肝（二）肝的西醫病理學

肝病4過程：脂肪肝、肝炎、纖維化、肝硬化

脂肪肝：

血液運送過多的脂肪酸到肝臟，超過肝臟可以負荷的程度，便囤積在肝臟，形成脂肪肝，定義為肝臟脂肪含量超過肝臟重量的5%以上。

肝炎有3種:

酒精性肝炎

喝酒喝到肝發炎

脂肪肝肝炎

脂肪肝引發的肝炎

病毒性肝炎有5種

A型肝炎：

A型肝炎病毒（HAV，全名Hepatitis A Virus)引起

A型和E型肝炎的傳播媒介都是藉由污染的飲食，因此主要盛行於經濟較為落後的國家，兩者都只會造成可以自行復原的急性肝炎，惟A型肝炎有極低機率演變成會致死的猛爆性肝炎。

B型肝炎：

B型肝炎病毒（HBV)引起

媽媽有，寶寶有超過九成的機率會感染，並演變成慢性帶原。而成人的傳染途徑則有血液、體液，並僅會有不到5%的患者轉變成慢性肝炎。

大部份的B型肝炎患者無明顯症狀，多半是體檢抽血檢查才發現自己帶原，少部分人會覺得自己食慾不振、容易疲累倦怠..等等，較嚴重的患者會出現黃疸。

B肝帶原者得到肝癌的機率遠遠高於普通人，因此務必定期抽血、腹部超音波追蹤檢查。

C型肝炎：

C型肝炎病毒（HCV)引起

血液傳播，症狀不明顯，絕大多數的患者會在急性感染後轉變成慢性感染。

D型肝炎：

D型肝炎病毒（HDV)引起，B肝病毒的跟屁蟲，患者體內沒有B肝病毒的情況便無法繁殖，因此打B肝疫苗可以一次預防B肝和D肝。

E型肝炎：

E型肝炎病毒（HEV)引起

產生與A肝患者類似的急性症狀如噁心、嘔吐、腹瀉，同樣藉由不潔的飲食傳遞，也都比較少演變成慢性肝炎。

纖維化/肝硬化

騎車犁田或是打球跌倒破皮，傷口久了會結痂，而纖維化的概念類似，肝臟在承受發炎的傷害後留下疤痕，覆蓋掉原本健康的肝組織，降低肝功能之外也減少流向肝臟的血流，劣幣逐良幣，當疤痕組織經年累月的累積，超出肝臟本身所能自行修復的程度之後，便出現肝硬化。

要走到肝硬化需要數十年的時間，然而一但到了這個地步肝這個沈默的器官便會打破沈默了，患者會感覺疲倦、噁心、腹脹、水腫甚至嚴重一點的黃疸等症狀。也正因為要到了肝硬化症狀才會較顯著，因此大部份患者發現時肝臟的狀況多半已不太樂觀。

肝硬化之後緊接著的兩個狀態都頗嚴重的：肝癌或是肝臟衰竭，都算是九死一生的情形。

黃麴毒素

強烈致癌物質，由黴菌在發霉的農作物如玉米、花生內產生，極耐高溫，可以承受到270度左右的高溫才開始分解，因此市售的玉米、花生食品多半經過爆炒、油炸處理，大大的消滅可能殘留的黃麴毒素。

如果食品本身一半發霉，一半沒發霉，別覺得可惜，全部丟掉，因為黴菌的菌絲可能已在看不見的內部生根，分泌毒素，省了小錢傷了肝，一點都划不來。

GOT和GPT

GOT天門冬胺酸轉胺酶（Glutamic Oxaloacetic Transaminase)=AST(Aspartate Amino Transferase)

GPT丙胺酸轉胺酶（Glutamic Pyruvic Transaminase)=ALT(Alanine Amino Transferase)

落落長的名稱看了就頭痛，簡單來說就是肝臟內部負責

蛋白質、胺基酸代謝的酵素們，正常數值皆在40U/L以下，過高通常代表肝臟在發炎。

掛號請按此~

A Thing or Two about Pregnancy Part 2

There is always a reason behind everything that happens in our daily lives. But what should you do when you cannot find the reason? There is a type of infertility that just happens without a reason, which indicates that the patient has undergone a series of routine gynecological examinations but could not find any problems.

The patient's menstruation arrives regularly, the ovarian function is healthy, both fallopian tubes are not obstructed, and there is no inflammation in the pelvic area. In addition, endometriosis, uterine adenomyosis, and uterine polyps are also all ruled out. The AMH value falls between 2-6, which is within the normal range.

AMH, is the abbreviation for anti-Müllerian hormone. The value of AMH can be evaluated by blood test to assess the patient's remaining ova reserve. 

The normal AMH range for women of reproductive age is between 2-4.

 If AMH<1, it means the patient's ovarian function is almost exhausted. 

If  AMH>6, the patient is then assumed to be diagnosed with polycystic ovary syndrome, which can hinder the pregnancy process.

Western medicine has the following conjectures about unexplained infertility:

1. The patient's cervix may undergoes inflammation, making it difficult for sperm to pass through.
2. The function of the fallopian tube may be low.
3. The sperm and ova  just can't pair up and despise each other.

The clinical treatment is to use medication and injection to initiate ovulation, then extract the concentrated sperm of the husband and inject it into the uterus of his spouse. With the assistance of progesterone to help the fertilized ovum implant. The procedure has a success rate of about 15%.

After introducing the Western medical perspective and treatment of unexplained infertility, let's observe this disease through the perspective of traditional Chinese medicine (TCM). We have the so-called "Eight-principle differentiation," which includes yin-yang, exterior-interior, cold-heat, and deficiency-excess. Combined with the five Zang organs and six Fu organs, six Evil qi. Palm Pulse and tongue diagnosis help we Traditional Chinese Physicians to determine what problems a patient has.

Perhaps an infertile patient often experiences back pain, which worsens during menstruation, with her palms and soles of the feet feeling heat, especially in the afternoon. Her tongue is quite red with less or none tongue coating on it, and the her Palm Pulse is Thin and Stagnated. We would then conclude that the patient has a Kidney Yin Deficiency and treat it with Sheng di huang, Shan zhu yu, and Du zhong.

Or perhaps this infertile patient often experiences dizziness, fatigue, and sleepiness while during working hours. Her voice is low, and her menstrual period lasts a long time, with small amount of  blood dripping continuously. Her tongue is pale red with thin white tongue coating, and her Palm Pulse is Deep and Thin. We would then conclude that the patient has a Deficiency of qi and blood and treat it with Dang gui, Huang qi, and Gin shen.

Unlike Western medicine, using devices to conduct detailed examinations to confirm the functionalities of organs, we Traditional Chinese Physicians tend to utilize "whole person healthcare" and integrate all  symptoms that appear on the patient's body to give a diagnosis.

It's hard for us to give out an exact physiological value like AMH, but we focus on the patients as the subject rather than individualized organs to determine whether their current status is excessive or deficient compared to themselves. Balance is our treatment goal, it is about supplementing the deficiency and reducing the excess.

肝（一）肝的西醫生理學

肝若不好，人生是黑白的；肝若好，考卷可能是空白的（誤）究竟這個沈默的器官默默扛起了多少身體裡的機能呢？

碳水化合物（例如葡萄糖）的代謝

當你挨餓、血糖低：

分解肝醣（Glycogen)為人體提供葡萄糖

當你再更餓一點：

藉由糖質新生（Gluconeogenesis)把一些非碳水化合物的素材諸如胺基酸（經蛋白質分解）、乳酸、丙酮酸（Pyruvate)、甘油（經脂肪分解）..等轉化成葡萄糖

當你血糖過高時：

a反過來將葡萄糖轉化成肝醣儲存在肝臟

b把葡萄糖拆成更小但是更多作用的元件：丙酮酸（pyruvate)

丙酮酸可以：

1. 走克氏循環（Krebs cycle) 

      =三羧酸循環（Tricarboxylic acid cycle)

      =檸檬酸循環（Citric acid cycle)

      （一樣的循環三種名稱，令人又困惑又頭痛呢！

      藉以轉化成三磷酸腺苷（ATP）一種能量的形式

2.    被轉變成酮體（Ketone bodies)或是脂肪酸

3.    被轉變成乳酸

也就是說過剩的血糖不一定都被存成肝醣，有可能以ATP的形式被身體內的其他反應拿去消耗掉了，或是變成大家都知道也看得到的肚子上那坨脂肪。

脂肪的代謝

肝臟分泌膽汁（bile）並由膽囊（gallbladder）儲存起來，協助溶解飲食中的脂肪。待脂肪被轉化成較小的組成如三酸甘油脂（Triglyceride )、脂肪酸、膽固醇..等。

這些較小的分子被包進乳糜粒（Chylomicra)中，像一個又一個的包裹，等著被貼上叫做蛋白元（Apoprotein)的標籤，例如:

蛋白元apo A1和A2是高密度脂蛋白(HDL，俗稱好膽固醇)的組成架構；apo B100是低密度脂蛋白（LDL，俗稱壞膽固醇）的組成架構；apo C2則像是一個指令標籤，指揮含有脂蛋白分解酶的組織像是脂肪或是橫紋肌，把包裹中的三酸甘油脂分解成人體可以利用的形式。

 

乳糜粒+蛋白元=脂蛋白（Lipoprotein)，脂蛋白便是脂肪在血液中運輸的一種形式，也就是我們常會聽到的好膽固醇、壞膽固醇：

高密度脂蛋白（HDL,High-density lipoproteins)

識別標籤碼為apo A1和A2，由小腸細胞產生，血液裡的HDL越多，一個人發生心血管疾病的機率就越低。

低密度脂蛋白（LDL,Low-density lipoproteins)

經由中密度脂蛋白（IDL）轉化而來，識別標籤碼為apo B100。當身體組織細胞需要膽固醇時，會合成LDL的受體放在自己的細胞膜上，有點像是在舉手跟快遞要求包裹的感覺。而肝臟也會刷條碼辨識apo B100吸收LDL，讓它卸貨膽固醇。

蛋白質的合成及代謝

合成

肝臟會合成血液中大部份的蛋白，除了免疫球蛋白

代謝

蛋白質被分解成胺基酸之後，會在肝臟被轉化成丙酮酸（Pyruvate)或是酮體（Ketone bodies)。另外由於諸如蛋白質此類的含氮化合物在代謝過程會產生氨（NH3，Ammonia)，而氨會對人體產生危害，肝臟此時便肩負起保護人體的責任，透過合成尿素來降低氨的危害。

血液

a製造肝素（Heparin）避免血液凝固

b老朽的紅血球在失去功用之後被組織內的巨噬細胞摧毀成血紅素（Hemoglobin)其後再繼續分解為膽紅素（Bilirubin)。肝臟會將膽紅素轉化成水溶性的膽紅素葡萄糖醛酸苷（Bilirubin diglucuronide)並分泌到膽管去排除。

膽紅素是造成我們的膽汁和便便是黃色的主因，而某些嚴重肝病的患者他們的肝臟無法有效排除掉血液中的膽紅素，因此皮膚會變成黃色的，我們稱為黃疸（Jaundice)

解毒、排除藥物、解酒

肝臟含有多種酵素可以解毒、將攝入身體內的藥物排出體外，還有乙醇去氫酶ADH負責代謝酒精。

掛號請按此~

性功能（五）性功能的中西藥理學

威而鋼(Viagra)

威而鋼這三個字應該說是無人不知無人不曉，學名Sidenafil citrate，商品名Viagra在1998年剛上市的時候便造成轟動，堪稱男性救星，為陽痿、不舉的患者帶來一絲曙光。

威而鋼運作機轉

先複習一下陰莖勃起的原理：在接受性刺激後海綿體產生NO（一氧化氮），NO會使一種叫做cGMP的二級傳訊者含量上升，進而促使海綿體平滑肌放鬆，讓血液大量流入陰莖，而大量的血液會擠壓住出口：

白膜下靜脈叢（Subtunical venous plexus)，導致輸入的血流量大於輸出的，從而產生勃起（Erection)

有一個掃興的傢伙叫做

第五型磷酸二酯酶（phosphodiesterase type 5)簡稱PDE5，專門找cGMP的麻煩，它會摧毀cGMP讓平滑肌沒辦法放鬆，從而降低勃起的時間和效率。

服用威而鋼除了能增加NO的生成之外，也可以抑制PDE5，增強勃起的效能。

威而鋼使用時機

它有3種劑型分別是25、50和100毫克，通常是建議在性交前一個小時服用，從低劑量的開始，一天一次，並盡量空腹服用，避免影響藥效。

威而鋼的副作用

頭暈（因為其降血壓的功能）、頭痛、臉紅、消化不良、視物模糊（因此不建議服用後駕車）

威而鋼的禁忌症

硝酸類藥物（Nitrates）如硝酸甘油主要用來處理心血管方面的疾病，具有降低血壓的功能，如果跟威而鋼一起服用有高機率導致過低的血壓，引發休克或死亡。因此心血管疾病患者、長期低血壓的患者、高血壓正在服藥控制的患者都必須特別小心。

威而鋼的類似藥物

威而鋼的學名是Sidenafil citrate，其他類似的PDE5抑制劑有avanafil、lodenafil、mirodenafil..等等

中藥處方

相比西藥較無顯著、嚴重的副作用。

中藥處方方面有許多不同的劑型，由弱到強，端看患者所需。有些人可能症狀輕微，簡單的藥粉就能見效；有些人可能症狀較重，需要較強效、較多重的水煎藥劑才有效果。

等級1 科學中藥粉 $

基本款、健保給付

等級2  丸劑 $$

濃度上升，較易吞服，成人約日服6-10顆，較典型的諸如含有鹿角膠、菟絲子的斑龍丸，或是含有龜板、鎖陽的虎潛丸，名稱裡有龍有虎，可能是古人取其服用之後，能夠達到生龍活虎的效果。

另外，有秘魯人參之稱的瑪卡對於提升戰鬥力也很也幫助！

等級3 水煎藥 $$$

有別於成方的固定藥物組成，水煎藥劑的優勢在於能隨情況需要追加藥材，例如氣虛的患者可以追加人參、黃耆；瘀血嚴重的患者可以追加三稜、莪朮等等。又或是說某些患者希望能加重處方中珍稀藥材的比重，例如龜板、鹿角膠、地龍等，也是沒問題的，增強火力支援直到達成療效。一般來說，水煎藥劑皆可達到科學中藥粉約5倍以上的效力。

常見問題

Q1:我的問題不大只是想要補補身體，有需要用到那麼好的藥材或是服用較昂貴的水煎藥嗎？

A1:殺雞焉用牛刀，如果只是偶爾上陣狀況不好垂頭喪氣，或是年過半百想要偶有佳作，定期服用丸劑便能有一定效果。

Q2:我藥要吃多久才能看到效果呢？

A2:羅馬不是一天造成的，身體也不是。舉個極端點的例子來說：照三餐手淫持續三年，然後希望吃三週的藥就能立馬生龍活虎嚇嚇叫，那真的算是難度極高，或是必須動用到極佳的藥材以極高的濃度服用才有一絲希望。一般來說粉劑、丸劑約可三到六個月收效，而水煎藥劑需時再短一些。

Q3:為什麼我有定期服藥效果卻不好？

A3:藥物輔助是「加分」作用，也要檢視一下自己是否有做許多「扣分」的行為，諸如抽菸、體重過重、長期熬夜等等。

詳情請參考本篇「改善性功能」

Q4:呂醫師的門診時間？

A4:「掛號請按此~」

A Thing or Two about Pregnancy Part 1

Some people want to have children but are unable to have one. Yet some without that eagerness  accidentally got conceived. Some traditional folks bear the responsibility of continuing their family name. Some are willing to cost an arm and a leg  just to produce an offspring. Is pregnancy predetermined by nature(gene) or can it be achieved through efforts ?

First of all, let us explore this issue from a physiological perspective. As long as a male's reproductive system does not suffer from major malfunctions or diseases, it will continuously produce mature sperm from the testicles every three months until the day you die. The quantity and mobility of the sperm may be affected by age, but in theory, even an elderly man can still have reproductive ability.

However, things are quite different for females. The number of ova carried throughout their lifetime is a fixed value. After the first meiosis, the limited quantity of ova becomes half-prepared and enters a dormant state until a woman's first menstrual cycle, when they gradually mature into their full form. With a fixed total amount, the number of ova will only decrease with age. As an old saying  goes, "At the age of 40 , the Yin Qi is halved." Without extra enhanced supplementation, body functions will decline by half at the age of 40 ! Therefore, it is more difficult for women to get pregnant at an older age.

In ancient times or during war, food was scarce, and most people were undernourished, making it difficult to obtain sufficient energy for oneself, let alone enough energy to support a new life. Therefore, the primary strategy for traditional Chinese medicine in assisting pregnancy during those times was to supplement Qi and blood, such as using Ba Zhen Tang, which  is like installing a high-capacity battery into an almost-worn-out gear to create a favorable environment for new life.

However, times have changed. Thanks to peace and prosperity, obtaining  foods has become an easy thing. With high-calorie, high-sugar, and high-salt processed foods readily available at convenience stores, fast-food restaurants 24-7. As a result, the consumption of overwhelming excessive energy knocks out our bodies, leading to what traditional Chinese physiology calls a "Phlegm-Damp" body constitution." It is like a highway jammed with cars during holidays, where the original speed of over 100 km/hr is reduced to only 50-60 km/hr. Some patients with "Phlegm-Damp" body constitution may also have difficulty conceiving and require treatment with some Chinese herbs such as Cang Zhu and Huo Xiang to eliminate dampness and phlegm.

With progress in gender equality, women's socio-economical status has significantly grown in modern times, and remaining single or marrying late have become a common thing. For couples who wish to have children at a rather older age, we Chinese physicians would prefer prescriptions containing  kidney-nourishing herbs, such as Du Zhong and Xu Duan. After all, regardless of gender, one's body functions will decline by half after the age of 40, and in the perspective of traditional Chinese physiology, the kidney is responsible for reproductive functions.

Better not  smoke if you want to have children, men and women alike. Smoking is extremely harmful to fertility, and not only does it damage the respiratory system, it also increases the probability of developing many chronic diseases, and significantly reduces both the quantity and activity of sperm. If pregnant women smoke, the probability of causing fetal malformations will also increase. For the sake of your own and your children, quit smoking now!