Shang Han Lun Theory Used to Treat Acute Gallbladder Meridian Pain in Postcholecystectomy Patients

ABSTRACT

Background: Patients who have had cholecystectomies will sometimes present with similar precholecystectomy symptoms, such as upper right quadrant pain and tenderness, bloating, belching and referred pain to the jaw and shoulder area. These symptoms are generally associated with cholecystitis, but without a gallbladder, these patients cannot be viewed as typical cholecystitis patients. TCM treatment can still follow the meridian and symptoms.

Objective: TCM treatment following the theory of six levels of cold invasion as described in the Shang Han Lun (Treatises on Cold Induced Febrile Diseases) was used to treat Gallbladder meridian pain.

Methods, Setting, Patients: Five patients ranging in age from 54 to 89 were treated in private practice with acupuncture and/or Chinese Herbal formulas for pain on the Gallbladder and San Jiao Meridian. All presented with positive Ashi reactions on or around Yang Ling Qian, GB 34.

Outcome measures: Treatment was judged to be successful if the GB 34 Ashi point was no longer tender. In addition, symptom relief, in epigastric or hypochondriac pain, bloating, gas, and neck and shoulder pain was also considered a factor of success.

Results: All patients received some degree of relief of symptomatic pain in the neck and shoulder, reduction of tenderness at GB 34 and a feeling of bloating or fullness under the hypochondrium.

Conclusions: Patients without a gallbladder were treated following a theory from the Shang Han Lun (Treatises on Cold Induced Febrile Diseases) for symptoms generally associated with cholecystitis. By following the treatment principles for the Shaoyang Level of Cold Invasion, patients received relief from their symptoms. Further study is suggested to confirm these results.

 

INTRODUCTION

Cholecystitis is an inflammation of the Gallbladder. The most common cause is gallstones and it is estimated that 10 to 15% of the population in industrialized societies have gallstones. (1) If fever is involved with or without gallstones being present, infection of the gallbladder may be the cause of the cholecystitis. The symptoms associated with cholecystitis are generally sudden severe pain in the upper right quadrant (URQ) or epigastric area. (2) Murphy's sign (tenderness over the intercostal rib during inspiration upon palpation) is also a symptom of gallbladder involvement. (3) Occasionally, the gallbladder is palpable. If jaundice occurs, stone blockage of the bile duct may have occurred. (2) Referred pain to the jaw and shoulder can also occur as can pain in the middle of the back. (4) Acute attacks are usually brought on by consumption of a meal heavy on fats and the attacks usually subside within days with minor intervention and dietary alterations. Chronic cholecystitis can occur if there are repeated acute attacks. Treatment for cholecystitis when gallstones are present, if gangrene of the gallbladder is suspected or chronic attacks do not respond to conservative treatment of dietary changes and antibiotics is surgical intervention to either remove the gallbladder or the stones. (2) The laparoscopic cholescystectomy, the conventional procedure for removal of the gallbladder or stone, allows for faster recovery and fewer complications. However, injury to the bile duct can occur. In addition, it is estimated that 20% of Postcholecystectomy patients continue to experience the same symptoms. (1) One possible explanation is that the original diagnosis was not correct and that the problem had not been present in the gallbladder but was possibly gastritis or pancreatitis.

 

WESTERN SCIENCE PERSPECTIVE

 

Pain in the URQ is one of the major reasons that convince patients to seek treatment for gallbladder problems. Acute or chronic attacks can be extremely painful; fever, nausea and vomiting can also occur. However, it is accepted that these symptomatic patients make up only about 20% of the Gallstone patients. (1) Not all patients with gallstone symptoms are suitable candidates for cholecystectomies. (5) Alternative techniques involving diet modifications, chemical dissolutions and mechanical lithotripsy have been shown to reduce the need for surgery. (1,5) When surgical intervention is deemed appropriate, as in cases where gangrene of the gallbladder has occurred, laparoscopic procedures appear to have the lowest rate of complications. (1) Sometimes patients, who otherwise would need emergency surgery, can delay or avoid more invasive surgical techniques by use of laparoscopic techniques to drain the gallbladder.

Problems with the gallbladder producing pain in the URQ, positive Murphy's sign, nausea or vomiting and/or referred pain can be caused by gallstones, changes in the wall of the gallbladder or even spasms of the sphincter of Oddi (SO). (2) 85% of Gallstones are cholesterol based. Formation of gallstones usually occurs when there is insufficient emptying of the gallbladder, which allows for a build-up of billiary cholesterol. The increased levels of cholesterol can then form crystals of cholesterol. Bile salts can dissolve cholesterol gallstones and can be used in place of surgery to remove gallstones, but there are side effects such as diarrhea, liver toxicity and interference with digestion. Recent studies have looked at bioactive substances that can increase activity of the SO. Even if the stones are dissolved, without addressing the question as to why the stones formed in the first place, new stones can form. (1)

If more complete emptying of the gallbladder occurs, this can decrease the chance of reformation of stones. (6) Usually in order for surgery or laparoscopic procedures to be carried out, confirmation of gallstones through diagnostic imaging needs to have been done. Sometimes engorged gallbladders will manifest on plain radiographs. Though usually contrast films or abdominal ultrasounds are made. If the stones are small or if the patient is obese, imaging may not show evidence of stones. Tests can be done to determine if the SO is emptying properly.

Laboratory tests may show elevation in white blood cells, liver enzymes or serum amylase. (2) The lab tests may not be elevated if the patient is experiencing an acute attack. Even when surgical intervention is carried out and a gallbladder is removed from a patient experiencing acute or chronic symptom, sometimes the pain will still return or never leave. Postcholecystectomy pain is present in some patients following surgery. If the gallbladder is left in place, the recurrence rate is about 10% annually for up to 5 years post-surgery. (1) If the gallbladder has been removed and the pain returns, there is some thought that the original diagnosis of gallstones may have been incorrect and the patient's pain is due to inflammation in another part of the digestive system, i.e. gastritis, pancreatitis or radiculopathy. (2) However, a study done over a 2 year period on 400 consecutive patients with gallstones that had the stones removed by laparoscopy, showed that 54 patients had to have two procedures and 22 patients had to have 3 or more procedures to remove stones (5) This study suggests pain could continue or return in gallbladder patients following surgical intervention. Even if the gallbladder has been removed, stone formation could continue and result in similar symptoms or even more intense symptoms especially if stones are present in the bile duct or pancreas. Formation of stones could be preceded by bile sludge, which if the patient still has a slow or incomplete SO function, could form into stones. Dietary intervention is recommended to help reduce crystallization of cholesterol. Besides bile salts, cyclic monoterpernes, a bioactive ingredient in Olive Oil has been shown to reduce crystal formation and actually was able to dissolve gallstones in humans and rats and hamsters. (1)

 

TCM PERSPECTIVE

Pain in the URQ, especially hypochondriac pain, distension, bloating or belching can be associated with Liver Qi stagnation. (7) In addition to physical symptoms, emotional symptoms associated with Liver Qi Stagnation can also occur, including irritability, flashes of anger, depression, sighing and sleep disturbances. (8) A study was carried out to determine if blood levels of neurohumoral compounds would change in those patients diagnosed with Liver Qi

Stagnation. The patient was diagnosed with Liver Qi Stagnation if they had 3 or more of the following six criteria: hypochondriac, breast or lower abdominal pain, depression, restless or easily irritated, period irregularities, throat obstruction or tense pulse. One group of patients meeting the Liver Qi Stagnation criteria had been diagnosed with chronic cholecystitis. (9)

According to Maciocia, pain in the URQ can be from Liver Qi Stagnation or Damp-Heat in the Gallbladder. The major difference between these diagnoses is the appearance of the tongue and pulse. Liver Qi Stagnation usually presents with a tense or wiry pulse, while one would expect a slippery, full pulse with Damp-Heat syndromes. The tongue appears with little coating in Liver Qi Stagnation but with yellow greasy coating with Damp-Heat. (7) However, the Gallbladder is the Foot Shaoyang Meridian and according to the Shang Han Lun (Treatises on Cold Induced Febrile Diseases), pulses of those who are suffering at the Shaoyang level can range from tight to floating, especially if the condition lingers. Another section on Shaoyang disease indicates that the pulse can be sinking and tight.

All the sections agree that the conformation is one that is best treated with Xiao Chai Hu Tang formula (Minor Bupleurum Decoction). (10) The Huang Di Nei Jing (Yellow Emperor Classic) also discusses conditions related to the Shaoyang. In Chapter 21, excess conditions of the Shaoyang can produce a slippery and perhaps weak pulse and respond to acupuncture at Zu Ling Qi, GB 41. Headaches associated with Shaoyang level are usually centered on the temporal region and Ren Ying, ST 9. In Chapter 40, Shaoyang channel disturbances will have a pulse at St 9, which is twice that at the radial pulses. (11,12) This would be consistent with headache descriptions of throbbing pain in this area. Cholecystitis is usually associated with infection or obstruction in the gallbladder and belongs to the categories of `xie tong' (hypochondriac pain), `dan zhang' (billiary distention) or `huang dan' (jaundice).

The common differentiations of syndromes are in the categories of Qi stagnation, Qi stagnation leading to blood stagnation or Damp -Heat. Qi stagnation is usually responsible for the distending pain under the ribs, pain up the neck and shoulder, taut or wiry and large pulse with white greasy coating. Damp-Heat syndromes usually involve jaundice, fever, nausea and vomiting along with pain in the URQ. Pathogenesis of syndromes usually starts with damp invasion from over consumption of fried, greasy foods or Qi stagnation from strong emotions, or cold invasion to the Shaoyang level. Damp heat invasion can lead to gallstone formation by blocking normal gallbladder function. The gallbladder is important in Qi movement, impairment of which can lead to Qi Stagnation which can lead to blood stagnation, which can then block the meridians, causing pain. (13) Table 1 summarizes the common signs and symptoms associated with the differentiation of syndromes involving the gallbladder.

 

Conformation	Pulse	Tongue	Symptoms
Liver Qi/GB Qi stagnation	Wiry, large	White and greasy	Reflux, Pain URQ, belching foul odor
Qi stagnation/Blood Stasis	Wiry, thready, rough	Dark purple, red spots	Severe pain URQ, dry mouth, bitter taste
Damp Heat	Wiry rapid	Yellow greasy	URQ distension, vomiting, nausea, jaundice, poor appetite, irritable restlessness,
Def Kidney Yang	Wiry, weak	Pale, white greasy	URQ distension, Distension in abdomen, cold aversion, cold limbs
Shaoyang level of cold invasion	Wiry, floating, small, sinking, tight	??????	Bitter taste, swelling around ear, tidal fever distension in URQ

Table 1. Summary of major signs and symptoms of different TCM syndromes of Cholecystitis. (7,8,10,13)

 

RATIONALE OF CASE SERIES

In my practice, I have seen multiple cases of patients presenting with URQ pain, neck and shoulder pain and digestive upsets ranging from belching and bloating to acid reflux symptoms.

During the initial work-up I would routinely palpate the Yuan ling quan, GB 34 point for patients that present any of the above symptoms. If the point demonstrated a positive reaction I would discuss with them how their symptoms could be related to their gallbladder. I started noticing that some of these patients were postcholecystectomy, some as many of 20 or 30 years post surgery.

My treatment would be essentially the same for those patients with or without a gallbladder. Upon reading of the literature, I found that the current Western Science viewpoint is that if the symptoms were the same pre- and post-cholescystectomy then an error had probably been made in the original diagnosis. I decided to review my case files of recent or current postcholecystectomy patients seen at my Office and determine if treatment of these symptoms followed protocol for treatment of Shao Yang (Gallbladder) level of Cold Invasion. I chose five patients that presented with clear symptoms related to the Shao Yang level. All patients had signed consent forms allowing their information to be used in a case series study.

 

CASE STUDY

Five patients were treated in the office suffering from URQ (Upper Right Quadrant) pain. All the patients had cholecystectomies. One patient had surgery as recent as 1 month prior to treatment, while the other patients had their gallbladders removed more than twenty years prior to seeking treatment. All patients remembered the symptoms that had lead them to have the surgery. The patient's current symptoms had certain components similar to the original symptoms but most had new symptoms separate from what they remembered. All patients had a positive Ashi point on or around Yang ling quan, GB 34 prior to treatment. All had decreased or absent Ashi after treatments. Ashi would return if symptoms returned. Table 2 summarizes the signs and symptoms of the 5 patients treated for postcholecystectomy pain.

 

GB 34 ashi  (+/-)

Name	# Of Txs	Yrs From Surgery	Age	Sex	Pulse	Tongue	Chief complaint	Treatment	Before Tx	After Tx.
E.G	2	>20	79	F	Liver full, Heart empty	Slight yellow/greasy	Hip, leg, back pain; edema, depressed	Herbal formula	+	-
C.J.	2	1 mo	57	F	Liver full Spleen deep	Pale	Pale Shoulder/neck pain	Acupuncture Herbal Formula	+	-
Y. G.	2	>20	63	F	Deep	Peeled/Greasy	Neck pain, HA, hypochondriac pain	Herbal Formula	+	-
J. H.	>10	>20	87	F	Liver full Heart empty	Yellow Greasy	Hypochondriac pain, bloating, neck pain	Herbal Formula	+	+*
C. Y.	>10	35	54	F	Liver full, spleen wiry	Yellow Greasy	Hypochondriac pain, fullness around ears	Herbal formula Acupuncture	+	-

 

*Ashi would decrease then return.

Table 2. Information on initial visit signs and symptoms of 5 patients presenting with pain associated with the Gallbladder Meridian as suggested by a positive Ashi response on Yang ling quan GB 34 left side. All 5 patients are post-cholescystectomy.

 

DIAGNOSES

All patients had some degree of pain or distension in the URQ. For some the pain went through to their mid-back and for others it stayed in one spot under the ribs. All patients had normal bowel movements, appetite, thirst and urination. All patients suffered from some sort of sleep disorder, either trouble falling asleep during Gallbladder time 11-1 am or waking during Liver time (1- 3 am). All the patients were menopausal and not taking hormone replacement. The pain reported if other than hypochondriac, followed the Gallbladder meridian. All patients had some degree of neck and shoulder pain and some degree of indigestion from belching and reflux to mild stomach upset. All the patients except for Y.G. presented with pulses consistent with Qi Stagnation. Y.G.'s pulse could indicate Shaoyang level of cold invasion or Yang deficiency. The tongue appearances except for C.J. suggest Phlegm-Heat. C.J.`s tongue and pulse diagnosis is more consistent with Qi stagnation leading to a deficiency syndrome. As mentioned earlier, a sign of Shaoyang excess can be a pulse that is both slippery (excess) and weak. (10,11) If one translates the pulse to be `full' on the Liver/GB pulse and `weak' at another position, then the patients presenting above have more classic Shaoyang patterns. We don't have the tongue appearance mentioned in either the Shang Han Lun (Treatises on Cold Induced Febrile Diseases) or the Huang Di Nei Jing (Yellow Emperor Classics), but the tongue appearances of the five patients are consistent with slippery excess pulses or even the classic thin, sinking or small pulse mentioned in the Shang Han Lun. All the patients have some degree of symptoms mentioned for Shaoyang Level. (10,11,12) The Diagnoses for the 5 patients are Liver and Gallbladder Qi Stagnation, phlegm-Heat and Shaoyang Level of cold invasion.

 

TREATMENT

 

Pain in the URQ is one of the major reasons that convince patients to seek treatment for gallbladder problems. Acute or chronic attacks can be extremely painful; fever, nausea and vomiting can also occur. However, it is accepted that these symptomatic patients make up only about 20% of the Gallstone patients. (1) Not all patients with gallstone symptoms are suitable candidates for cholecystectomies. (5) Alternative techniques involving diet modifications, chemical dissolutions and mechanical lithotripsy have been shown to reduce the need for surgery. (1,5) When surgical intervention is deemed appropriate, as in cases where gangrene of the gallbladder has occurred, laparoscopic procedures appear to have the lowest rate of complications. (1) Sometimes patients, who otherwise would need emergency surgery, can delay or avoid more invasive surgical techniques by use of laparoscopic techniques to drain the gallbladder.

Problems with the gallbladder producing pain in the URQ, positive Murphy's sign, nausea or vomiting and/or referred pain can be caused by gallstones, changes in the wall of the gallbladder or even spasms of the sphincter of Oddi (SO). (2) 85% of Gallstones are cholesterol based. Formation of gallstones usually occurs when there is insufficient emptying of the gallbladder, which allows for a build-up of billiary cholesterol. The increased levels of cholesterol can then form crystals of cholesterol. Bile salts can dissolve cholesterol gallstones and can be used in place of surgery to remove gallstones, but there are side effects such as diarrhea, liver toxicity and interference with digestion. Recent studies have looked at bioactive substances that can increase activity of the SO. Even if the stones are dissolved, without addressing the question as to why the stones formed in the first place, new stones can form. (1)

If more complete emptying of the gallbladder occurs, this can decrease the chance of reformation of stones. (6) Usually in order for surgery or laparoscopic procedures to be carried out, confirmation of gallstones through diagnostic imaging needs to have been done. Sometimes engorged gallbladders will manifest on plain radiographs. Though usually contrast films or abdominal ultrasounds are made. If the stones are small or if the patient is obese, imaging may not show evidence of stones. Tests can be done to determine if the SO is emptying properly.

Laboratory tests may show elevation in white blood cells, liver enzymes or serum amylase. (2) The lab tests may not be elevated if the patient is experiencing an acute attack. Even when surgical intervention is carried out and a gallbladder is removed from a patient experiencing acute or chronic symptom, sometimes the pain will still return or never leave. Postcholecystectomy pain is present in some patients following surgery. If the gallbladder is left in place, the recurrence rate is about 10% annually for up to 5 years post-surgery. (1) If the gallbladder has been removed and the pain returns, there is some thought that the original diagnosis of gallstones may have been incorrect and the patient's pain is due to inflammation in another part of the digestive system, i.e. gastritis, pancreatitis or radiculopathy. (2) However, a study done over a 2 year period on 400 consecutive patients with gallstones that had the stones removed by laparoscopy, showed that 54 patients had to have two procedures and 22 patients had to have 3 or more procedures to remove stones (5) This study suggests pain could continue or return in gallbladder patients following surgical intervention. Even if the gallbladder has been removed, stone formation could continue and result in similar symptoms or even more intense symptoms especially if stones are present in the bile duct or pancreas. Formation of stones could be preceded by bile sludge, which if the patient still has a slow or incomplete SO function, could form into stones. Dietary intervention is recommended to help reduce crystallization of cholesterol. Besides bile salts, cyclic monoterpernes, a bioactive ingredient in Olive Oil has been shown to reduce crystal formation and actually was able to dissolve gallstones in humans and rats and hamsters. (1)

TCM PERSPECTIVE

Pain in the URQ, especially hypochondriac pain, distension, bloating or belching can be associated with Liver Qi stagnation. (7) In addition to physical symptoms, emotional symptoms associated with Liver Qi Stagnation can also occur, including irritability, flashes of anger, depression, sighing and sleep disturbances. (8) A study was carried out to determine if blood levels of neurohumoral compounds would change in those patients diagnosed with Liver Qi

Stagnation. The patient was diagnosed with Liver Qi Stagnation if they had 3 or more of the following six criteria: hypochondriac, breast or lower abdominal pain, depression, restless or easily irritated, period irregularities, throat obstruction or tense pulse. One group of patients meeting the Liver Qi Stagnation criteria had been diagnosed with chronic cholecystitis. (9)

According to Maciocia, pain in the URQ can be from Liver Qi Stagnation or Damp-Heat in the Gallbladder. The major difference between these diagnoses is the appearance of the tongue and pulse. Liver Qi Stagnation usually presents with a tense or wiry pulse, while one would expect a slippery, full pulse with Damp-Heat syndromes. The tongue appears with little coating in Liver Qi Stagnation but with yellow greasy coating with Damp-Heat. (7) However, the Gallbladder is the Foot Shaoyang Meridian and according to the Shang Han Lun (Treatises on Cold Induced Febrile Diseases), pulses of those who are suffering at the Shaoyang level can range from tight to floating, especially if the condition lingers. Another section on Shaoyang disease indicates that the pulse can be sinking and tight.

All the sections agree that the conformation is one that is best treated with Xiao Chai Hu Tang formula (Minor Bupleurum Decoction). (10) The Huang Di Nei Jing (Yellow Emperor Classic) also discusses conditions related to the Shaoyang. In Chapter 21, excess conditions of the Shaoyang can produce a slippery and perhaps weak pulse and respond to acupuncture at Zu Ling Qi, GB 41. Headaches associated with Shaoyang level are usually centered on the temporal region and Ren Ying, ST 9. In Chapter 40, Shaoyang channel disturbances will have a pulse at St 9, which is twice that at the radial pulses. (11,12) This would be consistent with headache descriptions of throbbing pain in this area. Cholecystitis is usually associated with infection or obstruction in the gallbladder and belongs to the categories of `xie tong' (hypochondriac pain), `dan zhang' (billiary distention) or `huang dan' (jaundice).

The common differentiations of syndromes are in the categories of Qi stagnation, Qi stagnation leading to blood stagnation or Damp -Heat. Qi stagnation is usually responsible for the distending pain under the ribs, pain up the neck and shoulder, taut or wiry and large pulse with white greasy coating. Damp-Heat syndromes usually involve jaundice, fever, nausea and vomiting along with pain in the URQ. Pathogenesis of syndromes usually starts with damp invasion from over consumption of fried, greasy foods or Qi stagnation from strong emotions, or cold invasion to the Shaoyang level. Damp heat invasion can lead to gallstone formation by blocking normal gallbladder function. The gallbladder is important in Qi movement, impairment of which can lead to Qi Stagnation which can lead to blood stagnation, which can then block the meridians, causing pain. (13) Table 1 summarizes the common signs and symptoms associated with the differentiation of syndromes involving the gallbladder.

 

Conformation	Pulse	Tongue	Symptoms
Liver Qi/GB Qi stagnation	Wiry, large	White and greasy	Reflux, Pain URQ, belching foul odor
Qi stagnation/Blood Stasis	Wiry, thready, rough	Dark purple, red spots	Severe pain URQ, dry mouth, bitter taste
Damp Heat	Wiry rapid	Yellow greasy	URQ distension, vomiting, nausea, jaundice, poor appetite, irritable restlessness,
Def Kidney Yang	Wiry, weak	Pale, white greasy	URQ distension, Distension in abdomen, cold aversion, cold limbs
Shaoyang level of cold invasion	Wiry, floating, small, sinking, tight		Bitter taste, swelling around ear, tidal fever distension in URQ

Table 1. Summary of major signs and symptoms of different TCM syndromes of Cholecystitis. (7,8,10,13)

 

RATIONALE OF CASE SERIES

In my practice, I have seen multiple cases of patients presenting with URQ pain, neck and shoulder pain and digestive upsets ranging from belching and bloating to acid reflux symptoms.

During the initial work-up I would routinely palpate the Yuan ling quan, GB 34 point for patients that present any of the above symptoms. If the point demonstrated a positive reaction I would discuss with them how their symptoms could be related to their gallbladder. I started noticing that some of these patients were postcholecystectomy, some as many of 20 or 30 years post surgery.

My treatment would be essentially the same for those patients with or without a gallbladder. Upon reading of the literature, I found that the current Western Science viewpoint is that if the symptoms were the same pre- and post-cholescystectomy then an error had probably been made in the original diagnosis. I decided to review my case files of recent or current postcholecystectomy patients seen at my Office and determine if treatment of these symptoms followed protocol for treatment of Shao Yang (Gallbladder) level of Cold Invasion. I chose five patients that presented with clear symptoms related to the Shao Yang level. All patients had signed consent forms allowing their information to be used in a case series study.

 

CASE STUDY

Five patients were treated in the office suffering from URQ (Upper Right Quadrant) pain. All the patients had cholecystectomies. One patient had surgery as recent as 1 month prior to treatment, while the other patients had their gallbladders removed more than twenty years prior to seeking treatment. All patients remembered the symptoms that had lead them to have the surgery. The patient's current symptoms had certain components similar to the original symptoms but most had new symptoms separate from what they remembered. All patients had a positive Ashi point on or around Yang ling quan, GB 34 prior to treatment. All had decreased or absent Ashi after treatments. Ashi would return if symptoms returned. Table 2 summarizes the signs and symptoms of the 5 patients treated for postcholecystectomy pain.

 

GB 34 ashi  (+/-)

Name	# Of Txs	Yrs From Surgery	Age	Sex	Pulse	Tongue	Chief complaint	Treatment	Before Tx	After Tx.
E.G	2	>20	79	F	Liver full, Heart empty	Slight yellow/greasy	Hip, leg, back pain; edema, depressed	Herbal formula	+	-
C.J.	2	1 mo	57	F	Liver full Spleen deep	Pale	Pale Shoulder/neck pain	Acupuncture Herbal Formula	+	-
Y. G.	2	>20	63	F	Deep	Peeled/Greasy	Neck pain, HA, hypochondriac pain	Herbal Formula	+	-
J. H.	>10	>20	87	F	Liver full Heart empty	Yellow Greasy	Hypochondriac pain, bloating, neck pain	Herbal Formula	+	+*
C. Y.	>10	35	54	F	Liver full, spleen wiry	Yellow Greasy	Hypochondriac pain, fullness around ears	Herbal formula Acupuncture	+	-

 

*Ashi would decrease then return.

Table 2. Information on initial visit signs and symptoms of 5 patients presenting with pain associated with the Gallbladder Meridian as suggested by a positive Ashi response on Yang ling quan GB 34 left side. All 5 patients are post-cholescystectomy.

 

DIAGNOSES

All patients had some degree of pain or distension in the URQ. For some the pain went through to their mid-back and for others it stayed in one spot under the ribs. All patients had normal bowel movements, appetite, thirst and urination. All patients suffered from some sort of sleep disorder, either trouble falling asleep during Gallbladder time 11-1 am or waking during Liver time (1- 3 am). All the patients were menopausal and not taking hormone replacement. The pain reported if other than hypochondriac, followed the Gallbladder meridian. All patients had some degree of neck and shoulder pain and some degree of indigestion from belching and reflux to mild stomach upset. All the patients except for Y.G. presented with pulses consistent with Qi Stagnation. Y.G.'s pulse could indicate Shaoyang level of cold invasion or Yang deficiency. The tongue appearances except for C.J. suggest Phlegm-Heat. C.J.`s tongue and pulse diagnosis is more consistent with Qi stagnation leading to a deficiency syndrome. As mentioned earlier, a sign of Shaoyang excess can be a pulse that is both slippery (excess) and weak. (10,11) If one translates the pulse to be `full' on the Liver/GB pulse and `weak' at another position, then the patients presenting above have more classic Shaoyang patterns. We don't have the tongue appearance mentioned in either the Shang Han Lun (Treatises on Cold Induced Febrile Diseases) or the Huang Di Nei Jing (Yellow Emperor Classics), but the tongue appearances of the five patients are consistent with slippery excess pulses or even the classic thin, sinking or small pulse mentioned in the Shang Han Lun. All the patients have some degree of symptoms mentioned for Shaoyang Level. (10,11,12) The Diagnoses for the 5 patients are Liver and Gallbladder Qi Stagnation, phlegm-Heat and Shaoyang Level of cold invasion.

 

TREATMENT

The treatment plan for the five patients was to move Qi, soothe the Liver, regulate the Shaoyang and remove phlegm. All patients received the herbal formula Xiao Chai Hu Tang (san) (Minor Bupleurum decoction in powder form) plus Bai Shao, Paeonia radix, Hai Jin Sha, Lygodii Japonici spores and Wu Bei Zi, Galla Rhois Chinensis. * The 40 grams of powdered herbal formula were placed in 100 capsules and patients were advised to take 4 capsules twice a day before lunch and before bed. Eight capsules could be taken if pain returned. Xiao Chai Hu Tang is the primary formula to regulate the Shao Yang. The ingredients within the formula move Qi and harmonize the middle, Ban Xia, Pinellia removes phlegm, Bai Shao, Paeonia stops pain, Hai Jin Sha, Lygodum spores, dissolves stones. Wu Bei Zi (gallnut) is used because of its similarity to gallstones (principle of like to treat like) and it is used to detoxify. Acupuncture treatment was needling of the ashi point on or around Yang Ling Qian GB 34 (left side only) to a depth sufficient to produce strong deqi reaction. Yang Ling Qian GB 34 regulates the Gallbladder, relaxes tendons and removes damp heat. Patients were asked to take a deep breath and then exhale, the needle being inserted on exhalation to intensify the Qi response. San Yin Jiao, SP 6 and Yin Ling Qian, SP 9 were needled bilaterally for abdominal pain, remove damp and support the Yin organs of the leg. After insertion, the needle was strongly twirled once to the right. Zu Lin Qi GB 41 was needled bilaterally to decrease excess in the Shaoyang Channel. After insertion, the needle was lightly twirled ½ turn to the right. A second manipulation might be done if neck pain was still present. Tai Chong LV 3 was needled bilaterally to soothe the Liver, move Qi and stop pain. Zhong Zhu SJ 3 was needled bilaterally to use the Hand Shaoyang to treat Foot Shaoyang; the needles inserted into these two points were not additionally stimulated. All patients were advised to refrain from eating rich, greasy or fried foods and were advised to drink warm or hot drinks with meals and after eating. All patients were advised to start an exercise program involving deep breathing like Tai Chi, Qi Gong or Yoga to aid in the movement of Qi throughout their body.

 

RESULTS

All patients receiving acupuncture had no pain after treatment and returned for additional treatments as needed. Patients receiving only the herbal formula had a reduction in URQ by the second day of herbs and were able to reduce their dosage to as needed when they felt their URQ or neck/shoulder pain return. Table 3 summarizes the results of treatment of the five patients.

One patient, J.H, is noncompliant in exercise or diet modifications and uses the herbs on a frequent basis whenever the pain returns.

 

Name	Pulse	Tongue	Symptoms	Recommendation	Comments
E.G.	Liver wiry Heart thin	Greasy Decreased	Edema gone, pain came back when stopped herbs	Decrease cold foods and drink, continue herbs as needed, return as needed
C.J.	Liver wiry	Tongue unremarkable	Pain gone	Continue herbs as needed, stop sodas	7 months passed until next visit, pain still gone
Y.G.	Liver wiry	Less geographic	Main GB symptoms gone	Hot drinks, Olive oil, decrease cold & raw foods
J.H.	Liver full	Greasy	Symptoms decrease with herbs and acupuncture	Decrease cold; decrease fried greasy foods, rich foods	Patient noncompliant on diet recommendation
C.Y.	Liver sinking	Yellow	Symptoms improved	Decrease fried, greasy foods, protect from wind	Pain returns when drinks alcohol

Table 3. Summary of results of the five patients treated with the same herbal formula for symptoms associated with the Gallbladder Meridian. Some of the patients received acupuncture. Some of the patients received other formulas for additional symptoms.

 

DISCUSSION

Patients presenting with pain or fullness under the ribs, irritability, belching, and bloating are usually diagnosed with Liver Qi Stagnation, especially if the patient has a wiry pulse and purple tongue. Since these symptoms can also be present in patients with a history of gallbladder problems, Liver/Gallbladder Qi Stagnation can be an appropriate diagnosis. If the tongue is coated with yellow grease and the pulse is slippery. Damp Heat in the Gallbladder can also be an appropriate diagnosis. (7,8) However, Cold invasion into the Shao Yang Level can also produce symptoms associated with Gallbladder. (10) Some of the difficulties in diagnosing the Shao Yang Level are the absence of tongue description and the fact that multiple pulse descriptions are listed for Shao Yang both in the Shang Han Lun (Treatises on Cold Induced Febrile Diseases) and

Huang Di Nei Jing (Yellow Emperor Classic). (10,11,12) However, sufficient clues are present in-patient symptoms to suggest that Shao Yang level is appropriate for diagnosing and treatment.

 

As mentioned, the Shang Han Lun describes Shao Yang level patients as having fullness under the ribs (distension, bloating), tidal fever, alternating hot and cold, which is due in part to the fact that the pathogen has been trapped between Interior and Exterior (between Tai Yang and Yang

Ming). (10) I think that pulse has such a wide variation because of the Cold moving between those two levels. The basic treatment therapy, no matter which pulse is present, would be to harmonize the Shao Yang, for which the best formula is the Xiao Chai Hu Tang (Minor Bupleurum decoction), if bowel movement is normal. I think that these symptoms can be very frustrating for patients because they all assumed that after their surgery to remove their gallbladder that they would not have pain or digestive upsets again. Most of the patients admitted that while the post-cholesectomy pain was not as severe as the pain that lead to the surgery, the pain they were experiencing was severe enough to seek treatment. Most patients denied being told any dietary restrictions following cholesectomy, however, except for occasional lapses, suggestions involving restrictions of fried food, greasy or rich foods and drinking hot drinks with or after meals were met with compliance. Patients started noticing a cause and effect of lapses of diet restrictions and return of symptoms, which increased compliance. All patients found that their primary symptoms for seeking treatment had reduced or were eliminated following acupuncture or herbal formulas. All patients were advised to take the herbal formula as needed whenever their original symptoms returned.

 

CONCLUSION

In conclusion, the treatment of five patients all presenting with symptoms that were consistent with gallbladder problems following removal of the gallbladder was shown to be successful following the principles suggested in the Shang Han Lun for treatment of the Shao Yang Level of

Cold invasion. While all patients received the same herbal formula based on Xiao Chai Hu Tang

(Minor Bupleurum decoction), some patients also had acupuncture. The acupuncture helped reduce immediate symptoms such as pain along the Gall Bladder and/or San Jiao meridian, bloating and distension. The herbal formula was also able to reduce the pain as well. The results of this study suggest the validity of using the Shang Han Lun formula with appropriate modifications to treat symptoms related to the Level of invasion. Further study is needed to verify whether this treatment is valid for post-cholesectomy pain that follows the Shao Yang meridians.

*The formula used is a modification of Xiao Chai Hu Tang (Minor Bupleurum decoction) from the Shang Hun Lun (15) All the herbs Sheng Jiang are powdered raw, either prepared in the office or brought commercially.

5 parts Chai Hu, Bupleurum radix

3 parts Huang Qin, Scutellaria radix

3 parts Xi Yang Shen, Panax

3 parts Gan Cao, Glycyrrhia radix

4 parts Ban Xia, Pinellia

3 parts Sheng Jiang (commercial 5:1 extract) Zingiber

2 parts Da Zao, Ziziphus

4 parts Bai Shao, Paeonia radix

This formula is used intact and modified with:

6 parts of modified Xiao Chai Hu Tang (san)

1 part Wu bei Zi Galla Rhous Chinensis

1 part Hai Jin Sha, Lygodii Spora

(Example: for 100 capsules, 40 grams of formula is used, 5 grams of Wu Bei Zi, 5 grams of Hai Jin Sha and 30 grams of Xiao Chai Hu Tang (san)

 

REFERENCES

1. Konifoff, F. Gallstones-Approach to Medical Management Medscape General Medicine

5(4):1-10 2003 Medscape

2. Teirney L.M, McPhee S.J, Papadakis M.A. eds. Current Medical Diagnosis & Treatment

2005 Lange Medical Books/McGraw-Hill Pub Chap 20 pgs 790-792, 2005

3. Spraycar, M ed, Stedman's Medical Dictionary, 26th Edition, Williams & Wilkins, Baltimore,

MD 1995

4. Damjanov, I. Pathology for the Health-related Professions, W.B. Saunders & CO,

Philadephia, 1996

5. Carr-Locke, D.L. ERCP and Related Technologies: A clinical Update 7th International

Symposium on Pancreatic and Biliary Endoscopy. Torracne CA Jan 20-23 2000 Medscape

6. C.M. Woods, et al Effects of bioactive agents on biliary motor function Curr Gastroenterol

Rep Apr 5(2): 154-9 2003 abs Pub Med

7. Maciocia, G The Practice of Chinese Medicine Churchill Livingstone Pubs, 419-429 1994

8. Cheng X, ed. Chinese Acupuncture and Moxibustion Foreign Language Press, Beijing, 1996

9. Chen, Z-Q, et al , Plasma L-ENK, AVP, ANP and serum gasatrin inpatients with syndrome of Liver-Qi-Stagnation, Worild J Gastroenterology Feb 5 (1):61-63 1999

10. Hsu, H-Y and Peacher, W.G. Shang Han Lun: Wellspring of Chinese medicine, Keats Pub

1981Wu N.L and, Wu A.Q. eds Yellow Emperor's Canon Internal Medicine. China Science & Technology Press, Chap 62 pgs 740-741. 1997

11. Wu N.L and, Wu A.Q. eds Yellow Emperor's Canon Internal Medicine. China Science & Technology Press, Chap 21,40. 1997

12. Veith, I, Translator, The Yellow Emperor's Classic of Internal Medicine, Univ CA, Berkeley,

1972

13. Zhang, E. eds. Clinic of Traditional Chinese Medicine Shanghai Univ of TCM Section 17: 142-147, 1988

 

Gall Bladder Case Study

Treatment of Fecal IncontinenTreatment of Fecal Incontinence of no known origin using Auricular Acupuncture and Herbs

ABSTRACT

 

INTRODUCTION:  G.E. presented with distressing bouts of fecal incontinence that had been occurring for 3 years.   She had no warning of impending bowel movement.   In addition to the fecal incontinence, she experienced diarrhea of loose watery stools more than 4 times a day which also occurred at night during sleep.  Her bouts of diarrhea were preceded by indications of impending bowel movement so she could distinguish between diarrhea and fecal incontinence.    Her fecal incontinence could also occur at night.  Blood tests and diagnostic imaging indicated nothing organic or structural responsible for the diarrhea or fecal incontinence.   The only abnormality was an elevated ESR.

METHODS:    G.E. was treated at my office using auricular acupuncture and herbal formulas.  She was seen once a week for 3 weeks, then once after 2 weeks and then a follow-up visit occurred 3 months after initial treatment.

RESULTS:  Fecal incontinence was eliminated after 3 weeks of acupuncture and herbal formula.  The fecal incontinence returned one week after the herbs were stopped.   Resumption of the herbal formula stopped the fecal incontinence.

CONCLUSION:  Herbs to support the Spleen, Clear Heat and drain fluid through the urine were able to stop fecal incontinence, a condition that usually is only seen when there is neurological damage to the rectum and/or anal sphincter or extreme loose watery stools.  Further study is needed to determine if herbs and acupuncture would also be effective in treating fecal incontinence from known trauma to the rectal nerves and/or anal sphincter.

 

INTRODUCTION

 

     Bowel movements of loose watery stools occurring more than 3 times a day can be considered diarrhea and is usually a symptom of irritable bowel syndrome.   The diarrhea is usually accompanied by intermittent cramping of the lower abdomen which can be relieved by defecation.    However, diarrhea that occurs during sleep and is accompanied by weight loss may indicate an occurrence of an inflammatory process.  This can include inflammatory bowel diseases as well as cancer.1   Fecal incontinence is the inability to control stool and is generally considered to be a problem of neurological control of the anal sphincters, inability to detect rectal fullness or inability to make it to the bathroom in time. 2    Fecal incontinence may or may not be preceded by the urge to defecate.   If the stool is watery and very loose, bowel control can be difficult especially if there is no feeling of urgency or cramping. 1  

 

CASE PRESENTATION

     Case History

 

     46 year old female, G.E., presented at my office complaining of bouts of fecal incontinence.  The incidents started in 2003 and had been getting more frequent.  The bouts of fecal incontinence occurred at any time without warning, but usually were associated with meals.   The incidents were distressing and interfering with G.E.'s  lifestyle to the point where she claimed she was concerned about leaving her house and even eating.   In addition to the fecal continence, G.E. was concerned about her weight loss and inability to gain weight.    Full diagnostic testing had been done prior to her coming to see me and the only abnormality was an elevation in her erythrocyte sedimentation rate (ESR), suggesting an inflammatory response occurring in her body.   Diagnostic imaging showed no abnormalities in the colon.

 

    Assessment and Diagnoses

     G.E. listed her height at 5'4” and her weight at 109 lbs.   She admitted to being slightly depressed.  She stated that she had no problems sleeping except when she had to wake to use the bathroom, because the diarrhea could occur at any time.   She complained of night sweats and that her menstrual cycle was irregular.   When questioned about her bowel movements, she stated that sometimes she would get cramping prior to the movement, but usually no indication of movement would occur.  She described the stool as having the smell of a `stagnant  pond'.   She denied any burning around her anus.   Her appetite was not consistent.   Sometimes she stated she would be hungry but afraid to eat because of the possibility of having fecal incontinence, sometimes she stated that she wasn't hungry.    She stated that she had normal thirst and normal urination.  Her tongue had a yellow dry coat with a crack in the center.  Her Spleen pulse was wiry and her Liver pulse was full.  Both sides were rapid.   Palpation indicated Ashi at Liver 7.5 and Spleen 9 and on the right foot, Kidney 5 area.  No other ashi areas were present.   Ashi at 7.5 is from Richard Tan.   I use the ashi at this point and at Spleen 9 as a diagnostic indication of Liver/Spleen Disharmony.   I was taught that an ashi at or around Kidney 5 indicated the presence of a Kidney Stone.  Her TCM diagnoses were Internal Heat with Liver overacting on Spleen producing a Spleen deficiency.  She was given an herbal formulas (See Appendix A) and acupuncture and asked to return in one week.  She was also advised to avoid dairy products, cold raw foods and to stop her over the counter supplements until her bowel movements returned to normal   

 

Treatment

 

Date       Pulse          Tongue     Symptoms          Treatment

11/3/05	Wiry/full	Yellow dry	Fecal incontinence/ diarrhea	Ear Shen Men Capsules A/Soup
11/10/05	Wiry/rapid	Yellow reduced	Fecal incontinence 2x/wk BM normal 2x/day	Capsules B  Spleen
11/17/05	Less wiry	Yellow less	Fecal incontinence 2x/wk Rabbit pellet stool	Reduce caps B  Spleen
12/01/05	floating	unremarkable	Normal BM	Shao Yang level flu capsules
3/14/06	Wiry/sl floating	Yellow root White tip	Fecal incontinence returned	Caps B (Spleen)  as needed

 

TABLE 1.  Synopsis of treatment and symptoms for G.E. A more detailed account of the symptoms and herbal formulas are located in Appendix A.

 

RESULTS

 

     Following her initial treatment, G.E.'s symptoms greatly reduced and her mood improved.    Her bouts of fecal incontinence had reduced to only 2 episodes for the week and her bowel movements had stabilized at 2 times a day with normal stool.  She had no nocturnal episodes of fecal incontinence.   Her capsule formula was changed because she no longer presented with an ashi at KD 5.  She was given a modification of Shao Yao Wan that contains food stagnation herbs to help with appetite while balancing the Liver and Spleen.  Her mood continued to improve over the next week.   Her episodes of fecal incontinence remained at 2 times for the week, but her bowel movement changed to `rabbit pellet poop' appearance.     This stool characteristic usually indicates a Spleen that is too dry.    Her herbal formula was most likely too drying which resulted in an increased loss of fluids producing a Spleen Yin deficiency with heat still present.   The patient was advised to continue her herbs but at a lower dose and when she returned in two weeks, her stools were normal and her original symptoms had improved.  At this visit, her pulse was floating which I interpreted to mean that an external pathogen was present.  Since she was on her period, she was prescribed Xiao Chai Hu Tang in capsule form.   The patient was not seen for 3 months.  When she returned it was because her original symptoms of fecal incontinence had returned while she was overseas.  She stated that her bowel movements had been normal and that she had gained some weight until she had run out of capsules while on her trip.  She stated that after one week of no herbs her symptoms started to return.    She immediately came to see me upon her return and started the herbs.  The patient was advised to return as needed and to refill her herbs as needed.  The patient has not been back in almost 2 months but through communication with her one month ago, she continues to have a normal bowel movement.

 

DISCUSSION

 

     This patient presented an interesting case because while she appeared to suffer from an inflammatory bowel disorder, her primary complaint was one of asymptomatic bowel incontinence.    The usual symptoms of IBS, Celiac disease, or any of the bowel disorders characterized by diarrhea usually include abdominal cramping 3,4 which either improves with defecation or worsens (depending upon excess or deficiency conditions).    This patient rarely experienced cramping prior to a bowel movement.   This absence of abdominal cramps and the watery nature of the stool produced her chief complaint which was fecal incontinence.     Fecal incontinence is usually seen in patients with a history of nerve damage to the rectum.  This can be caused by trauma, aging (motility disorders) or surgery. 5   Usually there are comorbid conditions existing in the elderly such as impaction or infection which intensify the fecal incontinence. 6   Prolapse of the rectum can also contribute to the occurrence of fecal incontinence. 2   Conventional allopathic treatment of mild cases usually consists of diet modification, surgical repair if appropriate, fiber supplementation, bowel habit training and use of medications to slow bowel motility.  In extreme cases, creation of a colostomy can allow patients to resume more normal activities. 2   TCM treatment of diarrhea usually consists of acupuncture, moxa and/or herbal formulas. 3,4,7   Some of the most common causes of diarrhea are Spleen/Kidney Yang deficiency, Invasion of Damp Heat and Food retention.7    All the common types of diarrhea however are accompanied by some type of sensation in the abdomen (gurgling, pain around the umbilicus, intermittent cramping, etc) symptoms which were absent in this patient.   Since the patient reported that her stool smelled like a `stagnant pond', I took that to mean the stool consisted of undigested food.  The mild depression and the inconsistent appetite suggested that the patient suffered from a Spleen deficiency.  I thought at first she was suffering from a Yang deficiency, but her tongue and pulse suggested that Internal Heat was present.  A Kidney Yang deficiency could produce a urinary incontinence, but a fecal incontinence would more likely be caused by a Heat toxin.    If there was an incomplete blockage in the large intestine caused by Heat, only watery stool might be able to pass.   If the cause of the patient's fecal incontinence was caused by heat blockage, then use of Da Huang should remove the blockage and the watery diarrhea should be reduced.  The herbal broth the patient was given contained Da Huang and her watery stool/fecal incontinence was reduced from more than 4 times a day to 2 times in a week suggesting that her fecal incontinence was in fact due to heat blockage.   Even though there did not appear to be Damp present (dry coating with a crack in middle of tongue, an absence of a slippery pulse), a fluid imbalance was assumed because of the watery diarrhea.  Therefore the patient was also given capsules of powdered herbs that contained formulas that moved fluid out through the urine (Zhu Ling Tang san) and that would support the Spleen.   This formula was primarily given because of indications of a possible stone in the kidney.   Personal clinical experience has shown that this is a successful treatment.    Further study on fecal incontinence of the elderly, patients with rectal prolapse, or after surgery using Spleen supporting herbs as well as heat removing herbs would be needed to determine if this theory would be an appropriate treatment when no abdominal pain was present prior to uncontrolled bowel movement.

 

POSTSCRIPT

Since completing this report, I recently saw in my office a 13 year old boy, K.C., who complained of two incidences of fecal incontinence during sleep over four nights prior to his visit.   This was also a symptom present with G.E.   K.C. was not having any symptoms consistent with diarrhea (no cramping, urgency, burning around the anus) during the day.    However he was just starting to experience the need to defecate after eating.    Appetite, thirst and urination were normal.  Pulse and tongue were unremarkable.  K.C. had been involved in an accident with an all terrain vehicle.  He hit his head and thinks he might have passed out but was alone so wasn't sure.  The fecal incontinence started after that.   He denied any headache or vision changes. His mother had not noticed any changes in behavior or school work.  He had an ashi point around KD 5.  He was given the same herbal broth as G.E.  After five days on the broth, he hasn't had anymore bouts of nocturnal fecal incontinence and the ashi around KD 5 was reduced.   I recommended that he should seek neurological follow-up regarding possible head trauma.    The possibility that G.E.'s fecal incontinence might have also stemmed from a possible neurological event can not be disregarded.    Recommendations for an additional neurological work-up for G.E. will also be made if her fecal incontinence returns.   (G.E. had denied any history of head trauma and stated all her diagnostic imaging tests were normal)

 

REFERENCES:

Tierney, Jr., LM, McPhee,SJ, Papadakis, MA, CMDT 2005,Lange Medical Books, McGraw-Hill, New York, 2005

Baxter, NN, Madoff, RD, Motility Disorders: Introduction, 2006 ACS Surgery Online,http: www.Medscape posted on line 3/10/2006, accessed April 2006

Lui,X-F Treatment of Child Diarrhea and Intestinal Colic by Moxibustion with Ginger on Shenque plus Massage: A report of 52 cases, 2000 TCM Shanghai J Acu Moxa 1 :46-47

Stump, JI. Acupuncture Management of Celiac Disease, 2003 Medical Acupuncture 14(3): 38-40

Zetterstrom, AD. et al, Effect of hysterectomy on bowel function, 2004 Dis Colon Rectum, 47(4):502-8, http:www. Pub Med abs Pub Med, accessed April 2006

Palmer, RM. Management of Common Clinical Disorders in Geriatric Patients: Fecal Incontinence, 2006 ACP Medicine Online, http: Medscape WebMD Inc, posted 3/10/2006 Medscape accessed April 2006

Xinnong, C. ed. Chinese Acupuncture and Moxibustion, Foreign Language Press, Beijing,1996

APPENDIX A

Treatments

 

11/3/06

Acupuncture:  Ear points bilateral Shen Men (ear tacks to be retained for 6 days)

Capsules: Modified Zhu Ling Tang (san) used to treat kidney stone (or Ashi at Kidney 5)  (Capsules A, Fluid)

          Zhu Ling     3 gms

          Zie Xie     3 gms

          Fu Ling     3 gms

          Che Chian Zi     3 gms

          A Jiao          3 gms

          Huang Qi     3 gms

 

40 grams of this formula were placed in 100 capsules.  The dosage prescribed was

4 capsules once a day, 8 capsules if flank pain occurred or if urination changed.

Raw Herbs   Modified Xiao Chai Hu Tang (Gui Zhi Tang to support the Wei and stop the sweating), (Wu Ling San Tang, move heat and fluid formula from lower Jiao), herbs to move heat toxins in the lower Jiao and remove blockages,  Herbs to support the Spleen and Qi

          Mu Tong  9 grams

          Zie Xie     9 grams

          Bai Zhu    9 grams

          Chai Hu    9 grams

          Gui Zhi     9 grams

          Yu Jin           9 grams

          Sheng Jiang  2 pieces

          Fu Ling      9 grams

          Da Zao     12 dates

          Gan Cao     6 grams

          Chuan Lian Zi  9 grams

          Mu Dan Pi   9 grams

                     Bai Shao       9 grams

                        Tao Ren       9 grams

                        Huang Bai    9 grams

                         Ban Xia        9 grams

          Yuan Shen     9 grams

                         Zhu Ling     9 grams

                         Da Huang      3 grams

                         Huang Qin     9 grams

           Hua Shi          9 grams

          Chen Pi           9 grams

                         Tian Hua Fen  9 grams

The raw herbs were to be cooked in 9 cups of water until 3 cups of broth remained.  1 cup was to be taken twice a day before meals.  The herb mixture could be recooked 2-3 times depending whether symptoms are still present but decreasing in severity.

11/10/05

On the patient's second visit, she reported that she had only 2 incidences of fecal incontinence otherwise her bowel movements were normal and twice a day.  Her night sweats had decreased and she stated that she was sleeping better.  Her appetite was improved and she had more confidence about eating.  Her thirst had increased and her urine was unchanged in frequency but was yellow in color.  She stated that she did not feel as depressed but was tired.  There was no Ashi at Liver 7.5, Spleen 9 or Kidney 5.   She stated that her period had started and she had experienced some menstrual cramping.   The yellow coating on her tongue had retreated to the root and in the center.  Her pulses were wiry and still rapid.   She was advised to stop the capsules from her first visit and only take if needed (flank pain or changes in urination).  She was advised to continue her broth but to take ½ cup 1 -2 times a day before meals unless her symptoms returned.  She was given a new powdered formula to take.

New formula `Spleen'

Combination of Wu Ling San and modified Xiao Yao San (See Appendix B)  with Tian Hua Fen and Chen Pi added.  (Capsules B, Spleen)   She was advised to take 8 capsules 2 times a day before meals

11/17/05

Patient stated she had two fecal incontinent episodes.  Her bowel movements had become incomplete or `rabbit pellet ` stools.   Her energy had increased.  Her appetite was up and down as was her thirst.  Her urine was more normal and the night sweats were almost gone.  Pulses were not as rapid or as wiry.  The yellow coating on the tongue was decreased.

The herbal formula from 11/10/05 was given again and the dosage adjusted to 4-8 capsules 1-2 times a day depending on her symptoms.

Patient was advised to return in 2 weeks.

 

12/01/05

On G.E,'s 4th visit, she stated that her bowel movements were improved and that she had had no incidents of fecal incontinence.  Her appetite was improved and she was eating.  All her symptoms were improved.  She had started her period a week early and she complained of nasal congestion.  (G.E. was given Xiao Chai Hu Tang in powder form for her period flu symptoms).  The patient was advised to take her 11/10/05 capsules (`Spleen') as needed and to refill when she needed more.  She was advised to return to clinic as needed.

 

3/14/06

G.E. returned to clinic after traveling in Europe for 4 weeks.  She had not had any fecal incontinence until the last week of her trip when she ran out of capsules.   She had not adhered to diet restrictions and had eaten cold dairy products while traveling.   She complained that her weight had started to drop again with the fecal incontinence.  She stated that her bowel movements were increasing as was her thirst and her appetite was decreasing.  She had no night sweats and her last period had been normal.   Her tongue coating was yellow and thick at the root and white and thick at the tip.  The crack was wider.  Her pulses were wiry and slightly floating.   G.E, was given a refill of her 11/10/05 formula and advised to take 4-8 capsules 1-2 times a day until her symptoms lessened and then 2-4 capsules/day or as needed.  G.E, was instructed to return to clinic as needed and to refill her formula when she ran out.  

 

APPENDIX B

Formula for Modified Xiao Yao Wan

     Dang Gui     2 gms

     Bai Zhu     2 gms

     Chai Hu     2 gms

     Sheng Jiang     1 gm

     Shen Qu     2 gms

     Bo He          1 gm

     Mou Dan Pi     2 gms

     Bai  Jie Zi     2 gms

     Bai Shao     2 gms

     Ban Xia     2 gms

     Xuan Shen     2 gms

     Suan Zao Ren     2 gms

 

This formula was made in powdered form.  

 

Formula for Wu Ling San

     Fu Ling      4 gms

     Zhu Ling     4 gms

     ZeXie          6 gms

     Gui Zhi     3 gms

     Bai Zhu     4 gms

 

This formula was made in powdered form

The 11/10/05 formula `Spleen'  consisted of:

     Modified Xiao Yao Wan           15    gms

     Wu Ling San                    20    gms

     Chen Pi                      2.5 gms

     Tian Hua Fen                      2.5 gms

 

The forty grams of `Spleen' were placed in 100 capsules.