Lesson 5 Spleen / Stomach Diseases 1. Stomach ache

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• Stomach ache refers to a pain over the epigastrium, which is usually accompanied by epigastric upset, poor appetite, eructation and nausea. Epigastric upset

Stomach gas

Bowel motions Appetite

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Etiology and Pathogenesis • The common causes of stomach ache are immoderate eating and drinking, emotional upsets, psychic trauma, overstrain, affection of cold, etc. • However, these causative factors lead to stomach ache only when the Spleen and Stomach are dysfunctioning. • Although the Spleen and Stomach are the organs chiefly involved in this disorder, other organs may also be affected, particularly the 3 Liver.

Syndrome Differentiation and Therapeutic Principles

A. Syndrome differentiation (a) Differential diagnosis • Stomach ache should be distinguished from angina pectoris (心绞痛), hypochondriac pain (胁痛) and abdominal pain (腹痛). • Although angina pectoris is a disorder of the heart meridians characterized by precordial pain, it occasionally manifests itself as an epigastric pain. 4

• Angina pectoris may be differentiated by the colicky (绞痛) character of its pain and its associated symptoms e.g. suffocative sensation, sweating, coldness of limbs, ECG irregularities, etc. • Stomach ache caused by liver-qi attacking the stomach may manifest itself as a radiating pain to the hypochondria, but the epigastrium is the primary painful site. • Abdominal pain may complicate with stomach ache, and the two disorders can be distinguished from each other by the analysis of their causes and the associated symptoms. 5

(b) Differentiation between deficiency and excess syndromes

• The deficiency-syndrome of stomach ache is characterized by a insidious onset, a prolonged course with intermittent relief and pain relievable by pressure and warmth. • This type is mostly due to deficiency of spleen-yang and stomach-yang or insufficiency of stomach-yin and is difficult to cure. • The excess-syndrome of stomach ache is marked by an sudden onset, a short course and pain associated with tenderness. • This type usually results from retention of cold in the stomach, immoderate eating and drinking, an attack of liver-qi on the stomach or stagnation of blood in the stomach, and it responds well to medication. 6

B. Treatment principles

• Regulating qi circulation and the stomach and arresting pain are the general treatment principles for stomach ache, which may be modified according to the cause and the presenting syndrome of the individual case.

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• Moreover, aside from medications, mental and life care is also important for the treatment of stomach ache, such as:  Have fixed amounts of food at fixed times to avoid to to to avoid being hungry or too full.  Keep a food diary and abstain from those types of food and drinks that can trigger stomach ache. These usually include difficult to digest, spicy, oily, raw and cold food, nuts, dairy products, caffeinated drinks and alcohol.  Take easily digested food such as warm porridge and food that is low in fat and high in protein.  Avoid smoking, stress and mood swings.  Have sufficient sleep with regular exercise to enhance your energy circulation and improve your immune system system to prevent recurrence of symptoms. 8

Classification and Treatment A. Excess-syndromes (a) Retention of cold in the stomach • Symptoms: Sudden onset of stomachache which can be relieved by warmth and aggravated by cold, preference for hot drink, thin, white tongue coating and wiry or tense pulse. • Treatment principles: Expel cold and relieve pain. 9

Prescription: Liang Fu Wan (modified type using fresh ginger) Sheng Jiang

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Xiang Fu

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(b) Retention of food • Symptoms: Stomach ache, abdominal distention and fullness, acid eructation or vomiting with undigested food, dyschesia (大便困难), thick, greasy tongue coating and smooth pulse. • Treatment principles: Relieve dyspepsia (消化不良).

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Prescription: Bao He Wan

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Po Chai Pill – mild case prescription

China-made

HK-made

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Prescription: For cases of bloated stomach bloated even without over-eating Mu Xiang Shun Qi Wan

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(c) Attack of liver-qi to the stomach • Symptoms: Distending pain over the epigastric and hypochondriac regions which is induced by emotional upsets, frequent eructation, dyschesia (大便困难), , thin, yellow tongue coating and wiry and smooth pulse. • Treatment principles: Soothe the liver, and regulate qi circulation and the stomach. 17

Prescription: Chai Hu Shu Gan Tang

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Prescription:

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(d) Stagnation of heat in the liver and stomach • Symptoms: Burning pain over the epigastric region, irritability, bitter taste in the mouth, acid regurgitation, gastric upset, red tongue with yellow coating and wiry and rapid pulse. • Treatment principles: Disperse the stagnated liver-qi, regulate the stomach and arrest pain.

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Prescription: Dan Zhi Xiao Yao San

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Prescription: Add below for cases of severe acid regurgitation

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(e) Blood Stasis • Symptoms: Localized stabbing pain and tenderness over the epigastrium (which is aggravated by food intake), hematemesis (吐血) or hematochezia (便血), dark, purplish tongue and thready and unsmooth pulse. • Treatment principles: Activate blood circulation, eliminate blood stasis, and arrest pain. 23

Prescription: Compound Dan Shen formula

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B. Deficiency-syndromes (a) Deficiency of stomach-yin

• Symptoms: Dull pain over the epigastrium, dryness of mouth and throat, feverish sensation, constipation, red and dry tongue and thready and rapid pulse. • Treatment principle: Nourish stomach-yin.

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Prescription: Yi Wei Yang Yin Tang

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(f) Deficiency of the spleen-yang and stomach-yang • Symptoms: Dull pain over the epigastrium (relievable by warmth, pressure and food intake and aggravated by hunger), fluid eructation, mental fatigue, poor appetite, cold limbs, loose stool, pale, swollen tongue with white, greasy coating and feeble or slow and deep pulse. • Treatment principles: Warm middle jiao, and invigorate the spleen. 28

Prescription: Spleen & stomach nourishing tablets + Astragalus root (Huang Qi 黄芪) granules Xiao Jian Zhong Tang

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Huang Qi

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Exercise 5A 1. Which is not the usual symptom accompanied with the spleen disease of stomach ache? (a) nausea (b) epigastric upset (c) amnesia (d) poor appetite 2. In the differential diagnosis of stomach ache, which of the following will not be usually considered (a) angina pectoris (b) hypochondriac pain (c) lumbago (d) abdominal pain 3. For the syndrome differentiation of stomach ache, which of the following is usually used? (a) differentiation between yin and yang (b) differentiation between exterior and interior (c) differentiation between cold and heat (d) differentiation between deficiency and excess 31

4. Symptoms: Patient A has a sudden attach of stomach ache after taking ice cream with ice cold drink. He felt slightly better after drinking hot water. His tongue coating is thin, pulse is tense. The syndrome differentiation for the above of stomach ache is (a) stagnation of heat in the liver and stomach (b) attack of liver-qi to the stomach (c) retention of food in the stomach (d) rention of cold in the stomach 5. Symptoms: Patient B has burning pain over the epigastric region, irritability, bitter taste in the month, acid regurgitation, gastric upset, red tongue with yellow coating and wiry, rapid pulse. The syndrome differentiation for the above is insomnia of (a) stagnation of heat in the liver and stomach (b) attack of liver-qi to the stomach (c) retention of food in the stomach (d) rention of cold in the stomach 32

6. Symptoms: Patient is a fond eater of sashimi for many years. Presently, he has dull pain over the epigastrium, occasionally vomits water, metal fatigue, cold limbs, loose stool, pale, swollen tongue with side teeth marks, white, greasy tongue coating and slow & deep pulse. For the disease of stomach ache, which of the following should be prescribed? (a) liang fu wan 良附丸 (b) bupleurum & peony tablet (dan zhi xiao yao san) 丹栀逍遥片 (c) harmony tablet (bao he tang) 保和片 (d) spleen & stomach nourishing tablet (xiao jian zhong tang) 小建中片 7. Symptoms: Burning pain over the epigastric region, irritability, bitter taste in the month, acid regurgitation, gastric upset, red tongue with yellow coating and wiry, rapid pulse. For the disease of stomach ache, which of the following should be prescribed? (a) liang fu wan 良附丸 (b) bupleurum & peony tablet (dan zhi xiao yao san) 丹栀逍遥片 (c) harmony tablet (bao he tang) 保和片 (d) spleen & stomach nourishing tablet (xiao jian zhong tang) 小建中片 33

Spleen / Stomach Diseases

2. Diarrhea

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• Diarrhea refers to an abnormal frequency and liquidity of fecal discharges but without tenesmus* (里急后重) or purulent (脓性) and blood stools.

Diarrhea

Tenesmus

*Tenesmus = painful spasm of the anal sphincter (肛门括约肌) along with an urgent desire to defecate without the significant production of faeces; associated with irritable bowel syndrome. 35

Etiology and Pathogenesis • The disease chiefly involves the spleen, stomach and intestines and also affects the liver and kidney. • The common causes of diarrhea are the effects of dampness, immoderate diet and drinking, hypofunction of the spleen and stomach, emotional upsets and deficiency of kidney-yang. • The hypofunction of spleen with failure of transportation and transformation and the domination of dampness serve as the chief pathogenesis. 36

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Syndrome Differentiation and Therapeutic Principles

A. Syndrome differentiation (a) Differentiation between diarrhea/dysentery • Diarrhea is characterized by watery discharges and abdominal pain relievable after bowel movement. • Dysentery is marked by “jet spray” discharge of bloody and mucous stools and accompanied by tenesmus (里急后重). 38

(b) Identification of acute and chronic cases • Acute diarrhea is attributable to cold-dampness, dampness-heat and improper diet. • Chronic diarrhea may result from deficiency of the spleen and stomach, deficiency of spleen-yang and kidneyyang and in coordination of the liver and spleen. 39

B. Treatment principles

There are nine therapeutic principles for diarrhea summarized by the ancient physicians: 1. Eliminating dampness with bland drugs 2. Clearing away heat 3. Lifting up middle-jiao qi 4. Dredging with diuretics (利尿剂) “ease out urine to solidify stool 利小便实大便” 5. Soothing with sweet drugs 6. Alleviating diarrhea with sour drugs 7. Drying the spleen 8. Warming the kidneys and 9. Arresting discharge with astringents

These principles should be applied accordingly. 40

Classification and Treatment (a) Diarrhea of cold-dampness type • Symptoms: Watery stool, abdominal pain, increased borborygmus (腹鸣), loss of appetite, pale tongue with white greasy coating and deep and slow pulse. • Treatment principles: Expel cold and dampness, and arrest diarrhea. 41

Prescription: Huo Xiang Zheng Qi San

For best effect, use liquid type.

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(b) Diarrhea of dampness-heat type • Symptoms: Discharge of odorous, loose stool, abdominal pain, burning sensation in the anus, restlessness, thirst, dark yellow urine, thick and yellow greasy tongue coating and soft-floating and rapid pulse.

• Treatment principles: Clear away heat and eliminate dampness. 44

Prescription:

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Prescription: For mild case, use AA capsule (a coptidis or Huang Lian 黄连 substitution) Chuan Xin Lian

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(c) Diarrhea due to indigestion • Symptoms: Diarrhea with discharge of odorous stool, abdominal pain relieved after bowel movement, distension over the epigastrium and abdomen, eructation, anorexia (胃呆), thick greasy tongue coating and wiry or slippery pulse. • Treatment principles: Relieve dyspepsia, and stop diarrhea. 47

Prescription: Harmony + Kang Ling Digestive Comfort tablets Bao He Wan

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(d) Diarrhea due to weakness of the spleen and stomach • Symptoms: Loose stool containing undigested food, fullness over the epigastrium and abdomen, poor appetite, sallow complexion, fatigue, pale tongue with thin, greasy coating and deep and slow pulse. • Treatment principles: Strengthen the spleen and stomach, and eliminate dampness. 50

Shen Ling Bai Zhu San

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(e) Diarrhea due to deficiency of spleen-yang and kidney-yang (Dawn Diarrhea五更泻) • Symptoms: Morning diarrhea, abdominal pain and increased borborygmus before bowel movement, weakness and soreness of lumbus and knees, coldness of lower extremities, pale tongue with white coating and deep and thready pulse. • Treatment principles: Warm the kidneys and benefit the spleen, and arrest diarrhea by using astringents. 52

Prescription: Four-Miracle Pill (Si Shen Wan) 四神丸(original) 1. Fructus Jujube 6 g 2. Rhizoma Zingiberis 6 g 3. Fructus Psoraleae 15 g 4. Semen Myristicae 10 g 5. Fructus Schisandrae 6 g 6. Fructus Evodiae 10 g

1. Da Zao 大枣

4. Rou Dou Kou 肉豆蔻

2. Sheng Jiang 生姜

5. Wu Wei Zi 五味子 53

3. Bu Gu Zi 补骨脂

6. Wu Zhu Yu 五茱萸

Prescription: Four-Miracle Pill (Si Shen Wan) 四神丸(modified)

2. Sheng Jiang

1. Da Zao

3. Bu Gu Zi

5. Wu Wei Zi

4. Xian He Cao

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6. Sheng Jiang

(f) Diarrhea due to incoordination of the liver and spleen • Symptoms: Diarrhea upon onset of abdominal pain (which is not alleviated after bowel movement and is aggravated by nervousness), oppression and distention over the chest and hypochondrium, eructation, poor appetite, reddish tongue with white, greasy coating and thready and wiry pulse. • Treatment principles: Clear away liver-fire, support the spleen, and stop diarrhea. 55

Prescription: Important Formula for Painful Diarrhea (Tong Xie Yao Fang) 痛泻要方

1. Bai Shao

3. Fang Feng 56

2. Bai Zhu

4. Chen Pi

Exercise 5B 1. Which of the following is not considered significant when differentiating between diarrhea and dysentery ? (a) watery fecal discharge or “explosive” discharge of purulent/blood stools (b) without or with tenesmus (c) abdominal pain relievable or not relievable after bowel movement (d) without or with history of taken unhygienic food 2. Chronic diarrhea is the result of irregular functions of the following zang fu. (a) spleen, stomach, kidney, liver (b) ) spleen, stomach, kidney, heart (c) spleen, stomach, kidney, gallbladder (d) ) spleen, stomach, kidney, lung 3. Which of the following is not 1 of the 9 therapeutic principles for diarrhea? (a) Drying the stomach (b) Clearing away heat (c) Eliminating dampness (d) Warming the kidney

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4. Symptoms: Loose stool containing undigested food, fullness over the epigastrium and abdomen, poor appetite, sallow complexion, fatigue, pale tongue with thin, greasy coating and deep and slow pulse. The syndrome differentiation for the above is (a) diarrhea of cold-dampness type (b) diarrhea of dampness-heat type (c) diarrhea due to indigestion (d) diarrhea due to weakness of spleen and stomach 5. Symptoms: Diarrhea with discharge of odorous stool, abdominal pain relieved after bowel movement, distension over the epigastrium and abdomen, eructation, anorexia, thick greasy tongue coating and wiry or slippery pulse. The syndrome differentiation for the above is (a) diarrhea of cold-dampness type (b) diarrhea of dampness-heat type (c) diarrhea due to indigestion (d) diarrhea due to weakness of spleen and stomach 58

6. Symptoms: Loose stool containing undigested food, fullness over the epigastrium and abdomen, poor appetite, sallow complexion, fatigue, pale tongue with thin, greasy coating and deep and slow pulse. For the disease of diarrhea, which of the following should be prescribed? (a) four-miracle pill (si shen wan) 四神丸 (b) absorption & digestion tablet (shen ling bai zhu san) 参苓白术片 (c) agastaches qi regulating tablets (huo xiang zheng qi san) 藿香正气片 (d) harmony tablet (bao he wan) 保和片 7. Symptoms: Diarrhea with discharge of odorous stool, abdominal pain relieved after bowel movement, distension over the epigastrium and abdomen, eructation, anorexia，thick greasy tongue coating and wiry or slippery pulse. For the disease of diarrhea, which of the following should be prescribed? (a) four-miracle pill (si shen wan) 四神丸 (b) absorption & digestion tablet (shen ling bai zhu san) 参苓白术片 (c) agastaches qi regulating tablets (huo xiang zheng qi san) 藿香正气片 (d) harmony tablet (bao he wan) 保和片

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Thank You 60