行气化癖导滞作用。研究发现，针刺上述穴位可促使胆汁分泌和排泄增加，胆总管下段括约肌及Oddi括约肌先收缩后松弛，发挥镇痛和促进胃肠蠕动的作用，有效缓解临床症状[5]。通过神经调节，改善胆囊运动功能，促进胆囊收缩[6]。增强T细胞功能，影响体液或激素的动态平衡，保证疗效长久[7]。多项临床试验及动物实验已经证实针刺阳陵泉穴具有促进胆囊收缩的作用[8-11]。

胆囊收缩素又称缩胆囊素，是由小肠黏膜Ⅰ细胞释放的肽类激素，其主要作用是促进胰腺腺泡分泌各种消化酶，促进胆囊收缩和排泄。胆囊收缩素还可作用于迷走神经传入纤维，通过迷走-迷走反射刺激胰酶分泌。研究显示，胆囊收缩素受体数量减少有其分子病理学基础，胆囊收缩素受体mRNA表达下调，导致胆囊对胆囊收缩素敏感性降低，继而引起胆囊收缩功能降低[12-14]。常小荣等[15]研究证实，电针针刺家兔足三里穴和阳陵泉穴能够增加胃窦部平滑肌、Oddi括约肌组织及血浆中胃动素及胆囊收缩素水平。何国栋等[2]发现，针刺对胆囊收缩素的影响具有穴位特异性。NIU等[16]认为，针刺胆经相关穴位可能通过提高胃动素、胆囊收缩素的释放，增强胃肠平滑肌的运动能力。本研究结果显示，试验组电针针刺后胆囊收缩素水平较电针针刺前增加，且高于对照组，提示针刺阳陵泉穴可促进胆囊收缩素的释放。

胆囊动脉起始在Calot三角内，多由右肝动脉发出，行至胆囊颈部，分为前后两支分布于胆囊的肝面和腹膜面。由于血管细小，加之解剖变异较多，需选取灵敏度高的彩色多普勒超声仪器，同时操作者需具有娴熟的操作技巧[17]。在清晰显示胆囊长轴切面后，加用彩色多普勒血流显像，将速度标尺调整到0.06 m/s，在胆囊颈部到体部即可显示胆囊动脉血流。

本研究结果发现，试验组电针针刺后Vmax、Vmin较电针针刺前减小，RI较电针针刺前增加，而对照组电针针刺假穴前后胆囊动脉血流动力学无明显变化，提示胆囊动脉血流动力学的改变与胆囊动脉的解剖及走行分布有关。胆囊动脉行至胆囊颈部后，分出前支和后支分布于胆囊体部浆膜层表面，前后两支发出多条细小分支穿过胆囊平滑肌层，分布于胆囊黏膜层。在电针针刺阳陵泉穴后，胆总管下段括约肌及Oddi括约肌松弛，胆囊平滑肌收缩，促使胆囊排空。在胆囊平滑肌收缩的同时，胆囊动脉受到胆囊平滑肌的挤压，血流速度减小，RI增加。

综上所述，电针针刺阳陵泉穴通过提高血液中胆囊收缩素水平，降低胆囊动脉血流速度，RI指数，以达到促进胆囊排空的作用。而胆囊收缩素受体在针刺穴位后胆囊排空中的具体作用机制，有待进一步研究。

作者贡献：曹子洋进行课题设计与实施、资料收集整理、成文并对文章负责；张延彬、张宏春、郑英进行课题设计与实施、评估、资料收集整理；张宏春进行质量控制及审校。

本文无利益冲突。

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(本文编辑：吴立波)

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

山东省中医药管理局科技发展计划项目(2013-351)

252600山东省聊城市第二人民医院超声科(曹子洋，张延彬，张宏春)，针灸理疗科(郑英)

曹子洋，252600山东省聊城市第二人民医院超声科；E-mail：ziguang115@163.com

R 575.61

A

10.3969/j.issn.1007-9572.2016.33.014

2016-02-17；

2016-07-20)